A Developmental Perspective for Promoting Theory of Mind
Transcript of A Developmental Perspective for Promoting Theory of Mind
Top Lang DisordersVol. 34, No. 4, pp. 362–382Copyright c© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
A Developmental Perspectivefor Promoting Theory of Mind
Carol Westby and Lee Robinson
Social neuroscience research has resulted in changing views of the theory of mind (ToM) con-struct. Theory of mind is no longer viewed as a unitary construct, but rather as a multidimensionalconstruct comprising cognitive and affective ToM and interpersonal and intrapersonal ToM, eachof which has differing neurophysiological/neuroanatomical foundations and behavioral manifes-tations. Clinicians working with persons with social communication/pragmatic communicationdisorders should consider evaluating these dimensions of ToM and the cognitive, social–emotional,and language components underlying them. Then they might use this information to develop aToM profile for each client so they are better able to implement specific intervention strategies totarget the linguistic and cognitive/affective foundations for ToM development. In this article, wedescribe the characteristics of developmental stages of affective and cognitive and interpersonaland intrapersonal ToM and how to match intervention goals and strategies to those stages. Someactivities and strategies have empirical support; others are based on what is known about typi-cal development and patterns of impairment. Key words: intersubjectivity, intervention, jointattention, mental state vocabulary, metacognition, self-regulation, sentential complements,theory of mind
THE ARTICLES in this issue of Topics inLanguage Disorders (Vol. 34, No. 4) ex-
plore theory of mind (ToM) from variousperspectives. Neurophysiology, environmen-tal influences, language skills, and behavioralmanifestation of ToM deficits are consideredin several types of populations.
Author Affiliations: Bilingual MulticulturalServices, Albuquerque, New Mexico (Dr Westby); andBrigham Young University, Provo, Utah (Dr Westbyand Ms Robinson).
Dr Westby discloses that she is a member of the Edi-torial Board of Topics in Language Disorders and willreceive a stipend as Issue Editor for this issue of thejournal. She has no other relevant financial or nonfi-nancial conflicts of interest to disclose. Ms Robinson hasindicated that she has no financial and no nonfinancialrelationships to disclose.
Supplemental digital content is available for thisarticle. Direct URL citations appear in the printedtext and are provided in the HTML and PDF ver-sions of this article on the journal’s Web site (www.topicsinlanguagedisorders.com).
Corresponding Author: Carol Westby, PhD, CCC-SLP, 1808 Princeton NE, Albuquerque, NM 87106([email protected]).
DOI: 10.1097/TLD.0000000000000035
Effective and appropriate social commu-nication/pragmatic language skills require acommunicator to have a ToM. The conceptof theory of mind emerged in the 1970swhen Premack and Woodruff (1978) definedToM as the ability to impute mental statesto oneself and others. The term was rapidlyadopted by developmental psychologists. Bythe late 1980s and early 1990s, deficits in ToMhad become associated with autism (Baron-Cohen, 1995). Theory of mind deficits anddelays in developing ToM, however, are notlimited to children, adolescents, and adultswith autism spectrum disorders (ASDs) andsocial communication disorders. Deficits inToM underlie many of the social communi-cation difficulties exhibited by persons with avariety of conditions, including language im-pairment (Ford & Milosky, 2003), deafness(see Stanzione & Schick, 2014, in this is-sue), attention-deficit/hyperactivity disorder,traumatic brain injury (Martin-Rodrigues &Leon-Carrion, 2010), Parkinson’s disease, de-mentia (Freedman & Stuss, 2011), behavioraldisorders, and psychiatric conditions (Baron-Cohen, 2011). Because ToM deficits are com-monly associated with language impairment,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
362
A Developmental Perspective for Promoting Theory of Mind 363
it is imperative that speech–language pathol-ogists and other language specialists knowhow ToM develops, the effects of ToM deficitson social communication skills and discoursecomprehension, the cognitive and linguisticfoundations for ToM, and how to promote de-velopment of ToM.
THE THEORY OF MIND CONSTRUCT
Traditional ToM construct
Until relatively recently, ToM was viewed asa unitary construct wherein reasoning aboutthe mental states and emotional states of selfand others was considered to be one and thesame cognitive ability. In this unitary view,the presence of ToM has been defined oper-ationally based primarily on assessment tasksthat required comprehension of another per-son’s false beliefs. False belief tasks generallyhave involved questioning about other peo-ple’s beliefs about the contents of a box (e.g.,candies in a crayon box) or the location of anobject (e.g., when a toy is moved to a newlocation). In such tasks, children are showna crayon box and asked what they think isinside. After the children guess crayons, theyare shown that their prediction was wrong—the crayon box actually contains candy. Theexperimenter then recloses the box and asksthe children what they think another person,who has not been shown the true contents ofthe box, will think is inside. The children passthe task if they respond that another personwill think there are crayons in the box, but failthe task if they respond that another personwill think that the crayon box contains candy(Gopnik & Astington, 1988).
In the most common version of the falsebelief locations task, children are shown twodolls, Sally and Anne, who have a basket and abox, respectively (Frith, 1989). Sally also hasa marble, which she places in her basket, andthen she leaves the room. While she is outof the room, Anne takes the marble from thebasket and puts it in the box. Sally returns,and the child is then asked where Sally willlook for the marble. Children pass the task if
they answer that Sally will look in the basket,where she put the marble; children fail thetask if they answer that Sally will look in thebox, where the children know the marble ishidden, even though Sally cannot know this,since she did not see it being hidden there.For both of these tasks, children must be ableto understand that another’s mental represen-tation of the situation is different from theirown, and they must be able to predict behav-ior on the basis of that understanding.
New views of the ToM construct
There are at least two issues withthis traditional view of ToM that requirereconsideration—expansion of the ToM con-struct beyond cognition and extended de-velopment of ToM ontogenetically (bothyounger and older than previously thought).First, the traditional view is that ToM is aunitary construct that has to do with thecognitive aspects of knowing what anotherperson knows. Consequently, assessmentshave focused on evaluating understandingof cognition—thinking about what someonethinks, knows, or believes.
In the last 15 years, however, neuroimag-ing studies have provided evidence that ToMis not a unitary construct. Rather, thereare several different dimensions or typesof ToM, each having differing neurophysio-logical/neuroanatomical underpinnings (Abu-Akel & Shamay-Tsoory, 2011; Frith & Frith,2003; Northoff et al., 2006; Shamay-Tsoory,2011). Dvash and Shamay-Tsoory (2014), intheir article in this issue of this journal,identify cognitive and affective dimensionsof empathy. Shamay-Tsoory’s neurosciencegroup in Haifa, Israel, has been particu-larly active in documenting the neurophysi-ological/neuroanatomical and neurochemicalbases of ToM. This work has shown that ToMcan be differentiated into the traditionally rec-ognized cognitive ToM, which involves think-ing about the thoughts, knowledge, beliefs,and the intentions of others, along with a dis-sociable affective ToM, which involves think-ing about and experiencing the emotions ofothers. That is, affective ToM can be further
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
364 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
differentiated into affective-cognitive ToM,which can be described as cognitive empathy(i.e., awareness of, or recognition of, the emo-tions of oneself or others) and affective empa-thy, which can be described as the ability torespond to the emotions of others (i.e., to feelas others are feeling). Other researchers havereported that ToM also differentiates into in-terpersonal ToM (thinking about the thoughtsand emotions of others) and intrapersonalToM (thinking about or reflecting on one’sown thoughts and emotions) (Lucariello,Durand, & Yarnell, 2007; Northoff et al., 2006;Tine & Lucariello, 2012). Lucariello et al.(2007) and Tine and Lucariello (2012) havemodified traditional ToM tasks to assess bothinterpersonal and intrapersonal cognitive andaffective ToM (see examples in Table 1).
The second issue with the traditional viewof ToM is that ToM does not suddenly emergebetween ages 4 and 5 years. From the momentof birth, healthy infants in homes with caringadults attuned to their needs begin to developthe foundations of ToM. Infants attend to theircaregivers, who look at them and talk to them.
Essentially from birth, newborns also attemptto reproduce mouth and facial movements ofthe caregivers. Some neuroscientists attributethese early imitation skills to the functioningof mirror neurons—neurons that are activatedwhen one initiates a movement, but also whenone sees someone else engage in that move-ment (Keysers, 2011). It is thought that theseearly interactions lay the foundations for af-fective ToM (Gallagher & Hutto, 2008). Dur-ing the toddler and preschool years, childrenthen begin to realize that they are separatefrom others and develop the social–cognitiveand language skills that are associated withpassing false belief tasks.
