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

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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


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)



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,



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

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po

nsi

vejo

int

atte

nti

on

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pla

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y,sa

dn

ess,

dis

gust

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con

dar

yin

ters

ub

ject

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y(e

mer

ges

8-12

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)

8–12

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nth

s–F

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ws

line

of

rega

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ehav

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ula

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init

iate

sb

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req

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sem

oti

on

alex

pre

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cial

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ach

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id–I

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mo

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and

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rela

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line

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sigh

tan

dth

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ne

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wh

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ne

loo

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chan

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by

dir

ect

con

tact

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/co

regu

lati

on

of

inte

ract

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s

18m

on

ths-

2ye

ars

–Rec

ogn

izes

that

dif

fere

nt

peo

ple

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like

dif

fere

nt

thin

gso

rh

ave

dif

fere

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des

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erge

nt

sen

seo

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lf–E

nga

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ther

s;p

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ipt

of

bro

ken

toy

will

mak

ech

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app

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san

oth

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gin

gsu

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leto

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ses

word

sh

appy,

sad,m

ad,

sca

red

(con

tin

ues

)



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

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nt

peo

ple

can

see

dif

fere

nt

thin

gs

–Un

der

stan

ds

that

imag

inar

yo

bje

cts

are

dif

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nt

fro

mre

alo

bje

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–Wo

rds

like

rem

ember

,kn

ow

,an

dth

ink

app

ear

insp

on

tan

eou

ssp

eech

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ches

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tio

nw

ord

sh

appy,

sad,m

ad,a

fra

idto

ph

oto

grap

hic

face

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chem

atic

faci

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situ

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that

will

pro

voke

pri

mar

yem

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on

s(c

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atch

emo

tio

nw

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top

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–Tal

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use

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qu

ence

so

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oti

on

s(e

.g.,

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po

tty.

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ses

ob

ject

and

“fri

end

”to

chan

geaf

fect

–Beg

ins

tod

isp

lay

self

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sem

oti

on

s:em

ba

rra

ssm

ent,

pri

de,

sha

me,

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4–5

year

sFi

rst-

ord

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gnit

ive

theo

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ind

;pre

dic

tsw

hat

som

eon

eis

thin

kin

go

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elin

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asse

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lse

con

ten

tsan

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task

s–C

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red

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ap

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acti

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so

nb

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of

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kin

g;u

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and

sn

ot

on

lyw

hat

peo

ple

see

bu

tal

soh

ow

itap

pea

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them

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der

stan

ds

ho

wac

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toin

form

atio

nb

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go

rh

eari

ng

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usa

llyre

late

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and

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gean

db

elie

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nb

eca

usa

llyre

late

dto

acti

on

sin

the

wo

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(bel

iefs

cau

sep

eop

leto

act

ince

rtai

nw

ays)

–Fu

ture

tim

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avel

for

pre

dic

tin

gp

hys

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chan

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ogn

izes

amb

igu

ou

sfi

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t-o

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ctiv

eth

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of

min

d–P

red

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wh

atso

meo

ne

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elin

g–U

nd

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and

sth

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on

sar

eca

use

db

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hat

som

eon

eth

inks

isth

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se,e

ven

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hat

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thin

kco

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alit

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red

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tio

ns

bas

edo

nfa

lse

bel

iefs

–Id

enti

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char

acte

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feel

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gto

wh

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rn

ot

wis

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are

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and

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wh

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app

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care

d,a

nd

surp

rise

d

(con

tin

ues

)



Tab

le2

.D

evel

op

men

to

fT

heo

ryo

fM

ind

(Con

tin

ued

)

Co

gnit

ive

Th

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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)



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


http://links.lww.com/TLD/A35


http://www.ucdmc.ucdavis.edu/mindinstitute/ourteam/faculty_staff/escs.pdf




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



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



(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


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,


http://www.youtube.com/playlist?list=PL25410923E953E679

http://www.youtube.com/playlist?list=PL25410923E953E679


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



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


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


http://www.thetransporters.com


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


http://www.jkp.com/mindreading


http://web.uvic.ca/$sim $letsface/letsfaceit


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


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



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



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





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



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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A Developmental Perspective for Promoting Theory of Mind