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Original Paper

Folia Phoniatr Logop 2014;66:1824

DOI: 10.1159/000363697

Reading the Mind in the Eyes Test (ChildrensVersion): A Comparison Study between Childrenwith Typical Development, Children withHigh-Functioning Autism and TypicallyDeveloped Adults

Ioannis Vogindroukas Evripidis-Nikolaos Chelas Nikolaos E. Petridis

Medicopedagogical Center of Northern Greece, Psychiatric Hospital of Thessaloniki, Thessaloniki, Greece

ed in the Greek language, confirm findings of other studies

in the literature conducted with the RMET in the English lan-

guage. 2014 S. Karger AG, Basel

Among humans, understanding other peoples feelingsand intentions takes place during daily interactions andexchanges. The framework of evolutionary psychologystates that the human mind should be considered in termsof its evolved adaptedness to the environment [1]. Aware-ness of the emotional state of interaction partners proffersconsiderable advantage for the social perceiver [2]. Theability to predict, understand and explain the behavior ofother humans plays a crucial role in successfully adaptingto ones complex social environment [3, 4]. This ability isoften termed theory of mind (ToM). ToM is the capacity

humans have to understand mental states such as beliefs,feelings, desires, hopes and intentions. ToM is the abilityto attribute these mental states not only to oneself but alsoto others. ToM helps us understand that others can havedifferent beliefs or desires from our own, and it plays a rolein facilitating the ability to predict and explain the behav-ior of others [5, 6]. There is a significant body of evidencethat indicates that the majority of children with autismhave impairments in developing ToM [5, 7], and over the

Key Words

Reading the Mind in the Eyes Test Children Autism,

high-functioning Typical development

Abstract

Background/Aims:One of psychologys challenges is to de-

velop and evaluate sensitive tests in the area of social cogni-

tion. Yet, there are few available scales that can measure

mild deficits in social understanding, especially for typically

developing (TD) populations. The Reading the Mind in the

Eyes Test (childrens version) was translated and adapted for

use in the Greek language [RMET-G (child)]. The aim of this

study was to examine in the Greek language the qualitative

and quantitative differences between TD youngsters and

those with high-functioning autism (HFA), as well as the dif-

ference between TD children and TD adults. Methods: An

interview-based psychometric study was conducted. Partic-ipants completed the RMET-G (child), constituting 3 groups:

TD children older than 8 years, children with HFA and TD

adults. Results:103 participants completed the study. The

results demonstrated that TD adults scored slightly higher

than TD children, and children with HFA scored lower than

their TD peers. Children with HFA, however, were able to rec-

ognize many of the pictures shown in the test. Conclusion:

The results of this study, which were the first to be conduct-

Published online: November 14, 2014

Ioannis Vogindroukas, PhDMedicopedagogical Center of Northern GreecePsychiatric Hospital of ThessalonikiGiannitson 52, GR54627 Thessaloniki (Greece)E-Mail ioannisvogindroukas @ gmail.com

2014 S. Karger AG, Basel10217762/14/06620018$39.50/0

www.karger.com/fpl
http://dx.doi.org/10.1159%2F000363697http://dx.doi.org/10.1159%2F000363697


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DOI: 10.1159/000363697

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past 20 years, child development of ToM skills has beenextensively studied [8]. Such a deficit may play a substan-tial role in the development of social, communicative andimaginative abilities, and an impairment in ToM can re-

veal itself in early childhood, as early as age 1 [9].Several studies that have been conducted use a variety

of tests to evaluate how people use (or do not use) ToM.There are few tests, however, that can measure if a typi-cally developing (TD) child or adult may have a mild def-icit in social understanding [10]. Moreover, failure to findgroup differences in the studies with adults and childrenmay reflect the limits of many ToM measures [11]. Thedevelopment of an advanced ToM task has attempted toovercome this problem [9, 10]. This test, named Readingthe Mind in the Eyes Test (RMET) (childrens version)[12], requires participants to look at the eye region of aphotograph of a person, and then attribute a mental stateor feeling expressed by the photographed persons eyes.

This task is considered to be an advanced ToM test be-cause participants in the study are required to take theperspective of the person shown in each task and attributea relevant mental state to the persons eye expression [11].

