Baron Cohen et al. (1997): Adults with Autism (functioning test of theory of mind)

[NARRATOR] Okay, so the next study that
we are looking at is by Baron-Cohen et al.

When it says "et al.,"

it means that there has been
three or more researchers,

so if there's one researcher,
it'll say the researcher's name;

if there's two, it will say
the two researchers' names

(for example, Loftus & Palmer);

but if there has been three or more,

we usually put "et al.,"
so Baron-Cohen et al.

So it was done in 1997

and it is looking at autism and
something called Theory of Mind.

So I'm just gonna go
through some key terms,

through a bit of background,

so make sure you make notes
on the background information,

and then we'll look at the study.

So autism is a developmental disorder,

and it affects the social
functioning of individuals.

So it looks at how individuals can
have impairments in several areas

related to their ability
to function socially,

communicate socially,
and things like that.

So if you have autism,
you're on what is known as a spectrum.

So there isn't just one type of autism

and [not] everybody who has autism
has that type of autism, if you will.

What it is, is, there's a spectrum,

so when you're talking about a spectrum,
it means a range, okay?

The autistic spectrum refers
to a range of disorders

which consist along a continuum
from mildly affected to severely affected.

This is what your autistic
spectrum might look like.

So it's a continuum.

So a continuum means,
you could fall anywhere along here.

So it's not categories.

It's not "you're in this category"
or "you're in this category"

or "you're in this category."

It means that you could fall here...

...or here...

...or here...

...or here,

so you could be anywhere
along that continuum.

So you could be mildly affected,

so individuals who have things
like high-functioning autism

and Asperger's are in
this mildly affected region.

It might mean that
you've got an average IQ

or a slightly above average IQ.

It might mean that you have some
extreme ability in some area,

so we have something called autistic
savants who have particular abilities,

particular skills that
they are incredibly skilled at,

like memorizing large amounts of numbers

or memorizing what a city looks
like from above, things like that.

But it doesn't actually
affect your learning

in a particular type of severe way.

Whereas this end of the spectrum is
what's known as a severe learning disability,

so this is where you'd
find classic autism,

where your learning and skills
are massively affected.

Asperger's Syndrome is when an individual

is at the milder end,
if you will, of the spectrum,

and that's not to say-- "mild end,"

that's not to say
it's not affecting you at all;

obviously, it is, but it's what's known
as the milder end of the spectrum.

So it means that they have
problems with social interaction,

but they have generally normal levels
of cognitive development.

So we've got high-functioning autism
and then Asperger's Syndrome.

Now, there's a concept
called Theory of Mind.

Theory of Mind is having
the ability to understand

that other people have
independent minds of their own.

So it allows us to understand and predict

what other people
think and feel, basically.

So I'm gonna talk a bit more
about Theory of Mind in a moment.

But it's basically understanding

that somebody else has
another mind than you,

they know other things than you,
they've seen other things than you,

they feel other things than you.

There's a few things that we're gonna
talk about when it comes to autism.

Some of these,
we're gonna look at in lesson.

Half a million people
in the UK have autism,

and boys are four times more likely
to receive a diagnosis than girls.

So the statistics of autism
is that there are four boys

for every one girl that has autism.

And there's a number of things
that people have linked to autism

as a factor or a cause.

There's this kind of continuing debate
about whether autism is caused by nature.

(Is it something that you're born with?

Is it to do with your genetics
or your neurological development?)

Or is it nurture? So is it things like
how your parents raise you?

Is it something that you've
picked up in your environment,

like a bacterial infection?

Is it due to being around people
who smoke, or your mother smoking?

Is it due to being in a place
where there's lots of air pollution,

or where there's sorts of pesticides?

Or is it to do with something like
your parent or the age of your parent?

Is it something that is
within the environment?

You're gonna research
some of these in lesson

but there's a whole
different argument there.

But essentially, people who
are on the autistic spectrum

have what is known as
the triad of impairments.

So the triad of impairments.

If you are on that spectrum,

you have difficulties
in these three areas.

So you can have difficulties
in social communication,

so these are things like
not understanding facial gestures,

so like non-verbal communication,

They may use a set of phrases repeatedly,

They may have difficulties with verbal
and non-verbal communication;

and they may repeat what other people say.

Social interaction is another area
which they may be impaired in,

so that might be things like difficulty
in forming relationships.

They don't necessarily want to have eye
contact or might not want to be touched.

They may have difficulty in expressing
themselves to others like I currently am.

And the last area of your
triad is social imagination,

so you might find it difficult
to imagine how others are feeling

or wanting to engage in
pretend play with others.

So that's things like putting yourself
in somebody else's shoes

or understanding other
people's perspectives

or playing role-play games
like imagination games.

If you've ever watched
any programs or films

with somebody who is on
the autistic spectrum in it,

you might see a few of these things,

so if you have, I'd encourage you
to watch those again now

and see if you can pick
any of those things up.

There's things like,
"[Undateable]" is a program

which has raised a lot of awareness of
people with autism and with Asperger's,

and you quite often see things like having
a set of phrases that they use repeatedly,

like there's a fellow on there
that says "exactly" all the time,

so he'll finish a sentence
and say "exactly."