Clinical implications of the ToMconstruct
McPartland and Pelphrey (2012) suggestedthat findings from social neuroscience couldbe used to define subgroups of personswith disabilities with particular profiles. Re-searchers and clinicians could then work to-gether to determine which profiles respondbest to particular interventions. Using the
Table 1. Examples of Interpersonal and Intrapersonal ToM
Interpersonal ToM Intrapersonal ToM
Cognitive Child sees a sponge painted to looklike a rock, and touches it. Thenchild is asked: If another kid comesin, and does not touch the object,what will he think it is? (Must sayother child will think it’s a rock)
Child is shown a sponge painted tolook like a rock and asked: What isthis object? Then the child touchesthe sponge and is asked: What isthe object really? What did youthink it was before touching it?(Expected answers: rock, sponge,rock)
Affective Child is told a story: “David falls andgets hurt, but tries to hide how hefeels so that other kids will notlaugh at him.” Then child is asked:How does David really feel? Howdoes David try to look on his face?Does he look happy, sad, or okay?(Must describe underlying feelingsas being different from look on theface)
Child is told, “You are playing and falldown in front of some other kidsand hurt yourself. You try to hidehow you feel so that other kids willnot laugh at you.” Then child isasked: How do you really feelwhen this happens? How do youtry to look? Do you look happy,sad, or okay? (Must describeunderlying feelings as beingdifferent from look on the face)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Developmental Perspective for Promoting Theory of Mind 365
cognitive and affective ToM framework,Baron-Cohen (2011) has described cognitiveand affective ToM profiles in persons witha variety of psychiatric disorders as wellas classic autism and Asperger Syndrome.Lucariello and colleagues (Lucariello et al,2007; Tine & Lucareiello, 2012) reportedthat children from low socioeconomic back-grounds had better interpersonal than intrap-ersonal ToM and children with ASDs hadbetter intrapersonal than interpersonal ToM(Tine & Lucariello, 2012).
Clinicians working with persons with so-cial communication/pragmatic communica-tion disorders should consider evaluating allthe dimensions of ToM (cognitive/affectiveand interpersonal/intrapersonal) and the cog-nitive, social–emotional, and language com-ponents underlying these dimensions. Then,they might use the results to develop a ToMprofile for each individual so they are bet-ter able to implement specific interventionstrategies to target the linguistic and cogni-tive/affective foundations for ToM.
In this article, we describe the developmen-tal stages of affective and cognitive and inter-personal and intrapersonal ToM and match in-tervention strategies to those stages. We citethe evidence and provide a rationale for theseintervention strategies, even though the de-velopers of the interventions may rarely, ifever, refer to these ToM dimensions. Our in-tent is not to teach persons to pass the vari-ety of ToM tasks that have been developed,but rather to use persons’ performance onthese tasks as an indication of how they in-terpret social experiences and discourse inthe world. The goal is to teach the cognitive,linguistic, and social/emotional skills that un-derlie ToM so that individuals can use theseskills to communicate and interact more ef-fectively. This need for a different therapeu-tic approach is based on prior research thathas shown that children and adolescents whohave been taught explicitly to respond to ToMtasks often have shown little or no generaliza-tion from one ToM task to another. Further-more, trained performance on ToM tasks hasnot translated to social competence in every-
day life (Begeer et al., 2011; Hadwin, Baron-Cohen, Howlin, & Hill, 1997).
At this time, there are no standardized as-sessments available to evaluate the multiple di-mensions of ToM. Many research articles thathave assessed ToM dimensions, however, in-clude the protocols used, so one can developa set of assessment tasks to be used informallyas criterion-referenced tools. Some summariesof tasks are available. For example, Wellmanand Liu (2004) describe a developmental setof cognitive ToM tasks employed in a numberof studies. Pons, Harris, and de Rosnay (2004)describe tasks for evaluating affective ToMfor children between 3 years and 11 years.O’Hare, Bremner, Nash, Happe, and Pettigrew(2009) and Liddle and Nettle (2006) provideexamples of higher order levels of ToM tasks.Hutchins and Prelock (in press) are develop-ing a standardized ToM test battery that eval-uates some aspects of cognitive and affectiveToM, although they do not explicitly distin-guish between these ToM dimensions.
Table 2 shows the development of ToMand its precursors. Both cognitive and affec-tive ToM move through several levels of de-velopment. First-order ToM, which developsbetween 4 and 5 years of age, involves think-ing about what someone else is thinking orfeeling. Second-order ToM, which emergesshortly after first order (or by age 7 years) intypically developing children, involves think-ing about what someone is thinking or feel-ing about what someone else is thinking orfeeling. Beyond second-order ToM, higher or-der cognitive and affective ToM involves tasksthat require recognizing lies, sarcasm, figura-tive language, idioms, or understanding mul-tiple embeddings (e.g., He thinks that shehopes that they believe she loves the gift).These skills typically develop between 8 and12 years of age.
Precursors to these ToM stages beginin infancy. They involve reciprocal interac-tion/emotional sharing between infants andcaregivers (called primary intersubjectivity),joint attention in reference to objects (calledsecondary intersubjectivity) (Gallagher &Hutto, 2008), a sense of self, pretend skills,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
366 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
Tab
le2
.D
evel
op
men
to
fT
heo
ryo
fM
ind
Co
gnit
ive
Th
eory
of
Min
dA
ffec
tive
Th
eory
of
Min
d
Age
Inte
rper
son
alC
ogn
itiv
eIn
trap
erso
nal
Co
gnit
ive
Inte
rper
son
alA
ffec
tive
Intr
aper
son
alA
ffec
tive
Pri
mar
yin
ters
ub
ject
ivit
y(e
mer
ges
bir
thto
6m
on
ths)
Bir
thto
6m
on
ths
–Res
po
nd
sto
emo
tio
nal
reac
tio
ns
of
oth
ers
–Im
itat
esex
pre
ssio
ns
–Co
nta
gio
us
emp
ath
y6–
8m
on
ths
–Res
po
nsi
vejo
int
atte
nti
on
–Dis
pla
ysjo
y,sa
dn
ess,
dis
gust
,a
nge
rSe
con
dar
yin
ters
ub
ject
ivit
y(e
mer
ges
8-12
mo
nth
)
8–12
mo
nth
s–F
ollo
ws
line
of
rega
rd–B
ehav
iora
lreg
ula
tio
n;
init
iate
sb
ehav
ior
req
ues
t
–Use
sem
oti
on
alex
pre
ssio
no
fca
regi
vers
asso
cial
refe
ren
cefo
rap
pro
ach
-avo
idan
ce
–Dis
pla
ysem
oti
on
so
fh
appy,
ma
d,s
ad,s
urp
rise
d,
dis
gust
ed,a
fra
id–I
nit
iate
sjo
int
atte
nti
on
on
ob
ject
s13
–17
mo
nth
s–U
nd
erst
and
sp
hys
ical
rela
tio
nb
etw
een
ap
erso
n’s
line
of
sigh
tan
dth
eir
beh
avio
r;o
ne
sees
wh
ato
ne
loo
ksat
–See
ksto
chan
geaf
fect
of
ano
ther
by
dir
ect
con
tact
–Co
ord
inat
ion
/co
regu
lati
on
of
inte
ract
ion
s
18m
on
ths-
2ye
ars
–Rec
ogn
izes
that
dif
fere
nt
peo
ple
may
like
dif
fere
nt
thin
gso
rh
ave
dif
fere
nt
des
ires
–Em
erge
nt
sen
seo
fse
lf–E
nga
ges
inp
rete
nd
–Co
nsc
iou
sly
reco
gniz
esd
istr
ess
ino
ther
s;p
red
icts
that
rece
ipt
of
bro
ken
toy
will
mak
ech
ildu
nh
app
y
–Em
erge
nt
altr
uis
tic
beh
avio
r:co
mfo
rts
ano
ther
;ch
ange
san
oth
er’s
or
do
ll’s
affe
ctb
yb
rin
gin
gsu
itab
leto
y–U
ses
word
sh
appy,
sad,m
ad,
sca
red
(con
tin
ues
)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Developmental Perspective for Promoting Theory of Mind 367
Tab
le2
.D
evel
op
men
to
fT
heo
ryo
fM
ind
(Con
tin
ued
)
Co
gnit
ive
Th
eory
of
Min
dA
ffec
tive
Th
eory
of
Min
d
Age
Inte
rper
son
alC
ogn
itiv
eIn
trap
erso
nal
Co
gnit
ive
Inte
rper
son
alA
ffec
tive
Intr
aper
son
alA
ffec
tive
3ye
ars
–Un
der
stan
ds
that
peo
ple
’sac
tio
ns
can
be
det
erm
ined
by
thei
rd
esir
es,i
nte
nti
on
s,an
dth
ou
ghts
–Un
der
stan
ds
that
per
cep
tual
acti
vity
(see
ing,
bei
ng
told
)is
inso
me
way
con
nec
ted
tokn
ow
ing
–Un
der
stan
ds
that
dif
fere
nt
peo
ple
can
see
dif
fere
nt
thin
gs
–Un
der
stan
ds
that
imag
inar
yo
bje
cts
are
dif
fere
nt
fro
mre
alo
bje
cts
–Wo
rds
like
rem
ember
,kn
ow
,an
dth
ink
app
ear
insp
on
tan
eou
ssp
eech
–Mat
ches
emo
tio
nw
ord
sh
appy,
sad,m
ad,a
fra
idto
ph
oto
grap
hic
face
s–S
chem
atic
faci
alre
cogn
itio
n–K
no
ws
the
situ
atio
ns
that
will
pro
voke
pri
mar
yem
oti
on
s(c
anm
atch
emo
tio
nw
ord
top
ictu
re)
–Tal
ksab
ou
tca
use
san
dco
nse
qu
ence
so
fem
oti
on
s(e
.g.,
“San
taw
illb
eh
app
yif
Ip
eein
the
po
tty.
