Development of Theory of Mind: Considerations for Children with Visual Impairments

Mindy S. Ely; Hedda Meadan-Kaplansky; Michaelene M. Ostrosky

Development of Theory of Mind: Considerations for Children with Visual Impairments

By Mindy S. Ely, Hedda Meadan-Kaplansky, and Michaelene M. Ostrosky

Mindy S. Ely, MS Ed, is a doctoral candidate at the University of Illinois, Urbana-Champaign.

Hedda Meadan-Kaplansky, PhD, BCBA-D, is an associate professor at the University of Illinois Urbana-Champaign.

Michaelene M. Ostrosky, PhD, is a professor at the University of Illinois Urbana-Champaign.

Address correspondence to the first author at:
Mindy S. Ely
[email protected]
Dept. of Special Education
288 Education Building
1310 S 6th St
Champaign, IL 61820

Abstract

Theory of Mind (ToM) is defined as understanding the perspective of oneself and others (Premack & Woodruff, 1978). The false-belief task is used to assess the acquisition of ToM. Recently, researchers have adapted the test to validate it with children with visual impairments. In studies using these adapted versions of the false-belief task, researchers have found little delay in the development of ToM in children with visual impairments. In this literature review, current research was used to assess whether the newly adapted version of the false-belief test contains the salient features of traditional false-belief tests necessary to assure that the same constructs are being tested. Additionally, factors that correlate with the development of ToM are discussed. Questions are raised regarding how ToM is assessed and how it develops in children with visual impairments. Suggestions for practice and future studies are offered.

Keywords

Theory of Mind, visual impairment, false-belief task, perspective taking, assessment

Introduction

Theory of Mind (ToM) is defined as understanding the perspective of oneself and others (Premack & Woodruff, 1978). Key to this understanding is the realization that our own perceptions may not be the same as someone else’s perceptions. While the development of ToM is believed to occur incrementally throughout the early years of life (Wellman & Lui, 2004), ToM is said to have developed when the child demonstrates understanding that a person can have and act on a belief that is not true. This milestone in ToM development occurs during the 4th year of life in typically developing children. For example, ToM allows a child to participate in an April Fool’s ruse. He knows he can fool his mother into thinking one way while he knows the truth. A child without ToM does not understand that his mother does not hold the same knowledge that he does and, therefore, cannot participate in the April Fool’s joke. By 5 or 6 years of age, ToM becomes more sophisticated and children begin to understand that people can choose to display emotions that may not align with their true feelings (Flavell, 2004; Wellman, Cross, & Watson, 2001).

It is believed that a child’s ability to comprehend and anticipate the feelings and perspectives of others is an important factor in the development of prosocial skills. A rapidly growing body of research supports the notion that the development of ToM is at the very least correlated with factors known to advance social skill development, such as social communication, conflict resolution, dramatic play, executive function, and inhibitory skills (Capage & Watson, 2001; Flavell, 2004). In fact, neural correlations have been identified, suggesting that the development of ToM could be based on biological and environmental factors (Lui, Sabbagh, Gehring, & Wellman, 2009; Sabbagh, Bowman, Evraire, & Ito, 2009). Questions remain regarding the direction of the correlation between ToM and social factors. While this point is debated, researchers agree that ToM plays a significant role in the development of peer relationships (Capage & Watson, 2001; Flynn, O’Malley, & Wood, 2004; Suway, Degnan, Sussman, & Fox, 2012). In fact, some researchers have suggested that a bidirectional correlation is likely between ToM and social factors (Miller, 2012; Suway et al., 2012); ToM impacts the development of peer relationships and peer interactions can influence the development of ToM.

Researchers have devised a variety of tasks to evaluate children’s ToM abilities. Wimmer and Perner (1983) created the false-belief task, which has become widely used among ToM researchers. This test is designed to evaluate children’s understanding of differences in mental perspectives. While many adaptations have been made, the basic task involves a scenario in which a character puts an object in a cupboard and leaves the room. Another character enters the room and moves the object. The participant is then asked to predict where the first character will look for the object.

Historically, research shows that children with visual impairments experience a significant delay, not developing ToM until 8 to 12 years of age (Green, Pring, & Swettenham, 2004; Minter, Hobson, & Bishop, 1998; Peterson, Peterson, & Webb, 2000); however, recently this finding has been questioned. Brambring (2005) argued that past studies included items that were unfamiliar to children who were visually impaired yet familiar to sighted children, weakening the validity of the tests. In 2010, Brambring and Asbrock devised methods to test ToM using tactile and auditory test items. They believed that this would allow unbiased testing of children who were blind. Participants included children with and without sight, ranging in age from 4 to 10 years old. Using the test accommodations that they developed, Brambring and Asbrock (2010) found that sighted children could perform false-belief tasks at 61 months of age while children who were blind demonstrated the skill by 80 months of age, resulting in a 19-month difference between those with and without sight. A follow up study by Anghel (2012) confirmed these findings.

