Theory of Mind Abilities and Deficits in Autism Spectrum Disorders

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Top Lang Disorders Vol. 34, No. 4, pp. 329–343 Copyright c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Theory of Mind Abilities and Deﬁcits in Autism Spectrum Disorders

Yael Kimhi

Autism spectrum disorder (ASD) is a neurobiological disorder that significantly impairs children’s social interaction, verbal and nonverbal communication, and behaviors. Questions about theory of mind (ToM) deficits in ASD have generated a large number of empirical studies. This article reviews current studies of the relationship between ToM and ASD, including contributions to the understanding of social and academic manifestations of ASD. Several themes emerge: Enhanced language and verbal abilities facilitate better ToM understanding; implicit ToM elements that incorporate parallel processing pose more difficulties than explicit ones; and general and multimodal interventions are more effective than specific interventions. A brief overview is followed by a review of emerging research on the role of domain-general cognitive skills (executive function) and central coherence in the development of ToM. Next, a summary of studies addressing ToM across the development and social and academic manifestations is presented. The article ends with a critical review of ToM intervention studies, which suggests that generalization may be more likely to occur when ToM is targeted as part of broader sociocognitive interventions rather than as an isolated skill. Key words: ASD, executive function, intervention, social cognition, theory of mind

UTISM SPECTRUM DISORDER (ASD) is plained by the presence of coexisting cogni- A a neurodevelopmental condition defined tive difficulties in the areas of executive func- by impairments in social communication skills tion, weak central coherence, and theory of and behavior or interests relative to the child’s mind (ToM; Pellicano, 2013). Executive func- age and mental age (American Psychiatric As- tion is an umbrella term for cognitive pro- sociation [APA], 2013). It often presents with cesses that include working memory, inhi- comorbid intellectual disability and is associ- bition, planning, and shifting. Weak central ated with deficits across several domains such coherence is a term that refers to a spe- as language (Howlin, 2003), social cognition cific cognitive style that encompasses a lim- (Baron-Cohen, Leslie, & Frith, 1985), execu- ited ability to understand wider contexts. Ac- tive function (Hill, 2004), and weak central cording to social-cognition theory, many of coherence (Frith, 1989). The heterogeneity the social-interpersonal and academic difficul- found among children with ASD may be ex- ties seen in ASD derive to some extent from weaknesses in these children’s ToM. Briefly, ToM refers to children’s ability to represent and understand others’ mental states, such as goals, emotions, and beliefs (Bauminger- Author Affiliations: School of Education, Bar-Ilan University, Ramat-Gan, Israel; and Levinsky College Zviely, 2013b). of Education, Tel Aviv-Yafo, Israel. To date, the majority of ToM-related stud- Dr Kimhi has indicated that she has no financial and ies have shown that individuals with ASD no nonfinancial relationships to disclose. display deficits in ToM. That is, individuals Corresponding Author: Yael Kimhi, PhD, School with ASD, for the most part, perform signif- of Education, Bar-Ilan University, Ramat-Gan 52900, icantly lower on tasks designed to measure Israel ([email protected]). ToM than individuals with typical develop- DOI: 10.1097/TLD.0000000000000033 ment (Mathersul, McDonald, & Rushby, 2013; 329

