Theory of mind ability in children with

speciŽ c language impairment

Alinda Gillott
Highbury Hospital, Nottingham, UK

Frederick Furniss
The Hesley Group, Doncaster and Centre for Applied Psychology,
University of Leicester, Leicester, UK

and

Ann Walter
Derbyshire Children’s Hospital, Derby, UK

Abstract

Whilst evidence of theory of mind impairments in children with autism is well

established, possible impairments in children with language disorder have
only recently been investigated. Children with speciŽ c language impairment
aged between eight and 12 years were matched by age and gender to high
functioning children with autism and normally developing peers. The theory of
mind abilities of the groups were compared using the strange stories task.
Both the children with speciŽ c language impairment and the children with
autism gave fewer correct mental state answers than normally developing
children, but whereas the children with autism gave more inappropriate
mental state answers than the children who were developing normally, the
children who were developing normally and the children with language
disorders did not differ in this respect. These Ž ndings are discussed within
the context of theory of mind issues in autism and the classiŽ cation of
language disorders.

Introduction

One of the predominant theories aimed at understanding social impairments

in children with autism is the theory of mind hypothesis (Baron-Cohen

Address for correspondence: Alinda Gillott, Clinical Psychologist, Learning Disability Service, Highbury
Hospital, Highbury Road, Bulwell, Nottingham, NG6 9DR, UK.

# Arnold 2004 10.1191=0265659004ct260oa

2 Child Language Teaching and Therapy

et al., 1985). Theory of mind (ToM) relates to the ability to infer other people’s
mental states (such as their thoughts, beliefs, desires and intentions) and to use
this information to make sense of, and predict, behaviour (Howlin et al.,
1999). Thus, impairments in mentalizing ability have implications for both
understanding social interactions and communicating personal needs. Utiliz-
ing tests of Ž rst and second-order theory of mind (Perner and Wimmer, 1985;
Perner et al., 1987), research has consistently demonstrated that children with
autism have a deŽ cit in this area (Baron-Cohen et al., 1985; Baron-Cohen,
1989; Frith, 1989; Yirmiya et al., 1996).
A small number of studies have investigated the theory of mind perfor-
mance of children with speciŽ c language impairments (SLI). Leslie and Frith
(1988) and Perner et al. (1989) compared children with autism with children
with speciŽ c language impairment (affecting comprehension) using Ž rst-order
false belief tasks. In both studies, the group with SLI performed signiŽ cantly
better than the group with autism, with all children but one passing the tasks.
This Ž nding led Leslie and Frith (1988) to conclude that language deŽ cits
could not account for the impairment of mental state concepts in children with
autism. More recent studies have given further attention to the possible
implication of language disorder in the development of ToM deŽ cits, and
have considered whether type of language disorder may be relevant. Prag-
matic, semantic and syntactic aspects of language have all been considered to
be related to theory of mind abilities, although possibly playing different roles
(Astington and Jenkins, 1999).
Children with semantic-pragmatic language disorders have been found to
perform as poorly as children with autism on tasks of false belief and
deception (Shields et al., 1996), and a number of researchers have argued
that this suggests that these disorders exist on the ‘borderlands’ of autism
(Shields et al., 1996; Botting and Conti-Ramsden, 1999). Studies using
children with phonologic-syntactic disorder have found less clear results,
with these children performing better than children with autism, but not always
as well as age-matched controls without any developmental disability (Shields
et al., 1996; Ziatas et al., 1998). One signiŽ cant question with respect to these
children has been whether any impairment in performance on ToM tasks
re ects a real impairment in underlying ToM ability or rather results from
difŽ culties in managing the linguistic complexity of these tasks. Miller (2001)
systematically varied level of linguistic demand in ToM tasks and found that
children with SLI performed similarly to same-age peers when linguistic
complexity was low, but similarly to younger children matched with them
on language comprehension ability when linguistic complexity was high,
suggesting that linguistic ability rather than underlying ToM ability limits the
 TOM ability in children with SLI 3

performance of such children on standard ToM tasks. Johnston et al. (2001)

