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Child Psychiatry Hum Dev (2009) 40:169–182

DOI 10.1007/s10578-008-0119-4

ORIGINAL ARTICLE

The Relationship Between Theory of Mind


and Executive Function in a Sample of Children
from Mainland China

Juan Yang Æ Shijie Zhou Æ Shuqiao Yao Æ


Linyan Su Æ Chad McWhinnie

Published online: 9 September 2008


Ó Springer Science+Business Media, LLC 2008

Abstract To explore the relationship between theory of mind (ToM) and executive
function (EF) in a sample of individuals from mainland China, 20 children with autism
spectrum disorders (ASD), 26 children with Attention Deficit Hyperactivity Disorder
(ADHD), and 30 normal control subjects were compared on two batteries of ToM tasks and
EF tasks. Children with ASD had a significant theory of mind impairment relative to the
other controls, while non-verbal IQ removed group differences in executive function. ToM
was significantly correlated with inhibitory control. Performance on inhibitory control
tasks, however, did not affect performance on ToM tasks.

Keywords Theory of mind  Executive function  Autism

Introduction

At 4 years of age, two robust changes take place within the theory of mind and executive
function domains [1]. Theory of Mind (TOM) is a label for the commonsense psycho-
logical concepts we use to attribute mental states to ourselves and others (i.e., what one
knows, wants, thinks, feels) [2]. Executive function (EF) is traditionally used as an
umbrella term for functions such as planning, working memory, impulse control, inhibi-
tion, and shifting set, as well as the initiation and monitoring of action [3]. Around the age
of 4 years, typically developing children could be able to understand that one can be
mistaken about the world, that is, to understand false belief [1], and the distinction between
appearance and reality [1]. At about the same age, typically developing children outgrow
these limitations in executive function tasks [1]. They share a common developmental
timetable. Moreover, both ToM and EF appear to be mediated by the same region of the

J. Yang  S. Zhou (&)  S. Yao  L. Su


The Clinical Psychological Research Center of the Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, People’s Republic of China
e-mail: zhousj2003@yahoo.com.cn

C. McWhinnie
Department of Psychology, McGill University, Montreal, Canada

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prefrontal cortex in adults [4, 5]. Last, some studies found both ToM and EF are deficient
in individuals with Autistic Spectrum Disorders (ASD) [6–8] Further research needs to
demonstrate the precise nature of the link between ToM and EF.
Recently, the relationship between ToM and EF has been examined in children with
neuropsychological deficits, including ASD and ADHD [6, 8–14]. As deficits in ToM and
EF are thought to characterize or contribute to these disorders, findings related to the ToM/
EF relationship in ASD or ADHD could be good for the assessment and treatment of ASD
and ADHD.
Autism spectrum disorder (ASD) is a complex developmental disability that typically
appears during the first 3 years of life. All children with ASD demonstrate deficits in
(1) social interaction, (2) verbal and nonverbal communication, and (3) repetitive behav-
iors or interests. Autism spectrum disorder is often used interchangeably with Pervasive
Developmental Disorder (PDD) in the literature and in common practice to refer to Autism,
Asperger syndrome, and Pervasive Developmental Disorder Not Otherwise Specified
(PDD-NOS) [15]. Autism spectrum disorders are now generally regarded to be of
neurobiological origin. The specific underlying psychological or neurophysiological
mechanisms are simply not known, although it is likely that there are several etiological
pathways that lead to disorders in the autism spectrum.
Recent estimates of prevalence rates of autism in Western and Eastern cultures suggest
they are similar. Using national disability data provided by the Australian Institute of
Health and Welfare (AIHW), and Centrelink data, prevalence rates of autism in Australia
in 2003–2004 ranged from 8.5 to 15.3/10,000 for 0–5 year olds, 12.1 to 35.7/10,000 for
6–12 year olds and 8.3 to 17.4/10,000 for 13 to 16 year olds [15]. Data collected in the US
during 2003 indicate that 38 per 10,000 children have autism [16].
Research in Asian countries has suggested similar, albeit in the low range, prevalence
rates of autism spectrum disorder. From 1986 to 2005 in Hong Kong, autism spectrum
disorder occurred at a rate of 16.1 per 10,000 for children less than 15 years old [17]. In
Tianjin a city in mainland China, the prevalence of autistic disorder in children aged
2–6 years, was 11 per 10,000 (at the time, the population of children below 15 years old in
Tianjin is 1,283,700) [18].
Attention-Deficit/Hyperactivity Disorder (ADHD) is another neurodevelopmental dis-
order whose primary features include symptoms of impulsivity, hyperactivity, and/or poor
attention. The DSM-IV recognizes three subtypes of ADHD. The Predominantly Inattentive
Subtype (ADHD-I) is used to describe children who meet six of nine symptoms of inat-
tention, such as ‘‘often has difficulty sustaining attention in tasks or play activities.’’ The
Predominantly Hyperactive/Impulsive Subtype (ADHD-HI) is applied to those who meet
six of nine symptoms hyperactivity and impulsivity. A Combined Subtype (ADHD-C) may
be diagnosed if an individual meets criteria for both of the other subtypes. Recent family,
twin and adoption studies have provided strong evidence for a genetic etiology of the
disorder, although there is little compelling evidence for specificity of genetic factors.
Consensus among six studies conducted in the US suggests prevalence rates of 9.5–16.1%
for ADHD symptoms assessed using DSM-IV-TR criteria. [19]. Research in Asian countries
has revealed prevalence rates at the low end of this range. For example, an epidemiological
study in Taiwan revealed prevalence of ADHD in Taiwan in 1993 is 9.9% (DSM-III-R) [20].
Similarly, the prevalence of ADHD was 8.9% in Hong Kong, according to a 1996 study
(DSM-III) [21]. Between 2002 and 2005 in mainland China, four studies reported the
prevalence rate of ADHD in Mainland China as varying from 2.5 to 13.58% [22–25].
Based on recent investigations of typically developing children and children with ASD
or ADHD, researchers have proposed several hypotheses to explain the link including:

