Thought Bubbles help children with autism acquire an alternative to a theory of mind

Henry M. Wellman, Simon Baron-Cohen, Robert Caswell, Juan Carlos Gomez, John Swettenham, Eleanor Toye, Kristin Lagattuta Autism, Vol 6(4) 343-363.

Children with autism have specific difficulties understanding complex mental states like thought, belief, and false belief and their effects on behaviour. Such children benefit from focused teaching, where beliefs are likened to photographs-in-the-head. Here two studies, one with seven participants and one with ten, tested a picture-in-the-head strategy for dealing with thoughts and behaviour by teaching children with autism about cartoon thought-bubbles as a device for representing such mental states. The prosthetic device led children with autism to pass not only false belief tests, but also related theory of mind tests. These results confirm earlier findings of the efficacy of picture-in-the-head teaching about mental states, but go further in showing that thought-bubble training more easily extends to children's understanding of thoughts (not just behaviour) and to enhanced performance on several transfer tasks. Thought-bubbles provide a theoretically interesting as well as an especially easy and effective teaching technique.

The theory of mind hypothesis for autism proposes that a central cognitive deficit for individuals with autism is an impairment in using mental state concepts. Mental state concepts such as a person's beliefs, knowledge, desires, and intentions, ordinarily allow us to understand our own and other's lives ('She doesn't know the song'), to predict behaviour ('She'll sing the wrong tune'), to interact socially ('To make her happy I'll choose a different song'), and to communicate ('She doesn't know that song, I'd better tell her the words'). Difficulties in understanding and using mental state concepts may therefore underlie the difficulties in social interaction and communication in autism. Most children with autism with mental ages well beyond 4 years have difficulties with tasks testing understanding of emotions, knowledge and ignorance, deception, and the mental-physical distinction, although these tasks are normally solved by 3- and 4-year-olds. The theory of mind deficit for autism has inspired possible training interventions for children with autism.

To overcome this problem, two recent studies have attempted to teach children with autism a more conceptually intriguing, picture-in-the-head strategy, to aid an understanding of mental states. Swettenham et al. and McGregor et al. al. both used training sessions where photographs were slotted into a manikin's head or a doll's head and children were told, 'When a person looks at something, they make a sort of a picture in their head'. Thoughts, including false thoughts, were thus portrayed as actual pictures inside a head.

In the present study we extend a general picture-in-the-head approach using a very different pictorial analogy: thought-bubbles. Thought-bubbles arguably provide a particularly natural or effective way of depicting thoughts pictorially, one that could come to aid autistic individuals reasoning about people, behaviour, and mental states. Such a strategy should provide a device for thinking about thoughts, and to be most effective should be based on cognitive abilities or skills known to be intact in individuals with autism.

The theoretical rationale for exploring a picture-in-the-head strategy receives some indirect, empirical support from a study by Hulburt et al. They elicited reports of inner experience (sampled during everyday activities) from three individuals with Asperger's Syndrome. These individuals consistently described only their perceptions and actions, devoid of thoughts, emotions, or inner speech. To the extent that they described inner experiences at all, however, they described them solely in terms of pictures in their head. Typical controls described a complex mixture of inner speech, emotional reactions, mental images, and pure thought.

Thought-bubbles are somewhat naturally occurring in that they, and relatedley speech-bubbles, appear in comics, cartoons, and sometimes in children's books. Moreover, 3-and 4- year-old normally developing children easily understand thought-bubbles as depictions of 'what the person is thinking', even in the case of mistaken thoughts or two people having different thoughts about exactly the same object.

False belief tasks come in at least two different forms. One, as in the Sally-Anne task, focuses on false beliefs created by a change of location. A second, captured in classic smarties tasks concerns beliefs about unexpected contents (a Smarties candy box that is opened to reveal pencils, not candy in it).

We do not want to give the false impression that thought-bubble instruction works effectively or easily with all children with autism, or even all relatively able children with autism of the sort we worked with. Several of the children we worked with learned very little. For several others, as noted, progress required creative tailoring to the child's skills, preoccupations, and limits (as well as teaching persistence).