found, however, that the use of cognitive state terms (know, pretend, think) in
the conversational speech of children with syntactic impairments resembles
that of younger language-age matched children, and is less than that of
children matched on mental age, in terms of both the proportion of speech
occupied by such terms and in the variety of terms used. Johnston et al. (2001)
argue that the absence of any advantage in this aspect of lexical usage for the
children with SLI over language-age matched children suggests that the two
groups do not differ in everyday use of ToM and hence that syntactic
difŽ culties, by impairing children’s abilities to verbally represent complex
propositional structures, may inhibit the development of ToM abilities.
Astington and Jenkins (1999) provided further support for the hypothesis
that syntactic abilities may facilitate the development of ToM in a seven-month
longitudinal study of normally developing three-year old children. With age
and previous performance level controlled, performance on standardized tests
of language ability predicted later performance on ToM tasks, but not vice-
versa. Furthermore, syntactic ability was a more powerful predictor of later
ToM ability than was semantic ability.
One potential limitation of previous research with children with SLI has
been its reliance on false-belief and appearance-reality tasks, which may
investigate only speciŽ c aspects of ToM ability. Further light may be shed on
the relationship between syntactic and ToM abilities by the use of more
complex and ecologically valid tests of theory of mind abilities. Happé’s
(1994) ‘Strange Stories’ task evaluates theory of mind abilities by asking
children to account for a person’s behaviour in twelve short vignettes. Happé
(1994) has suggested that her task may reveal subtle impairments in ToM
abilities, which may not be apparent with simpler Ž rst- or second-order theory
of mind tasks. If children with phonologic-syntactic language disorder do
experience difŽ culties with ToM, therefore, these may be more apparent with
the Strange Stories task than with the simpler tasks. In the present study, we
compared the performance of children with phonologic-syntactic impairments
on the strange stories task with that of autistic and normally developing
children. Differences in patterns of performance between the groups may
illuminate the relative in uence of linguistic and ToM ability in determining
the level of success of the children with SLI. If ToM ability itself is impaired
in children with SLI, then they should perform similarly to children with
autism in producing predominantly ‘physical state’ answers (i.e. explanations
which do not resort to inferences about mental states). If, however, it is the
linguistic demands of the Strange Stories which limits the performance of
children with SLI, then we might expect them to perform worse in producing
4 Child Language Teaching and Therapy

correct ‘mental state’ answers than the normally developing children, but to
produce a more diverse pattern of errors than the children with autism,
producing some ‘physical state’ answers but also producing many incorrect
mental state answers in which the character’s behaviour is explained as arising
from an inferred mental state but the linguistic complexity of the story results
in an inappropriate inference being made.

Method

Prior to the study, ethical approval was sought from two local National Health
Service Trusts. Following some slight amendments to the original proposal for
the study, full ethical approval was granted.

Participants
Fifteen children with speciŽ c language impairment (phonologic-syntactic)
were compared with 15 high functioning children with autism and 15 normally
developing children. Children were between the ages of eight and 12 years
(mean age across all groups 10.26 years) and were individually matched across
groups for chronological age and gender. Each group consisted of 13 boys and
two girls. Children from the group with SLI received their diagnosis prior to the
study by a speech and language therapist from a speciŽ c language impairment
team. Children with additional language impairments (such as semantic or
pragmatic difŽ culties) were excluded. Children from the group with autism had
also received a prior diagnosis according to the Diagnostic and Statistical
Manual of Mental Disorders Fourth Edition (American Psychiatric Associa-
tion, 1994) criteria by a clinical psychologist or paediatrician. Children from
the normally developing group were free of any diagnosis of psychiatric or
developmental disorder. Children in all groups had intellectual and reading
abilities within the average range, as assessed by their teacher or therapist. All
participants were assessed using the Communication Domain of the Vineland
Adaptive Behavior Scales – Interview Edition (Sparrow et al., 1984). Mean
standard scores were 100.3 (SD ˆ 17.9) for the typically developing children,
72.4 (SD ˆ 14.5) for the children with SLI and 75.8 (SD ˆ 12.4) for the
children with autism. One-way analysis of variance demonstated the existence
of a signiŽ cant effect of group on the Vineland Communication score
(F(2,42) ˆ 15.2, P < 0.01). Subsequent Scheffé tests conŽ rmed that the mean
Vineland Communication scores of the groups with autism and SLI did not
differ, but that both were signiŽ cantly lower than that of the group of typically
 TOM ability in children with SLI 5

developing children. The authors undertook no formal intellectual assessments.