A recent study has gone further to suggest that children with visual impairments involving non-retinal portions of the eye showed no delay in the development of ToM (Begeer et al., 2014). Begeer at al. (2014) divided participants into two groups. One group had “ocular” vision loss, which they defined as vision loss including non-retinal portions of the eyeball. The other group had “ocular-plus” vision loss, defined as children with vision loss involving the optic neural pathways. Begeer et al. (2014) used the ToM tasks as devised by Brambring and Asbrock (2010) to test participants’ skills in false-belief understanding. They found that children with ocular-plus vision loss showed delays in ToM, while those with ocular vision loss did not. Begeer et al. (2014) concluded that when vision loss co-exists with brain involvement, delays in ToM could be related to non-vision issues. While Begeer et al. (2014) cautioned that more research is necessary, these results have called into question previous findings related to the development of ToM in children with visual impairments.

Regarding the findings from Brambring and Asbrock (2010), two considerations seem deserving of further exploration. First, it is not clear if the tests developed by Brambring and Asbrock (2010) are valid for measuring false-belief. If they are not, then the differences in the development of ToM for children with visual impairments cited in previous research could be more accurate than the newer findings by Brambring and Asbrock (2010). One avenue to consider the validity of the adapted false-belief tests designed by Brambring and Asbrock (2010) is to compare the salient features of these tests with traditional false-belief tasks in an attempt to evaluate if they require similar abilities from participants. Second, a study of the factors that correlate with the development of ToM in children with typical vision could provide insight about the development of these same skills in children with visual impairments. As a beginning step to this investigation, this literature review focuses on the following questions: (a) what features are essential for a valid measure of false-belief when evaluating the development of ToM in children?; and (b) what attributes correlate with the development of ToM in typically developing children?

Insights gained from these questions are then applied to understanding the development of ToM in children with visual impairments. The findings from this literature review provide directions for research that have the potential to increase our understanding of the development of ToM in children with visual impairments.

Methods

The ERIC database and Google Scholar were used to search for studies in peer-reviewed journals between 2002 and 2014, focusing on the assessment of ToM in young children. Keywords in the search included children, Theory of Mind, and perspective taking. The initial search yielded 101 articles, with 17 articles remaining after inclusionary criteria were applied. Articles were included if the study incorporated at least one assessment of ToM. The purpose of this assessment must have been to determine aspects of ToM or children’s characteristics that were correlated with ToM. Additionally, articles were included if they contained English speaking participants of which at least 50% were younger than 6 years of age. Literature reviews, opinion pieces, and studies that evaluated intervention strategies were excluded.

This review is organized into two sections. Information related to test validity is explored in the first section. As suggested by Wellman et al. (2001), false-belief tests should include a control question and a false-belief situation. Specifically, the child must demonstrate understanding of reality (control question) and then determine the response of another person based on that person’s erroneous belief (false-belief situation). Two of 17 articles discussed within this literature review directly challenged the assumption of Wellman et al. (2001), therefore, the first section on test validity explores these assumptions and the proposed counter arguments. The second section contains a review of the literature related to characteristics that are correlated with the development of ToM. Wellman et al. (2001) suggest the importance of language ability and executive function in the development of ToM. More recent studies have explored the impact of neurological development on ToM. Across the 17 articles included in this review seven focus on executive function, eight focus on language skills, and two focus on neurological development.

Review of the Literature

Test Validity

Even though skills linked to ToM develop over time, most researchers consider ToM to be achieved when a child can successfully accomplish the false-belief task. A variety of tests have been constructed to assess the development of ToM. Wellman et al. (2001) found that “the type of task, type of question, nature of the protagonist, and nature of the target object” (p. 664) had little effect on the age at which children successfully completed the ToM task. While these variations to the task design establish precedence for test variety, it is also expected that several prerequisite skills must be assessed within the false-belief measure in order for the test to be deemed a valid assessment of false-belief. These features are explored next including counterfactual reasoning, memory and reality, prerequisite skills, and knowledge control.