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(1) ToM is a prerequisite for EF; (2) EF is a prerequisite for ToM; and (3) executive
components are in ToM tests [1].
Regarding the notion that ToM is a prerequisite for EF, some researchers posit that ToM
deficits cannot exist when an individual possesses intact EF. Specifically, Wimmer [1]
suggested that with the formation of increasingly sophisticated mental concepts, the child
gains better understanding of her own mentality, which provides the child better control of
her mental processes and action. Similarly, Perner [11] proposed that the key conceptual
change for children around age 4 years is an explicit understanding of representations as
representations (i.e., metarepresentation), which is critical to the development of executive
control. Thus, Wimmer and Perner’s central claim is that the acquisition of a ToM leads to
improved self-control. Pellicano recently demonstrated empirical support for such a claim
when in a study that assessed high-functioning autistic children and typically developing
children, matched on age, verbal IQ, and nonverbal IQ, on a battery of tasks measuring
ToM and components of EF [11]. As expected, a significant correlation emerged between
ToM and EF composite scores in the autism group, independent of age and ability.
Conversely, contrary to the hypothesis that ToM is a prerequisite for EF, however, it was
revealed that autistic children had impaired ToM with intact EF.
Such contradictory findings have led other researchers support the idea that EF is a
prerequisite for ToM, which assumes that executive control is necessary for insight into
one’s own and other’s mental states [1]. According to this idea, the inability to monitor
one’s own actions is the central impairment in autism, and leads to a failure to develop an
understanding of mental concepts. This idea excludes the possibility of EF impairment
with intact ToM. In samples matched for chronological age, verbal ability, and gender,
researchers have compared groups of high-functioning autistic children and adolescents to
clinical control groups, including subjects with dyslexia, other learning disabilities,
attention deficit hyperactivity disorder (ADHD) and mild mental retardation, on ToM and
EF tasks [6, 9]. In the autism groups, significant correlations have emerged between the EF
and ToM composite scores, while similar correlations do not exist in the clinical control
groups.
Ambiguous findings from past studies examining the relationship between ToM and EF
have prompted further investigation from researchers seeking to disentangle the precise
relationship between ToM and components of EF, particularly among autistic children.
Zelazo et al. [8] examined the relationship between ToM and rule use, one aspect of EF.
ToM performance was unrelated to rule use for severely impaired children (VIQ B 40),
while conversely the correlation between ToM and rule use was high for mildly impaired
children (VIQ [ 40). The authors concluded that poor performance on ToM tasks might be
attributed to a more general difficulty using higher order rules to integrate two incom-
patible perspectives into a single system of inferences. Of note, Zelazo et al. study did not
include a comparison group, and just analyzed one aspect of EF.
Using a training paradigm, Fisher and Happé investigated the relationship between ToM
and EF in children with autism spectrum disorders. Results indicated significant
improvement on the ToM tasks in the EF-trained group, but no significant improvement on
the EF tasks in the ToM-trained group [10]. Furthermore, the same result was also found in
typically developing children. Examining EF–ToM relations in children age 24 and
39 months, Carlson et al. [26] found EF at Time 1 significantly predicted ToM at Time 2,
while the reverse relation was not significant.
Although research has shed light on the nature of the ToM–EF relationship through the
investigation of children with autism and typically developing children, a similar rela-
tionship between ToM and EF does not hold in children with Attention Deficit

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Hyperactivity Disorder (ADHD). A survey of the literature reveals mounting evidence that
children with ADHD have unimpaired ToM but executive dysfunction [12–14].
Finally, Russell [1] proposed that a typical ToM task contains an executive component-
inhibitory control, namely to suppress a natural response tendency. In support, Carlson
et al. [27] found that two inhibition tasks (Bear/Dragon and Whisper) were significantly
related to theory of mind after accounting for age, receptive vocabulary and planning has
supported the third account. Furthermore, studies using other inhibition tasks have similar
findings [28–31]. In spite of this, there are several indications that inhibitory control is not
the critical problem in the ToM task [32].
In sum, the nature of the relationship between ToM and EF remains perplexing.
Additionally, ASD and ADHD have been widely researched in Western countries and
cultures. With considerable attention given to the recent rise of psychopathology in
mainland China, especially among children and adolescents [33–35], there is growing
interest in the etiology, assessment and treatment of disorders such as ASD and ADHD.
The purpose of the present study, therefore, was to further explore the relationship between
ToM and EF in two clinical samples of children, one with autism spectrum disorder (ASD)
and one with Attention Deficit Hyperactivity Disorder (ADHD) as well as a sample of
typically developing children (TD). While there has been previous research examining the
relationship between EF and ToM in Asian countries, this study is the first to explore the
relationship between theory of mind and executive function in children with ASD and
children with ADHD in mainland China.