”)–U
ses
ob
ject
and
“fri
end
”to
chan
geaf
fect
–Beg
ins
tod
isp
lay
self
-co
nsc
iou
sem
oti
on
s:em
ba
rra
ssm
ent,
pri
de,
sha
me,
guil
t
4–5
year
sFi
rst-
ord
erco
gnit
ive
theo
ryo
fm
ind
;pre
dic
tsw
hat
som
eon
eis
thin
kin
go
rfe
elin
g–P
asse
sfa
lse
con
ten
tsan
dfa
lse
bel
iefs
task
s–C
anp
red
ict
ap
erso
n’s
acti
on
so
nb
asis
of
ap
erso
n’s
fals
eb
elie
fs–P
ersp
ecti
veta
kin
g;u
nd
erst
and
sn
ot
on
lyw
hat
peo
ple
see
bu
tal
soh
ow
itap
pea
rsto
them
–Un
der
stan
ds
ho
wac
cess
toin
form
atio
nb
yse
ein
go
rh
eari
ng
isca
usa
llyre
late
dto
kno
wle
dge
and
ho
wkn
ow
led
gean
db
elie
fca
nb
eca
usa
llyre
late
dto
acti
on
sin
the
wo
rld
(bel
iefs
cau
sep
eop
leto
act
ince
rtai
nw
ays)
–Fu
ture
tim
etr
avel
for
pre
dic
tin
gp
hys
ical
chan
ges
–Rec
ogn
izes
amb
igu
ou
sfi
gure
s
Firs
t-o
rder
affe
ctiv
eth
eory
of
min
d–P
red
icts
wh
atso
meo
ne
isfe
elin
g–U
nd
erst
and
sth
atem
oti
on
sar
eca
use
db
yw
hat
som
eon
eth
inks
isth
eca
se,e
ven
ifw
hat
they
thin
kco
nfl
icts
wit
hre
alit
y;p
red
icts
emo
tio
ns
bas
edo
nfa
lse
bel
iefs
–Id
enti
fies
char
acte
r’s
feel
ings
acco
rdin
gto
wh
eth
ero
rn
ot
wis
hes
are
fulfi
lled
–Sen
seo
fse
lfth
rou
ghti
me
–Ep
iso
dic
/au
tob
iogr
aph
ical
mem
ory
and
futu
reti
me
trav
el–C
and
escr
ibe
ap
erso
nal
situ
atio
nin
wh
ich
they
wer
eh
app
y,sa
d,m
ad,s
care
d,a
nd
surp
rise
d
(con
tin
ues
)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
368 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
Tab
le2
.D
evel
op
men
to
fT
heo
ryo
fM
ind
(Con
tin
ued
)
Co
gnit
ive
Th
eory
of
Min
dA
ffec
tive
Th
eory
of
Min
d
Age
Inte
rper
son
alC
ogn
itiv
eIn
trap
erso
nal
Co
gnit
ive
Inte
rper
son
alA
ffec
tive
Intr
aper
son
alA
ffec
tive
6–8
year
sSe
con
d-o
rder
cogn
itiv
eT
oM
;p
red
icts
wh
ato
ne
per
son
isth
inki
ng
abo
ut
wh
atan
oth
erp
erso
nis
thin
kin
g–A
bel
ieve
sth
atB
bel
ieve
s/th
inks
X–A
inte
nd
sth
atB
bel
ieve
/th
ink
X
–Mak
esap
pro
pri
ate
jud
gmen
tso
fsi
tuat
ion
sin
wh
ich
on
ekn
ow
s,re
mem
ber
s,fo
rget
s,o
rgu
esse
s
Seco
nd
-ord
eraf
fect
ive
To
M;
pre
dic
tsw
hat
on
ep
erso
nth
inks
/fee
lsan
oth
erp
erso
nfe
els
–Ab
elie
ves
that
Bfe
els
–Ain
ten
ds
that
Bfe
el–C
ano
ffer
app
rop
riat
esi
tuat
ion
sfo
rem
oti
on
slik
eje
alo
usy
,wo
rry,
pri
de,
sham
e,gu
ilt–U
nd
erst
and
sth
ato
ne
can
hav
efi
rst
on
eem
oti
on
and
then
ase
con
dem
oti
on
inre
spo
nse
toa
situ
atio
n
–Use
sw
ord
spro
ud,j
ealo
us,
worr
ied
–Dev
elo
ps
stra
tegi
esfo
rre
gula
tin
gem
oti
on
s
8–10
year
sH
igh
ero
rder
To
M–U
nd
erst
and
sst
rate
gies
toh
ide
dec
eit
and
tod
etec
td
ecei
t–U
nd
erst
and
sfi
gura
tive
lan
guag
e–R
eco
gniz
esco
gnit
ive
lies
–Use
sm
etac
ogn
itiv
est
rate
gies
for
com
pre
hen
din
gan
dm
on
ito
rin
gco
mp
reh
ensi
on
–Un
der
stan
ds
that
on
eca
nh
ave
two
con
curr
ent
emo
tio
ns
of
op
po
site
typ
ein
resp
on
seto
asi
tuat
ion
–Rec
ogn
izes
/un
der
stan
ds
affe
ctiv
esa
rcas
m–R
eco
gniz
esso
cial
fau
xp
as–R
eco
gniz
esaf
fect
ive
or
wh
ite
lies
–Em
oti
on
ald
isem
ble
nce
(can
hid
eem
oti
on
s)–C
anin
ten
tio
nal
lyu
sefa
cial
exp
ress
ion
sto
mis
lead
–Wo
rds
reli
eve
and
dis
appoin
ted
emer
geat
pre
ado
lesc
ence
–Em
plo
yssa
rcas
m–T
ells
affe
ctiv
eo
rw
hit
elie
s–T
ells
pre
sen
tati
on
allie
s(t
om
ake
on
esel
flo
ok
goo
din
the
eyes
of
oth
ers)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Developmental Perspective for Promoting Theory of Mind 369
emotional recognition, and mental state vo-cabulary (Astington & Baird, 2005).
We have placed these precursors andToM skills into 4 stages. Ideally, interven-tions for ToM should consider the cog-nitive, linguistic, and interactional under-pinnings for cognitive and affective ToMand interpersonal and intrapersonal ToMat each developmental stage. Table 3shows intervention goals and strategies foreach of these 4 stages. The interventions de-scribed represent only some of the activitiesthat can be used to develop the cognitive,linguistic, and social–emotional foundationsat each stage. Interventions for very youngor severely delayed children always begin atthe earliest stage. Children and adolescentswho have ToM deficits and are capable ofworking on first, second, or higher order ToMtasks still may need some focus on the earli-est pre-ToM stages as well. Even high func-tioning adults with Asperger disorder maycontinue to exhibit deficits at the level ofprimary and secondary intersubjectivity. Forexample, clinicians might work with ado-lescents on comprehending sarcasm, whichentails higher-order ToM, but simultaneouslytarget increased joint attention with, or refer-encing of, others so the individual with ASDis better able to interpret the emotions andbehaviors of others.