Counterfactual Reasoning. Reasoning includes the ability to consider action according to rules, given the various perspectives. Conversely, counterfactual reasoning is the ability to consider alternative conclusions about a situation given circumstances that differ from the immediate scenario. Counterfactual reasoning is considered central to false-belief understanding. For example, most false-belief tasks ask the child to predict where a character will look for an object in light of the fact that the child knows that where the character believes the object to be is different from where the object truly is located.

Memory and Reality. False-belief tasks also include memory and reality control questions (Wellman et al., 2001). The child must understand and remember reality (where the object is located) and conflicted belief (where the object was previously). This sets up the false-belief task and requires the child to use counterfactual reasoning. Memory is included as a control feature to rule out the possibility that the child fails the task (whether false-belief or counterfactual reasoning) because they cannot hold the given scenarios in their mind.

Prerequisite Skills Evaluated. While Capage and Watson (2001) have posited the relation between ToM and counterfactual reasoning, Müller, Miller, Michalczyk, and Karapinka (2007) devised a study to empirically evaluate this relation. First, they reasoned that memory was a potential mitigating factor in children’s ability to perform well on either counterfactual reasoning or false-belief tasks. They hypothesized that if counterfactual reasoning and false-belief were essential skills, then children should perform at similar levels on tests for each skill when memory was controlled.

In a study by Müller et al. (2007), children were given two counterfactual reasoning tasks, two working memory tasks, and two false-belief tasks. The assessment of counterfactual reasoning was attained by adding an additional question to the false-belief scenario. For example, in the false-belief task children were shown a vignette in which two characters were playing with an object. Character one put the object in a red bag and left the scene. The second character then removed the object from the red bag, played with it some more, and then placed it in a blue bag. To assess false-belief, the first character returned and the child was asked where the first character would look for the object. To test counterfactual reasoning, the child was then asked where the first character would look for the object if the second character had not moved it. Müller et al. (2007) found that counterfactual reasoning is related to performance on false-belief tasks even when memory is controlled.

Knowledge Control. In addition to memory and counterfactual reasoning, researchers posit that false-belief tasks require that the child resist the urge to respond with their own true knowledge (Carlson & Moses, 2001; Flynn, et al., 2004; Miller, 2012; Suway et al., 2012). This control makes it possible for a child to ignore his own understanding of reality in order to consider the situation from other perspectives. For example, in the false-belief task, when a child is asked where a character will think an object is located, the child must refrain from stating the truth. Instead, the child must hold this truth at bay and chose a location that he/she knows is false, but which the character believes to be true.

Houston-Price et al. (2011) challenged the widely-held belief that a false-belief task must include a knowledge control component. These researchers altered the traditional false-belief task by completely removing the object before the character returns. In this scenario, the character placed the object in one place and then left the scene. The second character entered the scene, took the object and left the scene with the object. When the first character returns to the scene, the child is asked to predict where the first character will look for the object. Houston-Price et al. (2011) posited that removing the object alleviated the child’s need to hold reality at bay. In this false-belief task, the child is only required to consider what is true and what the character believes to be true. Results showed that this manipulation did improve performance on the task by both 3- and 4-year-old children, although 3-year-olds still did not reach ceiling levels on this version of the task. Yet, improved performance could be interpreted to mean that the task was no longer comparable to the traditional false-belief task, thus confirming the need to include a knowledge control component to the false-belief task.

Developmental Correlates to ToM

Executive Function. Executive function has been defined by Müller et al. (2007) as “higher mental processes involved in the conscious control of action and thought” (p. 616). This includes such functions as cognitive flexibility (Capage & Watson, 2001; Wellman et al., 2001), reasoning, inhibitory control (Suway et al., 2012), temperament, and emotional understanding (Lane, Wellman, Olson, LaBounty, & Kerr, 2010; Wellman, Lane, LaBounty, & Olson, 2011). Many have suggested that executive function is related to the development of ToM (e.g., Wellman & Lui, 2004).

Behavior and Temperament. It has been proposed that when social conflicts arise, a child with an understanding of false-belief is able to consider that others could be acting on inaccurate information or from a different perspective. This flexibility in thinking allows the child to consider a wider array of possible solutions resulting in fewer aggressive actions (Capage & Watson, 2001). Research regarding the interaction between aggression and ToM is well supported in the literature (Capage & Watson, 2001; Wellman et al., 2011). Specifically, Capage and Watson (2001) found a negative correlation between ToM and teacher ratings of student aggression. Children who had ToM were found to have fewer aggressive solutions to social problem situations.

