© Borgis - Postępy Nauk Medycznych 1/2013, s. 91-96
Beata Blok, Zofia Brzeska, *Małgorzata Marszałek, Beata Ignaczewska
Teoria umysłu jako jedna z teorii wyjaśniających deficyty w zakresie umiejętności społecznych u osób ze spektrum autyzmu
The theory of mind – attempting to explain deficits in social skills among people with autism spectrum disorders
The Center for Children nad Adolescents with Autism, Gdańsk, Poland
Head of Center: mgr Małgorzata Rybicka
Autyzm to całościowe zaburzenie rozwojowe, które trwa przez całe życie. Choć o jego specyfice można przeczytać w wielu publikacjach zarówno naukowych, jak i popularnonaukowych, stanowi on cały czas swoistą zagadkę i wyzwanie. Osoba z autyzmem w kontakcie z inną, w tzw. normie rozwojowej, może wywoływać u niej zdumienie, ciekawość, czasem zniecierpliwienie lub ją urazić. Nie jest to jednak efekt złej woli lub niewłaściwego wychowania, ale skutek poważnego deficytu, braku prawidłowo rozwiniętych elementarnych umiejętności społecznych, którymi posługujemy się spontanicznie, wchodząc w różnorodne relacje z innymi ludźmi. „Zrozumieć” osobę z autyzmem można tylko wtedy, gdy pozna się mechanizm jej myślenia, spostrzegania, motywacji i innych aspektów będących motorem codziennego funkcjonowania. Próbą wyjaśnienia odmienności osób z autyzmem jest koncepcja oparta na tzw. teorii umysłu. W naszym artykule spróbujemy wyjaśnić na czym ona polega, poprzez szereg kluczowych przykładów będących opisem wielu osób z autyzmem, z którymi zetknęłyśmy się w naszej pracy.
Autism is a life-long developmental disorder. Despite the fact that there are many scientific and popular publications on the topic, autism is still considered not a well-known disorder. Individuals with autism may come across as awkward to other people. The reason certainly does not lie in ill-will of the individual, but it is rather related to many deficits that autistic people present, especially in the area of social skills and communication. Cognitive literature suggests that individuals with autism have a deficit in “theory of mind”, which is understanding mental states of other people, their thoughts and feelings. In the current article we will explain, based on clinical examples, how the deficit in the theory of mind may be an obstacle to proper functioning for children with autism.
We have been trying to help people with autism spectrum disorders for a number of years. We’ve conducted numerous diagnoses of children and teenagers, and sometimes adults, too. Some of them have been later diagnosed as patients suffering from autism or Asperger syndrome. Despite our considerable knowledge in the subject of the autism spectrum we often face the problem which even for us is both mysterious and fascinating – to what extend is perceiving of the human world by people suffering from symptoms belonging to the autism spectrum different from ours? What lies at the bottom of their problems?
One of the most disturbing symptoms observed by parents of younger children who were later diagnosed as those belonging to the autism spectrum patients, was little or no reactions to their own names and problems with making eye contact (1). It is unquestionable that most of the younger children with syndromes from the autism spectrum do not react when called by name, nor look at the caller in situations when eye contact would seem only natural.
It is also obvious that when somebody calls our name, when we greet or say goodbye to someone or when we are showed something, we at least take a look at the other person. It’s a spontaneous, clear communication sign, usually simultaneous with expressing certain emotions, such as: interest, curiosity, surprise, understanding, happiness, boredom, sadness, etc. But it’s not so in case of the patients with autism spectrum disorders. They don’t often look in the direction pointed by other people and don’t make eye contact in situations which normally ask for this kind of reaction. When such patients make a request, they often focus entirely on the object they desire, an event they find interesting or an activity they enjoy (e.g. blowing soap bubbles or listening to the same piece of music over and over again). Even the hand of the person they ask for an object is treated by them as the ‘tool’ necessary to get it. It’s very difficult to draw their attention or make them look at something. This kind of response demands focusing on other person and being able to read their intentions, whereas our patients concentrate on objects rather than people and do not usually realize that they are shown something, or that they were supposed to pay attention to something.