All participants from the autism and normally developing groups attended
mainstream school. Of the children with SLI, eight attended mainstream school
and seven attended a specialist school for children of average intelligence with
language disorders.

Measure
The Strange Stories (Happé, 1994) were designed to test theory of mind in
more able children and adults with autism. The stories concern the different
motivations that can lie behind everyday social utterances that are not literally
true such as sarcasm, pretence, joking and lying.
The Strange Stories consist of 12 short vignettes, each accompanied by a
picture and two test questions: a comprehension question (‘was it true what x
said?’) and a justiŽ cation question (‘why did x say that?’). The 12 story types
comprised lie, white lie, joke, pretend, misunderstanding, persuade, appearance=
reality, Ž gure of speech, sarcasm, forget, double bluff and contrary emotion. In
each Story a character says something which is not literally true and the
participant is asked to explain why the character said what he or she said.
Answers given in response to the ‘why?’ question were evaluated for
correctness and for reference to mental states or physical (literal) states.
Answers classiŽ ed as mental state answers included ‘he doesn’t want to hurt
her feelings’ (white lie), ‘she was being sarcastic’ (sarcasm) and ‘she’s just
pretending’ (pretend). Answers classiŽ ed as physical state answers included ‘it
looks like a telephone’ (pretend), ‘because her hair was short’ (joke) and
‘because it’s raining’ (sarcasm). Answers classiŽ ed as incorrect included those
which made references to mental states inappropriate to the context of the story
such as ‘to get her jealous’ (pretend) and ‘he wanted to play a trick’ (forget).
Answers were scored on a 3-point scale: 2 points for a correct mental state
answer, 1 point for a physical state answer, and 0 points for an incorrect answer.

Interrater agreement
The data were coded by two raters, the Ž rst author and a Consultant Clinical
Psychologist who was blind to group status. Interrater agreement was calculated
using Kappa. Kappa for all stories across all three groups was found to be 0.77,
the range across stories being 0.64–0.87. Disagreements between raters were
discussed until a consensus scoring was agreed.

Procedure
The Ž rst author and child sat at a low table where the child was able to see and
read the stories. The set of Stories was introduced as follows: ‘I am going to
6 Child Language Teaching and Therapy

read you some stories and I’d like you to listen carefully. I will then ask you
two questions at the end of each story’. After each Story was read out aloud to
participants, they were asked the two test questions. The Ž rst question ‘was it
true what x said?’ was treated as a test of comprehension and was not scored.
(The second justiŽ cation question was not asked until comprehension was
established). The second question ‘why did x say that?’ was then asked and the
participant’s answer was recorded verbatim.
Other measures, the results of which are reported elsewhere (Gillott et al.,
2001), were also administered.

Results

The median number of mental state, physical state and incorrect responses
given by children in each group are presented in Table 1. Kruskal–Wallis
analyses of variance showed signiŽ cant between-group differences for the
number of mental state answers given (w2 ˆ 7.4, df ˆ 2, P < 0.05) and for the
number of incorrect answers given (w2 ˆ 8.7, df ˆ 2, P < 0.05), but not for
the number of physical state answers given. Comparisons between the
groups were made using Mann–Whitney U tests. For the number of mental
state answers given, signiŽ cant differences were found between the normally
developing groups and groups with autism (U ˆ 54.0, P < 0.05), and between
the normally developing and language impaired groups (U ˆ 65.0, P < 0.05)
but not between the language impaired groups and groups with autism
(U ˆ 88.0, NS). For the number of incorrect answers given, signiŽ cant
differences were found between the normally developing groups and groups
with autism (U ˆ 47.0, P < 0.01) and between the language impaired groups
and groups with autism (U ˆ 62.5, P < 0.05), but not between the normally
developing and language impaired groups (U ˆ 91.0, NS).