Peterson, Wellman, & Slaughter, 2012). These ple items concurrently)—an ability that tends deficits appear on various ToM tasks, includ- to be deficient in many people with ASD/ ing tasks examining false beliefs (e.g., Baron- HF-ASD. Cohen et al., 1985), faux pas (Baron-Cohen, O’Riordan, Stone, Jones, & Plaisted, 1999), ABILITIES UNDERLYING ToM SKILLS cartoon animations (Castelli, Frith, Happe,´ & Frith, 2002), or inference of mental states Various mechanisms underlie ToM abili- from photographs (Baron-Cohen, Jolliife, ties. The following section discusses the rela- Mortimore, & Robertson, 1997). Other re- tions between language, executive function- search has shown that the ability to succeed ing, central coherence, and ToM. in such ToM tasks varies with age, IQ, and the nature of the task (Begeer, Malle, Nieuwland, Language & Keysar, 2010). Individuals with ASD/HF-ASD who have This article aims to provide a summary of better language skills are more likely to pass current research concerning ToM abilities and false-belief tests. Many studies have found deficits in ASD, with reference to two groups. causal relations between language and ToM, The first is cognitively able high-functioning both in typical development (e.g., Astington individuals with ASD (HF-ASD), defined op- & Jenkins, 1999) and in ASD/HF-ASD (Steele, erationally as having IQ of 70 and above; the Joseph, & Tager-Flusberg, 2003). Verbally able second is less cognitively able individuals with individuals with HF-ASD often can pass false- ASD, defined operationally as having IQ be- belief tasks; yet, even then the majority fail low 70. When referring to both groups in when expected to act spontaneously accord- this article, I use ASD/HF-ASD. The review ing to that knowledge (Senju, 2012). Need- includes a discussion of ToM development less to say, the majority of tasks used to eval- across the life span and focuses on the social uate ToM abilities rely on language abilities and academic manifestations of ToM that lie and comprehension. Better language abilities at the heart of everyday life skills. Finally, var- among some children with ASD (and espe- ious ToM interventions are presented, high- cially HF-ASD) give those children an advan- lighting best practices supported by current tage in their ability to pass the tasks, often research. by “hacking out” the solutions (Hughes & This review focuses on two levels of ToM Leekam, 2004). Moreover, research findings abilities and tasks—the first explicit and for- have shown that syntax competence facili- mal, the second implicit. In explicit tasks, tates, at least to some extent, false-belief task clear directions are given, as opposed to im- performance in ASD/HF-ASD (Lind & Bowler, plicit tasks, in which spontaneous ToM be- 2009), leading to the assumption that chil- havior is measured. The implicit level is asso- dren who do well in ToM tasks may be using ciated with poor social interactions (Hughes compensatory linguistic strategies. According & Leekam, 2004). It is the implicit level that to Tager-Flusberg (2007), the understanding appears to be more problematic in ASD/ of the syntax and semantics of verbs (e.g., HF-ASD (Frith, 2012). Current research sup- “Sarah said that Dan was eating”) may enable ports the hypothesis that explicit and implicit the analogy of mental states to the content ToM systems may indeed be separate systems of speech. In addition, spontaneous conver- (Schneider, Slaughter, Bayliss, & Dux, 2013; sations between a mother and her child that Senju, Southgate, White, & Frith, 2009). It include frequently mentioned mental states may be that the explicit level relies on se- seem to increase ToM task success in chil- quential processing (the ability to take in, dren with ASD/HF-ASD (Slaughter, Peterson, store, and process information in an orderly & Mackintosh, 2007). It may be that the dis- way), whereas the implicit level requires par- cussion of a greater variety of situations and allel processing (the ability to process multi- conditions may be more beneficial in helping

inherently implicit situations become explicit is, given their lag in ToM development, can to children. Although linguistic ability may ad- they ultimately reach the higher, more com- vance success on ToM tasks, this does not nec- plex levels of ToM? Does it simply take them essarily translate into improved performance a longer time to complete the same trajec- in real life. The social aspects of pragmatic tory as individuals with typical development, conversational skills and ToM are discussed thereby eventually developing both basic and in the section on the social manifestation of complex ToM abilities, albeit more slowly? ToM. This section of the article highlights the ToM abilities and deficits of individuals with Executive functions and central ASD/HF-ASD compared with peers with typ- coherence ical development, following life span stages In the past few years, a growing body of re- from preschool through adulthood. Gener- search has focused on abilities other than lan- ally, it seems that these individuals are not de- guage that underlie ToM capabilities. These void of ToM abilities, especially at the explicit findings underscore the cognitive facets of level; instead, their abilities appear to diverge ToM abilities. Studies have shown causal re- from the normative trajectory and show great lations between executive function and ToM variability. Because some studies reviewed in in typical development (Carlson, Moses, & this section did not separate participants by Claxton, 2004; Hughes & Ensor, 2007) and age, the subsection boundaries are not always also in ASD/HF-ASD (Kimhi, Kugelmas, Agam as clear-cut as the subheadings imply. Ben Artzi, Ben Moshe, & Bauminger-Zviely, 2014; Pellicano, 2010). False-belief ToM tasks require shifting from one’s own perspective Preschoolers to another’s; therefore, it is unsurprising that Wellman and Liu (2004) proposed a sequen- children with ASD/HF-ASD, who have diffi- tial model of ToM developmental stages in culties in executive function and cognitive typically developing preschool-age children shifting (i.e., the mental ability to switch be- as follows: 1) diverse desires: the understand- tween two stimuli), also show difficulty in ing that two persons can have different de- predicting false beliefs. In a study conducted sires about the same object; 2) diverse beliefs: by Kimhi et al. (2014), cognitive shifting pre- the understanding that two persons can have dicted preschoolers’ capacity to shift between different beliefs about the same object; 3) per- their own belief and the presented false belief, ceptual access to knowledge: not seeing leads while both predicting and explaining it. Ac- to not knowing where an object is hidden; cording to Pellicano (2013), executive func- 4) false belief (of location): the standard mis- tion plays a critical role in the emergence of leading container task; and 5) hidden emo- ToM. In a study of preschoolers with ASD/HF- tion: the understanding that one can feel a dif- ASD that Pellicano (2010) conducted over a ferent emotion than the one displayed. These 3-year period, early executive function and progressive stages depict how simpler ToM central coherence skills predicted develop- concepts emerge and form the basis for the mental changes in ToM skills, independent of later and more sophisticated concepts. age, language, nonverbal intelligence, and ear- Two follow-up studies with clinical samples lier ToM skills. showed that children with ASD/HF-ASD developed the first three stages in a similar, albeit ToM ACROSS THE LIFE SPAN: FROM delayed, fashion to typically developing and EARLY CHILDHOOD TO ADULTHOOD deaf children but the last two stages were reversed in sequence. This was interpreted Important questions arise concerning de- as showing that false-belief understanding is velopmental aspects of ToM among individu- apparently more difficult than hidden emo- als with ASD/HF-ASD. One important question tion understanding for the ASD/HF-ASD group