The remainder of this article describes thecharacteristics of each of these ToM stagesand goals and intervention strategies asso-ciated with these stages. The activities andstrategies are based on those that have em-pirical support or on what is known abouttypical development and patterns of impair-ment. (See Supplemental Digital Content Afor evidence-based studies, available at: http://links.lww.com/TLD/A35.)
DEVELOPMENT AND FACILITATIONOF TOM
Stage 1: Pre–theory of mind, engagement
Development and assessment
In typical children, this stage is betweenbirth and about 18 months. From birth,
neurotypical children exhibit primary inter-subjectivity or emotional sharing with others.In attuned intersubjective interactions withcaregivers, babies share the emotions of theircaregivers and mirror their expressions—theunderpinnings for affective ToM. Childrendevelop a variety of joint attention skills. By6 months, they follow the line of regard ofothers (responding to joint attention), andby 8 to 12 months, they develop secondaryintersubjectivity, employing joint attentionto initiate a behavior request to get desiredobjects or actions (e.g., to obtain a food itemor toy) or to initiate social joint attentionsimply for the sake of interaction (Mundy& Newell, 2007). In initiating social jointattention, neurotypical children also refer-ence those they are interacting with. Forexample, they borrow the perspective ofanother person, they use others’ reactionsas a reference point to resolve uncertainty,they determine the emotional meaning ofan unfamiliar person or object, and theydetermine the effect of their behavior onothers. They recognize if someone is fearfulor angry, responding by moving away, or ifsomeone is happy by moving closer. It is crit-ical for clinicians to recognize the differencebetween simple joint attention—lookingat the same object the caregiver is lookingat—and true social referencing—interpretingthe intents and emotions of the caregiver.Mundy (2003) has an assessment tool, theEarly Social Communication Scales (http://www.ucdmc.ucdavis.edu/mindinstitute/ourteam/faculty staff/escs.pdf), that can beused to assess and distinguish among thesetypes of joint attention. Once infants andtoddlers are able to engage in initiatingjoint attention, they begin to coordinate orcoregulate their joint attention with othersby taking turns in interactions.
Intervention
In Stage 1, intervention begins by fo-cusing on establishing engagement throughactivities involving emotional sharing or pri-mary intersubjectivity (e.g., face-to-face in-teractions such as peek-a-boo) or secondaryintersubjectivity in turn-taking activities with
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
370 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
Tab
le3
.In
terv
enti
on
sfo
rD
evel
op
ing
Th
eory
of
Min
d
Inte
rven
tio
nO
bje
ctiv
esO
utc
om
es
Ch
arac
teri
stic
so
f
Leve
lto
Dev
elo
p
Ch
arac
teri
stic
so
f
Th
ose
Rea
dy
for
Th
isLe
vel
Intr
aper
son
al
Co
gnit
ive
Intr
aper
son
alA
ffec
tive
Inte
rper
son
alC
ogn
itiv
eIn
terp
erso
nal
Aff
ecti
ve
Stag
e1:
Pre
-To
M
enga
gem
ent
–Pri
mar
yin
ters
ub
ject
ivit
y
–Sec
on
dar
y
inte
rsu
bje
ctiv
ity
–no
tre
spo
nsi
vere
adily
toth
ose
aro
un
d;n
oo
r
limit
edre
fere
nci
ng
–lim
ited
init
iati
on
of
inte
ract
ion
–mo
tor
imit
atio
nan
d
imit
atio
nw
ith
ob
ject
s
–em
oti
on
alsh
arin
g,
refe
ren
cin
g,co
regu
lati
on
–mu
tual
regu
lati
on
–aff
ecti
veim
itat
ion
–mo
tor
imit
atio
nan
d
imit
atio
nw
ith
ob
ject
s
–em
oti
on
alsh
arin
g,
refe
ren
cin
g,co
regu
lati
on
–aff
ecti
veim
itat
ion
Stag
e2:
Pre
-To
M
–Sen
seo
fse
lf
–Pre
ten
dsk
ills
–res
po
nsi
veto
tho
sear
ou
nd
;
refe
ren
ces;
enga
ges
intu
rn
taki
ng
–req
ues
tin
gb
ehav
iors
–fu
nct
ion
alu
seo
fo
bje
cts
–pre
ten
db
ehav
iors
–aw
aren
ess
of
ph
ysic
alan
d
psy
cho
logi
cals
elf;
mu
tual
regu
lati
on
–fo
un
dat
ion
sfo
r
auto
bio
grap
hic
al
mem
ory
by
self
talk
/par
alle
ltal
k
–pre
ten
dsk
ills
–des
crip
tive
lan
guag
esk
ills
–id
enti
fica
tio
no
fp
rim
ary
no
nso
cial
emo
tio
ns
inse
lf
and
oth
ers
–id
enti
fica
tio
no
fem
oti
on
s
asso
ciat
edw
ith
situ
atio
ns
Stag
e3:
Firs
t-o
rder
To
M
–Pas
ses
fals
eb
elie
fco
nte
nts
and
loca
tio
nta
sks
–Men
talt
ime
trav
el;
auto
bio
grap
hic
alm
emo
ry
and
futu
reth
inki
ng
–dem
on
stra
tes
anem
erge
nt
sen
seo
fse
lf
–en
gage
sin
pre
ten
d
–aw
aren
ess
of
wh
ato
ne
kn
ow
s,does
n’t
kn
ow
,
rem
ember
s,fo
rget
s
–co
gnit
ive
flex
ibili
ty;
mo
reth
ano
ne
way
tod
o
ata
sk;c
ogn
itiv
ely
reap
pra
ise
situ
atio
n
–refl
ecti
on
tod
evel
op
auto
bio
grap
hic
alm
emo
ry
–id
enti
fica
tio
no
fn
on
soci
al
emo
tio
nin
self
–str
ateg
ies
tob
egin
tore
gula
te
on
e’s
ow
n
beh
avio
r/em
oti
on
s
–vo
cab
ula
ryo
fse
nse
verb
s
(see
,hea
r,sm
ell,
tast
e,fe
el),
men
tals
tate
verb
s(t
hin
k,
kn
ow
,gu
ess,
etc.
),an
d
emo
tio
ns
wo
rds
–det
erm
inat
ion
of
ho
wo
ther
s
are
cogn
itiv
ely
app
rais
ing
the
situ
atio
n
–In
fere
nce
of
per
son
s’/
char
acte
rs’e
mo
tio
ns
fro
m
situ
atio
ns
–pre
dic
tio
no
fp
erso
ns’
emo
tio
ns/
beh
avio
rsin
a
situ
atio
n
–id
enti
fica
tio
no
fn
on
soci
al
emo
tio
ns
ino
ther
s
Stag
e4:
Seco
nd
-ord
erT
oM
and
hig
her
–Fig
ura
tive
lan
guag
e
–Met
aco
gnit
ive
stra
tegi
es
–Co
nve
rsat
ion
alsk
ills
–id
enti
fies
pri
mar
y/
no
nso
cial
emo
tio
ns
–pas
ses
To
MLe
vel1
task
s
–str
ateg
ies
for
lear
nin
g;
thin
k-al
ou
ds;
qu
esti
on
ing
the
auth
or
–go
al-d
irec
ted
pla
nn
ing,
pro
ble
mso
lvin
g
–refl
ecti
on
on
on
e’s
kno
wle
dge
/em
oti
on
s
–sel
f-pre
sen
tati
on
alsk
ills
–mu
ltip
lem
ean
ings
for
wo
rds
–figu
rati
vela
ngu
age
–sar
casm
–rec
ogn
itio
no
fm
ult
iple
fact
ors
inco
nte
xt
that
con
trib
ute
top
erso
n’s
inte
rpre
tati
on
/ap
pra
isal
of
situ
atio
n
–ru
les
for
con
vers
atio
nal
inte
ract
ion
s
–vo
cab
ula
ryfo
rse
con
dar
y
emo
tio
ns
–att
enti
on
toto
mu
ltip
le
feat
ure
sin
con
tex
tto
inte
rpre
tem
oti
on
s
–figu
rati
vela
ngu
age
–sar
casm
–rec
ogn
itio
no
fco
mp
lex
,
sub
tle
emo
tio
ns;
nu
ance
so
f
emo
tio
ns
–rea
dco
nve
rsat
ion
alcu
esfo
r
turn
taki
ng
and
resp
on
seto
con
vers
atio
n
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Developmental Perspective for Promoting Theory of Mind 371
a toy. To be engaged with others and main-tain interactions with others, all persons mustrespond to joint attention and initiate jointattention. They must notice what others arelooking at as well as draw the attention ofothers to their own interests. A number ofstudies have sought to train responding tojoint attention and initiating joint attention.Most of these studies employed a behavioralapproach, focusing on teaching attending toa stimulus for tangible reinforcers (Meindl &Cannella-Malone, 2011). Few considered therole of social attention. That is, such studieshave taken the form of responding to jointattention (eye-gaze shifting) but not the func-tion of responding to joint attention (to coor-dinate attention); or the function of initiatingjoint attention to access an object, but notto reference and engage with a person. Toensure that the participant’s behaviors are in-stances of responding to joint attention andinitiating joint attention and actually functionto obtain social attention, it is important thatthe behavior ultimately and demonstrably bemaintained by social attention. Socially ori-ented responding to joint attention and ini-tiating joint attention are frequently invokedthrough physical interactions such as tickling(Charman et al., 1997).