Table 1 Medians and semi-interquartile ranges (in parentheses) for numbers of

mental state, physical state and incorrect responses on the strange stories test
(maximum: 12)

Normally
developing SLI Autism
(n ˆ 15) (n ˆ 15) (n ˆ 15) w2
Mental state responses 8 (1.5) 7 (1.5) 6 (3.5) 7.4*
Physical state responses 2 (1) 4 (1.5) 2 (1.5) 4.9
Incorrect responses 1 (1) 2 (1) 3 (2.5) 8.7*

*P < 0.05.
 TOM ability in children with SLI 7

The semi-interquartile ranges for numbers of mental state answers given by

children in the groups with autism and SLI clearly indicate that despite our
failure to Ž nd a reliable difference between the groups on this measure, the
pattern of responses did differ between the groups. SpeciŽ cally, six (40%) of
the children with autism gave three or fewer correct mental state answers, three
giving no such answers, while only one child in the group with SLI performed
within this range, giving three correct mental state answers.

Discussion

In this study, normally developing children gave more correct ‘mental state’
responses to the Strange Story questions than either children with phonologic-
syntactic language impairments or children with autism, with the latter two
groups performing similarly in this regard. Unexpectedly, however, the groups
did not differ overall in the number of ‘physical state’ responses given. Rather,
the children with autism gave more incorrect responses than the normally
developing children and children with language impairment, with no signiŽ -
cant difference between the normally developing children and those with
language impairments in the number of such responses. Our results suggest
that children in the group with autism responded as if they did indeed have a
general ‘Theory of Mind’ insofar as they explained the behaviour of characters
in the Strange Stories in ways which suggest that they attribute mental states to
the characters, but that they were unable to accurately describe the mental state
likely to result in the behaviour described. The children in the language
impaired group produced a more heterogeneous pattern of responses, attribut-
ing correct mental states no more frequently than the children with autism, but
also attributing incorrect mental states no more frequently than the typically
developing children.
In contrast to the Ž ndings of Shields et al. (1996) and Ziatas et al. (1998), the
children with phonologic-syntactic language impairment in this study did not
succeed on a ToM task more frequently than the group with autism. There may
be several reasons for this Ž nding. It may be that there are substantial theory of
mind deŽ cits in children with phonologic-syntactic disorders which are more
evident with the more complex Strange Stories than with the Ž rst- and second-
order theory of mind tasks used in previous research with this population. We
cannot, however, exclude the possibility that the apparent similarity between
the performances of the children with autism and children with SLI results from
different impairments, with the performance of the children with autism being
limited by impairments in theory of mind ability, but the performance of the
8 Child Language Teaching and Therapy

children with language impairments being limited by impaired ability to

adequately express mental state attributions. The error patterns of the two
groups might be argued to support either conclusion. The fact that the children
with autism produced more incorrect mental state answers than the typically
developing children, whereas the children with language disorders did not, may
suggest that the errors of children with autism related speciŽ cally to ToM
deŽ cits, while those of the language disordered children resulted from a general
difŽ culty in expressing complex propositions. Alternatively however, these
results could be taken to suggest that the ToM development of the children with
autism was actually in some respect in advance of that of the group with
language impairments. This would suggest that the children with autism tended
to attribute the behaviour of characters in the Strange Stories to mental states,
but were unable to reliably infer the speciŽ c state involved, whereas the
children with language impairments did not even reliably identify the mental
state of the characters as a likely explanation of their strange behaviour. The
differences in patterns of correct mental state answers between the groups
suggest at least that the developmental trajectories of any ToM difŽ culties in the
two groups differ. A substantial proportion of the group with autism, but only
one of the children with SLI, gave very few (three or under) correct mental state
responses. Taken together with the higher number of incorrect mental state
answers given by the children with autism, this response pattern may indicate
that the children with autism experienced severe ToM difŽ culties but that many
had learned to apply generalized compensatory strategies such as offering an
explanation in terms of mental states to any question as to why a person acted in
a particular way. The frequency with which these explanations are inappropri-
ate to the given context would then suggest the continued existence of
underlying ToM difŽ culties. The children with severe language impairment
may by contrast demonstrate development of ToM abilities which is delayed
compared with that of nondisabled peers but which nevertheless follows an
otherwise normal developmental path.
In favour of the explanation of the performance of the children with
language impairments in terms of linguistic rather than ToM difŽ culties is
the fact that linguistic complexity has previously been shown to affect ToM
task performance for children with SLI, although the children in this study
were older than those in previous research (Miller, 2001). Shields et al. (1996)
also considered that difŽ culties in language comprehension may limit the
performance of children with language impairments on ToM tasks; this may have
been a factor in this study, although the children with language impairments
in this study were not reported to experience comprehension difŽ culties.
Although we took only a global measure of communication skills, the fact
 TOM ability in children with SLI 9

