Autism,Asperger's&TheoryofMind

ALiteratureReview

Abstract:Thisliteraturereviewexaminesthehistoryand
pertinentresearchonAutism,abraindevelopment
disordercharacterizedbysocialimpairment,
communicationdifficultiesandritualisticbehavior,and
TheoryofMind,theabilityforonetoimputementalstates
totheselfandtoothers.Anintroductiontothesetopicsis
followedbyaninvestigationofwhetherTheoryofMindis
missingincasesofautism,whetheritistrulyacore
deficitofthedisorderandwhattheramificationsareif
thisisthecase.Alsoexaminediswhetherthisdeficitis
alsopresentincasesofAsperger'ssyndrome,where
languageisnotdelayedandIQsareusuallyhigh,asthere
hasbeencontroversyinthisarea.Possiblebiological
connectionsareexamined,includingtheMirrorNeuron
system.Alookattheworldoftreatmentandadaptive
technologysolutionsforthedeficitisalsoundertaken.

LarsSorensen
CognitionandChildren'sThinkingSeminar:295:590Spring2009

Introduction
Theoryofmind(ToM),theabilitytoimputementalstatestotheselfandothersandmake
reasoneddecisionsbasedonthisinformation,isacognitiveskillusuallyfoundintypicalchildrenby
theageoffourorfiveyearsold.Itisnowbelievedtobeacoredeficitincasesofautism,a
neurologicaldisordercharacterizedbysocialandcommunicationimpairment,repetitivebehaviorand
delayedspeech.Agreatdealofresearchhasbeendoneinthelastthirtyyearsthatfocusesonthisarea.
Doautisticchildrentrulyhaveaninabilitytoimaginewhatsomeoneelseisthinking?Ifso,whatdoes
thistellusabouttheautisticchild'sbrain?Arehigherfunctioningpeoplewithautismandpeoplewith
Asperger's,aconditionontheautismspectrumwithnodelaysinspeechorcognitivedevelopment,also
withoutToM?Whataretheimplicationswhenyoulacktheseskills?Itisgenerallyacceptedthat
autismisbiologicalinorigin,soisthereanareainthebrainwhereToMisprocessedthat'sdefectivein
casesofautism?Whatbiologicalcomponentleadstothispsychologicalphenomena?Isthereawayto
remedythissituationandteachToMtochildrenwhodonothaveitdevelopnaturally?
Inthisreviewallofthesequestionsareexamined.Thetopicsofautismandtheoryofmindare
introducedandthenbroughttogetherinanexaminationoftheworkdoneonthistopicoverthelast
thirtyyears.Alookatthediscoveryofthephenomenaandpossiblereasonsforwhyitexistsare
undertaken.Asperger'sandhighfunctioningpeoplewithautismarealsoexaminedasfarasToMis
concerned,astheirstoriesdifferandthedebateastowhethertheyshowthesamedeficitsasclassic
autismismoreheated.Aninspectionofsomeofthebiologicalreasoningforthiscondition,a
considerationoftheneurology,looksatthepossibleexistenceofaneuralsubstratethatcouldbe
responsibleforToM.Themirrorneuronsystemthatmayplayadeeproleinsocialcognition,ToMand
autismareexamined.Ananalysisoftreatmentandeducationtoolstoaddressthisdeficitfollows.

ThestoryofToMdeficitsincasesofautismispartneuroscience,partpsychology,part
medicineandpartdetectivestory.Attheendoftheday,it'sthestoryofresearchersandscientists
tryingtogettotherootcausesofautismsowemightunderstandthisconditionbetterand,perhaps,find
awaytostopit.

Autism
In1943Dr.LeoKannerpublishedareportonelevenofhispatientsataBaltimoreclinic.
Entitled,AutisticDisturbancesofAffectiveContact.(Kanner,1943),thisseminalpaperbecamethe
baseforallstudyonwhatcametobeknownasautism.Itisadisordercharacterizedbydeficitsinthree
majorareasofbehaviorsocial,communicativeandthedisplayofrepetitiveorrestrictedbehaviors.
TheDSMIVTRliststheessentialfeaturesasthepresenceofmarkedlyabnormalorimpaired
developmentinsocialinteractionandcommunicationsandamarkedlyrestrictedrepertoireofactivities
andinterests(APA,1994).Thesocialproblemsincludelesseyecontact,lessattentiontosocial
stimulianddifficultyinlearningandusingthesocialskillsneededtofunctioninsociety.The
communicationproblemisduetoasignificantdelayinlanguagedevelopmentseeninclassiccasesof
autism.Thisvariesonacasebycasebasisandifspeechdoesdevelopitisoftenjoinedbyechoalia,a
simplerepeatingofwhat'sjustbeensaidbysomeoneelse.Lastly,andperhapsmostoftenidentified
withautism,istherepetitiveorritualisticbehaviorsthatmanifest.Behaviorssuchaswantingthesame
foodsandclothseveryday,organizingthingsintolistsandinsistingonsameness,resistinganychange
inroutineorschedule.Allofthesesymptomsarethehallmarksofclassicautism.
Intheearlypartofthelastcenturyautisticchildrenwereoftenmisdiagnosedasbeing
schizophrenic(Grinker,2007).Fourtimesasmanymaleshavetheconditionthanfemales.While