While these studies show a correlation between ToM and aggressive behavior, directional causation is unclear. In one longitudinal study, Wellman et al. (2011) measured aggressiveness as a temperament characteristic in children at 3.5 years of age. Two years later, the same children were tested for ToM understanding. The researchers found that low levels of aggressiveness at 3.5 years proved to be a predictive factor of more advanced ToM when the children were tested at 5.5 years of age. In this study, the participants’ mild temperament was measured prior to the development of ToM, which seems to suggest that aggressiveness could be a causal factor to inhibit the development of ToM. While previous studies have suggested that aggression was a response to an inability to understand another child’s perspective during conflict as is the case in a lack of ToM (Capage & Watson, 2001), research by Wellman et al. (2011) and others (Cutting & Dunn, 2006; Suway et al., 2012) show that at least a bidirectional interaction between social behaviors and ToM development must be considered.

As children are presented with moral dilemmas or conflicts in social experiences, they must consider their options and choose a response. Studies show a correlation between this ability to reason and ToM (Lane et al., 2010; Müller et al., 2007). Lane et al. (2010) studied the interaction between emotional understanding and ToM. Progression of moral reasoning includes (a) self-oriented reasoning, (b) others-oriented reasoning, and (c) societally oriented reasoning. Using societally oriented reasoning, a child chooses to act based on what is best for the social group as a whole over the needs of the individuals in the situation. Lane et al. (2010) found that while emotional understanding was important as one progressed through these developmental levels, ToM was also essential to reach the highest levels of moral reasoning. In order to move beyond others-oriented reasoning, a child must be able to interpret the perspective of those involved while also giving weight to perspectives from those in authority (e.g., adults who might have more insight or hold specialized information). Results showed that those with higher levels of emotional understanding but lower levels of ToM demonstrated moral reasoning at the others-oriented level while those who had higher levels of emotional understanding in addition to higher levels of ToM showed moral reasoning at the highest level. It appears that the combination of ToM development with emotional understanding is important for the development of moral reasoning (Lane et al., 2010). Such reasoning encourages socially acceptable behavior and impacts peer interactions.

Recent research has further investigated the impact of temperament and early social experiences on the development of ToM. In a longitudinal study, Suway et al. (2012) measured the impact of negative social behaviors and behaviorally inhibited children on the future development of ToM. They defined children who were behaviorally inhibited as those who, in novel situations, “often withdraw from play behavior, and are unlikely to approach a novel object or person. They seek proximity to their caregiver, remain vigilant of their surroundings, and sometimes display distressed affect” (Suway et al., 2012, p. 333). The researchers hypothesized that children who do not engage in social interaction miss critical opportunities essential to the development of ToM. Their hypothesis was supported when a one-year follow up showed behavioral inhibitions and negative social behaviors to be negatively predictive of ToM development. Of the two predictors, negative social behaviors resulted in lower overall scores than did those who were categorized with behavioral inhibitions (Suway et al., 2012). These results are in agreement with suggestions from Baird (2008) and Wellman and Miller (2008) that social experience plays a role in the development of ToM.

Some children are neither aggressive nor overly social, rather they remain reticent in social situations preferring to observe others rather than get involved. Interestingly, recent research is contradictory in finding that a shy or withdrawn temperament correlates to ToM development. Suway et al. (2012) conducted a longitudinal study of children at age 24 and 36 months. They measured participants’ behavioral inhibition, peer interactions, and ToM development. They hypothesized that children who displayed behavioral inhibition and negative peer interactions at 24 months would show poor ToM development at 36 months. Suway et al. (2012) purported that behavioral inhibitions coupled with negative peer interactions would result in fewer opportunities to develop the social understandings involved in ToM. Their findings supported this hypothesis. At roughly the same time, Wellman et al. (2011) conducted a longitudinal study of the correlation between temperament and ToM development. They asked parents to complete a temperament questionnaire regarding their children between the ages of 33-45 months of age. Two years later the children returned and completed a battery of tests including a measure of ToM. Contrary to Suway et al. (2012), Wellman et al. (2011) found that children who were rated as having a shy-withdrawn temperament at 3 years old, displayed advanced ToM at 5 years old. Close inspection of the two studies reveals interesting differences. Suway et al. (2012) categorized children as behaviorally inhibited by recording children’s latency to interact and vocalize in a novel environment with novel toys and an adult stranger. Wellman et al. (2011) identified temperament using parent report. Using the approach by Suway et al. (2012) all children with an inhibited personality would have been put into one category. Using the Wellman et al. (2011) approach, these same children would have been parceled into different categories for either a fearful or shy-withdrawn temperament. It could be that this separation into different temperaments impacted the overall results, thus producing opposing findings.