that the groups with autism and SLI performed similarly on this measure does
however suggest that the communication difŽ culties of the children with SLI
were no greater overall than those of the children with autism and therefore
that the difŽ culties of the language impaired group on the Strange Stories task
cannot be entirely attributed to purely linguistic difŽ culties.
Heterogeneity in the group of children with SLI may also have contributed
to the pattern of results seen. All children in the group with language
impairments had received a diagnosis of phonologic-syntactic language
impairment, which has been established as a robust language disorder
subgroup (Conti-Ramsden et al., 1997; Conti-Ramsden and Botting, 1999).
However, Chapman (1991) has argued that children with language disorder
can be variable in their language skills; and in fact, although Conti-Ramsden et
al. (1997) found psychometrically robust subgroups of SLI, they found in their
later study that individual children’s difŽ culties do change over time (Conti-
Ramsden and Botting, 1999). Therefore, Ž ndings in the present study may be
attributed to other unreported or newly emerging language problems, such as
pragmatic or language comprehension difŽ culties, in some members of the
language impaired group. Further research exploring theory of mind abilities
in children with different speciŽ c language difŽ culties would provide some
clariŽ cation on this issue.
Finally, the possibility must be considered that the patterns of ToM abilities
we observed might be accounted for simply by between-group differences in
intellectual ability. Although all the children in our study were evaluated by
teachers and therapists as having intellectual abilities within the normal range,
we undertook no formal intellectual assessments. We cannot therefore rule out
the possibility that overall performance IQ level might be higher in the group
of children with autism than in the group of children with SLI, and that such
an advantage in intellectual ability may have enabled the children with autism
to compensate for intrinsically greater difŽ culties with ToM so as to equal the
performance of the children with SLI in giving correct mental state answers.
In conclusion, the aim of this study was to explore theory of mind ability in
children with phonologic-syntactic language impairment. Early research
suggested that children with language disorders are not impaired in their ability
to mind read (Leslie and Frith, 1988; Ziatas et al., 1998) and that this
impairment is speciŽ c to children with autism (Baron-Cohen et al., 1985;
Frith, 1989). More recently, ToM impairment has been indicated in some
groups with SLI, although without clear results (Johnston et al., 2001; Miller,
2001). In the present study, children with SLI performed similarly to children
with autism in making appropriate mental state attributions to explain the
behaviour of characters in the Strange Stories task. We cannot exclude the
10 Child Language Teaching and Therapy

possibility that similarities in performance in the two groups result from

differing impairments, nor that heterogeneity in our group of children with
language disorders may be involved. Our results however add to the body of
evidence suggesting that children with SLI may experience difŽ culties with
ToM tasks, and further suggest that their performance more closely resembles
that of children with autism as the complexity and ecological validity of the
tasks involved increases.

Acknowledgements
This work was undertaken by Leicestershire and Rutland Healthcare NHS Trust
(or former Trust) which received a proportion of its funding from the NHS
Executive; the views expressed in this publication are those of the authors and
not necessarily those of the NHS Executive. The authors wish to thank the two
anonymous reviewers for their helpful editorial comments.

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