i The Development of Theory of Mind in Deaf People By Sylvia Glenn Thesis submitted to the University of Sheffield for the degree of Doctor of Clinical Psychology Januaq 2007 ii Declaration The Nvorkhas not been submitted for any other degreeor to any other institution iii Structure and Word Counts Literature Review - Prepared according to the guidance of the British Journal of Developmental Psychology Research Report - Preparedaccording to Option B and the guidance of the Journal of Deaf Studiesand Deaf Education' Section I- Literature Review Word Count Literatu.re Review 7995 References 1526 Section Il - Research Report Research Report 8084 References 973 Section III - Critical Appraisal Critical Appraisal 4997 References 106 Section IV - Appendices Appendices 7095 Total word count excluding references and appendices 21076 Total word count including references and appendices 30776 1 Copies of the letter of approval and guidance notes for contributors are included in Section IV: Appendix A 1. iv Thesis Abstract Section I. Literature Review Several authors claim that deaf children with hearing parents do not develop theory of mind (ToM) until adolescence,but this is largely basedon false-belief studies.Peterson & Siegal's (2000) review of false-belief studiesis updated and the section also reviews research using a wider range of methodologies with deaf children and adults. Deaf children have difficulties in false-belief, perspective-taking and emotional responses/reactions,but these skills may develop later. In contrast, deaf children do not appear to have deficits in mental-state attribution or emotional recognition. More researchwith deaf adults is needed. Section H. ResearchReport This study explores whether Deaf adults have impairments in ToM and empathy compared to hearing adults, and if Deaf forensic patients have further impairments. Tests were adaptedand translated for the purpose of the study. The Deaf community scored lower than the hearing community on the Reading the Mind in the Eyes test and produced fewer mental states. The Deaf forensic group was too small for reliable statistical analysis.Deaf people may continue to have ToM impairments into adulthood, but the results could be due to methodological, linguistic and social factors. Assessmentsmust be developed specifically for use with Deaf populations rather than relying on interpretedmeasures. Section III. Critical Appraisal T his section gives a commentary, and personal reflections, on the project. The challengesfaced during the progressionthrough the thesis and of researchingwithin the Deaf culture are explored. Methodological problems, clinical implications and areasfor further researchare discussedand key learning points are identified. V Dedication For Nana Lorna and Dolores vi Acknowledgments Firstly I would like to thank the 25 people who participated in this project for generouslyand freely giving their time to take part. Many thanks to Alpha Hospitals, Bury, who supported the project by providing me access to staff, patients and interpreters. Thanks also to the Sheffield Research Consortium and the Clinical Psychology Unit for funding this project. I would like to express my thanks to my supervisors Prof. Nigel Beail and Dr Sue O'Rourke for their patience, guidance and support through the whole researchprocess, and for giving me the opportunity to do researchin Deafness. I'd like to extend my particular thanks to my two interpreters, Claire Shard and Anna Wil.liams, for all the time, effort and wisdom they brought - especially for sticking with it when it took longer than planned! Many thanks to all the membersof the focus group for your advice, guidance,ideas and feedback throughout the project: SarahPowell, Trevor Bothwick-Hare, Dr Fiona Fitch, Dr Alun Thomas, Claire Shard, Anna Williams, James Lea and Dr Sue O'Rourke. A special thanks to Fiona for taking me under your wing after Sue left. Thank you to all the staff at Alpha for welcoming me - it was great working alongsideyou all. I would like to extend my thanks to the following people: Simon Baron-Cohen and Peter Kinderman for allowing me to use their tests; Adrian Simpson for your patience and for being so approachableand willing to explain things so many times until it sinks in! Dr Kath Boon -a very big thank you for all your support through my training; Dr Gill Crow, Dr Susie Black, Alison Wray and all my colleagues at SCH and West CAMHS - thank you for all your understanding,*support and good humour; Carolyn Lovelock - thank you for introducing me to Alpha. Thank you to everyoneelse who has helped and supportedme along the way! And finally a big thank you to my family and friends for all your support through this long researchprocess; in particular Dad, Hclen and Nan for your