Method

Participants

The study included 20 children with ASD (18 male, 2 female; minimum age = 3.5 years,
maximum age = 15.5 years, mean age = 8.1 years, SD = 3.5), 26 children with ADHD
(22 male, 4 female; minimum age = 3.3 years, maximum age = 13.5 years, mean
age = 8.2 years, SD = 2.9), and 30 typically developing children (27 male, 3 female;
minimum age = 3.7 years, maximum age = 15.8 years, mean age = 8.0 years, SD = 3.1).
There were no significant differences in age among the three groups (F = 0.013, p [ 0.05).
All the patients were recruited from the Second Xiangya Hospital of Central South
University in Hunan province in the central south of mainland China, meeting the fol-
lowing inclusion criteria: (1) DSM-IV diagnostic criteria for autism spectrum disorder
(N = 20, including five Asperger, 11 Autism, two PDD-NOS and two undifferentiated) or
Attention Deficit Hyperactivity Disorder (N = 26, including three ADHD-I, two ADHD-
HI, 17 ADHD-C, four undifferentiated); (2) no visual (including color blindness) or
auditory disabilities; and (3) no motor system disability. A veteran psychiatrist (affiliated
with Second Xiangya Hospital and Xiangya Medical College), with expertise in the
assessment of ASD and ADHD, conducted all diagnostic interviews and subsequent
diagnoses.
All healthy children were recruited from local preschools and schools and were assessed
by means of a structured interview with their teacher to ensure that each child had no
mental retardation or personal history of mental or medical illness that might impair
cognitive function (e.g., central nervous system infection). In addition, they also met the
inclusion criteria from (2) and (3). Approval was obtained from the Second Xiangya
Hospital Ethics Committee. All parents gave informed written consent.

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Measures

Intelligence Measures

Previous studies [36–40] have suggested that verbal ability can affect autistic children’s
ToM abilities, while others [41, 42] that verbal ability has no effect on ToM ability.
Because of the controversy, the impairment in verbal ability of autistic children, and the
limits of verbal tests, instead of using the China-Wechsler Young Children Scale of
Intelligence(C-WYCSI) or the Wechsler Intelligence Scale for Children-revised in China
(C-WISC), we chose the Gong’s Non-verbal Intelligence Test (GNIT) to assess their
nonverbal Intelligence Quotient (NVIQ). The test-retest reliability of the six subtests
ranged from 0.28 to 0.57. The correlation between GNIT and C-WISC is 0.65 [43].

ToM Measures

Appearance-Reality (ToM1) The task was adapted from Flavell et al. [44, 45], investi-
gating participants’ understandings of perceptive information and abilities of manipulating
two conflicting representations of an entity (its real and its apparent identity). Material was
styrofoam made to look like an apple. In the experiment, children first were shown how the
Styrofoam looked and the true identity. Next, the experimenter asked: (1) the appearance
question (What does this look like?) and (2) the reality question (What is it really?).
Participants received one point only if they passed the two questions. Thus, task scores
ranged from 0 to 1.

Unexpected-Location (ToM2) The task was modeled after Baron-Cohen et al.’s Sally-
Anne task [46]. Two puppets (Gang and Ling) were as materials in this task. Ling placed a
bag of candies in one location (a circular candy box) and left the room. When Ling was
absent, Gang transferred the bag of candies from the circular box to another location.
Children were asked to answer (1) the reality question (Where is the bag of candies now?)
and (2) the false belief question (After Ling returns and she wants to eat a candy, where
will she look for her candies?) The reality question was the control question. Children who
failed the reality question were excluded. Participants received one point if they passed the
false belief question. Thus, task scores ranged from 0 to 1.

Unexpected-Content (ToM3) This task is adapted from Perner’s et al. Smarties test [1].
For this task, the children were shown that a familiar candy box had unexpected contents
(a pencil) and then asked (1) the reality question (What does it contain actually?), (2) the
false belief question about oneself (When you saw the box in the first time, what did you
think it contained before it opened?), and (3) the false belief question about other (If your
best friend is coming in now, and he or she did not know what it was in the box, before he
or she sees the box, what will he or she think it contains?) The reality question was the
control question. Children who failed the reality question were excluded. Participants
received one point if they passed the second or the third question. Thus, task scores ranged
from 0 to 2. The ToM composite score ranged from 0 to 4, which met assumptions of
normality.

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EF Measures

Spatial Working Memory (SWM) The task is adapted from the Corsi Block Task, a
widely used neuropsychological test of spatial working memory [47]. Our Corsi apparatus
consisted of a set of twelve identical blocks (2.5 9 2.5 9 2.5 cm) irregularly positioned
on a wooden board (19 9 26 cm). The experimenter points to a series of blocks at a rate of
one block per second. Subsequently, the participant is required to point to the same blocks
(1) from left to right or (2) backwards. The length of the block sequences increases until
recall is no longer correct. The score is equal to the longest recalled sequences of type and
then added together. The Corsi Block task has become prominent enough to be included as
a component of a major neuropsychological battery. It was not feasible, however, to
calculate reliability estimates for the Corsi Block task, as this measure incorporates
stopping rules as part of its administration.

Stroop The Stroop test is a test of inhibition [48]. In the current study, numbers were used
instead of color words. Our version presents three levels of the task.
Level 1—Count how many black spots are in every rectangle.
Level 2—Count how many numbers are in every rectangle that matches the number
name, just like 1,22,333,4444, are numbered 1,2,3,4.
Level 3—Count how many numbers are in every rectangle that does not match the
number name, just like 3,55,111,2222, are numbered 1,2,3,4.
The score depends on performance in Level 3.
For most versions of the Stroop test, there are no available estimations of the reliability in
children. Only Siegrist reported the test-retest reliability for color words version was 0.86
in 45 female aged from 20 to 41 years [49], and Salthouse and Meinz [50] reported both
the color and number versions have good reliability (greater than 0.62).

