Juan Carlos Gómez, Beatriz López y Enrique López
School of Psychology, University of St. Andrews,
St. Andrews KY 16 9JU, UK
Equipo PAUTA
Centro PAUTA, c/Patrocinio Gómez 1 bis, Madrid
28022
INTRODUCTION
In this paper we report some preliminary results
of a project whose aim is to explore some practical implications
of the theory of mind approach for the assessment and intervention
of persons with autism. During the last years this approach has
produced important advances in the theoretical understanding of
autism (see Frith, 1989; Baron-Cohen, Tager-Flusberg and Cohen,
1993; Happé, 1994). According to it, persons with autism
suffer from an alteration in their ability to understand the nature
of mental representations and their role in determining the behaviour
of people. This approach has generated a wealth of empirical findings
and theoretical debates in relation to autism. However, its possible
impact upon the practical issues of assessment and intervention
in persons with autism has received less attention. The project
reported in this presentation was conceived as a collaboration
between the theory and the practice. It was carried out at PAUTA,
a school for children with autism and generalized developmental
disorders. The general aim was to develop new or modify existing
techniques for both the intervention and the assessment of the
children attending this center.
The project was focused upon three main areas of
impairment related to theory of mind:
a) Understanding that behaviour depends upon mental
representations, i.e., that people act on the basis of
their beliefs and desires. This ability is usually diagnosed by
means of "false-belief" tasks (Baron-Cohen, Leslie and
Frith, 1985), in which children with autism tend to fail to predict
the behaviour of people with inaccurate representations of reality.
They seem to find it extremely difficult to understand that other
people may have a wrong representation of the world and act in
accordance with this misrepresentation. In normal development,
this ability typically appears at around 4 years of age and it
is deemed to involve the capacity to form metarepresentations.
c) Joint attention behaviours.
Before pretend play, normally developing children are capable
of communicative behaviours such as showing or requesting things
by means of gestures (e.g, pointing). These behaviours imply some
understanding that one can make other people notice one's desires
or notice one's interest in particular things in the world. This
is why they are usually considered to imply some kind of theory
of mind or a precursor thereof. Many of these behaviours are typically
absent or rare in children with autism.
The project was divided into two phases. In the first
phase, we developed and applied techniques to assess the developmental
level of children in each area. In the second phase, new intervention
techniques or modifications of existing procedures were developed
and applied to the children.
In this report we are going to concentrate upon one
example of assessment and one example of intervention.
Traditionally it has been considered that people
with autism have more problems with protodeclarative communication
(e.g., pointing for showing things) than with protoimperative
communication (e. g., pointing for requesting things) (see Curcio,
1978; Baron-Cohen, 1989). However, it has been shown that when
the joint-attention components of protoimperative communication
are taken into account, most children with autism also have problems
with requesting (Gómez, Sarriá and Tamarit,
1993; Phillips et al., 1995). Good requesting behaviours consist
not only of producing gestures to which others can respond, but
also of checking and manipulating the attentional states of the
people who are expected to respond to the requests.
Teaching how to make requests is an important component
of intervention with children with autism. Some degree of control
for visual attention is usually included as a part of the teaching.
We felt that it was necessary to create a systematic procedure
to assess the degree of understanding of the role played by the
attention of others in requesting siuations. Do the children take
into account the attentional availibility of others when making
their requests? If so, what are the cues they use to assess attention
and inattention?
The assessment scenario was the following. In a small
room an adult was sitting behind a table. Desirable objects (chosen
in accordance with the known preferences of each individual child)
were available on a shelf to the left of the adult. Neither the
shelf nor the adult were directly accessible to the children (although
they could touch the hands of the adult when these were resting
on the table).
We recorded the spontaneous strategies, if any, used
by the children to request the objects, noting if eye contact
was or not used. After a few normal trials in which the adult
was attentively responding to the chlld's attempts, experimental
trials began to be interspersed among the normal ones. In these
experimental trials the adult adopted a variety of "inattentive"
postures that prevented him/her from seeing the gestures used
by the child.
This is a list of the "inattention" conditions used:
a) Adult sitting with his/her back to the child
b) Adult's head turned to a corner.
c) Head to the child but eyes closed.
d) Head and eyes oriented to the target object
e) Adult oriented to the child but failing to respond
for a while.
Since a favourite form of request for some children
with autism involves taking the adult's hand and pushing it towards
the object (which would intrinsically perform the function of
calling the attention of the adult even if this were not intended
by the child), we systematically controlled the accesibility of
the adult's hands, keeping them under the table in some critical
trials.
The aims of the situation were, first, to confront
the children with a situation that was unusual in terms of the
ones in which they were being taught at the school. (The positioning
of the adult behind the table with the corresponding limitation
in direct physical access was not a usual one for the children);
and, second, to see if the children were sensitive to different
signs of inattention and they were capable of modifying their
request procedures resorting to some kind of attention getting
behaviours. This could give us an idea of the extent to which
the children had mastered the joint attention component of requesting
behaviours or they were just using effective gestures without
any insight as to the connection between these and the response
by the adult.