autismwasoncethoughttobeveryrare(4in10,000),autismisnowthoughttobeverycommon
(possibly1in166)(SicileKira,2004).Thisislikelyduetothefactthatautismisnowseenasa
spectrumofdisorders,fromclassicautism(sometimescalledKanner'sautism)toAsperger'sSyndrome
toPDDNOS,PervasiveDevelopmentalDisorderNotOtherwiseSpecified.Autismisdiagnosedbased
onbehavioralsymptomsandnotwithanyobjectivebiologicalmeans,asituationthatwouldalso
bolsterprevalencenumbers.
Thecauseisalmostsurelyamixtureofbiologicalandenvironmentalfactorswithgenetics
playingalargerole.Inthe1960s,psychoanalystBrunoBettelheimportrayedautisticchildrenas
unreachableandblamedtheirconditiononunaffectionaterefrigeratormothers.Becausechildren
withautismoftenlookperfectlynormalphysicallyitwasthoughtthattheconditionwaswholly
psychogenic,orpurelyinthemind(BaronCohen,2008).Brainscanningtechnologyhasallowed
sciencetoprobetheautisticbrainanddiscoverthattherearemanyphysicaldifferenceswhencompared
totypicalbrains.Childrenwithautismwillhavemoregreyandwhitebrainmatterasyoungsters.
Eventually,thegreymatterwillstopincreasingbutwhitematterwillcontinuetoincrease,givingan
autismpatientmoreconnectivewhitetissuethanneurotypicalpeoplethroughttheirlives.Oftenthe
amygdalaandthehippocampusoftheautisticpatientaresmallerthanaverage.Thismayplayarolein
someofthesocialdeficitsseenlaterinanautisticchild'slife.Recently,therehasbeenascare
concerningchildvaccinationandwhethervaccinescouldplayaroleinautism.Spurredonbyone
faultystudy,theideathatvaccinescancauseautismhasnoevidencebehinditandisnowseenas
biologicallyimplausible(Paul,2009).
Veryfewpeoplewithseveretomoderateautismliveindependently,butsomearevery
successful(Howlin,Goode,Hutton&Rutter,2004).TempleGrandin,anautismadvocateandauthor

whodoublesasadoctorofanimalscienceatColoradoStateUniversity.PeterTorkoftheMonkees
rockandrollbandhasAsperger'sSyndrome.JasonMcElwain,ayoungmanwithautismwhowasthe
teammanagerforhishighschoolbasketballteam,gotachancetoactuallyplayattheveryendofthe
team'slastgamewhenhewasasenior.Withonlyfourminutesleftinthegamehescoredtwentythree
pointsandhitaschoolrecordsixthreepointers,lightingthebasketballworldonfireintheprocess
(McElwain&Paisner,2008).Unfortunately,storieslikethoseabovearefewandfarbetween.
Thereremainsnocureforautism.Newtreatmenttechniquesandearlyinterventionstrategies
givehopeforthefuture,buttheprognosisforapatientwithautismismixed.Sometimesachildcan
recoverorlosetheirdiagnosis,butthisisrareandinmostcasesduetoafaultyinitialdiagnosis.If
oneacquiresspeechandhasanIQabove50theirchancesforthefutureimprovedrastically,butbelow
thosefiguresresidesalifeofdependence.Autismisadevastatinganddebilitatingconditionthat
continuestoperplexthefieldsofmedicine,neurologyandpsychology.

TheoryofMind
In1978aresearchpaperwaspublishedthataskedthequestionwhetherachimpanzeecould
imaginewhatsomeoneelsewasthinkingandusethisinformationtoalteritsbehavior(Premack&
Woodruff,1978).Inthispaper,theabilitytoimputementalstatestotheselfandtootherswasgivena
name,TheoryofMind.It'smostoftendescribedas,Theabilitytoputyourselfinsomeoneelse's
shoesandusuallydevelopsintypicalchildrenbyfourorfiveyearsold.Itisconsideredahighorder
cognitivefeat.ManyclaimtothisdaythatToMispresentinchimpanzees(Call&Tomasello,1998)as
wellasinhumans.
Earlyinaninfant'slifetherearemanymechanismsthathelpussupportsocialcognitive

understanding,thingslikejointattention,gazefollowingandmonitoringgoaldirectedactions.As
thesemechanismsallowustogaininformationthedevelopinginfantwillsoonstartmakinginferences
andbegintoexpectpeopletostartlookingforitemswheretheylastleftthematfifteenmonths
(Goswami,2008).Inordertodothisonemustbeabletorepresentanotherperson'sthoughtsintheir
minds,theymusthaveawayoftreatingthisabstractinformationasanobjectintheirmind.Thisis
calledmetarepresentationalability.
Inhis1987paper,PretenseandRepresentation:TheOriginsofTheoryofMind,Dr.Alan
Leslieexaminedtheabilityofinfantstopretendandstillmanagetoavoidthecontradictionswithreality
astheinfantdealtwithpretense(Leslie,1987).Hepresentstheideaofprimaryrepresentations,our
ideasthatrepresenttherealitiesofourworld.Inorderforachildtopretend,theexampleusedinthe
paperistohaveachildpretendthatabananaisatelephone,thechildneedstodecouplefromthe
primaryrepresentationandformasecondaryrepresentationthat'snotnecessarilyinlinewithreality,a
representationofarepresentation,orametarepresentation.Thissecondaryrepresentationdoesnot
reflecttherealworldastheprimarydoes,itisnotveridicalasabananaiscertainlynotaphone.It
showsthattheholderisabletosuspendtheprimaryrepresentation,quarantiningit,andusethis
secondaryrepresentationforthepretendplay.
WhatdoesthishavetodowithToM?Lesliestatesthatwhenonethinksofrepresentationin
termsofmentalstates,people'sbeliefsanddesires,theyneedtodeploymetarepresentationsbecause
realitymayormaynotbeinuse.Theexampleusedis,Johnbelievesit'srainingandjumpsintoashop
doorwaybecausehedoesn'twanttogetwet.Itdoesn'tmatterifit'srainingornot,Johnbelieveditwas
andthisbeliefdictatedhisactions.Lesliepositsthatasecondaryrepresentationmustbeatplayhere
forustoconsiderthissituationproperlyandthattousethisopaquelogictoimputeactionsisto

