Saturday, 26 March 2011

Whatever happened to ToM and autism?

Don't get me wrong about this post; I am not trying to cause trouble. I am just doing what this blog is supposed to do - questioning answers. My question in this case is: what has happened to the 'theory of mind' concept related to autism spectrum conditions?

A lack of 'theory of mind' (ToM) connected to autism was, during my undergraduate education and early autism research career, like ham and eggs, Laurel and Hardy, Woody and Buzz. I remember reading paper after paper describing how autism was 'exemplified' by a lack of ToM, over and above every other explanation that psychology could offer (executive dysfunction, weak central coherence, etc).

From a psychology perspective, a lack of ToM was very interesting stuff. It was quite a simple concept to understand - 'putting yourself in another's shoes'; it seemed to concur with an important aspect of autism; and it was relatively easy to test for - ideal for the psychology undergraduate project. The research papers flowed in their hundreds on ToM and autism.

In recent years however, I have heard less and less about ToM in relation to autism. You still get quite a few papers on ToM and autism but less and less I see it being discussed either in the research world or in the blogosphere. Maybe it is just me. Maybe I am not as attentive as perhaps I once was. Maybe I am not going to the right websites and conferences.

One could argue that everything that needed to be said about ToM, has been said and that journals are perhaps less likely to publish on something which has, in all likelihood, already been published before. Similarly it is not outside the realms of possibility that ToM and autism is so installed into our psyche hard-drive that we don't need to hear any more about it. Possibilities anyway.

Perhaps also there are other reasons for the 'reduction' in ToM exposure?

Several authors (including those with autism or Asperger syndrome) have talked about ToM. Some of them are supportive of the concept of ToM as perhaps being a key aspect of autism spectrum conditions. Others have perhaps been less enthusiastic about ToM's attachment to autism. It seems to be a very personal thing to talk about; varying from person to person.

What does the research say?

Well, I don't think anyone can dispute the fact that for some people on the autism spectrum, a problem with ToM is present. There is little point in me posting the papers showing this because we would be here all night (search Google Scholar) - lots of experimental evidence which shows a good correlation between ToM and autism - at least in the laboratory setting.

The research literature also shows that ToM has changed and adapted as all good theories should when new evidence comes to light. ToM went to/was consumed by the concept of 'mindblindness', which then itself seems to have been taken up in the 'extreme male brain theory of autism' which seems also to be tied into the 'testosterone theory' of autism.  The main changes highlight the fact that a specific cognitive style is perhaps apparent in at least some cases of autism, which includes ToM as part of its presentation. Apparent also is the movement from psychological theory to biological theory.

But ToM has not had a completely easy ride through autism.

A global relationship between ToM and autism has been questioned because of the lack of apparent specificity of ToM. Remember first my autism and n=1 post. ToM problems are seen in a diverse array of conditions and states including schizophrenia, depression and Alzheimer disease; also noted in studies of alcoholism. Unless one accepts that these and other conditions are somehow related to autism in some way (directly not peripherally), ToM problems in autism could just as well be linked to other cognitive processes or personality traits outside of autism, that are shared with these other conditions. Think also about the cultural differences in ToM ability, as detailed by this study of English and Italian children.

A second issue relates to the use of the term 'autism' in ToM problems. One of the earliest studies on ToM and autism is this one from 1985. Note the use of the word 'autism'. Why? Well, Asperger syndrome (AS) as a discrete diagnostic entry was not around at the time; indeed not around until 1992 in the ICD criteria and 1994 in the DSM diagnostic manual. The question therefore is this: are ToM problems related more to 'autism' or are they more relevant to Asperger syndrome?

Again, not an easy question to answer, and the research is confusing on this issue. Some authors suggested that AS is not on the whole affected by ToM problems; others suggest the opposite position. Much of this boils down to whether or not any fundamental differences are inferred between autism and AS. Is ToM present therefore purely as a function of some co-morbid intellectual disability?

Finally, there is a question about whether it matters if someone does or does not possess a theory of mind, and can people improve their ToM skills? Think about it, the ability to infer the mental states of another person. Mmm, how many people in the 'general' population have, and use this ability? The husband who sits on the sofa expecting to be 'waited on hand and foot'? The person who parks in a disabled car-parking space just because it is close to the shops? The employer who does not praise his/her employees when they do a good job? The burglar who steals from a house? ToM or no ToM?

Finally, finally! Can we ToM-train? The jury is still out on this one. A recent RCT suggests not; but perhaps further studies are required on this topic.