This current study aims to present and evaluate theoutcomes and the answers that TD children, childrenwith high-functioning autism (HFA) and TD adults gavein the Greek language version of the RMET [RMET-G(child)]. Furthermore, the results of this current study areused to make an effort to fill the gap regarding statisticalanalyses on results of the RMET-G (child) acquired fromchildren and adults. Finally, this current study is one ofthe first efforts to adapt the RMET to a different language(Greek) and to evaluate the use of the Greek language ver-sion RMET-G (child) as a clinical outcome measure fordeficits of ToM in children.

Methods

Design and ParticipantsAn interview-based psychometric study was implemented. All

researchers were speech and language therapists who were experi-enced in working with children with HFA and TD adults. Partici-pants were TD children, children with HFA and TD adults. Allparticipants were recruited to participate in this study by speechand language therapists working for the national health system orin private practice in 3 different cities in Greece. The inclusion cri-teria were: (1) children with HFA who had an intelligence quotient(IQ) score within normal limits and had been diagnosed at a publicdiagnostic center in Greece; (2) parents as well as teachers of theTD children both had to sign a consent form saying the childrenhad no signs of developmental delay; (3) all children were at least 8years old; (4) adults participating in the study were not mentalhealth professionals. The evaluation tests and diagnostic criteria

used for the diagnosis of autism from the public diagnostic centerwere: (1) evaluation by a child psychiatrist based on the diagnosticcriteria of DSM-IV-TR [13], (2) the Childhood Asperger SyndromeTest [14] and (3) the Greek version of the Wechsler IntelligenceScale for Children III [15] performed by a psychologist. Two groupsof children were excluded from participation in the study, i.e. chil-dren diagnosed with HFA who did not have an IQ score withinnormal limits and TD children who were unable to provide a com-pleted consent form and proof of no developmental delays.

Procedure and MeasuresEthical approval was obtained from the Organization for Social

Protection and School Education from the City Council of Ioan-nina. Moreover, all speech and language therapists who examinedthe participants in the private sector had ethical approval from thePan-Hellenic Association of Logopedists. The participants wereinterviewed in a quiet room in their home, in their school environ-ment or at the speech-language therapy clinic. Subjects in all 3groups were tested using the RMET-G (child).

The RMET (child) [12] is a test where the participant is present-ed with a series of 28 photographs of the eye region of the face ofdifferent people. Afterwards, participants were asked to use only thevisual information to choose a word that best described what theman or woman was feeling or thinking based on the visual informa-tion from the photograph. For each item of the test, a photograph isframed with 4 words that describe the possible mental state or feel-ing of the person shown in the photograph. Three of these wordswere foils, only one was the target word that correctly identified themental state of the person in the photo. The test was scored by total-ing the number of items correctly answered by the participant.

The RMET (child) [12] was downloaded via the Autism Re-search Centre website [16], translated and cross-culturally adaptedfor use in the Greek language. First, all target and foil words weretranslated by a certified translator into Greek in order for the foilwords to have the same emotional valence as the target word. Thewords were then piloted on a group of 8 judges (4 male, 4 female).All judges were TD adults. The pilot process was carried out as inthe study of Baron-Cohen et al. [10]. The criterion for adaptationof the translated words was that at least 5 out of 8 judges agreedthat the target word best described the persons mental state, andthat no more than 2 judges selected any single foil word for thesame test item. In the RMET-G (child), all items met the abovecriterion, which indicated that the translation was adequate forGreek children and adults to comprehend.

Psychometric Evaluation and Data AnalysisDescriptive statistics were used to summarize participant char-

acteristics and performance on the measure used. Standard psy-chometric methods were used to evaluate the internal consistencyand validity of the RMET-G (child).