employToM.HebelievesthatpretendplayisthebeginningsofToMasbothparticipantsinabanana
phonegamearesharingthepretensethatthebananaisaphone.Achildunderstandsthatanotheris
representingthebananaasaphoneforthegamejustliketheyare,andthereforehavesomeinsightasto
whattheotherchildisthinking.
ItisgenerallyagreedthatToMisnotpresentatbirthanddevelopsslowly(Goswami,2008).
Whiletheabilitytohavetwodifferentrepresentationsofthesamethinginone'smindisthebeginning
ofToM,thesituationquicklybecomesmorecomplex.Lesliestatesthatanexampleofcomplex
reasoningacrossmetarepresentationalstructuresistheabilityofachildtopredictthebehaviorof
someonewhoholdsafalsebelief(FB)(Leslie,1987).
ThephilosopherDanielDennettofTuftsUniversity,inhisbookBrainstorms,wasdiscussing
theoriginalToMchimpanzeepaperofPremack&Woodruffandstatedthattheonlyconvincing
evidencethathecouldthinkofforanapesuccessfullyattributingamentalstatetoanotherisifthey
couldpredicttheactionsofsomeonewhoheldabeliefthatwasn'ttrue(Dennett,1978).Hesaidthat
anyonecanpredictabeliefbasedonreality,butifwecanfigureoutwhatsomeonewoulddoifthey
wereinpossessionofbadinformation,thatwouldshowthatyouthattheywererepresentinganother
person'smentalstateintheirminds.
Alongtheselines,HeinzWimmerandJosephPernerdevisedatest,afalsebelieftest,thathas
cometobeseenastheclassicToMtestforchildren.Thatchildrenagedthreetofouryearsoldhaveno
understandingofFBwasabeliefthatwaswidelyheldintheearlyeighties(Wimmer&Perner,1983).
UnderstandingFBwasconsideredaqualitativeshiftincognitivedevelopmentandWimmerandPerner
lookedforawaytodetectthisshift.TheydevisedatestwhereachildwouldhearthestoryofMaxi,a
storycharacterthatleavesapieceofchocolateinacupboard.BeforegoingouttoplayMaxileaveshis

chocolateincupboardX.Whileheisoutsidehismothercomesalongandmoveshischocolateto
cupboardY.Maxithemcomesbackinsidethehouseafterplaying.Thechildrenbeingtoldthestory
arethentestedbybeingaskedwhereMaxiisgoingtolookforhischocolate.Thisisthekeypoint,
whereachildhastochoosebetweenwhathe/sheknowsisreality,thatthechocolateresidesincupboard
YorimputefromMaxi'sfalsebeliefthatMaxiisgoingtolookincupboardX.Theresultsofthestudy
showedthatchildrenatorundertheageoffourperformedatchance,nobetter,whilechildrenagedfive
tosixyearsoldperformedata92%successrateandsaidthatMaxiwouldlookforthechocolateinthe
lastplaceheknewittobe,cupboardX.Itseemedthattheabilitytorepresentafalsebeliefwas
somethingthatdidnotdevelopuntilonewasfiveyearsold.
ItwasnotlongbeforepeoplebegantoexpressworryabouttheMaxiFBtest.Somestatedthat
ithadarelianceonlanguagethatathreeyearoldmightnotbeabletonegotiateandthatotherresearch
wasshowingvestigesofToMinchildrenmuchyoungerthanfouryearsold.WastheWimmer&
PernerFBtesttheendallbeallofToMtestingorwasitfundamentallyflawed?Thetruthlikelyliesin
themiddleaspassingaFBtestdoesshowacertainlevelofToMbutdoesnotmeanthephenomenais
completelyabsentifonefailsit.Thelanguageobjectionissomethingweexaminelaterinthisreview
asadelayinlanguageisadefiningsymptomincasesofautismandtheuseofFBtestsinautistic
spectrumdisorders(ASDs)isnotwithoutcontroversy.Othermentalrepresentationtests,Flavell's
appearancerealitytests(Flavell,Flavell&Green,1983)andtheFalsePhototestofZaitchik(1990),
arewidelyusedteststoseeifachildhasissueswithrepresentations,buttheFBtestisstillconsidered
thegoldstandardfortestingbeliefrepresentationandToM.
HavingaToMandpassingthefalsebelieftestisconsideredamilestoneinsocialcognitive
development.Intheearlyeighties,whenagrowingawarenessofautismandASDsbegan,people

begantomakeaconnection.Ifacoresymptomofautismisalackofsocialskillandsocial
developmentandoneofthekeymilestonesforsocialcognitivedevelopmentisToMandfalsebelief
understanding,thenitmightbeinformativetoseehowToMdevelopsincasesofautismwhen
comparedtotypicalchildren.