Inhibitory Control. Inhibitory control is another area of executive function closely linked to ToM. Inhibitory control “is the ability to stop oneself from performing an action that is dictated by a prepotent response” (Flynn et al., 2004). For example, inhibitory control allows a child to consider an alternative course of action when it differs from a presented situation. This ability develops throughout the first 6 years with significant gains during the preschool years (Carlson & Moses, 2001).

Researchers have studied how inhibitory control develops in relation to ToM. Carlson and Moses (2001) used a battery of traditional tests of inhibitory control and tests of ToM. Tests of inhibitory control often require either a delayed or a conflicting response in a given situation. For example, in a delayed response task, a child might be asked to hold a ball and wait until instructed before throwing it. In a task of conflicting response, a child could be shown alternating pictures while being required to say “dog” when a cat is presented and “cat” when a dog is presented. Carlson and Moses (2001) found a strong positive correlation between the development of inhibitory skills and ToM. But, upon closer inspection they found that tests of inhibitory control requiring children to delay their response were less correlated to ToM than tests of inhibitory control that required children to give a conflicting response. Carlson and Moses (2001) pointed out that their study did not identify causation, nor was it clear if one skill developed before the other. Instead, they suggest that ToM and inhibitory control develop in tandem. In studying the same phenomenon, Flynn et al. (2004) concluded that while inhibitory skills developed gradually, evidence of ToM is sudden. First children lack understanding, then progress through a period of confusion before finally comprehending the concepts of ToM. After this point of comprehension, children consistently pass tests of false-belief (Flynn, 2006; Flynn et al., 2004; Wellman et al., 2001). Flynn et al. (2004) found that for most children, the skills of inhibition support their display of ToM. But, in looking at individual participant profiles, they found that a small number of children attained ToM without developing inhibitory control. In a comparison of effect variables, Flynn et al. (2004) concluded that children develop ToM in different ways. A small subset of children in their study passed the false-belief task without inhibitory control; these same children scored higher in verbal ability. Flynn et al. (2004) concluded that while most children rely on inhibitory control to accomplish false-belief tasks, it is possible that some children use communication skills to master ToM understanding.

Language Ability. Other researchers have suggested that the development of ToM could be impacted by strong verbal ability. Communication is a means by which we realize the thoughts and intentions of others. Children must possess strong verbal abilities in order to understand what is required of them (Flynn, 2006). It is possible that exposure to verbal experience is foundational to the development of ToM (Astington & Jenkins, 1995; Cutting & Dunn, 2006). For example, Symons, Fossum, and Collins (2006) found that performance on ToM tasks were positively associated with children’s mean length of verbalizations. Additionally, Flynn (2006) conducted a longitudinal study evaluating the development of ToM in addition to various other developmental markers. Results showed that early language skills were predictive of later ToM abilities, but early ToM was not predictive of future verbal skills. While verbal ability is a precursor for performance on many ToM tasks, Flynn (2006) concluded that language abilities played a larger role by impacting social cognition and experiences thus fostering ToM development. Additionally, Cutting and Dunn (2006) studied the role of sibling and peer relationships in the development of ToM in 4-year-olds. They found that children who had a positive relationship with either their sibling or peers participated in more cooperative play. Higher levels of interaction were positively correlated with ToM and language ability.

In addition to siblings and playmates, young children spend large amounts of time with their parents. Researchers have investigated the impact of mother-child interactions on development. In relation to these interactions, maternal mind-mindedness is used to describe a mother’s comments about her child’s internal states. Research shows a positive correlation between maternal mind-mindedness and the development of ToM (Laranjo, Bernier, Meins, & Carlson, 2010; Lundy, 2013). Longitudinal studies have further delineated which aspects of such interaction between parent and infant are predictive of ToM development. Researchers agree that ToM is enhanced in children whose mothers engage them in conversations using mental state language related to beliefs and desires (Laranjo et al., 2010; Lundy, 2013; Ontai & Thompson, 2008; Ruffman, Slade, & Crowe ., 2002; Symons et al., 2006). These interactions include elaborations that appropriately reflect the child’s perceptions (Ontai & Thompson, 2008; Symons et al., 2006), provide contrasting perceptions with alternatives (Ontai & Thompson, 2008), offer information about another person’s feelings, desires, or thoughts (Ontai & Thompson, 2008; Ruffman et al., 2002), or evaluate the child’s perspective (Ontai & Thompson, 2008). Symons et al. (2006) noted the importance of making these elaborations appropriate to the child’s line of thought, emphasizing that the key is engaged communication about mental states.