They don’t seem to understand that there are reasons of drawing other person’s attention other than making a request. Nor do they seem to comprehend another aspect of communication, which is creating a common ground of interest, related to the aspect of sharing with other people our emotions evoked by the same objects, subjects or activities (2). Most of us expect to be perceived and acknowledged. We also seek the confirmation that our way of perceiving the surrounding is similar to that of other people’s. If anything unusual happens in our presence, we try to make sure that other people are also surprised, and interpret the situation in the way that corresponds to our expectations. Certain kind of interaction is thus established. We experience interactions of this kind continually in our life. However, they seem to be beyond the grasp of the people suffering from autism spectrum syndromes.
During interviews, our patients’ parents point out the fact that their children involve themselves in disturbingly limited plays. The kids often enjoy exclusively manual activities which sometimes develop in their complexity. These activities are usually very schematic and hardly ever creative. They are mostly repetitive, too. The parents rarely see their children pretend something or take on different roles. They easily notice that their children play in a different way than other kids. The main difference is that most children within commonly accepted personal development norms, at some age prefer creative activities. They are able to see a car when looking at a wooden block, which can next turn into a phone in their eyes, and after that – into a talking creature. Our patients will as a rule stick to the basic function of the objects they play with. They will not see in those objects any other features than the real ones, they will not imagine any objects in their surrounding, nor pretend they’re something or someone other than themselves. They simply cannot pretend anything. Pretending is a state of mind, and in order to know how to pretend, we must know the difference between imagination and reality. It’s vital to understand this particular agreement that we act out something we first imagine (2, 3). Children normally realize what it means. They say, for instance, ‘I only pretended that I cooked this soup’.
The majority of our patients don’t understand activities in which they’re asked to take on different roles, pretend to be an animal or a story character. Neither do they understand why they should run away or hide as part of a game just to chase or find somebody minutes later. These problems cause major difficulties for them when playing with peers. Even when they do try, the results are awkward and unnatural. Literal treatment of objects, rules and customs is undoubtedly the base of these difficulties.
In the process of a diagnosis, the parents, and whenever possible also the children are asked standard questions. They are often confronted with various tasks, which enables us to assess, among others, their social skills, including their empathy level and the ability to look at the world from a perspective different from their own. In case of children with developed verbal skills, we check their ability to understand verbal messages. Our questions, but also spontaneous expressions result in somewhat comic situations. One diagnosed person, after hearing the therapist say, ’I can’t remember now. It’s on the tip of my tongue,’ started to observe intensively the therapist’s mouth as if trying to see what really is there on her tongue. She was so absorbed by it that for some time she was unable to concentrate on the conversation.
Some of the interviewed clients (who are usually eventually diagnosed as autism or Asperger syndrome patients) often explain with confidence the meaning of idioms or phrasal verbs they are asked about. And below we quote samples of such explanations:
– on one’s shoulders – „a person has something on his shoulders”;
– have one’s heart in one’s mouth – „the heart is in one’s mouth”;
– to know each other inside out – „I know the inside of your body”;
– be all fingers and thumbs – „a person has only fingers and thumbs”;
– badger – „this is not a person, he is an animal called a badger”;
– be as happy as a clam – „he is happy the same as clams are”;
– to have butterfingers – „his fingers are made out of butter”.
The parents also give us examples of their children’s literal understanding of verbal messages. One mother told us an anecdote from her son’s classroom. The pupils had been asked to work individually and the sit up straight in their chairs after finishing the task. That was to be the signal to the teacher that the task had been completed. Our patient assumed that he should work on the task with his back bent down, and then straight it up. He later complained to his mum that he had a backache because he had had to write in a very uncomfortable position. Another patient got terrified at the health centre when a nurse asked him to give her his arm during taking his blood sample. He thought she really wanted to take his arm away from him.
We can see, that to understand verbal messages properly we must first understand their author’s intentions expressed by verbal and non-verbal aspects of communication, that is: intonation, gestures, body posture, facial and eye expression. All these aspects are necessary to understand jokes, metaphors, idioms, etc. For some children with the autism spectrum disorders it’s easier to understand context anecdotes than jokes based on social agreements or playing on words. Being unable to understand the meaning of conventionality frequently results in them behave like a proverbial bull in a china shop. Their comments are often too blunt and considered rude. They don’t know when something should be said and how, and when something should be left unsaid for the politeness sake. Most people would find it hard to accept as a compliment to hear, ‘I like your yellow teeth’, or answer the question, ‘Why do you have a moustache, madam?’