Responding to joint attention and initiatingjoint attention are separate skills requiringseparate interventions. This is not surprisingwhen considering the evidence from neu-roimaging studies that responding to jointattention is associated with posterior corticalsystems—the superior temporal cortexand the parietal, temporal, and occipitalassociation cortices, whereas initiating jointattention is associated with the prefrontalassociation cortex and the orbital frontal cor-tex (Mundy & Newell, 2007). Initiating jointattention is more complex than respondingto joint attention. Studies have not shownan increase in initiating joint attention as aresult of an increase in responding to jointattention, but learning to imitate does tendto result in an increase in responding to jointattention (Ingersoll & Schreibman, 2006).Imitation activities may activate the mirror
neuron system that has been associated withempathic responding (Keysers, 2011).
Engagement with others requires that chil-dren participate in more than single isolatedinstances of responding to joint attention andinitiating joint attention. Playful interactionsand communication require ongoing coordi-nation or coregulation of responding to jointattention and initiating joint attention. All par-ticipants in an interaction must be watchingone another, know when they are to take theirturn, and provide a signal to others to taketheir turns. Gutstein (2009) recommendedthat, for many persons with ToM deficits, in-teracting partners should amplify their emo-tions because individuals with ToM deficitsfail to notice subtle emotional cues.
To encourage engagement and gain sharedattention with a child, an adult should chooseactivities and objects that the child enjoys andoffer them for play. If the child is focused onthe objects, but not the adult, the adult in-trudes in the play, holding back some mate-rials, using parallel play and proximity to thechild to allow the child to get used to hav-ing the adult in his or her space. During theseinteractions, adults also should seek to havechildren imitate actions, drawing attention toimitation by imitating the children’s behaviorsas well as seeking to have the children imitatethe adults’ behaviors. In our work on primaryand intersubjectivity with older students, wemake videos of interactions between adultsand other students in which the participantsamplify their emotional behaviors (facial ex-pressions, vocal prosody and intensity, andbody gestures). Students analyze and interpretthe interactions. As students begin to iden-tify the obvious cues, we make new videosin which the emotional cues are increasinglymore subtle.
Several well-known interventions for ASDs,with varying degrees of empirical evidence,focus on activities that promote social engage-ment through responding to joint attention,initiating joint attention, and coordina-tion/coregulation of responding to joint at-tention and initiating joint attention, for exam-ple, Relationship Development Intervention
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372 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
(Gutstein, 2009); DIRFloortime (Developmen-tal Individual-Difference Relationship-basedModel; Greenspan & Wieder, 2009); theJASPER intervention (Joint Attention, Sym-bolic Play, Emotional Regulation; Goodes,Ishijia, Chang, & Kosari, 2013; Lawton &Kasari, 2012): the SCERTS model (SocialCommunication, Emotional Regulation, andTransactional Support; Prizant, Wetherby,Rubin, Laurent, & Rydell, 2006), and theMore Than Words program (Sussman,2012). (See research evidence on inter-ventions in Supplemental Digital ContentA http://links.lww.com/TLD/A37.) Gerber(2007) produced a DVD, Visual Realty, thatdemonstrates assessment and interventionto increase engagement. It can be viewedat http://www.youtube.com/playlist?list=PL25410923E953E679.
Stage 2: Pre–theory of mind, sense of self
Development and assessment
In neurotypical children, this stage devel-ops between 18 months and 4 years, begin-ning with the emergence of a sense of selfand pretend play. Awareness of a sense of selfhas often been assessed by placing a spot ofrouge on children’s faces and observing theirresponse when they see themselves in a mir-ror (Lewis, 2014). Children with a sense ofself show embarrassment, touching the spoton their faces, and even avoiding looking inthe mirror again.
With a sense of self, children realize thatthey are separate from others, and they be-gin to notice that they might have differentlikes and desires from others, a foundationfor ToM. They also begin to exhibit consciousaffective empathy or altruism manifested byintentionally attempting to help or comfortanother (Thompson & Newton, 2013). At thisstage, children also begin pretending. For ex-ample, they can pretend to eat a plastic cookiewithout really attempting to eat it. A sense ofself and pretending both involve developmentof cognitive intrapersonal ToM because theyboth entail the ability to reflect consciouslyon the representations children have of theirappearance and behavior (Perner, 1993).
Between 2 and 5 years, neurotypical chil-dren learn to identify nonsocial emotions,essential for interpersonal and intrapersonalaffective ToM. By 5 years of age, childrenare usually accurate in recognizing universalnonsocial emotions (happy, sad, mad/angry,surprised, disgusted, afraid) and associatingthese emotions with particular events and ex-periences such as, The boy is angry becausehis bike was stolen; The girl is sad becauseher cat is sick (Michalson & Lewis, 1985;Pons et al., 2004). Children in environmentsin which adults reflect on experiences alsodevelop a variety of mental state words (e.g.,think, know, guess, remember), and someevidence suggests that children who are ex-posed to more mental state words developToM earlier (see Stanzione & Schick, 2014, inthis issue). When adults not only discuss withchildren what they have done or experienced,but also evaluate those experiences, childrenbegin to develop the foundations for autobi-ographical memory for experiences (Fivush,2011). Autobiographical memory involves re-membering or experiencing oneself in thepast. This is in contrast to semantic mem-ory, which involves knowing some facts aboutan event. For example, young children mighthave semantic memory (also called scriptalknowledge) for things associated with a birth-day party, such as getting gifts, eating cakeand ice cream, playing games, but they mightnot yet have an autobiographical memory fortheir own last birthday. That is, they may notremember their personal experience at theirown birthday party, such as not liking thecake, spilling juice on the carpet, or how theyfelt when they won a game. Autobiograph-ical memory furthers people’s sense of self,and hence, their intrapersonal ToM (Prebble,Addis, & Tippett, 2013).
Intervention
Pretend play is viewed as a precursor toToM (Doherty, 2009) and targeting pretendplay in intervention provides a way to developmany of the cognitive, social–emotional, andlinguistic foundations necessary for ToM. Onestudy showed that preschool children whowere trained to pretend to take on mommy,
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A Developmental Perspective for Promoting Theory of Mind 373
daddy, and child roles in topics about home,shopping, and school exhibited improvedemotional recognition and improved perfor-mance on appearance reality tasks (recog-nizing that an object that looks like a rockis really a sponge), both of which are pre-cursors to first-order ToM (Allen & Kinsey,2013). Another study showed that elemen-tary and high school students who partici-pated in a class in creative dramatics, com-pared with those who participated in art andmusic, exhibited greater affective empathyand the high school students also exhibitedincreased performance on higher order ToMtasks (Goldstein & Winner, 2012). This studyinvolved using creative dramatics to teach stu-dents explicitly to think about the mental andemotional states of the characters they wereplaying and to feel as the characters wouldfeel, thus developing both cognitive and af-fective ToM.
