The Case For Addressing Theory of Mind Deficits in Language Intervention

Many years ago Charles Hart, author of Without Reason: A Family Copes with Two Generations of Autism, shared a story about his son Ted that gave me a window both on the social / communication problems that are hallmark features of autism spectrum disorders (ASD), and their relationship to theory of mind. He said that when Ted was approximately fourteen years of age, sitting across the room reading a book, he came across a word that he didn’t understand. He pointed to it and—without getting up to show his father the word—said, “What does this word mean?” Unsure that he had heard his son correctly, his father said, “What word?” Ted again pointed to the word and said, “This word.” According to Mr. Hart, when he informed his son that he couldn’t see the word, and that Ted would have to get up and show it to him, his son seemed puzzled. It was at that moment that Mr. Hart realized that Ted’s concept of the human mind and its contents were very different from that of a person without autism. The analogy Mr. Hart gave was brilliantly insightful. He said that for Ted it was as if the human mind was a universal mind to which everyone had his or her own “computer terminal” hook-up. As such, if there were a word on Ted’s mind (or, by extension, an idea or a thought), it would—based upon Ted’s conceptualization of the world—be on everyone’s mind at the same time. Hence, there would be no need to show his father the word since from Ted’s point of view his father would already know it. Could that type of thinking explain why a child or adolescent becomes inconsolable when you cut his or her sandwich in quarters because you should have known that he or she wanted it cut in half? Could it explain poor perspective-taking skills and the difficulty with empathy that is associated with ASD, particularly since those constructs require an appreciation for the other person’s thoughts and feelings?

Although neither one of us knew it at the time, Charles Hart was describing the quintessential deficit in theory of mind—the lack of knowledge / appreciation that different people have different minds and hence different ways of thinking, feeling, and believing; and further, that these internal mental states have a lot to do with the person’s external behavior. The following examples may help to illuminate these important points.

To have a theory of mind is to be able to attribute mental states to others. In other words, we use mental state terms to try and understand what people mean in order to make sense of their behavior—for example, she’s crying (external behavior) because she feels (internal mental state) sad. People who don’t have autism attribute internal mental states to external behavior quite naturally, using their attributions to guide their own behavior. For example, you wouldn’t ask your boss for a raise if he or she were speaking harshly to someone and hence, in an obvious bad mood! The importance of being able to link external behavior with internal mental state cannot be overstated, since assigning an internal reason for the behavior that we see:

• helps us to understand (i.e., make sense of) a person’s behavior (Daddy is yelling at me because he is angry.);

• enables us to use the information that is gleaned to predict what a person might, or might not do (If he’s angry he might not let me have dessert.); and,

• provides the basis by which we may modify and/or adjust our own behavior to meet the needs of the situation (I’d better not ask him for a cookie right now.).

There is a great deal of research today that indicates that individuals with ASD have deficits in theory of mind, and further, that these are linked to language development. Like autism itself, these deficits exist on a continuum from mild (in the case of more able individuals), to severe (in the case of those with significant challenges).

By “reversing” the content of the bulleted points above one can get an idea how deficits in theory of mind impact individuals with ASD:

• If you aren’t able to understand that a person’s overt behavior has a lot to do with his or her internal mental state (e.g., harsh words reflect anger), you will not be able to make sense of the person’s behavior.

• If you can’t make sense of a person’s behavior, you are not likely to be able to predict what he or she will do.

• Without the ability to predict likely future action, one would not know how to adjust his or her own behavior to meet the demands of the situation.

Joint Attention as an Early Indicator of Theory of Mind Knowledge

Normally developing children, from approximately 9 – 12 months of age, will follow an adult’s line of regard—that is, his or her point or eye gaze—for the purpose of sharing attention. This is called joint attention, and while very few people have even heard of it, joint attention is a critical precursor to language development. In fact, it is actually the gateway to intentional symbolic communication, and very much reflective of underlying theory of mind knowledge. Eventually, neurotypical children learn to use a pointing gesture themselves to attempt to get adults to follow their line of regard, as they quite literally point out items and events of interest to them. Pointing to share attention is considered one of the earliest indicators of theory of mind knowledge. Conversely, the lack, or impoverishment of this type of behavior in children with ASD is indicative of theory of mind difficulty. It should be obvious that given its intimate connection to communication and language development, the competencies involved in the social-cognitive construct of theory of mind should be targeted in intervention activities.

Putting the Horse in Its Proper Place

If one doesn’t understand the concept of theory of mind and how it relates to language development, it is easy to put the proverbial cart before the horse. This happens when we ignore the importance of joint attention and comprehension, and start intervention at the level of language expression. It also occurs when we fail to build in intentionality because we are too busy force-feeding vocabulary. That said, I belong to the “it’s never too late to get it right” school of thought. Human beings are amazingly resilient. Under motivating conditions, it is relatively easy to establish joint attention and to build in intentionality. And, since both of these constructs are foundational to communication and language development that is where the focus of language intervention should always begin.

© Diane Twachtman-Cullen, Ph.D., CCC-SLP

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