love and care, Uncle Brian for proof-reading, Ruth for being a fantastic friend, Alexci for being there, to other trainees for sharing the journey and to all my friends at St Johns church for being a wonderful extended family to me! And of course, thanks to God for always being there and for giving me purpose! vii List of Contents SECTION 1: LITERATURE REVIEW THE DEVELOPMENT OF THEORY OF MIND AND EMOTIONAL UNDERSTANDINGIN DEAF PEOPLE: CONSIDERINGPROCEDURAL ISSUES 1 ABSTRACT 2 DEAFNESS 3 THEORY OF MIND 4 THE CURRENT REVIEW 7 FALSE-BELIEF TESTS 8 OTHER MEASURES OF TOM 13 DISCUSSION 24 CLINICAL IMPLICATIONS 26 CONCLUSIONS 28 REFERENCES 30 SECTION II: RESEARCH REPORT 35 TiIEORY OF MIND AND ENiPATIIY IN DEAF ADULTS IN COMMUNITY AND FORENSIC SETTINGS: AN EXPLORATORY STUDY 35 ABSTRACT 36 METHOD 40 RESULTS 48 DISCUSSION 57 CONCLUSIONS 62 REFERENCES 64 SECTION III: CRITICAL APPRAISAL 67 CRITICAL APPRAISAL 68 ORIGINS OF THE PROJECT 68 DEVELOPMENT OF THE RESEARCH PROPOSAL 69 RESEARCHING IN A HOST-COMM UNITY 70 GAINING APPROVALS 70 CONTRACTING INTERPRETERS 71 ADAPTATION OF MEASURES FOR DEAF POPULATIONS 72 THE CHALLENGES OF RECRUITING CROSS- CULTURALLY 72 MEETING OTHER RESEARCHERS IN DEAFNESS 76 ANALYSIS OF DATA 76 DRAWING CONCLUSIONS 77 WRITING UP AND MAINTAINING MOTIVATION 78 METHODOLOGICAL LIMITATIONS OF THE RESEARCH STUDY 78 CLINICAL IMPLICATIONS 80 FURTHER RESEARCH 82 KEY LEARNING POINTS 83 REFERENCES 86 SECTION IV: APPENDICES 87 APPENDix A 88 LFORMAT 89 2. ETI IICAL APPROVALS 96 3. MEASURES 105 4. OTHER 112 viii APPENDIX B 121 APPENDicEs To LITERATURE REVIEff" 121 APPENDIX C 132 APPENDicEs To RESEA RCII REPOR T 132 Section 1: Literature Review I Running head: DEVELOPMENT OF ToM IN DEAF PEOPLE SECTION 1: Literature Revie-w The Development of Theory of Mind and Emotional Understanding in Deaf People: Considering Procedural Issues Section 1: Literature Review 2 Abstract Basedexclusively on the false-belief paradigm, several authors claim that deaf children with hearing parents do not develop theory of mind (ToM) until adolescence.This section provides an updated review of studies using false-belief tests published since Peterson & Siegal's (2000) review. It also reviews research using a range of methodologies investigating ToM in deaf children since 2000 and deaf adults since 1970. The results of false-belief studiesprovide support for a conversationalaccount for the developmentof ToM, as performanceappears to dependon accessto a fluent signer in early childhood. Narrative methodologies show that deaf children appear to have difficulties in perspective-takingand emotional reactions, but these skills may develop later. In contrast,deaf children produce mental-statesequally well as, if not better than, hearing children. Emotional recognition may also be intact but more studies arc needed to clarify this. More research with deaf adults is needed. Theoretical and clinical implications are discussed. Section1: LiteratureReview 3 The Development of Theory of Mind and Emotional Understanding in Deaf People: Considering Procedural Issues Deafness In the United Kingdom approximately 840 babies are born moderately- to profoundly-deae every year3 (Royal National Institute for the Deaf, 2006). Causesof deafnessinclude genetics, pre- and post-natal complicationsý, head injuries and loud noise (National Deaf Children's Society, 2006), therefore additional impairments are possible. Neonatal screening-programmes for hearing-impairmentS5 improve opportunities for communication developmentthrough hearing aids, cochlea implants, and importantly, adaptations in parental communication. Deaf adult populations may have been undiagnoseduntil a later age6,which may have affected their development. There are two main models of deafness;the medical model aims to reduce the disability of deafness,and the cultural model acceptsdeafness as a part of the person's Deaf identity. Deaf culture uses a distinct language; British Sign Language (BSL) has its own grammatical structure and its signs do not match each English word. For this paper, the term deaf will be used to include the medical condition of deafnessand those who identify themselvesas culturally Deaf. Language choices depend on local provision and family preference: Children taught sign language (SL) either have classesdelivered in sign or use interpreters to access mainstream education. Oral education aims to teach a child to use speech, 2 The level of an individual's deafnessis describedin decibels (dB) by the quietestsound they can hear in their best ear, or by terms of 'mild' (24-40 dB), 'moderate' (41-70 dB), 'severe' (71-95 dB) or 'profound' (>95 dB). 3 The current population of severely- and profoundly-deaf people in the UK is around 698,000 (RNID, 2006). 4Pre-natal causes include rubella,