Results

ParticipantsA total of 103 participants met the eligibility criteria

and agreed to take part in the study. Table 1 presents theparticipant characteristics. The sample consisted of 3


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DOI: 10.1159/000363697

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groups. Group 1 comprised 23 TD adults (10 females, 13males) with a mean age of 38.2 years (SD = 9.03). Group2 comprised 27 children with HFA (2 females, 25 males)with a mean age of 10.06 years (SD = 1.7). Group 3 con-sisted of 53 TD children (26 females, 27 males) with amean age of 9.84 years (SD = 1.13). Both groups of chil-

dren had a similar mean age of approximately 10 years.All participants in group 2 were formally assessed regard-ing the IQ with the Greek version of the Wechsler Intel-ligence Scale III. Children with HFA had a mean IQ scoreof 93.6 (SD = 7.7). All participants completed the testwithout asking for help with any of the questions or ask-ing for clarification of the meaning of the words used todescribe the persons feelings or mental states.

Table 2 shows the scores of the participants in theRMET-G (child). Correct answers of TD adults had amean score of 17.3 out of 28 (SD = 2.5), with 100% of theparticipants responding correctly to question 20, which

shows a man who feels not pleased. Question 1 had thesmallest number of correct responses (17.3%), which hada photograph of a woman with the target word kind. TDchildren had a mean score of 16.4 out of 28 (SD = 3.01)with question 18 having the greatest proportion of correctresponses, which had the target mental state of thinkingabout something sad (96.2%). Question 1 had the lowestpercentage of correct responses for the target word kind(5.66%). Children with HFA had a mean score of 13.6 outof 28 questions correct (SD = 3.9) with question 20 notpleased having the most correct responses (85.7%), andthe lowest number of correct responses for question 1 fora woman who is kind (18.5%).

Psychometric PropertiesA psychometric evaluation of participants scores was

performed to identify statistical differences between thetwo different diagnostic groups (children with HFA andTD children). The Mann-Whitney test was used to iden-tify if there was any difference in the mean scores betweenthe two diagnostic groups. Results showed that meanscores are significantly different (p < 0.005) for 5 items(concern, serious, thinking about something sad, sure

and nervous). The same psychometric test (Mann-Whit-ney) was also used to evaluate the significance of scoredifferences between sexes (feminine vs. masculine). Re-sults of the Mann-Whitney test showed that 3 items(friendly, made up her mind and thinking about some-thing) were significantly different (p < 0.005).

The participants were also divided into 3 different agegroups to determine if age plays a substantial role in theway participants interpret mental states from eye expres-

sions. These groups were: (1) 810 years old, (2) 1013years old and (3) 1362 years old. Because there weremore than 2 age groups, the nonparametric Kruskal-Wal-

lis test was used. Results indicated significant differencesfor 8 items (concern, thinking about something, serious,made up her mind, thinking about something sad, un-happy, sure about something and worried). In terms ofpsychometric evaluation, results revealed that the variableof age had the most statistically significant items com-pared to variables of diagnosis (HFA and TD children)and sex (masculine and feminine). Table 3 presents thestatistically significant differences for these 3 variables.

Mental States and FeelingsMore in-depth qualitative analysis was conducted by

grouping emotions described in the test into 4 groups andcomparing the mean scores based on this grouping. Emo-tions were first divided into feelings and mental states andwere then further separated according to their levels ofpositivity. The following groups were created: (a) positivefeelings (hoping, happy), (b) negative feelings (sadness,concern, not pleased, worried, nervous), (c) positive men-tal states (kind, friendly, interested, remembering, think-ing about something, sure about something) and (d) nega-tive mental states (serious, misbelief, made up her mind, abit worried, thinking about something sad, not believing).

Table 4 presents the participants mean scores based on thegrouping of the emotions. Results indicate that adultsscored higher (mean = 16.6) in identifying negative feel-ings and lower in identifying positive mental states(mean = 12.9). Children with HFA scored higher in iden-tifying the negative mental states and negative feelings(mean = 7.2 and 7.1) and lower in identifying positive feel-ings (mean = 4.75). TD children also scored higher in iden-tifying the negative mental states and negative feelings

Table 1.Participant characteristics (n = 103)

GenderMale 65 (63.2%)Female 38 (36.8%)

DiagnosisTD children 53 (51.5%)

Children with HFA 27 (26.2%)TD adults 23 (22.3%)Mean age SD, years

TD adults 38.29.03Children with HFA 10.061.7TD children 9.841.13

Mean IQ SDChildren with HFA 93.67.7


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(mean = 19.4 and 16.3), but the lowest mean score was ob-served identifying positive mental states (mean = 13.3).