(Peterson et al., 2012; Peterson, Wellman, & 2001) and internal mental states (e.g., the Liu, 2005). Strange Stories task by Happe,´ 1994). Despite The studies that examined explicit ToM the impairments illustrated in some studies, a abilities in preschoolers with ASD/HF-ASD recent study showed conflicting results. The found that their performance on false-belief study (Scheeren, de Rosnay, Koot, & Begeer, tasks was significantly lower than that of 2013) examined second-order false beliefs, control groups. This was the case, whether emotional display rule understanding, double in comparison with preschoolers with typical bluff, faux pas, and sarcasm within a large sam- development (Kimhi et al., 2014) or with ple (N = 194) of children (N = 59; CA = 10.2) preschoolers with specific language impair- and adolescents (N = 135; CA = 15.3) with ment (Colle, Baron-Cohen, & Hill, 2007). HF-ASD and revealed intact advanced ToM Nonetheless, preschoolers with HF-ASD abilities for both age groups, even after con- showed significant changes in ToM abilities trolling for age. Scheeren et al. (2003) found over the preschool years, marking a similar that the adolescents in both study groups trajectory to that of children with typical (typical development and HF-ASD) performed development. For example, Steele et al. consistently better than the younger children, (2003) found that 57 preschool- and school- irrespective of group status. According to the age children (aged 4–14 years) with ASD or authors, both verbal abilities and general rea- with HF-ASD (i.e., low- or high-functioning soning capacity appeared to facilitate better children) showed significant improvement advanced ToM understanding in HF-ASD. in their ToM abilities between two time intervals 1 year apart, developing mental Adolescents and adults state concepts between the two times. By adolescence, individuals with ASD, and particularly those with HF-ASD, often pass ex- Elementary school-age children plicit conceptual ToM tasks at various levels In comparison with elementary school-age of complexity; yet, their performance on such children with typical development or intel- tasks does not predict age-appropriate social lectual disabilities (chronological age [CA] = behavior in everyday settings (Begeer et al., 10.50; verbal IQ = 75), matched for age 2010). Studies that have examined the spon- and verbal ability, children with ASD/HF-ASD taneous use of ToM have found that adults (CA = 10.42; verbal IQ = 75.23) perform with HF-ASD do not spontaneously anticipate significantly lower on ToM tasks in general, another person’s actions, even when those even on the basic explicit tasks designed adults have passed explicit false-belief tasks to assess false beliefs concerning location with ease (Senju, 2012; Senju et al., 2009). (Lind & Bowler, 2010), parallel to Wellman As Baron-Cohen (2001) summarized, stud- and Liu’s (2004) fourth stage. According to ies that have examined ToM abilities in ado- Frith’s (2012) meta-analysis, the average age lescents and adults with HF-ASD have shown, for passing the Sally and Anne false-belief for the most part, that they can pass explicit test reveals an approximate 5-year delay for first-order ToM tasks, make simple ToM judg- children with ASD compared with children ments, and sometimes can even pass explicit who are neurotypical (i.e., children with ASD second-order false-belief tasks that involve em- pass the test at the age of 9 years rather bedded mental states, such as what X thinks than at the age of 4 years, on average). Fur- that Y thinks. In other words, some older thermore, elementary school children with individuals with HF-ASD apparently possess ASD demonstrate impairment on advanced, ToM skills that resemble those of typically de- second-order, explicit ToM tasks that exam- veloping adolescents and adults (Roeyers & ine the ability to recognize facial emotional Demurie, 2010). Nonetheless, various stud- expressions (e.g., the Eyes Test by Baron- ies have yielded mixed results concerning Cohen, Wheelwright, Hill, Raste, & Plumb, the higher order ToM abilities of adolescents