Wisconsin Card Sorting Test (WCST) This task was originally developed by Grant and
Berg [51] to measure mental flexibility. In this task, subjects must sort cards on one of
three possible dimensions (color, number, and figure) according to a non-spoken rule and
then shift to sort cards along a different dimension. Measures for scoring include: Total
trials (TT), Categories completed (Cc), total number of errors (E), and number of per-
severative errors (PE). Because subjects’ total trials are different, E, and PE are expressed
in the form: E/TT, and PE/TT. It has been used successfully with children [52], and
extensively used to examine executive function deficits in children with autism [53].
Ozonoff reported the test-retest generalizability coefficients are greater than 0.90 in autistic
group [54].

Procedure

Permission was granted by the school’s educational board, as well as children’s guardians,
to test participants in schools and in the mental health center. Before the experiments, the
experimenter was acquainted with autistic participants by playing with them. During the
experiments, the experimenter and the autistic children sat face to face, while their parent
or teacher was behind him or her. Other children were not accompanied by a parent or
teacher. All tasks were presented in predetermined orders, which were counterbalanced
across subjects. Participants answered the questions verbally or using gestures.

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Data Analysis

Analyses were carried out using SPSS Version 12 for Windows. Covariance analysis was
performed to study differences among the three groups, and partial correlation analysis was
applied to evaluate the relationships between EF and ToM.

Results

Background Data Analysis

Preliminary analysis of NVIQ scores revealed skewness in ASD was 0.16, in ADHD was
0.60, and in TD was 0.14. It is widely accepted that data sets with indices of skew that
range between ±0.50 may be considered sufficiently symmetrical for most practical
applications [55]. Skewness quotients for NVIQ scores in the ASD and TD samples fell in
the acceptable range, which suggests that a skewed distribution was not a critical problem
in the current study. One autistic child could not complete the Gong’s Non-verbal Intel-
ligence Test, so we had 19 children with ASD (M = 96.68, SD = 24.63, Range: 47–147,
including NVIQ \ 70:2, 70 \ NVIQ \ 120:14, NVIQ [ 120:3, and one child could not
complete the Gong’s Non-verbal Intelligence Test), 26 children with ADHD (M = 109.96,
SD = 14.93, Range: 87–142), and 30 typically developing children (M = 118.23,
SD = 12.06, Range: 97–143). There were significant differences between ASD and TD
groups (d = 21.55, p \ .05), while no significant differences were found between ADHD
and ASD (d = 13.28, p [ .05), ADHD and TD (d = 8.27, p [ .05) individually. Thus,
NVIQ covaried in all subsequent analyses involving these groups.

Theory of Mind Assessment

Children’s performance on the theory of mind measures in each group is shown in Table 1.
As indicated, group differences were found on ToM composite after controlling nonverbal
IQ. Post hoc tests revealed that the group effect was due to significantly worse performance
on ToM tasks by the autistic than the control groups (the ADHD group, d = -1.731,
p \ 0.01; and the TD group, d = -2.153, p \ 0.01). The ADHD group did not differ

Table 1 Group differences on ToM and EF tasks controlling for nonverbal IQ (means (SD))
Autism (n = 20) ADHD (n = 26) TD (n = 30) F

ToM Com 1.32 (1.38) 3.23 (1.18) 3.77 (0.90) 18.381**


SWM 9.21 (3.35) 11.82 (6.18) 12.21 (3.94) 0.681
Stroop 4.71 (3.06) 6.36 (3.59) 7.12 (3.08) 1.629
TT 123.79 (13.97) 120.58 (13.42) 117.17 (15.20) 0.609
E/TT 0.37 (0.13) 0.37 (0.15) 0.35 (0.14) 0.378
PE/TT 0.22 (0.10) 0.22 (0.11) 0.19 (0.10) 0.515
Cc 3.11 (1.59) 3.77 (2.07) 4.24 (1.79) 0.272

** p \ 0.01
Note: ToM Com, theory of mind composite score; SWM, spatial working memory; TT, total trials,
Wisconsin Card Sorting Test (WCST); E/TT, errors/total trials (WCST); PE/TT, perseverative errors/total
trials (WCST); Cc, categories completed (WCST)

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significantly from the TD group (d = -0.421, p [ 0.05). As shown in Table 2, Appear-


ance-Reality, False belief (across location, contents [oneself], and contents [other]
measures) and theory of mind composite scores were significantly related with each other,
indicating high internal consistency in ToM tasks.

Executive Function Assessment

Mean scores on each of the executive function measures are shown in Table 1. As is clear
from Table 1, there were no group differences across three EF tasks when controlling
nonverbal IQ. Intercorrelations among the executive function tasks are provided in
Table 2. Most EF variables were significantly related with each other, indicating high
internal consistency in EF tasks.