Autism&TheoryofMind
InDoestheautisticchildhavetheoryofmind?,aresearchpaperbySimonBaronCohen,
AlanLeslieandUtaFrith(1985),theauthorssetouttodiscoverifToMwasdeficientincasesofautism
andifitwas,toshowthatitwasaphenomenathatwasspecifictoautismandindependentofmental
retardation.Thetheoryheldbytheauthorswasthatchildrenwithautismlackedtheabilitytocreate
andusesecondaryrepresentationsandthatthisdeficitwasnotduetomentalretardation,buttoanas
yetundetermineddeficitinaToMmechanismuniquetoautism.Afewthingsleadthemtothis
hypothesis.One,ifLeslie'sconnectionofsecondaryrepsandpretendplaywasontrack(Thispaper
waspublishedtwoyearsbeforeLeslie's1987Metarepresentationpaper,butmajorpartsofitare
includedherein1985,hehadalreadydevelopedthemajorideas)thenalackofsecondary
representationswouldhelpexplainthelackofpretendplayincasesofautism.Pretendplayisnot
lackinginclassicmentalretardationcases.EvenhighIQcasesofautismlackpretendplaybutseverely
retardedDown'ssyndromechildrendonot(Hill&McCuneNicholich,1981).Secondly,alackof
secondaryrepresentationswouldleadtopoorlydevelopedToMandthesocialineptnessthatthiscan
leadto.Socialineptnessisahallmarkofautism.Peoplewithautismoftenreportnotunderstanding
howothersthink.Onemanwasquotedassaying,otherpeopleseemtohaveaspecialsensebywhich

theycanreadotherpeople'sthoughts(Frith,Morton&Leslie,1991).AlackofToMcouldgoalong
waytowardsexplainingsomeofthesocialdeficitsthatappearinautismbutnotinotherformsof
mentalretardation,suchastheextrovertedexuberanceseenincasesofDown'ssyndrome.
Manyothercognitivedeficitshadbeenproposedtoexplainthebehavioralsymptomsofautism
inthepast(Frith,etal,1991).Theyincludedobjectpermanenceandperception,butwhenthese
aspectswereinvestigatednothingsolidcouldeverbefound.ToMseemedtantalizinglylikeacognitive
deficitthatcouldreasonablyexplainagooddealofthebehavioralsymptomsthatappearedinautism.
ThemethodoftheaforementionedBaronCohen,etal.,(1985)paperwassimple.Twenty
autisticchildrenwereadministeredafalsebelieftask,withfictionalSallyandAnnedollstakingthe
placeofMaxiandhismotherandamarbletakingtheplaceofthechocolate.Asacontrol,twenty
sevenclinicallynormalchildrenweretestedaswellasfourteenchildrenwithDown'ssyndrome.The
resultswerestriking.
TwentythreeofTwentyseven(85%)typicalchildrenandtwelveofthefourteenDown's
children(86%)passedtheFBtestwhilesixteenoftwentychildren(80%)withautismfailedit.Allof
thechildrenweretestedforreality(whereisthemarblenow?)andformemory(Wherewasthe
marble?)andallpassed.Thereseemedtobenomisunderstandingoflanguageusedduringthetests,it
seemedthatthechildrenwithautismcouldnotdifferentiatebetweentheirownknowledgeandthedoll's
knowledge.TheresultsseemedtoconfirmthehypothesisthatthereisaspecificToMdeficiencyin
casesofautism.
Furtherconfirmationofthisresultappearedin1989withtheSmartiestest(Perner,Frith,
Leslie&Leekam,1989),whereachildisaskedwhatwillappearinaboxclearlylabeledsmarties.
Oncetheboxisopeneditisrevealedthattheboxisfullofpencils.Thechildisthenaskedtwobelief

10

questions.Whatdidtheythinkwasintheboxbeforeitwasopened,towhichthetypicalchildanswers
smarties,andwhatwillthenextchildtowalkintheroomthinkisinthebox?Theanswergivenbya
normalchildwithtypicalToMwillalsobesmarties.Whenthistestwasadministeredtoautistic
childrentheyrepliedpencilstobothquestions,reflectingtherealityastheyknewitatthattimeand
nottheirpreviousfalsebelieforthefalsebeliefofthenextchildthatwouldwalkintotheroom.
FurtherinvestigationintothisphenomenahasshownthatverbalToMFBtaskscanbepassedby
typicalfiveyearoldsandstillfailedbyadolescentautistics(Roth,1991).
Soon,questionsabouttheFBtest'srelianceonlanguagebegantocropup.Ifdelayedlanguage
developmentisahallmarkofautism,peopleargued,whyareyouadministeringanFBtestthatrelieson
theunderstanding,somewouldsaynuance,oflanguage?HowcouldyouuseFBtestslikeMaxi'sto
testautisticchildrenwithoutlanguage?Anestimatedonethirdofautismcasesarewithoutlanguage
(Colle,BaronCohen&Hill,2007).CanFBToMtestsbetrustedifafullonethirdoftheautism
populationcannotbetestedinthesestudies?Thesewerevalidissuesandinordertocombatthemthere
havebeensomenonverbaltestsdeveloped.PicturesequenceshavebeenusedtotestToMability
(BaronCohen,1995)aswellasarecentmethodthatwasusedtotestautisticchildrenandchildrenwith
casesofselectivelanguageimpairment(Colle,etal.,2007).ToMdeficiencyincasesofautismwere
confirmedinbothcases.
ItseemsthatToMspecificallyiswhatisatissuehereaschildrenwithautismpassmanyother
perceptionandcognitionteststheywouldbeexpectedtofailiftheyweremerelyarrestedintheir
development.Theypasstheperspectivetakingtestsofthethreemountiansandthelineofsight
(BaronCohen,etal,1985)andalsopassZaitchick'sfalsephotographtest(Leslie,1992)thatdoesnot
testbelief,buttherecognitionthatphotosage.