Validity and Determining Factors of the IntroducedTestIn order to assess the internal consistency of the trans-

lated test, Cronbachs alpha measure was computed. Thisdescribed the extent to which all items in a test measurethe same concept [17], and in this study it showed the de-

gree to which participants correctly perceived and under-stood the true meaning of items in the RMET-G (child).Cronbachs alpha values range from 0 and 1, and mostpsychometric tests primarily have values fall between 0.75and 0.83 [18]. The validity of the introduced modified testwas evaluated using an initial sample of 25 examinees(pretest) and resulted in a Cronbachs alpha value of0.687, which is considered acceptable. This value indi-cates that the test in general can be acknowledged as suc-cessfully translated (fig. 1), because the overall mean cor-rect response was over 55% (horizontal line) and over90% for some questions. More specifically, figure 1 pre-sents all the test items (x-axis) regarding the percent ofcorrect responses for every test question (y-axis).

The authors were interested in investigating the un-derlying variables that aided participants to respond cor-rectly. Since responses were recorded using a binary sys-tem (i.e. 0 for incorrect responses and 1 for correct re-sponses), the logit model was useful for analyzing theunderlying variables that influenced the participants re-sponses [19]. Logit binary choice models demonstrate theprobability that an event is happening, and that the eventis related to some external (independent) variables. It is

used extensively in many disciplines, including the med-ical and social science fields. Like other forms of regres-sion analysis, logistic regression makes use of one or morepredictor variables that may be either continuous or cat-egorical data. Unlike ordinary linear regression, however,logistic regression is used for predicting binary outcomesfor the dependent variable (treating the dependent vari-able as the outcome of a Bernoulli trial) rather than con-tinuous outcomes. Given this difference, it is necessary

that logistic regression take the natural logarithm of theodds of the dependent variable being a case to create acontinuous criterion as a transformed version of the de-

Table 2. RMET-G (child) scores (n = 103)

Participants Mean SD Score range Highest scored answer Lowest scored answer

TD adults 17.32.5 1121 Man not pleased KindChildren with HFA 13.63.9 720 Man not pleased KindTD children 16.43.01 1024 Thinking about something sad Kind

Table 4.Mean scores based on feelings and mental status grouping

Variable TDchildren

Childrenwith HFA

TDadults

Positive feelings 13.7 4.75 13.5Negative feelings 16.3 7.1 16.6Positive mental states 13.3 6.2 12.9Negative mental states 19.4 7.2 15.5

Table 3.Psychometric evaluation of the RMET-G (child) (n = 103)

Psychometric test

Mann-Whitney Kruskal-Wallis

Diagnostic groups(TD vs. HFAchildren)

ConcernSeriousThinking aboutsomething sadSure

Nervous

Sex groups(male vs. female)

FriendlyMade up her mindThinking aboutsomething

Age groups(810, 1013,1362 years)

ConcernThinking aboutsomethingSeriousMade up her mindThinking aboutsomething sadUnhappy

Sure about somethingWorried

The table presents the statistically significant items in terms ofeach different factor.


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pendent variable. Thus, the logit transformation is re-ferred to as a linking function in logistic regression, al-though the dependent variable in logistic regression is bi-nomial. The logit is the continuous criterion upon whichlinear regression is conducted [20]. Mathematical formu-lation of these models is given as follows:

exp1 ,

1 exp

x bP y

x b

where P(y =1) is the probability that the binary variablereceives a value of 1 (success), xis a vector of covariatesand brepresents the parameters to be estimated using themaximum likelihood method. In the present work, thesecovariates are age, sex and group of participants. Positivevalues of estimated parameters depict a potential increasein the covariates of the model, which would increase theprobability of a successful response. However, negativeparameters of the logit model show that a potential in-crease in one of the covariates would decrease the prob-

ability of a successful response occurring.Table 5 not only shows which factors influence theprobability of a participant providing a correct responsein the test but also provides information about the magni-tude to which a covariate influences responses. In the ma-

jority of the cases, the sex of the participant appeared toincrease the probability that a participant correctly identi-fied the target word of the photograph. Women answeredmore items correctly than men. When the estimated pa-