Table 2 Bivariate and partial correlations between measures


2 3 4 5 6 7 8 9 10 Tom com

(a) Bivariate correlation


1. SWM .74** -.23 -.30* -.36** .46** .29* .27* .22 .31* .32**
2. Stroop -.39** -.34** -.40** .45** .45** .46** .25* .46** .48**
3. TT .65** .56** -.66** -.31** -.25* -.22 -.30** -.32**
4. E/TT .88** -.80** -.24** -.22 -.25* -.38** -.32**
5. PE/TT -.74** -.34** -.32** -.32** -.49** -.43**
6. Cc .36** .40** .37** .49** .47**
7. ToM1 .70** .50** .70** .85**
8. ToM2 .51** .74** .86**
9. ToM3(3) .73** .78**
10. ToM3(4) .92**
(b) Partial correlations controlling for nonverbal IQ
1. .75** -.20 -.23 -.28* .40** .23 .18 .17 .22 .24
2. -.35** -.24 -.30* .36** .31* .37** .18 .31* .36**
3. .64** .55** -.65** -.20 -.16 -.16 -.18 -.21
4. .89** -.83* -.06 -.07 -.14 -.20 -.14
5. -.69** -.09 -.10 -.12 -.25 -.17
6. .10 .15 .26* .24 .22
7. .61** .39** .50** .78**
8. .56** .66** .86**
9. .76** .80**
10. .87**

* p \ 0.05
** p \ 0.01
Note: SWM, spatial working memory; TT, total trials, Wisconsin Card Sorting Test (WCST); E/TT, errors/
total trials (WCST); PE/TT, perseverative errors/total trials (WCST); Cc, categories completed (WCST);
ToM1, appearance-reality task; ToM2, unexpected location task; ToM3(3), question (3) in the unexpected
content task; ToM3(4), question (4) in the unexpected content task; ToM Com, theory of mind composite
score

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Table 3 Group differences on ToM tasks controlling for nonverbal IQ and Stroop score (means (SD))
Autism (n = 20) ADHD (n = 26) TD (n = 30) F

ToM Com 1.32 (1.38) 3.23 (1.18) 3.77 (0.90) 17.320**

** p \ 0.01
Note: ToM Com, theory of mind composite score

The Correlations Between Tom and Ef Measures

The correlations between ToM and EF are also shown in Table 2. Performance on the
Corsi Block Task was significantly related to the ToM composite as well as Appearance-
Reality and Unexpected-Location and Unexpected-Content (other) measures in the raw
correlations. The same general pattern was apparent for total trials (TT) in WCST. E/TT in
WCST was significantly related to ToM scores, except Unexpected-Location False Belief
task. Stroop, PE/TT and Cc in WCST were related to every ToM score taken separately.
However, when nonverbal IQ was partialled out, only Stroop remained significantly cor-
related to ToM scores.
Table 3 indicates that after covarying nonverbal IQ and the inhibitory task (Stroop)
score, group differences were still found on ToM composite. As expected, post hoc tests
revealed that the group effect was due to significantly worse performance on ToM tasks by
the autistic than the control groups (the ADHD group, d = -1.609, p \ 0.01; and the TD
group, d = -2.026, p \ 0.01). The ADHD group did not differ significantly from the TD
group (d = -0.417, p [ 0.05).

Discussion

Previous studies have demonstrated that the children with autism have problems solving
ToM tasks, independent of IQ [8, 9, 11]. The present findings corroborate and extend these
findings to include children with ASD: Children with ASD performed statistically sig-
nificantly worse than children with ADHD and normal children in ToM tasks. Thus, ToM
deficit seems to exist reliably for children with ASD. For ADHD children, the results
showed that the ADHD group did as well as the normal group in ToM tasks, which
confirms earlier studies [12–14].
With respect to EF, children with ASD or ADHD did not show impairments compared
with the normal group on executive measures when controlling NVIQ. Previous studies of
working memory and Stroop in children with ASD have failed to find autistic-normal
group differences [56, 57]. Interestingly, children with ASD didn’t show a significant
deficit on the WCST after controlling NVIQ. Earlier studies finding autistic children and
adolescents are highly perseverative in their response to this task only included autism
sample [58, 59]. Using a sample aged from 8 to 11 years old, including individuals with
Asperger’s, and matched for IQ, Nyden and colleagues didn’t find significant differences
between Asperger and normal group [60]. A possible explanation might be our inclusion of
children with Asperger Syndrome.
For ADHD children, this pattern of results related to EF was unexpected, as previous
studies generally have reported EF impairments in children with ADHD as assessed by
executive measures. Firstly, the characteristics of EF measures might be the reason. In a
meta-analytic review, Willcutt found the majority of studies did not detect significant