Neurologic Development. Prefrontal regions of the brain show activity during false-belief tasks. This suggests a neural correlate with ToM. Studies have been conducted to further investigate this phenomenon. Liu et al. (2009) measured event-related brain response (ERP) in adults and children while they participated in false-belief tasks. Adults consistently passed the tasks and showed localized activity in the prefrontal cortex. Children who passed the false-belief tasks also showed activity in the prefrontal cortex, yet within a more dispersed area. Children who failed the false-belief tasks did not show activity in the prefrontal cortex. These results are in agreement with findings from Sabbagh et al. (2009) which showed that the prefrontal cortex is involved in ToM tasks. Additionally, neurocognitive specialization occurs throughout development. In fact, after children consistently pass false-belief tasks, this development continues to occur even on a neurological level. This suggests that environmental interaction plays a role in refining specialization within the prefrontal cortex (Lui et al., 2009).

Sabbagh et al. (2009) conducted targeted testing to investigate the neurologic constructs responsible for the development of ToM as assessed through the false-belief task. They reported that executive function and ToM develop separately, although often simultaneously. Thus, executive function is associated with ToM reasoning, but can be dissociated. In one study, Sabbagh et al. (2009) controlled for executive functioning to investigate functioning and purpose of various regions of the brain. For example, they documented that the area of the brain called the cuneus was active differently in children than in adults who were engaging in false-belief tasks. The cuneus was active in children (but not in adults) while the children engaged in tasks requiring reasoning about self-knowledge and mental imagery. Sabbagh et al. (2009) speculated that perhaps children who were developmentally immature in false-belief performance require more reflection on self-knowledge and imagery when working through a false-belief task than the mature ToM processes found in adults completing the same task. The work by Sabbagh et al. (2009) served to inform the field of the brain structures involved in the development of ToM in children.

Limitations of Studies

Of the 17 studies included in this review, there were few similarities in measures, including those characteristics used for primary comparisons within this review. For example, measures for emotional understanding, temperament, aggression, mind-mindedness, and inhibitory control varied greatly across studies. Some measures were researcher-designed while others were published tests with established reliability and validity results. Twelve studies included a test that could be categorized within the language domain (i.e., Peabody Picture Vocabulary Test), yet eight different tests were used across the 12 studies. Such diversity in measures impacts our ability to compare results. It should be noted that tests of false-belief were very similar across 16 of the 17 studies with 11 studies referencing Wimmer and Perner (1983) as the source for their task design. Despite the difficulty in comparing results, general principles can be gleaned from this review and considered for possible application within the field of visual impairments. This discussion will provide direction for future research in the development of ToM in children with visual impairments.

Discussion of Findings in Relation to Visual Impairments

For many years researchers have concluded that children with visual impairments are significantly delayed in the development of ToM. This belief is based on the findings of studies assessing the development of ToM in children with visual impairments using traditional false-belief tasks (Green et al., 2004; Minter et al., 1998; Peterson et al. 2000). But, recent research has called this belief into question (Begeer et al., 2014; Brambring, 2005).

Validity of the Adaptations to the False-belief Task

As outlined in the first section of this literature review, there are essential components of a false-belief task that ensure the task is valid (counterfactual reasoning, memory, reality, and knowledge control). Begeer et al. (2014) proposed accommodations to the false-belief task for children with visual impairments. Critical evaluation of the validity of these adapted false-belief tasks is necessary in order to compare results from the adapted version to results from studies using traditional test methods. In addition, this validity assures that measures are consistent in testing what has been defined as false-belief for the purpose of measuring ToM. Many versions of the ToM task are prevalent in the literature. In fact, in a meta-analysis, Wellman et al. (2001) reported consistent findings among studies that used a variety of alternate versions of the false-belief task originally described by Wimmer and Perner in 1983.

Three features appear key to any false-belief task. First, a false-belief task should include control questions for reality and memory. Second, the task should be constructed in such a way that the child must consider alternative options (counterfactual reasoning) that are perceived differently by the given characters based on their knowledge of reality. Finally, the child must be required to provide a response by using the false knowledge of reality of the proponent rather than the child’s own true knowledge of reality when the child knows the proponent is misinformed (knowledge control).