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ToM,consideredahigherordercognitivefunction,hasleadsometoattempttodigevendeeper,
positingthatadeficitinachild'sbasicattentionalabilityasyoungaseighteenmonthsoldmayleadto
thepoorlydevelopedToMseeninthestudies.Inonestudy,anewmethodtoscreenautismateighteen
monthsoldwasusedtoidentifyandstudytwelveautisticinfantstoexaminetheirattentionshifting.It
wasfoundthatevenattwentymonthsoldthesechildrenshowedattentionaldeficitsthatmightbe
responsibleforthedeficitsinToMseenlaterintheirdevelopment(Swettenham,BaronCohen,
Charman,Cox,Baird,Drew,ReesandWheelwright,1997).Thiscouldalsoexplainthefailureof
autisminfantstomaintainjointattention(BaronCohen,1995).
WhatdoesthediscoveryofaToMdeficitincasesofautismmean?Inadisorderwithmultiple
possiblebiologicalcausesandamyriadofdifferentbehavioraloutcomes,thesestudiesmayhavefound
somethingthatallASDsshare,acoredeficitinacognitivefunction.Dr.UtaFrith,JohnMortonand
AlanLeslieexplainitwellbyexaminingautismatfourdifferentlevels(Frith,etal.,1991).The
biologicalaspectsofthedisorderleadtocognitivedeficitswhichleadtobehavioralsymptomsthat
lead,finally,tosocialimpairmentastheoutcome.Withmultiplepossiblebiologicalreasons(genetic,
disease,etc),multiplebehavioraloutcomes(languagedelay,nopretendplay,etc)andmanysocial
outcomes(inabilitytocommunicate,socialineptness)itseemsthattheonlythingthatiskeeping
autismasasinglediagnosisisthefacetthatissharedbyallcases,alackoffullydevelopedToMatthe
cognitivelevel.Itformsabottleneckthatleadsonetobelievethatallofthepossiblebiologicalreasons
maybeattackingasinglesystemthat'sresponsibleforToMandthatthissystem'slackofproper
developmentisresponsibleformostofthebehavioraloutcomes.Iftrue,thiscouldleadresearchersin
fruitfuldirectionsandhelpfocusasearchforfutureunderstandingoracure.

TheimplicationsofamodularToMsystemwillbediscussedlaterwhenthebiologyofautism

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andToMisdiscussed.First,anexaminationofanaspectthatcandogreatdamagetotheframework
givenaboveneedstobediscussed.ItisgenerallybelievedthatthereisacoredeficitinToMinclassic
autism,butdoesthesameapplytoalldisordersontheautismspectrum,specificallycasesof
Asperger's?

Asperger's
In1944,ayearafterthepublicationofLeoKanner'spaperonautism,adoctornamedHans
AspergerpublishedapaperinhisnativeGermanaboutahighfunctioninggroupofchildrenwithmany
ofthesymptomsofclassicautism,butsomedifferencesaswell.Imagineacaseofautismwithoutthe
delayoflanguageandwithanIQatorabovetheaverage.Havinganexcellentmemoryandanattention
fordetailthisgroupofchildrenstillhadsomeofthesymptomsofclassicautism,adesireforsameness,
ritualisticbehaviorandnarrowinterests.In1981whenDr.LornaWingsuggestedthatautismwasa
spectrumandnotacategoricaldiagnosis,shebroughtDr.Asperger'sideastotheEnglishspeaking
world(WoodburySmith&Volkmar,2008).In1994Asperger'ssyndromebecameadiagnosisinits
ownright(APA,1994)andisconsideredthehighestfunctioningconditionintheautisticspectrumof
disorders.
NotingthatsomeofthekeysymptomsofAsperger's,ritualisticbehavior,desireforsameness,
aresomeoftheaspectsofautismthatarenotclearlydefinedasresultingfromalackofToM,the
scientificcommunitybegantowonderifthedeficitinToMfoundinclassicautismreallyexistedin
casesofAsperger's.Ifitdidn't,thentheideathatlackingToMwasacoredeficitacrosstheentire
AutismspectrumofdisorderswouldbeinjeopardyandtheframeworklaidoutbyFrith,Mortonand
Lesliewouldcrumble.