In our clinical work, we assess children’sdevelopmental pretend play levels, using theWestby Playscale (Westby, 2000). Between18 months and 4 years, children’s pretensemoves from pretend on oneself about familiareveryday themes with concrete props, to pre-tend on dolls or stuffed animals (first actingon and talking to the dolls and then talkingfor the dolls), to taking on familiar, observedroles (store cashier, doctor, firefighter), andfinally to less familiar themes and roles withmore abstract themes or no props. We de-velop play and language goals on the basisof the children’s baseline developmental pre-tend play and language levels, and attemptto extend those levels through play. Initially,when themes are introduced, we act as di-rectors or coplayers, scaffolding the play,modeling dialogue, and expanding children’sutterances. In this way, language skills are de-veloped along with symbolic play skills. Playthemes provide opportunities to display emo-tions, interpret emotions, and respond to theemotions of others. For example, one childcan pretend to be sad and worried becauseher dog is sick. The child can be scaffoldedto take her dog to the vet, who can respondby being concerned but comforting. The vet
then treats the dog, the dog recovers, and theowner is relieved and grateful.
Children with ASDs often have rigid playscripts (e.g., playing pirate repeatedly in thesame way). Introducing new and varied playscripts based on scripted plays or on story-books with an emphasis on the emotionalstates of characters can target developmentof interpersonal cognitive and affective ToM.Reading a story with props and exposing thechild to the story several times can lay thefoundation for beginning to move the child topretending within the story in a more creativeway, using props such as an eye patch, parrotpuppet, and pirate hat. The Play Prompt Hi-erarchy (Kasari, Fannin, & Goods, 2012) pro-vides a system for evaluating how much sup-port children require to play from requiringa general verbal prompt, for example, “Whattoy should we pick?” to requiring a full physi-cal prompt in which the adult assists the childin obtaining and playing with the toy.
Language is also promoted through con-versations about personal experiences. Thesetypes of conversational interactions areparticularly helpful in promoting children’sdevelopment of mental state and emotionalvocabulary that are essential for supportingToM (Howard, Mayeux, & Naigles, 2008).Staff at the New Mexico Preschool for theDeaf engage children in interesting activitieswith the intent to later have conversationsabout the experiences. For example, childrentook a field trip to a pumpkin patch to getpumpkins and have a hayride. At school theymade jack-o-lanterns from the pumpkins. Theactivities were photographed and videoed.Clinicians, teachers, or parents then used thephotos or videos to reminisce about the ex-perience. They not only discussed what theydid, but also evaluated the experience, re-membering not only their behaviors, but alsotheir thoughts, feelings, and interpretations.In reminiscing about the experiences in thismanner, adults are promoting not only chil-dren’s understanding and use of mental stateand emotions words but also children’s senseof self or intrapersonal ToM. Furthermore,these guided conversations highlight for
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374 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
children that different people can havedifferent subjective perspectives on the sameobjective event, thus promoting develop-ment of interpersonal ToM. For example, thechildren were excited to find a dead mousein a smashed pumpkin, but the teacher feltdisgusted. Children produced storyboardsfor the experiences. Photos of the activitieswere glued to a large poster board. Thechildren dictated captions that were writtenunder each photo; and when their parentsvisited, the children related the experiencesusing the storyboards to guide them. In thisway, the storyboards supported the childrenreminiscing. According to Laible (2004a,2004b), young children who have moreopportunities to reminisce about emotionalexperiences show higher levels of emotionalunderstanding and regulation (interpersonaland intrapersonal affective ToM).
Stage 3: First-order ToM
Development and assessment
First-order ToM involves reflecting on whatsomeone is thinking or feeling. Classic first-order ToM tasks assess cognitive or affectivefalse belief through false belief contents (e.g.,candy in a toothpaste box) or false belief lo-cation (e.g., Sally-Ann task) activities. Neu-rotypical children usually pass first-order ToMtasks between 4 and 5 years of age. PassingToM tasks is highly dependent on languageskills, particularly mental state and emotionwords, and comprehension of sentential com-plements with communication verbs (e.g.,Cookie Monster asked, “Can I have anothercookie?”) and mental state verbs (e.g., Ginnydidn’t think she would win the spelling bee)(Hale & Tager-Flusberg, 2003).
With the development of first-order ToM,children’s understanding of emotions ex-pands beyond nonsocial emotions to socialemotions. Social emotions require the repre-sentation of the mental states of other people.Examples are embarrassment, guilt, shame,and pride. In contrast, basic emotions suchas happiness, sadness, or anger require onlythe awareness of one’s own emotional state.
Children as young as 2 to 3 years can expressemotions resembling guilt and remorse. Five-year-old children are able to imagine situationsin which nonsocial emotions would be felt;however, the ability to describe situations inwhich social emotions might be experienceddoes not appear until 7 years of age (Harris,Olthof, Terwogt, & Hardman, 1987).
The cognitive and language foundations forautobiographic memory are being laid downin Stage 2. In Stage 3, between ages 4 and 5years, children begin to exhibit mental timetravel. This means that they can exhibit auto-biographical memory for experiences, or theability to think about themselves in the past,as well as future mental time travel, or theability to think about themselves in the fu-ture (Atance & O’Neill, 2005). Mental timetravel involves a sense of self and, therefore,it both requires and promotes development ofintrapersonal ToM. Future mental time travelfrequently involves counterfactual reasoning,which is the ability to think about alterna-tives to reality. Counterfactuals often take theform of “if-then” conditional propositions inwhich the “if” specifies a personal action andthe “then” specifies a goal, for example, “IfMatt had run, he would have caught the bus.”Engaging in role play promotes children’scounterfactual reasoning because they mustconsider what is reasonable/unreasonable orpossible/not possible in a particular role. Forexample, If I’m a vet, then I can give the doga shot and bandage its leg. If I’m the dog’sowner, not the vet, then I can’t do surgeryon the dog’s broken leg.
Intervention
To develop affective ToM, children willneed to continue to develop the ability to rec-ognize emotions and the situations in whichthey occur. A number of DVDs, computerprograms, and apps have been developed toteach emotions, some of which have evidenceto support their use. The Transporters isa DVD program (www.thetransporters.com)that was developed to improve emotionalrecognition and understanding in childrenwith ASDs aged 3–8 years. It has 15 stories
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A Developmental Perspective for Promoting Theory of Mind 375
based around eight characters who are trans-portation vehicles. All vehicles have humanfaces showing emotions and are depicted astoys in a child’s bedroom. The Transportersseries was designed so that each emotion andmental state are not only labeled by the narra-tor but also explained in terms of its context.In one study, children who used The Trans-porters improved in recognition of the emo-tions and generalizing this emotional recog-nition to naturalistic clips of human charac-ters not attached to vehicles (Golan et al.,2010).
Mind Reading is an interactive com-puter program developed for children andadults with ASDs to help them learn torecognize both simple and complex emo-tions and mental states from facial and vo-cal expressions (Baron-Cohen, Golan, Wheel-wright, & Hill, 2004; http://www.jkp.com/mindreading). This program covers 412 dis-tinct emotions and mental states, organizeddevelopmentally. Results from a treatmenttrial of Mind Reading (Golan & Baron-Cohen,2006) found that adults with ASDs who usedthe program improved significantly more intheir ability to recognize a range of complexemotions and mental states (e.g., ashamed,jealous, panicked, arrogant) compared witha matched control group with ASDs who didnot use the program. Training with the soft-ware led to improvement on close generaliza-tion tasks using stimuli from the software, al-though there were problems with distant gen-eralization tasks, which involved stimuli notincluded in the software. Let’s Face It! is a freeseries of games (which can be downloadedfrom http://web.uvic.ca/∼letsface/letsfaceit)that are designed to improve line of regardand face recognition abilities (Tanaka et al.,2010). Children with ASDs in the treatmentgroup playing the Let’s Face It! games exhib-ited significant improvements in face recog-nition (recognizing mouths in isolation andprocessing eyes holistically) compared with acontrol group with ASDs.
Picturebook stories also can be used todevelop interpersonal cognitive and affec-tive ToM (Adrian, Clemente, & Villanueva,
2007; Nikolajeva, 2013; Slaughter, Peterson, &Mackintosh, 2007). Books by Jan Thomas areparticularly useful for teaching mental stateand emotions words and developing ToM.The books are geared toward preschool chil-dren, but they can be used with childrenthrough mid-elementary school. Each booktypically has a single episode story told pri-marily through the voices of its animal charac-ters. The amount of text is minimal. The char-acters’ expressions are superb. In her draw-ings, Thomas conveys various emotions—not only happy, sad, frightened, and angry,but additional emotions such as surprised,frustrated, concerned, puzzled, worried, en-thusiastic, disappointed, confused, and re-lieved. The emotions are conveyed throughthe characters eyes/eyebrows, mouths, andbody stances. The plots of the stories trig-ger the characters’ emotions and the emotionscarry forward the stories.