and adults with HF-ASD. One reason for the ine the perspective-taking abilities of adults discrepancies in the findings may be the na- with HF-ASD, in comparison with those with ture of the tasks themselves because some typical development, found no significant were explicit, static, unimodal tasks, whereas difference between the groups, indicating others were implicit, multimodal, dynamic, the capability for psychological perspective- ecological tasks. The artificial nature of many taking ability in individuals with HF-ASD of the static tasks does not permit them truly (Au-Yeung, Kaakinen, & Benson, 2014). to address a deficit with an implicit compo- Perspective taking is considered to be com- nent. Thus participants may demonstrate suc- plex because it requires maintaining knowl- cess in the static tasks but without that suc- edge about what other people would be inter- cess carrying over to the dynamic situations ested in and making use of relevant social cues of real life. Multimodal, dynamic, ecological to infer their mental states. On the contrary, tasks aim to draw a closer parallel to real-life it appears to be a different kind of complex- situations (Mathersul et al., 2013). ity, because it does not require spontaneous Schneider et al. (2013) examined explicit anticipation as was required in Schneider versus implicit ToM processing in adults with et al.’s (2013) study or when recognizing sar- HF-ASD compared with age-matched controls casm and lying as in Mathersul et al.’s (2013) with typical development. During the implicit study. task, the participants were expected to antic- Taken altogether, research thus far has ipate spontaneously the action of an actor, yielded mixed results as to the degree of which was examined via an eye tracking de- impairment in ToM capabilities, especially vice. No differences were found on the ex- within HF-ASD. In ASD, the impairment is ap- plicit ToM measures, as opposed to sustained parently more severe. These results suggest group differences for the implicit measures. that cognitively able individuals with HF-ASD Furthermore, spontaneous implicit learning have varying difficulties in ToM, which may did not occur in the ASD group. Using the become mitigated over time. That is, life expe- Awareness of Social Inference Test, which is rience may help some of the individuals with an authentic ecological assessment that ex- HF-ASD make up for the seemingly innate dis- amines audiovisual representations of social abilities. In line with these findings, the next interactions, Mathersul et al. (2013) found sections discuss the social and academic man- that adults with HF-ASD revealed an impaired ifestations of ToM. understanding of nonliteral expressions such as sarcasm and deception, which require ad- ToM SOCIAL MANIFESTATIONS vanced ToM to know that someone might say something opposite to what they intend In real-life social situations, one is ex- (sarcasm) or believe (lie). pected to grasp intuitively what is transpir- Contrary to these results, an earlier study ing and how to respond spontaneously to that used a dynamic perspective-taking task various events. While applying ToM capa- (Begeer et al., 2010) showed that adolescents bilities spontaneously, rapid “online” social and adults with HF-ASD were identical to information has to be processed, facilitat- those with typical development in their ability ing engagement in appropriate social activ- to take another person’s knowledge into ac- ities. Constantly changing social and emo- count when interpreting what she or he said tional cues demand immediate, parallel data during a structured social interaction. Accord- processing. Therefore, the absence of spon- ing to the authors, these results demonstrate taneous ToM results for the most part in so- that in real-life situations, especially when cial communication deficits, as often seen in they are structured, some individuals with individuals with ASD/HF-ASD (Loth, Gomez, HF-ASD can use ToM appropriately. A recent &Happe,´ 2008; Senju, 2012). Components study that also used a dynamic task to exam- of ToM are interrelated, creating notions that

are combined in explanations, predictions, relationship with their social and conversa- and justifications of behavior. Individuals with tional behaviors in spontaneous everyday ASD/HF-ASD demonstrate difficulties in most life. Following mixed findings concerning the areas necessary for appropriate social func- relations between false-belief tests and tioning (Bauminger-Zviely, 2013b) and often measures of adaptive social skills using the tend to show diminished attention to social Vineland Adaptive Behavior Scales (Sparrow, cues (Klin, Jones, Schultz, Volkmar, & Cohen, Balla, & Cicchetti, 1984), Peterson, Garnett, 2002). Even when their verbal and intellectual Kelly, and Attwood (2009) developed and val- levels are high, their social adaptive behavior idated a new caregiver report measure—the is found to be lagging (Klin et al., 2007). The Everyday Mindreading Skills and Difficulties next section presents a review of research that scale. This scale examines pragmatic social investigated the relations between ToM and and conversational difficulties that, in theory, various social skills. It is important to note that require a ToM-based understanding of false only some social skills have been examined in beliefs. The authors explored the connections relation to ToM in ASD/HF-ASD. between ToM tasks and everyday behavior in children with ASD/HF-ASD and found that Symbolic play and ToM children who passed the false-belief tasks At preschool ages, one social manifestation exhibited fewer everyday social and conver- of ToM is symbolic play. Symbolic play is rel- sational difficulties than those who failed. Fur- evant because it requires children to decou- thermore, correlations showed that children’s ple the primary representation of an object scores on standard false-belief tests were sig- from its pretend representation (e.g., a banana nificantly linked to their everyday ToM skills, cannot be a banana if one pretends it is a tele- showing that children who received higher phone) (Leslie, 1987). Children with ASD ex- scores on ToM tasks displayed better everyday hibit such marked impairments in symbolic ToM abilities. Nevertheless, it is important to and pretend play that these deficits were part note that the authors found that even those of the diagnostic criteria for autistic disor- children with ASD/HF-ASD who passed the der in the Diagnostic and Statistical Manual ToM tasks still had poorer everyday skills than of Mental Disorders, Fourth Edition (APA, children with typical development who did 1994). Lam and Yueng (2011) also found not pass the ToM tasks. These results led to the that the symbolic play of a small sample of conclusion that ToM success in the laboratory preschoolers with HF-ASD was limited com- is insufficient to guarantee competent social pared with typically developing preschoolers and conversational interaction for a child and that their difficulties in mentalizing oth- with ASD/HF-ASD (Peterson et al., 2009). ers’ perspectives were at the root of their dif- Deficits in pragmatics are evident through- ficulties in symbolic play. One explanation is out the autism spectrum (Hale & Tager- that the parallel processing necessary for sym- Flusberg, 2005). Furthermore, ToM deficits in- bolic play is lacking, at least at this age. tensify individuals’ difficulties in taking into account the listener’s perspective, thereby Pragmatic conversational skills and ToM interfering with the ability to engage mean- Another important aspect of social develop- ingfully in conversations. Children on the ment is the ability to communicate with one’s autism spectrum, therefore, demonstrate re- peers. Pragmatic functioning (i.e., the ways ciprocal social discourse of a lower qual- in which context contributes to meaning) ity than children with typical development. is crucial in facilitating appropriate commu- Hale and Tager-Flusberg (2005) conducted nication skills. The question is still being a longitudinal study that examined concur- investigated as to whether the levels of ToM rent and predictive relationships between understanding that individuals with ASD/HF- ToM and discourse skills in 57 children with ASD display on ToM tasks bear a significant HF-ASD (aged 4 years 0 month to 13 years