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ABowlerstudy(1992)foundthatadultswithAsperger'snotonlypassedToMtests,theypassed
secondorderToMtests,whereasubjectisaskedtoreasonaboutthethoughtsofanotherperson.When
askedtoexplainsituationstheydidnotusementalstateterms,buttheydidscorejustaswellasthe
controlsinthestudy'sexperiments(Bowler,1992).Ifthisweretrueitwouldleadonetoadmitthata
ToMdeficiencyisnotacoredeficitacrosstheASDs.Theideathatthereisaconvergenceacrossthe
spectrumatthecognitivelevelofthedisorderwoulddisappearandjustificationforcallingallofthe
conditionsalongthespectrumbythesingletermautismwouldbequestioned(Frith,etal.,1991).
Dr.SimonBaronCohen,ProfessorofDevelopmentalPsychopathologyintheDepartmentsof
PsychiatryandExperimentalPsychologyandDirectoroftheAutismResearchCentreattheUniversity
ofCambridge,cametothetheory'srescue.HenotedwhathesawasaflawintheBowlerstudy.Adults
withAsperger'ssyndromewerepassingsecondorderToMteststhatwereactuallydesignedtoprobefor
ToMinatypicalchildattheageofsix.Childrenovertheageofsixwilloftenproduceceilingeffectsif
thesesecondorderToMtestsareused.Hestatedthatneitherfirstnorsecondordertestsweretruly
complextestsofToMandthat,findinga30yearoldindividualwithautism,ofnormalintelligence,
whocanpassatheoryofmindtestatthelevelofanormalsixyearolddoesnotleadtotheconclusion
thattheyarenecessarilynormalinthisdomain(BaronCohen,Jolliffe,Mortimore&Robertson,
1997).
WhatwasneededwasatesttodetectaToMdeficiencyinadults.TheHappeStrangeStorytask
wasintroducedin1994,andtestsasubject'sabilitytounderstandanonliteralstatement(Happe,1994).
Thistestwasaimedateightornineyearoldsandwasseenasabeingmoreadvancedthanprevious
ToMtests.Dr.HappefoundthatadultswithautismorAsperger'ssyndromedidhavetroublewith
mentalstatestorieswhilethecontrolsinthegroupdidnot.

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BaronCohenwentfurther,developingtheEyesTask,whereasubjecthastoinferthemental

stateofapersonfromjustlookingatapictureoftheperson'seyes(BaronCohen,etal.,1997).When
thistestwasused,adultswithautismandAsperger'sweresignificantlyimpairedinToMfunctioning.
ThereseJolliffeandSimonBaronCohenreturnedtotheHappetestandreplicatedherresultsin1999
(Jolliffe&BaronCohen,1999).ThefailureofautismandAsperger'ssubjectstoperformontheEyes
taskhasbeenreplicatedaswell(Kaland,Callesen,MollerNelson,Mortensen&Smith,2008).New
higherlevelToMtestscontinuetobedeveloped,liketheATOMIC,TheAnimatedTheoryofMind
InventoryforChildren,thatusesacomputerisedformatthattakesadvantageofthespecialinterestin
computingthatexistsintheAsperger'scommunity.ToMmeasuresarelackingwhenthistestis
administeredtoadultswithAsperger'saswell(Beaumont&Sofronoff,2008).Thereweresome
questionsastowhetherpeoplewithAsperger'ssyndromehadthesameToMdeficiencyseeninclassic
autismintheyearsaftertheASDToMtheorywaspublicized,butfurtherstudyhasleadtothe
conclusionthatwhilenewertoolswereneededtodetectit,aToMdeficitdoesindeedexistincasesof
Asperger'ssyndrome.

TheBiology
Attheveryendofhisseminalpaperonautism,LeoKannerfinishedhisstudy(1943)witha
rathersubjectivebuttellingnote.Hewrote,Oneotherfactstandsoutprominently.Inthewhole
group,thereareveryfewreallywarmheartedfathersandmothers...theyarepersonsstrongly
preoccupiedwithabstractionsofascientific,literaryorartisticnature,andlimitedingenuineinterestin
people.NotasbadasBrunoBettlehiem,butonedoubtswhethersuchaseeminglysubjectivething
couldbewritteninapublishedpeerreviewedarticletoday.

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ThereasontheKannerpassageisbroughtuphereistodiscussthepointthatautismandASDs
havelongbeenthought,eveninthedaysofKanner,tohavealargebiologicaland/orgeneticcomponent
involvedinthecause.Twinstudiesandthefactthatautismrunsinfamiliesisconvincingevidenceof
thisphenomena(BaronCohen,2008).Alsoseenwithinfamiliesthathavememberswithautismis
likelywhatKannerisdescribingabove,theBroaderAutismPhenotypeorBAP.Thisiswhenmembers
oftheimmediatefamilyofchildrenwithautismoftenshowmildmanifestationsandsome
characteristicsofautism,thingslikebeingsociallywithdrawnormildlyobsessive(BaronCohen,
2008).
WhatdoesthishavetodowithToM?IfToMisacoredeficitinautismthenonemightexpect
toseeloweredToMlevelsinfamilymembersaswell.Justthisphenomenawaslookedforandfoundin
astudywhererelativesofindividualswithautismexhibitedlowerthannormalratesofToMfeatures
suchasreasoningaboutother'semotionsandonmentalstatereasoningtasks(Gokcen,Bora,Erermis,
Kesikci&Aydin,2009).KnowingthatdeficientToMisatraitthat'salsopartoftheBAPleadsoneto
thequestion,isthereaphysicalbasisforToMdeficits?
AlanLesliehasproposedtheideaofadomainspecificprocessingmoduleforToMand
understandingmentalstatesinthebrain(Leslie,1992).Ifthistheoryofmindmechanismwaspartof
thebrainanditweredamagedordevelopedabnormally,onemightexpecttoseecaseslikethoseof
autism.Childrenwithautismcanpassothertasksthatrequiresophisticatedreasoning,it'sjustbelief
thattheyhaveproblemswith,sotheideaisreasonable.Leslieputsitthisway,Ihavearguedthatthe
normalandrapiddevelopmentoftheoryofmindknowledgedependsonaspecializedmechanismthat
allowsthebraintotoattendtoinvisiblementalstates.Veryearlybiologicaldamagemaypreventthe
normalexpressionofthistheoryofmindmoduleinthedevelopingbrain,resultinginthecore