The Doghouse (Thomas, 2008) encourageschildren to predict what the animals are think-ing that would cause them to be afraid. Mouse,Pig, Cow, and Duck are playing a game of ballwhen Pig accidently kicks the ball into thedoghouse. They all look worried as they ask,“Who will get it out?” Mouse volunteers eachanimal in turn to go into the doghouse. He jus-tifies his decisions, for example, Mouse says,“Cow will. Cow is big, brave, and strong.”Cow goes in but does not come out. Pigtries next, as Mouse deems him smart, wise,and stinky. Pig takes offense at the “stinky”designation but proceeds into the doghouse.Pig does not return either. As the story pro-gresses, the animals look more frightened.This facilitates teaching a continuum of wordsfor fear—worried, scared/frightened, terri-fied, petrified. Duck, who is noisy, goes last—and disappears just like the others. Mouse isnow the only one left outside. He timidly callsout, “Can’t you come out, Duck?” Dog appearsin the doorway and says, “No! Because I amhaving duck for dinner.” Mouse assumes theworst—that the dog is eating the duck (hehas a false belief), but the last spread showsall the animals inside the dog’s house sittingdown to a meal. Mouse joins the party on the
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376 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
endpapers, just in time for dessert. Followingreading and discussing the story, the childrenenact it.
Because ToM skills are highly correlated notonly with mental state and emotional vocabu-lary, but also with syntax, it is important thatchildren’s syntactic skills be evaluated and de-veloped along with targeting ToM develop-ment. Wilson (2012) is producing a series ofCDs to teach the language structures underly-ing ToM, beginning with verbs of perception(hear, see, smell, taste, feel) and verbs of inten-tion/desire (want, need, like). Additional CDsto be developed will teach verbs of commu-nication (say, tell, ask) with sentential com-plements and verbs of cognition (e.g., know,don’t know, think, believe, guess, remem-ber, forget) with sentential complements. Re-search studies training children on sententialcomplements not only resulted in their acquir-ing the linguistic knowledge fostered by thetraining, but also significantly increased theirscores on a range of ToM tasks (Hale & Tager-Flusberg, 2003). Questions using communi-cation and mental state verbs can easily beasked about the Jan Thomas stories, for exam-ple, “What did mouse say to cow?” Answer:“Mouse said, ‘Cow will. Cow is big. Cowis strong. Cow is brave.’” “What did Mousethink when the dog said he was having duckfor dinner.” Answer: “Mouse thought that doghad eaten duck.”
We also teach sentence structures with ad-verbial dependent clauses to explain whenand why characters’ feelings in stories oc-cur. Table 4 shows some examples based onthe story, Yeh-Shen, a Chinese version of Cin-derella (Louie, 1996). The adult puts the char-acter names and the when situations in thechart and students then complete the chart byputting in the appropriate feelings and expla-nations. The adult then models how the con-cepts can be expressed, for example, “Whenthe fish talked to Yeh-Shen, she felt happyand contented because she now had a friend”or “The stepmother was resentful and jealouswhen she found out about the fish becauseshe didn’t want Yeh-Shen to have anythingthat would make her happy.”
To foster development of episodic memory(and intrapersonal ToM), clinicians can usejournal writing or journaling, using a videocamera. After making a video of a favorite ac-tivity such as a family vacation, allow childrento watch the video, commenting on how theyfelt at the time of the episode depicted onthe screen, what they did, and how much funthey had. Have the children talk about the ex-perience, first while watching the video, andthen when not watching the video. As partof autobiographical memory activities, men-tal time travel can be facilitated. After remi-niscing about an experience, children can talkabout what could have happened if at differ-ent points in the experience they had donesomething differently. They can make plansregarding how they might do the activity inthe future, particularly when an activity didnot work out as intended. Adults can modelthe use of counterfactuals—“if we . . . then”“if we do not . . . then” regarding what theycould or could not do the next time to makethe activity more fun or to accomplish a par-ticular goal.
Stage 4: Second-order ToM and higher
Development and assessment
For neurotypical children, this stage be-gins immediately after their development offirst-order ToM. Second-order ToM, which in-volves predicting what one person thinks orfeels another person is thinking or feeling,generally develops by the age of 7 years.Higher order ToM develops after the ageof 7 years. Cognitive and affective inter-personal ToM involve multiple embeddings(Sarah hoped that Joe would believe that sheknew what Mrs. Brown wanted) or compre-hension of lies, sarcasm, figurative language(where what is said is not what is meant)or faux pas (where what is said causes un-intended harm).
Although most research has focused on cog-nitive ToM tasks at first, second, and higherorder, assessment tasks at all these levels caninvolve either cognitive or affective ToM. Forexample, a lie can be cognitive (e.g., taking
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A Developmental Perspective for Promoting Theory of Mind 377
Table 4. Syntactic Frame for Expressing Emotions Based on Stories
Person/Character When Feeling Why
Yeh-Shen the fish talked to her happy, contented, joyful she had a friendStepmother stepmother found out
about the fishjealous, resentful she didn’t want Yeh-
Shen to have anythingthat would make herhappy
Yeh-Shen stepmother ate the fish sad, forlorn, distraught she had lost her onlyfriend.
Note. These examples are related to the story, Yeh-Shen, a Chinese version of Cinderella (Louie, 1996).
your friend’s iPad and saying you have notseen it when she asks if you know where itis) or affective (e.g., telling your aunt you loveher rhubarb pie even though you think it isdisgusting), or sarcasm can be cognitive (e.g.,saying, “What a tidy office,” when walkinginto an office with books scattered all overthe floor and chairs and the desk piled withpapers in disarray) or affective (e.g., saying,“What a good father you are,” when the fatherhas forgotten to pick up his son after school).
Many of the higher order intrapersonal cog-nitive and affective ToM skills are associatedwith metacognitive and self-regulation skills.Metacognition refers to learners’ awareness oftheir own knowledge, emotions, and strate-gies for learning and managing emotions. Self-regulation refers to the use of processes thatmotivate and sustain thoughts, behaviors, andaffects to attain goals (Zimmerman & Moylan,2009). Learners with good metacognitive andself-regulatory skills are able to monitor anddirect their own learning processes and socialinteractions.
Intervention
Explicit teaching of figurative language, in-cluding metaphors, idioms, and sarcasm, is apart of the Common Core language arts cur-riculum from mid-elementary through highschool. In addition to addressing these spe-cific language needs at stage 4, we give con-siderable attention to developing metacogni-tive (intrapersonal cognitive ToM) skills and
emotional regulation (intrapersonal affectiveToM). Improved intrapersonal ToM can con-tribute to improvements in interpersonal ToMwhen persons evaluate what they know, donot know, and need to know in particularsituations. This reflection can cause personsto consider more closely and evaluate the ac-tions of others.
Think-alouds can be used to teach the ToMskills that students need to monitor their com-prehension as they view pictures or read. Us-ing such an approach, the speech–languagepathologist or teacher models a think-aloudby verbalizing what he or she is doing to at-tempt to make sense of what he or she is see-ing or reading. Think-alouds require both in-trapersonal and interpersonal ToM. Studentsmust first be able to recognize whether ornot they are comprehending; if they are not,they must reflect on the strategies they coulduse (intrapersonal ToM) to understand whythe characters in a story are doing what theyare doing, and as they interpret the behav-ior of characters in the stories, they mustuse their interpersonal cognitive and affectiveToM. Traditionally, students are asked to usethink-alouds as they read a text. They reada portion of the text and then stop to de-scribe how they are making sense of whatthey are reading—what they understand ordo not understand; how they are trying tomake sense of what might be confusing; theinferences they are making about the char-acters and what evidence they use to make
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378 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
these inferences. This provides the oppor-tunity for clinicians to scaffold higher levelthinking and affective sensitivity. For studentswith language-learning and reading impair-ments, doing think-alouds while reading canbe particularly challenging because of theload placed on working memory, particularlyif students have to struggle with decodingwhile they simultaneously are expected to re-flect on their processing of the text. For thisreason, we initially teach think-alouds withpictures. We have found the books The In-vention of Hugo Cabret (Selznick, 2007) orWonderstruck (Selznick, 2011) particularlyuseful for students from upper elementaryschool through high school. These books are530 and 630 pages, respectively, but morethan half of the pages are pictures. The pic-tures do not represent the printed text, butrather are their own “texts.” (See the com-ponents of a think-aloud and a sample think-aloud from the Invention of Hugo Cabret inthe Supplemental Digital Content B for this ar-ticle, available at: http://links.lww.com/TLD/A36).