And then he'll say something else
then turn around and go "exactly."

Even if nobody has responded to him,

he'll have that phrase
that he uses quite consistently.

There's also repeating what other people say.

If anybody has ever seen "Rainman,"

there's a couple of scenes in there
which really display that.

If you have difficulties
in all three of these areas,

right there in the middle, that's you.

You'd be on the autistic spectrum.

So don't necessarily go,
"Well, that's me,"

which a lot of students do.

They'll say, "Oh, I don't like making
eye contact, so I must be autistic."

That's not the case, okay?

So you have to have some level
of impairment in three areas.

So don't self-diagnose, is the lesson.

So Theory of Mind.

So if you lack theory of mind,
it's known as a cognitive deficit.

This is Baron-Cohen, who conducted
the study, et al., with his friends.

So he suggests that problems
with developing theory of mind

can explain the social and
communication problems.

So if you struggle with theory of mind,
if you have a lack of theory of mind,

it can explain some of these things.

Like I said, theory of mind

is the ability to recognize and attribute
mental states, thoughts, perceptions,

desires, intentions, and feelings
to oneself and to others.

So it's about being able to understand

that somebody else has got a different
perspective on a scene than you.

If one person stood
on one side of the room

and another of you stood in a completely
different side of the room,

they're going to see the lesson
from a different perspective.

They'll see different things
happen than you.

It's about understanding
that that's what they've seen,

and this is what you've seen,
and they're different.

They haven't seen exactly
the same thing as you.

Or about understanding
other people's intentions.

So somebody hurts you,
but they didn't mean to,

it was accidental.

But can you understand

that their intention was to
help you not to harm you?

So in order to interact with
people in a “normal way,”

you need to be able to understand

how the things that you say
might affect somebody,

how it might make them
think and them feel,

but also understand the reasoning
behind what they say.

So if you come into the room

and you're wearing
a particularly ugly jumper,

I might be thinking,
“Well, that's an ugly jumper,”

but I wouldn't say,
“What an ugly jumper,”

because that would hurt your feelings.

So I might just go,
“Is that a new jumper?

It's a nice jumper,”
something like that.

That's because I have an
awareness of your feelings,

and I have an awareness

that what I say could
affect you in this way.

If I say, “What an ugly jumper,”
you might take it as a joke,

or you might actually have
your feelings hurt by that.

Now, somebody
who lacks theory of mind

might not necessarily be able
to make that connection.

So if I said, “What a nice jumper,”

they might think,
“It's not a nice jumper, though.

It’s a bit of an ugly jumper,”

and wouldn't understand that my intention
is to avoid hurting somebody's feelings.

So that might be one example.

I think sometimes, particularly in the media,

you see people who are
autistic and on the spectrum

appearing to look like
they hurt people's feelings.

You see that quite often in TV shows.

That's again, having
a lack of theory of mind,

potentially affecting how we understand

the things that we say
can affect somebody else.

There's just a couple of examples there.

So there's several experiments
that have been conducted

to show that people with autism
struggle to employ a theory of mind,

so struggle to use theory
of mind and develop it, okay?

There's really a classic example
I'm just going to run through with you.

This is the Sally Anne Test.

In the Sally Anne Test,

you can do what’s called a first-order
and a second-order theory of mind test.

This is what the Sally Anne Test looks like.

This is Sally, and Sally's got a basket.

And this is Ann, and Ann has a box.

So Sally has a marble.

She puts the marble into her basket,
and Sally goes out for a walk.

Now Anne takes the marble out of
the basket and puts it into the box.

Now Sally comes back and
she wants to play with her marble.

Where will Sally look for her marble?

This is a first-order test of theory of mind,

so it's testing whether you could
understand somebody else's perspective.

So can you understand the world in
this scenario from Sally's perspective?

Where will Sally look for her marble?

I want you to think and I want you
to just say out loud to yourself right now

where you think Sally
will look for her marble.

Now, a normal 4-year-old child,

(and hopefully you) will correctly
state that Sally will look in her basket.

That's the last place that she
left her marble (in her basket),

so she's going to look
for her marble in her basket.

Now what we often find
is that children with autism

often say that Sally
will look in Anne's box.

They struggle to employ theory of mind

and understand things
from Sally's point of view.

Their awareness is that
that marble is in that box.

They struggle to use theory of mind
in the sense of understanding

that Sally hasn't seen
the scene that we've just seen

(for lack of a better sentence).

“Sally hasn't seen the scene
that we've just seen.” [chuckles]

Sally doesn't know that while
she's been out of the room,

Anne has gone to take that
marble and put it in her box.

If you're passing the theory of mind test,

you're going to say Sally is
going to look in the basket.

If you are not going to pass the test,

you say that she's going to look in the box.

Now, the second-order
test is very similar,

but then Sally comes back

and instead of asking,
“Where will Sally look?”

you ask, “Where will Anne
think that Sally will look?”

In your second-order test,

you're not only viewing things
from somebody else's perspective,

but you're looking at
that person's perspective

of another person's perspective.