Conversation plays a significant role in verbal communication and social relations. It’s seemingly a simple interaction. To take place, a speaker and a listener are needed. However, a conversation consists of a chain of elements. Let us consider just a few of them. It needs a topic (which can be evoked by asking a question or sharing a piece if information), directing towards another person (coming up to someone and making eye contact, sometimes calling someone’s name or drawing their attention in other ways) and taking turns. It’s also necessary to understand received messages, read other people’s intentions, be able to listen and derive information from the intonation or a particular emphasis. Moreover, it’s important to express interest by meaningful: ahem, eh?, oh!, or such expressions as: You’re joking!, Really?, By the way..., Would you believe?.., Speaking of which..., etc. Unfortunately, it is not obvious to people with symptoms belonging to the autism spectrum. We happened to observe children who talked to another person standing way too far, or on the contrary, almost making physical contact with them, delivered a monologue instead of actually talking, or even spoke to empty walls. People suffering from symptoms belonging to the spectrum of autism don’t maintain conversation through confirmation. Talking to them usually consists in them answering questions in a very concise way, most often only by nodding or shaking a head. They don’t use proper intonation nor emphasize important words to put a stress on something particularly significant or new for them. They can’t comprehend why they are asked anything or in what ways whatever they say can influence other people (2, 4, 5). They have problems reading emotions necessary to make a conversation. And here we come to our next issue – recognizing, understanding and appropriate expressing emotions by the autism spectrum syndrome patients.
During diagnosing the children’s emotional competence, they are showed a number of pictures or photos of people depicted in various situations and poses clearly expressing different emotional states, easy to explain from the context of the situation. For most of us it would be obvious that people presented in the pictures are happy, sad, scared, irritated or surprised. The vast majority of us would also be able to say why they are laughing or crying, show irritation or fear. It’s not so in case of our patients. Even when they are capable of naming basic emotions, they’ve got serious problems explaining their adequacy to the circumstances. An eight year old boy, after seeing a picture in which a boy and a girl are covering their ears and are clearly upset (you can see that they are in a very noisy place) said, ‘He is upset because maybe there’s too much wax in his ear’. Looking at the picture, our patient probably remembered a problem with ears from his own experience.
The same boy, seeing a picture showing a smiling baby, speculated that: ‘He looks like someone who says letter ‘s’. The boy was then showed another picture. In its foreground, a boy was sitting in a wheelchair and some children standing nearby were laughing and making unfriendly faces at him. The disabled boy’s feelings were visibly hurt. You could see school walls covered with graffiti in the background of the photo. After looking at it, our patient said, ‘These walls are dirty, damaged, sprayed over. You mustn’t do it.
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Płatny dostęp do wszystkich zasobów Czytelni Medycznej
1. Pisula E: Małe dziecko z autyzmem. GWP 2005.
2. Frith U: Autyzm. Wyjaśnienie tajemnicy. GWP 2008.
3. Howlin P, Baron-Cohen S, Hadwin J: Jak uczyć dzieci z autyzmem czytania umysłu. Kraków, KTA 2011.
4. Winczura B: Dziecko z autyzmem. Terapia deficytów poznawczych a teoria umysłu. Kraków, Impuls 2008.
5. Bokus B, Shugar GW (ed.): Psychologia języka dziecka. Osiągnięcia nowe perspektywy. GWP 2007.
6. Pisula E: Autyzm u dzieci. Diagnoza, klasyfikacja, etiologia. Wydawnictwo PWN 2000.
7. Pisula E: Autyzm. Przyczyny. Symptomy. Terapia. Harmonia 2012.
8. Młynarska M: Autyzm w ujęciu psycholingwistycznym. Terapia dyskursywna a teoria umysłu. Wydawnictwo Uniwersytetu Wrocławskiego 2008.