16

symptomsofautism.(Leslie,1992)
Thisleadstothenextquestion,istherereallyaneuralsubstrate,somethingphysicaland
tangible,inthebrainforreasoningaboutbeliefs?Theideathatthereisaspecializedregioninthebrain
justforrepresentingbeliefshasbecomeverypopular(Goswami,2008).Themassiveleapsforwardin
brainimagingtechnologyhaveallowedscientistsandresearcherstobegintoprobethebraininnewand
uniqueways.Onecannowtakepicturesofthebrainandmonitoritsactivityasitperformscertain
tasks.Itwasduringanexperimentofthistypewithmonkeysthatasystemwasidentifiedthatmay
haveagreatdealtodowithToMdevelopment,theMirrorNeuronsystem(MNS).
Whilestudyingthebrainactivityofprimatesthemirrorneuronsystemwasdiscoveredwhenthe
subjectmonkeyswereengagedinobjectdirectedactions(Iacoboni&Dapretto,2006).Theseneurons
firednotonlywhenthemonkeyperformedtheactionbutalsowhenthemonkeysobservedsomeone
elseperformingthesameactions.Thiswasstrikingbecauseitleadthescientiststobelievethatthe
MNSmighthavesomethingtodowiththewayprimateslearntoimitateorcodeintentions.Inthemid
1990sPETscansprovidedevidenceforanMNSinhumans.Thesuggestionwasmadethatafully
developedMNSsystemisneededforearlyimitationandthatadysfunctioninthissystemcouldleadto
thedeficitsthatconstituteautism(Williams,Whiten,Suddendorf&Perrett,2001).
Iacoboni's(2009)contentionisthatifMNsfirewhenwewatchanactionandwhenweperform
theactiontheylikelyhavesomethingtodowithimitation.Notonlythat,butfurtherstudieshave
discoveredthattheMNSseemstobesensitivetobiologicalbeings,onlyfiringforpeopleperforming
actionsandnotmachines,andthatthesameactionwithdifferingintentionsfiresoffdifferentneurons.
Differentmirrorneuronsfirewhensomeonereachesouttodrinkfromacupofcoffeethantheneurons
thatfirewhensomeoneisreachingtopickupthesamecupandputitinthesink.Thiswasfascinating

17

becauseunderstandingintentionscanbethoughtofasimputingastateofmindfortheperson
performingtheaction,adefinitevestigeofToM.
CouldtheMNSbetheToMmechanismproposedbyLeslie?Currentlythisexplanationis
completelyspeculative(Goswami,2008)andafewpiecesofthepuzzle,suchasthefactthatvia
echoaliaandotherbehaviorsautisticchildrenareexcellentimitators(BaronCohen,2008),workagainst
thistheory.Still,manynewstudiescontinuetotieadysfunctionintheMNStoautism(Oberman&
Ramachandran,2007).Astechniquesforstudyingthebraincontinuetoimprovemoreinformation
abouttheconnectionbetweentheMNSandToMissuretobeontheway.

TreatmentandAdaptiveTechnology
NowthatithasbeenestablishedthatpeoplewithASDs,includingpeoplewithAsperger's
syndrome,haveadiminishedToMandthatthereasonmightbebiologicalinorigintherestillremains
onequestion,whatcanwedotoimprovethesituation?
Earlyinterventioninautismhasbeenshowntoimprovecognitiveskillsandtoaffectprogressin
cognitivelevelsreached(Itzchak,Lahat,Burgin&Zachor,2008)sotheearlierinachild'slifeone
looksfortreatmentandaidsthebetterthefuturesituationwillbe.ToaidToMperformancethereisone
areawheregoodresultshavebeenfound,computerinstruction.Unfortunately,usingthesemethods
usuallyrequireachildtobeolder,atleastoldenoughtooperateamouseandakeyboard.
ForyoungchildrenthereareDVDsandanimationprogramstoimproveToM.Avideoseries
calledThetransportersfeaturescarsthatmovealonginafictionalcity,eachwithafacegraftedonto
thefrontofthevehicle(BaronCohen,2008).Asthecarsgointodifferentsituationstheirfacial
expressionschangeandtheytalktoeachotherabouthowtheyfeelinmentalstateterms.

18

Oncechildrenbecomealittleoldertheycanbegintouseacomputer.Manycomputertraining
programsandadaptivetechnologysolutionstargetedatimprovingToMareinusetoday(Bernard
Opitz,Sriram&NakhodaSapuan,2001).Onedrawbacknotedisthatworkingalonewithacomputer
maynotbethemostsocialofexperiences,buttheskillslearnedinthisoneononepressurefree
environmentarepreferredbypeoplewithASDs(Siegal,2003).Otheradvantagestousingcomputer
aidedinstructionforToMtrainingarethatit'seasiertoscreenoutunnecessarysensoryinformation
whenconcentratingonthecomputerscreenandthatcomputershaveexplicitroutinesandclearstepby
stepprocessing.BoththesefeaturesareperfectforpeoplewithASDs.Computerinstructionisso
widelyfavoredamongpeoplewithASDsthatithasbeenreportedthattheyoftenpreferusingthe
computertoplayingwithtoys(Silver&Oakes,2001).