In the study by Brambring and Asbrock (2010), which included children with visual impairments, all three of these constructs were accounted for in each test. Brambring and Asbrock (2010) developed nine tasks requiring auditory or tactile experiences rather than the vision-based experiences of traditional false-belief tasks. For example, the story described in the change location task involved a boy being put to bed by his mother. When the mother left, the boy hid under the bed. In the test, the child was asked control questions for reality and memory. The child was then asked to predict where the mother would begin looking for the boy. The scenario provides the need for counterfactual reasoning as well as knowledge control. This alteration involved a situation with which a child with or without vision would be familiar (i.e., a bedtime routine, a mother checking on her son). The alterations to the false-belief tasks devised by Brambring and Asbrock (2010) appear to be true to the constructs being tested by traditional false-belief tasks.

Attributes that Contribute to Development of ToM

If the false-belief tasks used by Brambring and Asbrock (2010) are true to the intended constructs of traditional tests, and children with visual impairments show limited delays when given the opportunity to display their awareness of ToM given these altered tasks, then a logical next question is to discern whether children with visual impairments develop ToM in the same way that children with typical vision develop ToM.

Social Behavior. Social behaviors appear to be a significant contributing factor to the development of ToM in typically developing children. Specific factors that are positively correlated with ToM include strong social skills thereby offering multiple peer interactions to hone skills in emotional understanding, flexible thinking, conflict reasoning, and inhibitory control. An aggressive temperament is negatively correlated with ToM development, and a child who is less engaged might gain an understanding of ToM by learning from the behaviors of others. This appears to be true as long as the child is observant of his or her surroundings, as is consistent with the definition of a shy temperament. But, when a child is socially engaged to a limited degree, ToM development is negatively impacted. Researchers show that children who have visual impairments are often less engaged with their peers (Celeste, 2006; Crocker & Orr, 1995), and they tend to be egocentric in their language and play behaviors (Dale & Salt, 2008; Erin, 1990).

Research on typically developing children suggests the importance of social behavior in the development of ToM, yet children with visual impairments lack many of the social behaviors deemed important for this area of development. This finding does not appear to align with the findings of Brambring and Asbrock (2010), who claim that children with visual impairments display very little delay in the development of ToM. Most of the research related to the social behaviors of children with visual impairments is dated, and further investigation is needed to understand if a correlation exists between the development of ToM and social behaviors in children with visual impairments.

Executive Function. A positive correlation was found between divergent thinking or problem solving and the development of ToM. Wyver and Markham (1999) reported that no significant difference was found between children with severe visual impairments and their sighted peers between the ages of 4 and 12 on tests of divergent thinking. But, they caution that the standard deviation in scores was much greater among children with visual impairments. These deviations were positively correlated with age. While further study is needed, this could indicate that the development of divergent thinking develops at a later age in children with visual impairments compared to their sighted peers.

The literature shows that the development of ToM is positively correlated with inhibitory control even when memory is controlled. There does not appear to be research related to inhibitory control in children with visual impairments. However Pring (2008) found that children with visual impairments have better spatial and short-term memory than their sighted peers. This would suggest that children with visual impairments might be able to hold information about a situation in memory better than their sighted peers. While the development of memory is correlated with inhibitory control in sighted children, it is unclear if memory skills might also indicate greater inhibitory control by children with visual impairments. Research is needed to better understand whether inhibitory control is correlated with the development of ToM in children with visual impairments.

Language Ability. Research supports a strong positive correlation between ToM and early mother-child language that includes mental state elaborations regarding belief and desires. Use of mental state elaborations is particularly effective when these interactions are attuned to the child’s thinking and encourage reciprocal interaction. Research shows that mother-child interactions when children have a visual impairment are comparable in quality to the interactions of mothers and their children with typical vision (Behl, Akers, Boyce, & Taylor, 1996; Tadić, Pring, & Dale, 2013). Behl et al. (1996) noted that mothers of children with visual impairments provide more directives and verbal involvement than mothers of sighted children, but this occurs as an appropriate and necessary adaptation to the child’s visual impairment. Tadić et al. (2013) studied the mental state language that mothers of children with and without vision loss provide to their children. They found that mothers of children with visual impairments actually provide more mental state and descriptive elaborations than do mothers of children who are typically sighted. These elaborations were positively correlated with children’s socio-communicative competence.

In their study of typically developing children, Flynn et al. (2004) found that children with strong language skills developed ToM even if they lacked inhibitory control. It could be that children with visual impairments are able to develop ToM through language even though they lack other opportunities typically correlated with the development of ToM in sighted children (i.e., social interaction, inhibitory control). More research is needed to understand the interplay between language development and ToM in children with visual impairments.

