The 'Theory of Mind' model suggests that people with autism spectrum disorder (ASD) have a profound difficulty understanding the minds of other people, their emotions, feelings, beliefs, and thoughts. It has been proposed that this may underlie many of the other difficulties experienced by people with ASD, including social and communication problems, and some challenging behaviours. Therefore, a number of studies have attempted to teach theory of mind and related skills to people with ASD.
This review aimed to explore whether a) it is possible to teach theory of mind skills to people with autism and b) whether or not this evidence supports the theory of mind model. Having a 'theory of mind' may depend on developing related basic skills, including joint attention (sharing a focus of interest with another person), recognising other people's emotions from faces or stories, and imitating other people. Therefore, we included intervention studies that taught not just theory of mind itself, but also related skills.
We found 22 research studies involving 695 participants, which reported on the efficacy of interventions related to theory of mind. The evidence is current to 7th August 2013.
Key results and the quality of the evidence
Despite all studies using a high-quality basic methodology (the randomised controlled trial), there was concern over poor study design and reporting in some aspects. While there is some evidence that theory of mind, or related skills, can be taught to people with ASD, there is currently poor quality evidence that these skills can be maintained, generalised to other settings, or that teaching theory of mind has an impact on developmentally-linked abilities. For example, it was rare for a taught skill to generalise to a new context, such as sharing attention with a new adult who was not the therapist during the intervention. New skills were not necessarily maintained over time. This evidence could imply that the theory of mind model has little relevance for educational and clinical practice in ASD. Further research using longitudinal methods, better outcome measures, and higher standards of reporting is needed to throw light on the issues. This is particularly important as the specific details of the theory of mind model continue to evolve.
While there is some evidence that ToM, or a precursor skill, can be taught to people with ASD, there is little evidence of maintenance of that skill, generalisation to other settings, or developmental effects on related skills. Furthermore, inconsistency in findings and measurement means that evidence has been graded of 'very low' or 'low' quality and we cannot be confident that suggestions of positive effects will be sustained as high-quality evidence accumulates. Further longitudinal designs and larger samples are needed to help elucidate both the efficacy of ToM-linked interventions and the explanatory value of the ToM model itself. It is possible that the continuing refinement of the ToM model will lead to better interventions which have a greater impact on development than those investigated to date.
The 'Theory of Mind' (ToM) model suggests that people with autism spectrum disorder (ASD) have a profound difficulty understanding the minds of other people - their emotions, feelings, beliefs, and thoughts. As an explanation for some of the characteristic social and communication behaviours of people with ASD, this model has had a significant influence on research and practice. It implies that successful interventions to teach ToM could, in turn, have far-reaching effects on behaviours and outcome.
To review the efficacy of interventions based on the ToM model for individuals with ASD.
In August 2013 we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Social Services Abstracts, AutismData, and two trials registers. We also searched the reference lists of relevant papers, contacted authors who work in this field, and handsearched a number of journals.
Review studies were selected on the basis that they reported on an applicable intervention (linked to ToM in one of four clearly-defined ways), presented new randomised controlled trial data, and participants had a confirmed diagnosis of an autism spectrum disorder. Studies were selected by two review authors independently and a third author arbitrated when necessary.
Risk of bias was evaluated and data were extracted by two review authors independently; a third author arbitrated when necessary. Most studies were not eligible for meta-analysis, the principal reason being mis-matching methodologies and outcome measures. Three small meta-analyses were carried out.
Twenty-two randomised trials were included in the review (N = 695). Studies were highly variable in their country of origin, sample size, participant age, intervention delivery type, and outcome measures. Risk of bias was variable across categories. There were very few studies for which there was adequate blinding of participants and personnel, and some were also judged at high risk of bias in blinding of outcome assessors. There was also evidence of some bias in sequence generation and allocation concealment. Not all studies reported data that fell within the pre-defined primary outcome categories for the review, instead many studies reported measures which were intervention-specific (e.g. emotion recognition). The wide range of measures used within each outcome category and the mixed results from these measures introduced further complexity when interpreting results.
Studies were grouped into four main categories according to intervention target/primary outcome measure. These were: emotion recognition studies, joint attention and social communication studies, imitation studies, and studies teaching ToM itself. Within the first two of these categories, a sub-set of studies were deemed suitable for meta-analysis for a limited number of key outcomes.
There was very low quality evidence of a positive effect on measures of communication based on individual results from three studies. There was low quality evidence from 11 studies reporting mixed results of interventions on measures of social interaction, very low quality evidence from four studies reporting mixed results on measures of general communication, and very low quality evidence from four studies reporting mixed results on measures of ToM ability.
The meta-analysis results we were able to generate showed that interventions targeting emotion recognition across age groups and working with people within the average range of intellectual ability had a positive effect on the target skill, measured by a test using photographs of faces (mean increase of 0.75 points, 95% confidence interval (CI) 0.22 to 1.29 points, Z = 2.75, P < 0.006, four studies, N = 105). Therapist-led joint attention interventions can promote production of more joint attention behaviours within adult-child interaction (mean increase of 0.55 points, 95% CI 0.11 to 0.99 points, Z = 2.45, P value = 0.01, two studies, N = 88). Further analysis undermines this conclusion somewhat by demonstrating that there was no clear evidence that intervention can have an effect on joint attention initiations as measured using a standardised assessment tool (mean increase of 0.23 points, 95% CI -0.48 to 0.94 points, Z = 0.63, P value = 0.53, three studies, N = 92). No adverse effects were apparent.