11 months). They found that the children to cover a misdeed, such as peeking at a hid- made significant gains over time in their den toy and denying their transgression; yet, ability to maintain a topic of discourse and they showed difficulty in effectively conceal- that ToM contributed unique variance in ing and maintaining the lie when asked follow- discourse skills beyond the significant con- up questions. It may be that lying to cover a tribution made by language skills. According misdeed has an explicit nature, whereas con- to the authors, their findings indicate a dy- cealing the deed in follow-up questions may namic interaction between social cognition— be more implicit, as children do not grasp that as manifested by ToM abilities—and so- these questions may, in fact, lead to discovery cial communication among children with of their transgression. It is important to stress HF-ASD. that the groups were not matched on chronological age and that the children with typical Deception and ToM development were younger than the children A further important sociocognitive mile- with HF-ASD. Therefore, the authors empha- stone is the ability to deceive and lie actively, sized that the ability to conceal false denials as distinct from the ability to recognize lies and misdeeds is observed in the preschool (as discussed in the earlier section on ado- years in typical development but may develop lescents and adults). What happens in ASD later for children with HF-ASD. Correlations regarding the ability to generate lies? When between ToM tasks and lying were not exam- one deceives or lies, one intentionally instills ined in this study, but children who told lies a false belief in the other’s mind and there- had higher first-order ToM task belief scores fore the ability to lie is considered an impor- than those who did not, suggesting that the tant manifestation of ToM (Li, Kelley, Evans, development of lying may be related to ToM & Lee, 2011). Studies that have examined de- ability (Talwar et al., 2012). ception in the context of competition found that children with HF-ASD indeed show diffi- Autobiographical memories and ToM culties in deceiving. Nonetheless, in a study Autobiographical memories, which include that examined school-age children’s ability to individual memories of single events, con- tell a lie of their own volition (Li et al., 2011), tribute to the psychological and social func- children with ASD/HF-ASD were able to tell tioning of the individual. Recent studies have both antisocial and white lies of their own indicated that, during the process of under- choice. They told an antisocial lie to conceal standing the other’s mental state to under- their misdeed (e.g., peeking at a gift) and stand social events, one relies on autobio- also told a white lie (e.g., saying they liked graphical memories (Adler, Nadler, & Eviatar, their prize, even though they did not). How- 2010). Studies have shown that individuals ever, when investigating the correlations be- with HF-ASD generate fewer autobiograph- tween false-belief tasks and deception, the re- ical memories than individuals with typical searchers found that both antisocial and white development and that ToM is related to au- lies told by children with HF-ASD seemed to tobiographical memory difficulties in HF-ASD reflect scripted knowledge based on past ex- (Adler et al., 2010; Crane, Goddard, & Pring, periences rather than fluid ToM abilities. Inter- 2011). A possible explanation is that both call estingly, although the children could gener- for parallel processing that includes the ca- ate lies, they had difficulty maintaining those pacity to be aware of, and mentally repre- lies. sent, experiences from one’s past into one’s Similar findings were found in a later study future concurrently. These findings under- (Talwar et al., 2012) that scrutinized the lie- score previous conclusions that individuals telling behavior of children with HF-ASD (av- with HF-ASD have difficulties understanding erage CA = 8.9) in comparison with children both others’ and their own minds (Rajendran with typical development. Most children lied & Mitchell, 2007).