Neurologic Development. Research shows the role that neurologic development plays in the development of ToM. Structures within the brain undergo maturation and neural activity during false-belief tasks is general and becomes more specific with ToM development. Researchers have concluded that neural development foundations are biological, but the development of ToM is likely based on environmental experiences (Liu et al., 2009). The interplay between nature and nurture is apparent. No research was found that investigated the neurological development or activity of the regions of the brain used in ToM development by children with visual impairments. Research in this area would provide important information regarding the foundations of ToM development in children with visual impairments. Because some neurologic activity during the false-belief task is based on visual input, it would be interesting to see if these same regions are active when children are engaged in false-belief tasks using different sensory modes. Such an investigation might also provide insight into whether children with visual impairments accomplish the false-belief task using the same constructs. For example, Flynn et al. (2004) suggested that ToM could be accomplished through the use of inhibitory control, yet a subset of the children in the study by Flynn et al. (2004) accomplished the task using verbal constructs. If various pathways lead to the accomplishment of the false-belief task, it is conceivable that children with visual impairments might develop ToM using different means than sighted peers.

Implications

Research

Research is needed to understand the development of ToM in children with visual impairments. Because ToM is an important component in the development of social skills, investigation into the development of ToM in children with visual impairments may provide insight into strategies for assisting social skill development in these children.

Many of the same factors that have been shown to correlate with the development of ToM in sighted children may guide research on ToM development in children with visual impairments. Research is needed to understand if children with visual impairments gain inhibitory control prior to the acquisition of ToM. Also, the role of language in accomplishing the development of ToM with children with visual impairments should be investigated. Given that Tadić et al. (2013) found that mental state language was more common in the interactions of mothers of children with visual impairments than those of children with typical vision, research could focus on the relation between mental state language and ToM development in children with visual impairments. Also, because research has shown that children with visual impairments acquire skills in ToM, further investigation is needed to understand whether children with visual impairments use the same areas of the brain as do their sighted peers when completing ToM tasks. Begeer et al. (2014) have suggested that the type of vision loss (ocular vs. ocular-plus) may influence the propensity for a delay in ToM development, but it could be assumed that severity of visual impairments could impact this development as well. Several interesting questions remain unanswered related to the development of ToM in children with visual impairments.

Practice

Providing teachers with an understanding of the need to support young children with visual impairments in opportunities that can foster the development of ToM could have a long-term impact on their development of social skills. The development of social skills has been identified as problematic for children with visual impairments, yet it is possible that characteristics correlated with the development of ToM will result in improved social skills. For example, research with typically developing children has shown the importance of using mental state language to help children develop an understanding of the thoughts and desires of others (Laranjo et al., 2010; Lundy, 2013; Ontai & Thompson, 2008; Ruffman et al., 2002; Symons et al., 2006). This strategy could be implemented with children with visual impairments with little need for adaptation. Parents could be encouraged to identify the perspective of their child and expand on that view to promote an awareness of the thoughts of others. Teachers also should be encouraged to challenge preschool and kindergarten children to recognize the perspective of peers. For example, preschoolers with visual impairments are likely to miss environmental cues and facial expressions that would indicate that peers are happy, lonely, embarrassed, or sad. Teachers can facilitate awareness in the perspective of peers by helping children with visual impairments consider peer responses. For example, a peer is likely to feel sad when a toy is taken, lonely when a parent is out of town on a business trip, and happy when a toy is shared. Simple understanding of peer perspective helps the child with a visual impairment anticipate peer perspective and fosters interaction. In addition, research with typically developing children has shown that children who have skills in divergent thinking are better problem solvers and, therefore, better at ToM tasks (Wyver & Markham, 1999). The flexibility required in divergent thinking can be beneficial in maintaining peer engagement as children find solutions to problems without displaying less mature behaviors such as aggression. It is possible that teaching strategies that develop divergent thinking would be beneficial for young children with visual impairments. For example, parents and teachers could be a third partner in a game. When conflict arises, as is often the case with young children, the parent or teacher can model options for resolution and encourage the children to problem-solve additional solutions. Building and practicing skills for solving problems in social situations will promote positive and sustained peer interactions. Little research was found on the development of ToM in children with visual impairments, but logic would suggest that there may be many benefits to the development of this skill in children who have a visual impairment, just as outcomes such as positive social skills and problem solving are evident in sighted children.

Conclusion

It is unclear how children with visual impairments develop ToM. Research on the development of ToM in sighted children is robust, but there are limited studies that specifically investigate ToM in children with visual impairments. Recent research, such as studies by Brambring and Asbrock (2010) and Begeer et al. (2014), provoke new questions about the development and similarities between the two populations. While more research is needed, further exploration and debate on this important topic promises to promote positive social gains for children with visual impairments.

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