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group differences on the WCST, a pattern similar to the findings of recent meta-analyses
investigating the Stroop task [61]. Apparently, the two tasks are poor candidates for a
primary neuropsychologic deficit in ADHD. Secondly, the subtypes of ADHD might
influence the result. Willcutt suggested that EF deficits are primarily associated with DSM-
IV inattention symptoms rather than hyperactivity-impulsivity symptoms [62]. Thirdly,
there are many kinds of working memory measures. Different working memory measures
might explain the differences between this study and other executive functions studies in
ADHD. As in our study, Pasini used Corsi Block task and also found no difference on this
task between ADHD and controls [63].
With respect to ToM as a prerequisite for EF, our findings suggest that possibility of a
ToM deficit with intact EF is unlikely. Our findings through assessing children with ASD,
children with ADHD, and typically developing children, matched on age and covaried
nonverbal IQ, on a battery of tasks measuring ToM and components of EF provided some
evidence against the theory of ToM being a prerequisite for EF. Regarding normal chil-
dren, the results of the current study are consistent with previous research examining the
relationship between ToM and EF. Over the course of a year, Hughes followed children
and found that EF performance at Time 1 accounted for 34% of the variance in theory of
mind scores 1 year later. In contrast, Time 1 scores in theory of mind were uncorrelated
with four out of five executive function tasks at Time 2 [29]. Carlson and his colleagues
examined EF–ToM relations in children at 24 and 39 months. As a result, EF at Time 1
significantly predicted ToM at Time 2, independent of several controls; a reciprocal
relation was not significant with the controls included [30]. The idea that ToM is not a
prerequisite for EF was also supported by Fisher and Happé [10]. They significantly
improved performance on theory of mind task in ten children with ASD who were trained
in executive function. As such, there seems to be little support for ToM as a prerequisite for
EF. At the same time, we found no support for EF as a prerequisite for ToM in the current
study.
Correlational analyses are important for establishing a relation between ToM and EF.
Only inhibition was significantly related to ToM performance after partialling out NVIQ.
These results were consistent with previous researches that suggested a close association
between inhibition and theory of mind using other inhibition tasks (e.g., Bear/Dragon and
Whisper) [13, 29–31]. Moreover, in Carlson and his colleagues’ study, the relation between
inhibition and theory of mind was a specific one [30]. These findings suggested that inhi-
bition may be central to the relation between ToM and EF. Two theories, expression theory
and emergence theory, attempt to explain the relationship. With respect to expression, EF
might affect children’s ability to translate already-present conceptual knowledge into
successful task performance. For example, children fail a false belief task because they lack
the inhibitory capacity to suppress the prepotent true state of affairs. With respect to
emergence, EF might be necessary for the acquisition of mental state concepts. Once
formed, ToM is considered to no longer require EF for their operation. Without inhibitory
control to suppress irrelevant stimuli, children would be unable to disengage themselves
from salient aspects of the real world and consequently be unable to consider the possibility
of alternative perspectives of the world. From what has been discussed above, it is possible
to see an executive component, inhibition, is in ToM tasks, which supports the third
hypothesis—executive components are in ToM tests. However, the result of examining
ToM deficit in autistic children by covarying nonverbal IQ and Stroop scores in this study
supported the idea that inhibition just only explains a part of the variance.
It is important to note several limitations of the current study. Firstly, because we
matched chronological age there was an apparent ceiling effect in typically developing

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children, as all but one normal child in our study passed the three ToM tasks. Future
research should explore the relationship between ToM and EF in ASD and TD children
matching mental age. Secondly, some autistic children can pass theory-of-mind tasks; an
indication that ToM deficit is not universal among individuals with autism. Future research
should investigate whether ToM deficit is a critical feature in ASD. Thirdly, the presenting
mode of the tasks might influence the autistic children’s performance. The current study
told the story by showing puppets. The story required repetition, however, which may have
enhanced the performance of the autistic group.
Additionally, high internal consistency was reported for the ToM tasks and EF mea-
sures, indicating good convergent validity. However, the reliability of the scores for some
EF tasks remains uncertain. Lastly, our sample size was small. Future research should
consider the characteristics of ToM and EF in different subtypes of ASD or ADHD.
In sum, our study found children with ASD has ToM deficit with intact EF, providing
evidence contrary to the first hypothesis: ToM is a prerequisite for EF, while we found no
evidence for the second hypothesis: EF is a prerequisite for ToM. At the same time, we did
find inhibition is the only EF component relating to ToM, supporting the notion that
inhibition may be central to the relation between ToM and EF. This is consistent with the
third hypothesis: Executive components are in ToM tasks. Further research should
ascertain whether EF is a prerequisite for ToM.

Summary

The current study addressed theoretical questions concerning the relationship between ToM
and EF. Twenty children with autism spectrum disorders (ASD), 26 children with Attention
Deficit Hyperactivity Disorder (ADHD), and 30 normal control subjects were compared on
two batteries of ToM tasks and EF tasks. The present results provide evidence for a link
between ToM and EF, and further point out inhibition may play a central role in the
relationship between ToM and EF. Our results provided tentative support for the existence
of executive components in ToM tasks, while at the same time, failed to support the notion
that ToM is a prerequisite for EF. As the ToM–EF relation is complex and multi-factorial,
future research should further investigate whether EF is a prerequisite for ToM.

Acknowledgments The authors would like to thank Layan Zhang, Yu Ding, and Gang Zhang, Medical
Psychological Research Center, the Second Xiangya Hospital for assistance in sampling work, and Anton
van Hamel, Department of Psychology, McGill University for proofreading work.

References

1. Perner J, Lang B (1999) Development of theory of mind and executive control. Trends Cogn Sci
3(9):337–344. doi:10.1016/S1364-6613(99)01362-5
2. Sodian B (2005) Theory of mind—the case for conceptual development. In: Schneider W, Hengsteler
RS, Sodian B (eds) Young children’s cognitive development: interrelationships among executive
functioning, working memory, verbal ability, and theory of mind. Lawrence Erlbaum Associates,
Mahwah, New Jersey, pp 95–130
3. Hill EL (2004) Evaluating the theory of executive dysfunction in autism. Dev Rev 24:189–233. doi:
10.1016/j.dr.2004.01.001
4. Channon S, Crawford S (2000) The effects of anterior lesions on a story comprehension test: left
anterior impairment on a theory of mind-type task. Neuropsychologia 38(7):1006–1017. doi:
10.1016/S0028-3932(99)00154-2