BecausepeoplewithASDshavelowToManddifficultyrecognizingorunderstandingemotions

inothers,computertrainingprovidesEmotiontraining.Softwarewasdevelopedandtestedin
Englandthatdisplaysafaceandletstheuserchoosewhatemotionisbeingdisplayed.Thereisno
pressureorscorewhengoingthroughasession.Wronganswersarejustmetwithasmallsignthat
says,tryagain.Aftertwentycorrectanswersthestudentcangoontothenextlevel.Heretheyare
presentedwithapicture,asmallstory,andaquestionaskingthemhowtheywouldreacttothe
situation.Againthereisnopressureandnoscore.Thesessionendswhentwentycorrectanswersare
tallied.AsampleoftwelvepeoplewithASDsusedtheexperimental'EmotionTrainersoftwareand
alldisplayedsignificantimprovementsinemotionrecognition(Silver&Oakes,2001).Onepieceof
interventionsoftware,GainingFace(http://www.ccoder.com/GainingFace/),isapublicprogramwritten
tohelpchildrenwithautismorAsperger'stolearnaboutfacialexpressions.Whileuseful,thisprogram
hasnopublishedevidenceorresearchastoitseffectiveness.

19

TechnologysolutionsforToMandunderstandingothersinsocialsituationsarenottiedtothe
desktop,mobiledevicesarecomingintowideuseaswell. Oneofthemoreinterestingprojectsisthe
PARLE(PortableAffectRecognitionLearningEnvironment)project(Bishop,2003).Peoplewith
autismtendtotakethingsliterally,tooliterally.IfIweretosay,Iwouldkillforaglassoflemonade,
apersonwithautismwouldlikelybefrightened,especiallyiftheywereholdingapitcheroflemonade.
PeoplewithanASDaresometimesmadetofeelsociallyinadequatewhentheyaren'tableto
understandsuchidiomsandbegintoavoidsituationswheretheymighthappen.Thisbeginsa
downwardspiralthathurtsthesocialgrowthofthepersonwithanASD.PARLEprovidesawayto
begintocombatthisandbeginimprovingaperson'sToM.
PARLEtakestechniquesfromSocialSkillsTrainingandputtheminahandhelddevice.When
involvedinasocialsituationapersonwithASDcantakeastepback,consultthePARLEsystemand
getaresponsetheyunderstand.Forexample,whenaskingforhelpinagrocerystoreamanwithan
ASDmightbecomequietallofasudden.Thewomanhelpinghimsays,What'sthematter,thecatgot
yourtongue?Asyoucanimagine,aliteralinterpretationofthissentencewouldbeabitconfusing.
EnterPARLE.TheusercanenterthephraseintoamobileInternetbasedphonethatconnectstoa
databasesystemthatfieldstheman'squery.Thedatabasethenresponds,youappearquiet,why?
Thisissomethingourmaninthestorecanunderstand.Hecanrespondtothewomanproperlynowand
theirsocialinteractioncancontinue.Suchsociallearningwouldbeenormouslybeneficialtoaperson
withanASD,expandingtheirzoneofcomfortandallowingthemtoexperiencemoreintheirlives.
ThiskindofinsightcouldimproveToMaswell.Theycouldbeconfidentthattheywillbeabletoreact
andrespondproperlytoahostofsocialsituations,learnaboutthementalstatesofothersandsocialize
moreasaresult.

20

ThroughtheuseofDVDs,computeraidsandsocialtrainingthelackofToMseeninASDsis
beingaddressedspecifically,apositiveresultthathascomefromtheresearchinthisareaoverthelast
thirtyyears.

Conclusion
Afteranexaminationofthescholarshipofthelastthirtyyearsonthesubjectofautismand
theoryofmind,onethingseemsclear.Theredoesindeedexistevidencethatalackofafully
functioningtheoryofmindisacoredeficitincasesofautism.Whilethereexistedsomecontroversyas
towhethercasesofAsperger'ssyndromeshowedthesamedeficit,furtherstudyrevealedthatthisis
likelythecaseaswell,thattheToMdeficiencystretchesacrosstheentireautismspectrum.Afterthe
discoveryofthisphenomenafurthertestingwithmoreadvancedToMtestshaveconfirmedthese
findingsmanytimes.Inadisorderwithmultiplepossiblebiologicalcausesandmanydifferent
behavioraloutcomesitseemsthatalackoffullydevelopedToMatthecognitiveleveliswhatreally
definestheASDs.
Thishasleadthescientificcommunitytolookforabiologicalcomponenttothispuzzle,a
physicalmechanismthatmayberesponsibleforfunctionalToMinhumans.Mirrorneuronsmayvery
wellbethatmechanism.Computerassistedtraininghasproventobeasuccessfulmethodfor
combatingsomeofthesocialoutcomesthatresultfromtheToMdeficit.Computerapplicationsthat
helppeoplewithautismunderstandemotionsandthemetalstatesofothersshowpositiveresultsand
newermobileapplicationsletchildrenandadultswithautismtaketheirsolutionsontheroadwith
them.Thediscoveryofthiscoredeficithasallowededucatorstofocusonthisaspectofcognitive
functioningandtailortheircomputersolutionsaccordingly.

21

Byrecognizingandstudyingthisaspectofcognitivedevelopmenttheresearchcommunityhave
providedaguidefortreatments,understandingforfamiliesandpeoplewithautismandadirection
forwardforfutureresearch.Hopefully,someday,researchofthiskindcanleadtothedetectionofthe
rootcauseofASDs.

22

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