All trials were videotaped and subsequently analysed.
On the whole the requesting strategies of the children when the
adults were attending to them could be classified in the following
four categories:
a) No request: the child tries to use physical means to obtain the object.
b) Takes and uses the other person's hand without making eye contact.
c) Use of distal gestures and vocalization without eye contact.
d) Use of distal gestures and vocalization with eye
contact.
None of the children stuck to the use of the first
strategy which involves completely ignoring the human. Although
some initially tried to obtain the target by themselves, all of
them eventually resorted to the human in one way or another. Four
of the children assessed were using the hand without paying any
attention to the face of the person. Two of them used the hand
but looked at the face of the adult. Three children used distal
gestures and vocalizations without looking at the face, and seven
did so looking at the face of the other person.
The reactions of the children to the different situations
in which the adults were not attending were as follows:
--Same strategy as in the previous trials. No sign of having detected the lack of attention of the adult. This reaction was shown by five children.
--Absence of request when the adult is not looking, but fails to call his/her attention. (4 children).
--Calls the adult's attention but without making eye contact. (one child).
--Calls the adult's attention making eye contact.
(two children).
As many as nine of the children were helpless when
confronted to the situation where the adult was not responding
because he was not attending to them. Some of them seemed to detect
the lack of attention of the adult (especially in the situation
when he was with his back turned to them), but did not know how
to alter the situation. So, they simply stopped making requests.
However, others would just repeat their request without regard
of the other person's attentional availibility.
It is specially remarkable the reactions of the children
whose main requesting procedure was taking the hands of people
towards the target object. When they were deprived of this simple
means because the adult hid his hands under the table, most of
them were totally unable to produce an alternative strategy. Some
would strive to get hold of the adult's arm and then take his
hand to employ their usual procedure. Others would give up or
try a physical strategy. None of them would request the hand of
the adult, for example by means of stretching his/her own hand
towards the other person.
The results of each individual child can be used
to plan individualized intervention strategies. For example, in
the case of the children using the hands of others, the intervention
will consist of promoting the use of distal gestures as a way
of obtaining the hands of people and/or as a substitute for the
hand-taking procedure. In the case of children showing their sensitivity
to the inattention of others by interrupting their requests, it
is possible to try to make them notice how they can affect the
attention of the other people by means of actions (such as touching)
or vocalizations (such as calling the name of the person).
The results of this preliminary application of the
assessment procedure show the real complexity of requesting behaviours
and the need to assess the understanding of their joint attention
components. The systematic variation in the subtlety of the available
cues of inattention (ranging from gros cues, such as having the
back turned, to subtler cues, such as having the eyes closed)
could give an idea of what are the signs of attention to which
different children are sensitive. This, in turn, can be used to
help in designing the targets of the intervention in the area
of joint attention.
One of the most surprising findings of Theory of
mind research has been the contrast between understanding pictographic
representations versus understanding mental representations in
high-level persons with autism. Children who remain unable to
understand false beliefs and their connection to mis-directed
behaviours (as shown by their failure in the Sally-Ann test) are,
however, capable of understanding false photographs or pictures.
For example, they can predict that the colour of a doll's dress
on a photograph will not change although in reality the doll changes
her dress after the photograph has been taken (see Happé
1994 for a summary of these studies).
The idea behind this intervention technique is to
use this intact ability to understand pictographic representations
as a basis to teach children with autism an alternative to a regular
theory of mind. This possibility has been explored in collaboration
with a British team. So far we have carried out a controlled experiment
with 8 young children using the mind-as-photograph-camera analogy
(reported in Swettenham et al., 1996), and the case study I'm
going to present here using the "drawings in the head"
analogy.
The aim was to teach a young girl the idea that people
make drawings of things in their heads and they have a look at
them before acting in relation to these things. To illustrate
this idea, we resorted to the convention of drawing "bubbles"
besides the heads of drawn characters. These bubbles -the child
was told- show the "thoughts" of the character, what
she or he has in the head. The girl was also told that a character
can be "thinking" (or have in his/her head) the "truth"
or a "lie". People had the "truth" in their
minds when the contents of the bubble coincided with what was
the case in the world; however, they had a "lie" when
the contents of the bubble differed from reality.
This was first introduced as a game with a couple
of dolls (Ana Roberta and Roberta Ana). The dolls were involved
in different situations in which objects were changed in location.
The girl was told, first, that the bubbles did not change when
the changes in the real world occurred in the absence of the bubble
holder. Then, she was also taught that the actions of the doll
would correspond to the contents of the bubble, even when these
were a "lie".
Progressively, the need for actually drawing the
bubbles corresponding to each character was faded. The girl was
encouraged just to think of the bubble each doll would have and
tell what they would be doing as a consequence.
After several weeks of teaching in these informal
situations, the girl was capable of passing the standard false-belief
test posed with the same dolls that had been used for the training.
This passing was accompanied by a verbalization in which she reasoned
"ah, she has the lie in her head, therefore she will look
there".