The think-aloud strategy can be inte-grated with the questioning-the-author strat-egy (Beck & McKeown, 2006). When usingquestioning-the-author strategy, clinicians orteachers first remind students that texts havebeen written or drawn by someone. They thensay that to understand the texts, it can behelpful to try to figure out the author’s in-tent (which requires interpersonal cognitiveToM). Clinicians and teachers then can guidestudents to begin to see the difference be-tween what the author actually says and in-ferring what the author probably means. InThe Invention of Hugo Cabret, when Isabelasks Hugo, “Why are you so interested in mykey?” the clinician can point out that studentswatched a video of Brian Selznick, the book’sauthor, demonstrating how a real automatonneeded to be wound by a key to work and thathe had made the key a central part of his story.The students then can be encouraged to makesuggestions about where the key came from.Finally, the clinician/teacher validates the stu-dents’ suggestions and asks for evidence that
the author may have provided to support thestudents’ ideas.
Students also can learn to employ metacog-nitive skills to reflect on and analyze theiremotional responses to situations. This re-quires that they use both intrapersonal cog-nitive and intrapersonal affective skills. Thegoal of the STAMP program (Stress andAnger Management Program; Scarpa, Wells, &Attwell, 2012) is to teach children to rec-ognize and regulate their own emotions (in-trapersonal affective ToM). Children first aretaught about the range of emotions (e.g., vary-ing intensities of happy or angry), the vocab-ulary for the emotions, and how to recog-nize their body cues that signal when theyare happy, stressed, or angry. Then they aretaught how to use an emotional toolbox,which consists of strategies they can use tohelp them deal with their anger and anxiety,and cognitive restructuring, which includeschanging the way they think about somethingso they have more positive feelings and ac-tions. STAMP emphasizes the use of self-talk,which is a metacognition/intrapersonal ToMtarget. Self-talk has an effect on internal statesand internal states have an effect on how oneinteracts with others (thus affecting interper-sonal ToM) (Gross, 2008).
Superflex is a curriculum designed to teachelementary school students how to regulatetheir behaviors and become stronger socialproblem solvers by employing intrapersonalcognitive ToM (although the authors do notspecifically refer to ToM) (Madrigal & Win-ner, 2008). Children learn to associate pat-terns of thought with Superflex, a hero whohas flexible thinking and a Team of Unthink-ables, a set of characters who have inflexi-ble thinking. For example, the Unthinkablecharacter, Rock Brain, does not want to listento others’ ideas and keeps trying the samesocial strategy over and over again. Super-flex tries to avoid Rock Brain by listeningto others’ ideas and trying a different socialstrategy. Superflex and his pals visually andexplicitly model to students what might behappening to them when they are not hav-ing social success, as well as strategies that
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A Developmental Perspective for Promoting Theory of Mind 379
can help them achieve a more positive socialresult.
Southam-Gerow (2013) offers a variety ofstrategies to develop intrapersonal and inter-personal ToM for upper elementary schoolchildren and adolescents. The techniqueswere developed for children with poor emo-tional awareness, limited emotional under-standing, poorly developed empathy skills, orchildren who have poor emotion regulation.Clinicians present vignettes, talk about howthe person might feel, and then add informa-tion and ask how this new information willchange the way the child thinks that personmight feel. Consider the following examplefrom Southam-Gerow:
First, the clinician sets the scene by saying,“Darius’s neighbor just got a new dog that reallylikes kids.” The clinician then asks how the childthinks Darius might react to the dog. Following thisdiscussion, the clinician adds some new informa-tion to the vignette, saying, “Darius’s neighbor justgot a new dog that really likes kids, but Darius wasonce bitten by a dog.” The child is next asked howhe now thinks Darius will react to the dog now;how might Darius’s feelings change given that hehas had a traumatic experience with the dog?
By varying the parameters of the situation,the goal is to teach children to develop flex-ibility in their thinking so they can begin tounderstand why a social strategy that mightwork in one situation may not work in an-other. Students are taught to consider multi-ple factors when inferring the thoughts andfeelings of others as well as when recogniz-ing their own thoughts and feelings. Thesestrategies fit well with the concept that per-sons with ASDs may be considered to be“context blind” (Vermeulen, 2012). That is,even when individuals with ASDs are able torecognize emotional facial expressions, theymay not recognize how other contextual fac-tors in the specific situation might influencepeople’s thoughts and feelings. Contextualfactors could include the setting for the sit-uation (familiar/unfamiliar; formal/informal),the age and gender of the persons, the inten-tions of persons in the situation, or persons’experiences.
By the time neurotypical children compre-hend second-order and higher ToM, they areengaging in complex peer social interactions.These interactions prove to be quite diffi-cult for students with ToM deficits becausethey require integration of all ToM dimen-sions. Brinton, Robinson, and Fujiki (2004)used the Conversation Game to teach theskills needed for conversation. The game com-bines video analysis, role-play, and practiceconversations to promote conversational skilldevelopment, perspective taking, awarenessof, and responding to the needs of the con-versational partner. Movie clips not only helpstudents recognize conversational cues in realtime with real people but also allow cliniciansto pause the clip, rewind, and watch againfocusing on one character’s perspective andthen another’s. Creating clips of social situ-ations loosely based on the life of the stu-dent can be helpful in targeting specific so-cial situations without subjecting the studentto psychological stress. A clip of a mother anddaughter arguing over why the daughter can-not take the car contrasted with a second clipof the same mother and daughter resolvingtheir conflict over the car can be used to ex-plicitly teach the student what the mom anddaughter are thinking and feeling.
CONCLUSIONS
Theory of Mind deficits lie at the heart ofautism and are major contributors to prag-matic language difficulties exhibited by chil-dren and adults with a wide variety of con-ditions. ToM is not a unitary construct. Inthe last 15 years, neuroimaging studies haveprovided evidence of distinctive dimensionsof ToM. Cognitive ToM, affective cognitiveToM, and affective empathy have differingneuroanatomical foundations. Furthermore,thinking about the thoughts or emotions ofothers (interpersonal ToM) and reflecting onone’s own thoughts and emotions (intrap-ersonal ToM) involve differing neurophysi-ology and appear to involve different skillsets. Clinicians working with persons withpragmatic communication disorders should
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380 TOPICS IN LANGUAGE DISORDERS/OCTOBER–DECEMBER 2014
consider evaluating these types of ToM intheir clients so they can develop a ToM pro-file for each client with needs in this area.In that manner, they will be prepared bet-ter to implement specific intervention strate-gies to promote development, some of whichhave been reviewed in this article. Interven-tions should then be directed to developingthe cognitive, social–emotional, and languagefoundations for ToM.
Our goal for this article is to enable serviceproviders to locate and use a variety of clini-cal tools to promote ToM across the life span.The research literature indicates that childrenwith disabilities most likely follow a devel-opmental trajectory similar to that of neu-rotypical children, but at a slower rate (Conti-Ramsden et al., 2012). Hence we, typicallyselect goals based on students’ present devel-opmental levels in each ToM dimension. How-ever, there are other issues to consider whenselecting goals. For example, just because askill develops at a particular time in typical
development does not necessarily mean thatthat skill is a precursor to a later developingskill. Therefore, when establishing interven-tion goals, service providers should ask twoquestions: (1) What is the child ready to learn?and (2) What would help communication themost? (Brinton & Fujiki, 2010). The first ques-tion addresses the developmental issue andthe second addresses the functional aspect ofall communication. Each ToM dimension hasits own developmental trajectory (Lucarielloet al., 2007; Sebastian et al., 2012). The in-tent of the interventions is not to teach per-sons to pass a hierarchy of ToM tasks, butrather to learn to interpret social experiencesand discourse in the world. Consequently,when establishing intervention goals for per-sons with ToM deficits, service providersneed to consider both the persons’ devel-opmental strengths and needs in each ToMdimension and the contextual social expec-tations or demands in home, school, andcommunity.
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