Event schemas and ToM are based on emotional states, can be trying Loth et al. (2008) examined the relation when the individual reading the text has between ToM and event schema knowledge weak ToM abilities (Carnahan, Williamson, (generalized knowledge of what happens at & Christman, 2011). Yet, understanding common real-life events) in adolescents with and explaining why a character, imaginary HF-ASD. They found that adolescents who or historical, behaves in a certain manner failed ToM tasks showed profound impair- are critical components of literary compre- ments in describing common events in a gen- hension (Bauminger-Zviely & Kimhi, 2013; eralized manner whereas those who passed Constable, Garrie, Moniz, & Ryan, 2013). The the tasks could generate event schemas, even ability to make predictions based on others’ though their descriptions and explanations perspectives also influences the ability to were unusually concrete and rigid, impacting understand a narrative text. Thus, weak their problematic understanding of various as- ToM may lead to inaccurate predictions and pects of social experiences. inferences (Carnahan et al., 2011). Indeed, To sum up these findings, better ToM abili- research has shown that students with ties in individuals with ASD and HF-ASD lead, HF-ASD have difficulty making inferences for the most part, to better social skills. Still, and comprehending information that is not the improved social skills do not match the so- factual (Saldana & Frith, 2007). cial skills of individuals with typical develop- Narrative and ToM ment, even when they are of the same chronological age and cognitive developmental level. Reading and interpreting narratives has As expected, social skills that demand parallel been found to be challenging for children processing are more challenging in ASD/HF- with ASD/HF-ASD at all cognitive levels. When ASD than those that demand only serial retelling a story from a wordless picture book processing. (Capps, Losh, & Thurber, 2000), few quantita- tive differences were found between children ToM ACADEMIC MANIFESTATIONS with ASD and control groups with typical development and developmental delays on nar- In the past decade, a growing body rative measures such as length, structure, and of research has developed concerning complexity. Nonetheless, better ToM abilities the academic abilities of individuals with were related to better narrative abilities only ASD/HF-ASD. In contrast with the social- within the ASD group. According to the au- communication aspects, individuals with thors, this finding is indicative of two basic as- ASD/HF-ASD show academic strengths as well pects of narrative within ASD. The first is that as academic weaknesses, although the for- narrative, as a social activity, involves moni- mer have received minimal attention from re- toring and maintaining the listener’s attention searchers. The following section is a review of throughout the story. The second is that narra- recent studies that examined the relationships tive provides a means to explain a character’s between academic abilities and ToM. emotions, thoughts, and actions, which are associated with ToM. Reading comprehension and ToM In a later study, Diehl, Bennetto, and Young Characteristics related to the reader, the (2006) reported that children with HF-ASD text, and the learning situation all influence were able to recall the gist of narratives but reading comprehension (Jennings, Caldwell, had difficulty organizing events coherently. & Lerner, 2006). Therefore, ToM capabilities Similar findings were found in an earlier study, have a direct influence on reading compre- in which Losh and Capps (2003) examined hension abilities, whether in academic or the narrative abilities of school-age children leisure settings. Understanding a character’s with HF-ASD in comparison with children intentions and desires, especially when they with typical development in both personal

and storybook narratives. They found that deficits. Brown and Klein (2011) examined the children with HF-ASD had difficulty pro- the relations between ToM and writing. They ducing thematically integrated and elaborated also compared written narrative and exposi- narratives, alongside limited use of causal lan- tory texts of adults with HF-ASD. The results guage in both narrative types. Surprisingly, showed that both text types were of poorer and contrary to previous studies, ToM was quality and had poorer text structure than not associated with narrative ability, leading those of typically developing peers. Theory the authors to surmise that the relation be- of mind was positively related to the length tween ToM and narrative varies throughout of the text and the quality composite score in the spectrum. That is, it ranges from being both text types, showing that individuals who related to narrative competence among less had better ToM skills wrote higher quality cognitively able children with ASD (as found texts on measures such as structure, context, in Capps et al.’s, 2000, study) to not being quality, and global coherence. At the narrative related to narrative competence among chil- text, the level of complexity and insightful- dren with HF-ASD (Losh & Capps, 2003). ness of the internal worlds of their characters An important aspect that combines ToM was most strongly linked with ToM, thus and narrative abilities is the capacity to shift supporting the notion that poor social under- between the perspectives of two interacting standing indeed renders narrative writing a characters in a given story. In a study that challenging task for students with HF-ASD. examined the role-taking abilities of children In conclusion, although the academic skills with HF-ASD, Garcia-Perez, Hobson, and Lee in ASD/HF-ASD have been less explored in (2008) found that most of the children were the literature than the social communication able to make some adjustments in their narra- domain, individuals on the autism spectrum tives according to the alternative viewpoints exhibit many specific difficulties, including of the story’s characters and they used terms those related to ToM abilities. It is inter- referring to the characters’ mental states. esting to note in passing that, to date, no Nonetheless, they had difficulty adjusting to studies have examined the relations between the perspectives of the different characters ToM abilities and mathematics or science, within the narratives and also in shifting from two strongly explicit areas with apparent one perspective to another. It is important strengths in ASD/HF-ASD. There is a need for to stress that some of the children showed increased research in the field of academics higher role-taking abilities than those who and ToM to develop best practices. The fol- seemed to produce stories without any sign of lowing section discusses the varying sociocog- adjustments in the characters’ perspective. Al- nitive interventions for enhancing ToM skills. though complex, in role-playing, there is time, presumably, for the player to get to know the ToM INTERVENTIONS role. For some of the children, this may, in effect, change the nature of complexity from The most important issue in ToM training parallel to serial, making it easier to handle. is the assessment of whether training gen- eralizes to other tasks or, more importantly, Writing abilities and ToM to real life. Generally, findings have demon- Deficits in ToM also account for many strated that improvement in ToM skills fol- difficulties seen in the writing abilities of lowing specific interventions does not appear individuals with ASD. The intent of written to correspond with improved social capabil- discourse is to lead the reader through the ities (Hadwin, Baron-Cohen, Howlin, & Hill, written text, an intent that often escapes 1996). As discussed in this section, ToM inter- individuals with ASD. Furthermore, the ventions can be categorized into two major ability to write narrative genres, along with groups—specific ToM sociocognitive training writing about fictitious characters’ thoughts that focuses on improving specific ToM skills, and feelings, is often lacking due to ToM and more general social skills interventions