123
180 Child Psychiatry Hum Dev (2009) 40:169–182

5. Sabbagh MA, Taylor M (2000) Neural correlates of theory-of-mind reasoning: an event-related


potential study. Psychol Sci 11:46–50. doi:10.1111/1467-9280.00213
6. Ozonoff S, Pennington BF, Rogers SJ (1991) Executive function deficits in high-functioning autistic
individuals: relationship to theory of mind. J Child Psychol Psychiatry 32(7):1081–1105. doi:
10.1111/j.1469-7610.1991.tb00351.x
7. Hughes C, Russell J, Robbins TW (1994) Evidence for central executive dysfunction in autism.
Neuropsycholgia 32:477–492. doi:10.1016/0028-3932(94)90092-2
8. Zelazo PD, Jacques S, Burack JA, Fyre D (2002) The relation between theory of mind and rule use:
evidence from persons with autism-spectrum disorders. Infant Child Dev 11:171–195. doi:
10.1002/icd.304
9. Wong D, Maybery M, Maley A, Hill W (2003) Theory of mind and executive function: primacy and
independence in autism. In: Katsikitis M (ed) Proceedings of the 38th APS annual conference. The
Australian Psychological Society, Melbourne, pp 252–254
10. Fisher N, Happé F (2005) A training study of theory of mind and executive function in children with
autistic spectrum disorders. J Autism Dev Disord 35(6):757–771. doi:10.1007/s10803-005-0022-9
11. Pellicano E (2007) Links between theory of mind and executive function in young children with autism:
clues to developmental primacy. Dev Psychol 43(4):974–990. doi:10.1037/0012-1649.43.4.974
12. Happé F, Frith U (1996) Theory of mind and social impairment in children with conduct disorder. Br J
Dev Psychol 14:385–398
13. Hughes C, Dunn J, White A (1998) Trick or treat? Uneven understanding of mind and emotion and
executive dysfunction in hard-to-manage preschoolers. J Child Psychol Psychiatry 39(7):981–994. doi:
10.1017/S0021963098003059
14. Charman T, Carroll F, Sturge C (2001) Theory of mind, executive function and social competence in
boys with ADHD. Emot Behav Diffic 6:31–49
15. Sarah MD, Katrina W, Greta R et al (2007) The prevalence of autism in Australia: can it be established
from existing data. Report to the Australian Advisory Board on Autism Spectrum Disorder
16. Hollenbeck DF (2004) Public schools autism prevalence report series, 1992–2003. Fighting Autism,
Gibsonia, PA
17. Wong Virginia CN, Hui Stella LH (2008) Epidemiological study of autism spectrum disorder in China.
J Child Neurol 23(1):67–72. doi:10.1177/0883073807308702
18. Chang X, Ji CY (2005) Autism and mental retardation of young children in China. Biomed Environ Sci
18(5):334–340
19. Faraone S, Sergeant J, Gillberg C et al (2003) The worldwide prevalence of ADHD: is it an American
condition? World Psychiatry 2:104–113
20. Wang YC, Chong MY, Chou WJ et al (1993) Prevalence of attention deficit hyperactivity disorder in
primary school children in Taiwan. J Formos Med Assoc 92(2):133–138
21. Leung PW, Luk SL, Ho TP et al (1996) The diagnosis and prevalence of hyperactivity in Chinese
schoolboys. Br J Psychiatry 168(4):486–496
22. LU L, Shi QJ, Tao FF et al (2006) Epidemiological study on subtypes of ADHD of children aged 4–16
years old in Wuhan. Chin Ment Health J 4:221–225
23. Chen SZ, Zeng F, Tang HP (2004) Incidence and related factors of ADHD in children of Guilin City.
Chin J Clin Psychol 4:386–387, 370
24. Jiang L, Chang WJ, Su W et al (2004) Epidemiological survey of attention-deficit hyperactivity disorder
in pupils of urban districts in Zhenjiang. Acad J Second Mil Med Univ 11:1238–1240
25. HuangFu ZM (2006) Research about epidemiological information and family factor of children with
attention deficit hyperactivity disorder in Foshan city. Chin J Mod Med 16(1):149–150, 153
26. Carlson SM, Mandell DJ, Williams L (2004) Executive function and theory of mind: stability and
prediction from ages 2 to 3. Dev Psychol 40(6):1105–1122. doi:10.1037/0012-1649.40.6.1105
27. Carlson SM, Moses LJ, Claxton LJ (2004) Individual differences in executive functioning and theory of
mind: an investigation of inhibitory control and planning ability. J Exp Child Psychol 87:299–319. doi:
10.1016/j.jecp.2004.01.002
28. Frye D, Zelazo PD, Palfai T (1995) Theory of mind and rule-based reasoning. Cogn Dev 10:483–527.
doi:10.1016/0885-2014(95)90024-1
29. Hughes C (1998) Finding your marbles: does preschoolers’ strategic behavior predict later under-
standing? Dev Psychol 34:1326–1339. doi:10.1037/0012-1649.34.6.1326
30. Carlson SM, Moses LJ (2001) Individual differences in inhibitory control and children’s theory of mind.
Child Dev 72:1032–1053. doi:10.1111/1467-8624.00333
31. Carlson SM, Moses LJ, Breton C (2002) How specific is the relation between executive function and
theory of mind? Contributions of inhibitory control and working memory. Infant Child Dev 11:73–92.
doi:10.1002/icd.298