rameter value is negative, this indicates that sex of the par-ticipant does not improve the ability to find the correctanswer. The age of the participant also influenced theprobability of participants responding correctly, as it wasa statistically significant covariate in 18 out of 28 variables.Children, both children with HFA and TD, correctly iden-

tified the emotions in pictures more frequently thanadults. The diagnosis of participants positively affectedapproximately half of the variables examined in the study.TD participants (children or adults) had more success inidentifying the correct response for the pictures, whilechildren with HFA scored better in fewer cases. In 5 outof 28 variables, none of the 3 covariates used above had aneffect. This may indicate that there are other factors affect-ing these 5 variables or that there is no statistical differencebetween the levels of these categorical variables.

Discussion

This study investigated the performance of 3 differentgroups (TD children, children with HFA and TD adults)in the Greek version of the RMET (child), which is an ad-vanced ToM test [12]. The RMET-G (child) has beentranslated and adapted to the Greek language using thestudy of Baron-Cohen et al. [10]. The criteria for adapta-tion were met, and all the participants understood thewords describing the feelings/mental states and complet-ed the test without asking any questions about the targetor foil words. More specifically, adults and TD childrenhad a similar mean score (17.3 and 16.4, respectively) andchildren with HFA had a mean score of 13.6. It is also im-portant to note that the score range for the test was pro-portional to each group and its mean score. Adults scoresrange between 11 and 21 correct answers, children withHFA scored between 7 and 20 correct and TD childrenscored between 10 and 24 correct answers. The higherscores for TD children showed us that children can un-derstand the emotions better than adults which may beattributed to TD children not trying to analyze the eyeregion shown as adults might do because they have more

life experience in similar situations. Considering the va-lidity of the RMET-G (child), Cronbachs alpha 0.687 isgenerally considered as acceptable. Combination of theabove criteria gives us the ability to generalize the suit-ability of using the RMET-G (child) for the Greek popu-lation with HFA. Moreover, results between groups ofTD children and children with HFA support this out-come because there were many significant differences be-tween these two groups.

0

X4X1 X7 X10 X13

Test item

X16 X19 X22 X25 X28

0.2

0.4

0.6

0.8

1.0

Proportiono

fcorrect

responses

Fig. 1.Bar graph of correct answers for each question in the RMET.


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TD adults and children with HFA, and a negative mentalstate for TD children. In general, all the participants rec-ognized more negative feelings than positive ones basedon the eyes of the person in the photograph which couldbe attributed to people requiring the whole facial expres-sion, and not just the eyes, to recognize positive feelings

and mental states. Another factor that had been analyzedfor its effects on correct responses was the sex of the par-ticipant. There were statistical differences between thesexes for 3 of the test items, although in general, femaleparticipants scored better than males. These findings sup-port the statement of Baron-Cohen et al. [12] that femaleshave a social brain while men have a technical brain.

In general, results from this study for the Greek lan-guage support the findings of previous research [12].Data revealed statistically significant differences betweenparticipant groups, which also occurred in the originalstudies. However, there are no other data to compare with

the data in this study because there is currently no otherpublished research using the RMET (child) translatedinto other languages.

As is common with new measures, further testing isneeded with the RMET-G (child), with a focus on measur-ing its responsiveness to change and its use as a clinical

outcome measure. So far the RMET-G (child) has beenused in research, and future studies should evaluate its ap-propriateness and usefulness as outcome measures in peo-ple with HFA undergoing educational or therapeutic pro-grams. Lastly, future studies should include larger samplesof participants of different ages and who speak different

languages in order to make comparisons between HFAand TD groups using the RMET (child). This would en-able a better understanding of the impact of social deficitsin HFA, as opposed to the general impact of a lack of ToM.

Conclusion

The RMET-G (child) has good validity to be used as ameasure of social understanding in the Greek language forpeople with HFA. The main advantages of the RMET-Gare that it was adapted well into the Greek language and

that the participants understood all target and foil words.People with or without HFA are able to complete theRMET-G (child) in an interview format. Its use can informthe clinicians about the social understanding deficits intheir clients and can allow for many qualitative outcomes.

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