that incorporate ToM training among other Swettenham, 1996) to children with ASD of social skills. Methodological issues often influ- varying cognitive abilities who were random- ence study results. A randomized controlled ized to the experimental condition. Accord- trial (RCT) design, with a randomized control ing to the authors, the participants were ran- group or wait-listed control group, is consid- domly allocated to the ToM training group, ered to be the gold standard for examining the executive function training group, or the efficacy of interventions. to a control group that received no intervention. The children who underwent train- Specific interventions ing showed significant improvement in their Theory-of-mind-specific interventions are ToM performance compared with the control based on the teaching of internal, subjective group, and this improvement remained sta- mental representations of oneself and others ble 6 and 12 weeks later. Still, according to (Begeer et al., 2011), which may include de- their schoolteachers, the training did not af- veloping role-playing, picturing thought bub- fect their ToM abilities in daily life (Fisher & bles, and perspective taking (Gould, Tarbox, Happe,´ 2005). O’Hara, Noone, & Bergstrom, 2011; Paynter & Peterson, 2013). As noted previously, how- General interventions ever, apparently, not all the skills learned dur- General interventions that incorporate ToM ing these interventions generalize to other training among other social skills seem to ToM skills or settings. Results of an interven- be more likely to generalize to other set- tion study that taught a basic component skill tings. This is not always the case, however. of perspective taking to children with ASD via Begeer et al. (2011) implemented an inter- a behavioral intervention procedure showed vention using an RCT design that involved that although the children mastered the skill, training the children with HF-ASD on con- generalization to the natural environment was ceptual understanding of ToM. The training limited (Gould et al., 2011). targeted the ability to reason about beliefs Studies that have examined thought bub- and false beliefs, the understanding of mixed ble training demonstrated mixed results. and complex emotions, emotion recognition, Wellman et al. (2002) showed modest success pretense-reality distinction, and second-order on the trained ToM tasks; yet, again, evidence reasoning. Overall, the experimental group for generalization to new ToM concepts was made significant gains in their ability to rea- limited. A later study (Paynter & Peterson, son about beliefs and false beliefs, and about 2013), which included a nonintervention con- the understanding of mixed and complex trol group of children with HF-ASD who were emotions, in comparison with the control matched with the trained children at pretest, group. Nevertheless, according to parental showed that the children with HF-ASD who reports, the training did not improve the had undergone training made significant gains children’s social skills or their self-reported that also generalized beyond explicit false be- empathy. lief (of changed location) to other ToM con- Mackay, Knott, and Dunlop (2007) de- cepts. These gains were maintained after the scribed a group intervention aimed at intervention period ended. The authors’ con- enhancing social interaction and understand- clusion was that thought bubble training can ing in children and adolescents with HF-ASD. facilitate and advance success on ToM abili- This intervention focused on social under- ties in children with HF-ASD. However, they standing and ToM skills via group discussion, could not infer that this strategy taught ToM role-playing, and games. The training also understanding that was similar to ToM under- integrated strategies aimed at improving standing of the students’ typically developing generalization to real-life settings such as peers. outings to community settings, home prac- Fisher and Happe´ (2005) taught a ToM tice, and feedback meetings with parents. strategy (“picture in the head” based on In this study, the participants demonstrated