123
Child Psychiatry Hum Dev (2009) 40:169–182 181

32. Russell J, Hala S, Hill E (2003) The automated windows task: the performance of preschool children,
children with autism, and children with moderate learning difficulties. Cogn Dev 18:111–137. doi:
10.1016/S0885-2014(02)00163-6
33. Hesketh T, Ding QJ, Jenkins R (2002) Suicide ideation in Chinese adolescents. Soc Psychiatry Psychiatr
Epidemiol 37:230–235. doi:10.1007/s00127-002-0536-9
34. Zhou TX, Zhang SP, Jiang YQ et al (2000) Epidemiology of neuroses in a Shanghai community. Chin
Ment Health J 14:332–334
35. Liu XC, Ma DD, Kurita H et al (1999) Self-reported depressive symptoms among Chinese adolescents.
Soc Psychiatry Psychiatr Epidemiol 34:44–47
36. Prior M, Dahlstrom B, Squires T (1990) Autistic children’s knowledge of thinking and feeling states in
other people. J Child Psychol Psychiatry 31:587–601. doi:10.1111/j.1469-7610.1990.tb00799.x
37. Leekam SR, Perner J (1991) Does the autistic child have a metarepresentational deficit? Cognition
40:203–218. doi:10.1016/0010-0277(91)90025-Y
38. Bowler DM (1992) ‘‘Theory of mind’’ in Asperger’s syndrome. J Child Psychol Psychiatry 32:877–893.
doi:10.1111/j.1469-7610.1992.tb01962.x
39. Roslyn S, Pauline MH (1995) Theory of mind in children with autistic disorder: evidence of devel-
opmental progression and the role of verbal ability. J Child Psychol Psychiatry 36:249–263. doi:
10.1111/j.1469-7610.1995.tb01823.x
40. Pilowsky T, Yirmiya N, Arbelle S et al (2000) Theory of mind abilities of children with schizophrenia,
children with autism, and normally developing children. Schizophr Res 42(2):145–155. doi:
10.1016/S0920-9964(99)00101-2
41. Baron-Cohen S (1989) The autistic child’s theory of mind: a case of specific developmental delay. J
Child Psychol Psychiatry 30:285–297. doi:10.1111/j.1469-7610.1989.tb00241.x
42. Leslie AM, Firth U (1988) Autistic children’s understanding of seeing, knowing and believing. Br J Dev
Psychol 6:315–324
43. Gong YX (1997) The manual of the Gong’s non-verbal intelligence test. Hunan Medical College,
Changsha
44. Flavell JH, Green FL, Flavell ER (1989) Young children’s ability to differentiate appearance-reality and
level 2 perspectives in the tactile modality. Child Dev 60(1):201–213. doi:10.2307/1131085
45. Flavell JH, Green FL, Flavell ER (1986) Development of knowledge about the appearance-reality
distinction. Monogr Soc Res Child Dev 51(1):i–v, 1–87
46. Baron-Cohen S, Leslie AM, Frith U (1985) Does the autistic child have a ‘‘theory of mind’’? Cognition
21:37–46. doi:10.1016/0010-0277(85)90022-8
47. Vandierendonck A, Kemps E, Fastame MC, Szmalec A (2004) Working memory components of the
Corsi blocks task. Br J Psychol 95:57–79. doi:10.1348/000712604322779460
48. Stroop JR (1935) Studies of interference in serial verbal reactions. J Exp Psychol 18:643–662. doi:
10.1037/h0054651
49. Siegrist M (1997) Test-retest reliability of different versions of the Stroop test. J Psychol 131(3):
299–306
50. Salthouse TA, Meinz EJ (1995) Aging, inhibition, working memory, and speed. Psychol Sci
50B(6):297–306
51. Heaton RK (1981) Wisconsin card sorting test manual. Psychological Assessment Resources, Florida
52. Chelune GJ, Thompson LL (1987) Evaluation of the general sensitivity of the Wisconsin card sorting
test among younger and older children. Dev Neuropsychol 3:81–89
53. Pennington BF, Ozonoff S (1996) Executive functions and developmental psychology. J Child Psychol
Psychiatry 37:51–87. doi:10.1111/j.1469-7610.1996.tb01380.x
54. Ozonoff S (1995) Reliability and validity of the Wisconsin Card Sorting Test in studies of autism.
Neuropsychology 9(4):491–500. doi:10.1037/0894-4105.9.4.491
55. Richard PR, Kay AC, David JP (2000) Fundaments of behavioral statics, 9th edn. The McGraw-Hill
Companies, New York, p 107
56. Ozonoff S, Strayer DL (2001) Futher evidence of intact working memory in autism. J Autism Dev
Disord 31(3):257–263. doi:10.1023/A:1010794902139
57. Griffith EM, Pennington BF, Wehner EA et al (1999) Executive functions in young children with
autism. Child Dev 70:817–832. doi:10.1111/1467-8624.00059
58. Prior MR, Hoffman W (1990) Brief report: neuropsychological testing of autistic children through an
exploration with frontal lobe tests. J Aut Dev Dis 20:581–590. doi:10.1007/BF02216063
59. Shu C, Lung W, Tien AY et al (2001) Executive function deficits in non-related autistic children.
Autism 5:165–174. doi:10.1177/1362361301005002006
60. Eskes GA, Bryson SE, McCormick TA (1990) Comprehension of concrete and abstract words in autistic
children. J Autism Dev Disord 20:61–73. doi:10.1007/BF02206857

123
182 Child Psychiatry Hum Dev (2009) 40:169–182

61. Nyden A, Gillberg C, Hjelmquist E et al (1999) Executive/attention deficits in boys with Asperger
syndrome, attention disorder and reading/writing disorder. Autism 3:213–228. doi:10.1177/
1362361399003003002
62. Willcutt EG, Doyle AE, Nigg JT et al (2005) Validity of the executive function theory of attention-
deficit/hyperactivity disorder: a meta-analytic review. Biol Psychiatry 57(11):1336–1346. doi:
10.1016/j.biopsych.2005.02.006
63. Pasini A, Paloscia C, Alessandrelli R et al (2007) Attention and executive functions profile in drug naive
ADHD subtypes. Brain Dev 29(7):400–408. doi:10.1016/j.braindev.2006.11.010

123