However, the aim of the teaching was not to enable
this girl to pass Theory of mind tests, but to give her a tool
that would be useful in her everyday life. Consequently, the teachers
would encourage her to analyse spontaneous situations arising
in her everyday life that involved some kind of false belief misunderstanding.
She was encouraged to think of these situations in terms of the
kinds of bubbles ("true" or "false") held
by the people involved. For example, in an occasion she was punished
for having hit another girl. Soon after, it turned out that it
was likely that she did not hit that girl and, therefore, she
had been punished wrongly. To ascertain what happened she was
asked to draw what the punisher had in her head and to label it
as "true" or "false". She drew a picture of
herself hitting the other girl and labeled the bubble as "false".
In another occasion, upon hearing that a Fax had
arrived from Juan Carlos, she said: "A fax from the king!".
She was then explained that it was not the king's fax, but a fax
from me. When asked to draw what she had thought, she again was
capable of correctly analysing the misunderstanding.
We are now conducting an experimental study about
the suitability of this technique with a group of children from
Great Britain, in collaboration with the same team that camed
out the "photos-in-the-head" study.
The use of photographs and drawings has also proved
useful in teaching aspects of pretend play. A crucial step in
the development of this ability in the children from the school
is the passage from playing with miniatures to using substitute
objects instead of the miniatures. A good technique to facilitate
this passage is to keep constant a particular scenario with which
the child is already familiar while substituting an object for
a single particular miniature. For example, if the child knows
a script for playing the "Cafeteria" with a collection
of bottle, dish, and cutlery miniatures, one possibility is to
hand him a wood block instead of the ketchup bottle at the particular
step in which he introduces the action of putting the ketchup
bottle on the tray. Keeping constant the other objects and the
action may help him to accept the pretence.
However, even in these conditions some children have
difficulties accepting the pretend object and reject the block
as a suitable object for the game. In these situations we have
found that it can be helpful to keep a photograph of the absent
object as reminder of the identity to be attributed to the block.
At least in one case, the passage from rejection to acceptance
was instantaneous upon recelving this help.
This suggests that the use of pictographic representations
may be a highly suitable technique for trying to develop in children
with autism some of the "metarepresentational" skills
they seem to lack. Of course, what we are doing is to provide
them with an analogue to deal with some aspects of this most important
side of our world and life. This analogue is bound to have limitations
and constraints in comparison with the original ability.
In summary, the discussion of new theoretical developments
in the context of the practical issues of assessment and intervention
with children with autism can be a useful source of ideas about
new ways to carry out these functions. In this presentation we
have discussed the practical derivations of a theoretical discussion
about the role of joint attention in requesting behaviours. Also,
we have shown how discoveries like the contrast between understanding
pictographic versus mental representations can generate new ideas
for intervention.
* Baron-Cohen, S. (1989). Perceptual role taking and protodeclarative pointing in autism.
British Journal of Developmental Psychology, 7: 113-127.
* Baron-Cohen, S.; Leslie, A. M.; & Frith, U. (1985). Does the autistic child have a 'theory of mind'? Cognition, 21: 37-46.
* Baron-Cohen, S.; Tager-Flusberg, H.; & Cohen, D. (Ed.). (1993). Understanding other minds: perspectives from autism. Oxford: Oxford University Press.
* Curcio, F. (1978). Sensorimotor functioning and communication in mute autistic children. Journal of Autism and Childhood Schizophrenia, 8: 281-292.
* Frith, U.; & Happé, F. (1994). Autism: beyond theory of mind. Cognition, 50: 115-132.
* Gómez, J. C.; Sarriá , E.; & Tamarit, J. (1993). The comparative study of early communication and theories of mind: ontogeny, phylogeny and pathology. In S. Baron-Cohen, H. Tager-Flusberg, & D. Cohen (Eds.), Understanding other minds: perspectives from autism (pp. 397-426). Oxford: Oxford University Press. (Trad. castellana: "El estudio comparativo de la comunicación temprana y las teorías de la
mente: ontogénesis, filogénesis y patología". Siglo Cero Vol. 24 (6): 47-62.)
* Happé, F. (1994). Autism: an introduction to psychological theory. London: UCL Press.
* Phillips, W.; Gómez, J. C.; Baron-Cohen, S.; La , M. V.; & Rivière, A. (1995). Treating people as objects, agents or "subjects": How young children with and without autism make requests. Journal of Child Psychology and Psychiatry, 16(8): 1383-1398.
* Swettenham, J.; Gómez, J. C.; Baron-Cohen,
S.; & Walsh, S. (1996). What's inside someone's head? Conceiving
of the mind as a camera helps children with autism acquire an
alternative to a theory of mind. Cognitive Neuropsychiatry
.1(1): 73-88.
This project was funded by a grant of the Spanish Ministry of Social Affairs (Ministerio de Asuntos Sociales). J. C. Gómez also acknowledges the support of a DGICYT grant (PB92-0143-CO2-02) from the Spanish Ministry of Education.