significant gains in all measures following the ecological (CBE) intervention, ToM skills are intervention program. Enhanced social skills not taught directly as a separate skill, as they that generalized into other settings were areconsideredtobecoreskillsthatcrossall reported both by parents and by participants. social topics, and therefore may be enhanced Another intervention included a group in all parts of the intervention. In an inves- curriculum that combined various social tigation of the CBE intervention, Bauminger skills, with an emphasis on learning through (2007) found that the intervention facilitated role-playing (Tse, Strulovitch, Tagalakis, sociocognitive processes in general (such as Meng, & Fombonne, 2007). After 12 weeks of defining and recognizing emotions, solving so- intervention, the parents reported that their cial problems, revealing a better understand- adolescents with HF-ASD had generalized ing of others) and also improved ToM skills. their social skills to settings outside the Here too, however, a major limitation was the treatment sessions. Although both of these lack of a control group. studies indicated that generalization of the In summary, specific ToM sociocognitive new social skills did occur, it is important training has been found to enhance the tar- to note that neither study used a control geted skills; yet, generalization to other skills group and no objective observations, such and settings, for the most part, has been mini- as teacher views or direct observation of mal. In contrast, general and multimodal inter- interactions with peers, were implemented. ventions seem to improve ToM skills as well Another intervention study conducted with as enhance generalization and social skills, al- adolescents and adults with HF-ASD targeted though some of the experimental designs in the development of social skills, including this research have been weak. In the specific, specific ToM skills such as analyzing how controlled situations, the children learned one’s behaviors influence the opinions of how to use certain tools (e.g., “pictures in the others, as well as vocational skills (Hillier, head”), but they learned this skill outside their Fish, Cloppert, & Beversdorf, 2007). In this real-life context. Generalization to real life re- study, the participants showed significant im- quires that children engage in parallel process- provement on pretest–posttests on the Em- ing, as children must recognize the situation, pathy Quotient questionnaire (Baron-Cohen figure out the relevant “tool,” and implement & Wheelwright, 2004). These results indi- it. The advantage of working with general and cated that the participants showed an in- multimodal interventions is that the partici- creased awareness concerning other peoples’ pants with HF-ASD are supported to practice thoughts and feelings, alongside an improved skills in general settings during the interven- ability in perspective taking. This study did tion itself, apparently overcoming the paral- not have a control group; yet, direct obser- lel processing complexity. Notwithstanding, vation of the participants, including a tally it is important to adapt interventions individ- of responses throughout the intervention ually to the social and cognitive levels of the was recorded. More relevant comments were individual. made toward the end of the program than at the beginning. SUMMARY

Multimodal interventions As this review illustrated, ToM deﬁcits More sophisticated interventions take a affect daily social and academic life in individ- multimodal approach, combining social in- uals with ASD/HF-ASD. Even though social- teraction training along with sociocognitive communication impairments cannot be abilities. Such studies aim at augmenting explained exclusively on the basis of ToM more holistic social functioning for chil- impairments (Tager-Flusberg, 2007), ToM dren with HF-ASD (Bauminger-Zviely, 2013a). is a crucial factor in the sociocognitive In Bauminger’s (2007) cognitive-behavioral- development of children. Although out of

this review’s scope, it is important to note Throughout the reviewed studies, there ap- that Baron-Cohen (2009) extended the ToM pears to be a consistent theme of success in deficit hypothesis and suggested that the explicit testing, learning, and other controlled sociocommunicative deficits in ASD/HF-ASD situations that does not always translate to im- derive from a delay in the development proved skills in everyday life. This may well be of the empathizing system (i.e., the ability due to the fact that the controlled situations to identify mental states in others and to eliminate the need for parallel processing and, produce appropriate emotional responses), consequently, do not resemble real-life situa- whereas their intact abilities in systemizing tions. The key to success, especially for in- (i.e., the ability to construct and analyze dividuals with HF-ASD, may lie in developing systems) may explain the nonsocial aspects generalized and multimodal interventions that of ASD, such as their repetitive behavior and incorporate training of the skills acquired in narrow interests. Following Baron-Cohen’s general settings. (2009) theory, the impaired empathizing A further issue that appears in this review is capabilities may account for the reduced ToM that of compensatory skills. The evidence re- abilities seen in individuals with ASD/HF-ASD. garding success on ToM tasks, as opposed to The delayed empathizing system may in poor social or academic manifestation, raises fact be analogous to the spontaneous, implicit questions regarding the use of compensatory ToM level, in which parallel processing is ex- skills. Verbal abilities and general reasoning fa- pected, as the individual needs to recognize cilitate better ToM understanding in HF-ASD. and identify others’ mental states, reacting si- Yet, the contribution of IQ level, memory, multaneously, generating appropriate social executive function, and attention abilities, as and emotional responses. At the same time, well as the response to intervention, requires the systematizing system is not impaired, as further research to understand the mecha- also seen for the most part in explicit ToM nisms by which they facilitate ToM abilities. tasks and behaviors that entail serial process- It is important to note that this review did ing. Hence, there is relative success when not address all fields concerning ToM, such examining explicit ToM abilities such as per- as brain networks, skill assessments, and ToM spective taking and role-playing. More com- as a mediator in the association between lan- plex social and academic behaviors such as guage abilities and developmental outcomes thematically integrated narratives, social in- in ASD. Numerous areas require further re- teraction, recognizing sarcasm and lying, au- search. For example, there are calls for in- tobiographical memory, and so forth, rely on depth examination of developmental effects implicit ToM abilities that involve parallel pro- in ToM (e.g., Pellicano, 2013), longitudinal cessing and coincide with the delayed em- studies examining trajectories of developmen- pathizing system. Further research regarding tal change in ToM abilities (e.g., Steele et al., the systems responsible for explicit and im- 2003), and RCT examinations of multimodal plicit ToM processing is necessary, as is the interventions. It is hoped that these will war- need to tease out the relations between the rant greater attention in the future, leading to two systems. improved clinical interventions.

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