So from Anne's perspective,
where does she think Sally will look?

So again, a normal 6-year-old child

will correctly state that
she'll look in her basket,

because they know that Anne
is aware that Sally doesn't know

that [Anne] has moved the marble.

But adults with Asperger's Syndrome
have also been shown to pass this test.

We're saying that adults with autism
have a lack of theory of mind,

and we've seen that in children
with this Sally Anne Test.

But then what we're saying is,
an adult can pass this test as well,

even though they've got Asperger’s
or they're on the autistic spectrum.

So does this mean that they
have developed theory of mind,

or does this mean that there's
a problem with the test?

Now, what Baron-Cohen suggests
is that there's a problem with the test.

He argues that passing this test,
this second-order theory of mind test,

doesn't show that people
with autism have theory of mind.

It says that these tests are designed
for 4- to 6-year-old children.

It only shows that adults with autism

have the equivalent theory
of mind as a 6-year-old child.

It's not necessarily showing
that they have theory of mind,

They have a good level of theory of mind.

It's showing that their theory of mind is
equivalent to that of a 6-year-old child

because they've passed it,
and a 6-year-old child can pass it.

This is known as a ceiling effect.

This test only measures as high

as the theory of mind skills
of a normal 6-year-old child.

That's the ceiling on this test is the
normal theory of mind of a 6-year-old child.

So Baron-Cohen suggested that
different tests need to be employed

in order to test whether adults
with autism and Asperger's Syndrome

can actually use theory of mind.

There's some other tests that have
already been designed for autism

and for theory of mind.

Sally Anne is one,
but we've got some different ones.

So Happé's Strange Stories is another.

Happé developed an advanced
test of theory of mind.

So it's called advanced because
it's trying to reduce that ceiling effect.

Children are read stories,

then they're questioned
about the characters.

It's called Happé’s Strange Stories
because it's like unique scenarios.

These stories have characters who will
do things like, they will pretend play,

they will joke, they will tell white lies,

things like “That's a nice jumper”
when it's an ugly jumper.

They will use figure of speech,
things like “raining cats and dogs.”

They will use irony.

These are called mental stories
or mentalistic stories.

So If the children had trouble answering
the questions about the stories,

then they were said
to lack theory of mind

when they're compared to match controls.

Because these require you
to use some abstract thought,

some imagination, somebody
else's perspective, things like that,

it requires a certain level
of theory of mind.

Baron-Cohen used Happé Strange Stories
as well as developing his own test.

Baron-Cohen wanted
to create a functioning test

of theory of mind for adults.

The tests that exist at the moment
don't really function very well for adults.

There's still that ceiling effect there.

So he had a few research questions.

Would adults with high-functioning autism
(people who don't have severe autism)

and Asperger's syndrome

be impaired on a theory of mind task
designed for adults specifically?

Would females be better than males at
mind reading or at using theory of mind?

Theory of mind is sometimes
informally called “mind reading”

because it's requiring you
to think sort of think about

what somebody else is thinking,
think about their perspective.

They thought that females
were better at this than males.

This is a commonly held belief
that women are more able

to understand other people's perspectives.

Then Baron-Cohen also hypothesized

that adults with autism will have
a specific deficit of theory of mind.

They conducted a quasi experiment.

It's a quasi because you've got
an independent variable,

which is the type of person.

They had three groups of people.

They had adults with high-functioning
autism and Asperger’s,

they had normal adults,

and they had adults
with Tourette’s Syndrome.

And it's naturally occurring.

So they all already were either
on the autistic spectrum

or they had Tourette’s
or they were normal.

Then the dependent variable is measured,

so the performance is
a score on the Eyes Task.

Baron-Cohen developed a brand
new task called the Eyes Task

to measure theory of mind.

All participants were tested individually,

It was in a quiet room that was either in
their own home, in the researcher’s clinic,

or in the lab at Cambridge University.

Sample: So we've got our three groups.

The first group, we have 16 individuals

with high-functioning
autism or Asperger’s.

So we’ve got-- 4 of these participants
have high-functioning autism,

12 have Asperger’s.

There was 13 males and 3 females

and all of them were
of normal intelligence.

They were recruited through an advert
in the "National Autistic" magazine

and a wide variety of clinical sources,

but the main bit is the advert
in the autistic magazine.

Then you've got 50 normal
age-matched adults.

Don't feel harsh about
calling them “normal.”

You have to call them normal.

That's what they referred to in the study.

It means neurotypical.
rather than normal.

There's no such thing as normal,

but they're called
the normal group in this study.

So it means individuals
with no neurological disorder.

There's 25 males, 25 females,

and they were drawn from the subject
panel of the university department,

compromising of the general
population of Cambridge.

There were no members of the university,

but the subject panel drew them.

Then you've got your third group.
This is 10 adults with Tourette’s.

They were also age-matched.

The sex ratio was 8-to-2,
so 8 males, 2 females.

They were all of normal intelligence,

and they were all recruited
from a referral center in London.

All three groups ended up age-matched.

Obviously, we're interested
in the autistic group

and if the autistic group
show a lack of theory of mind.

Now, we need to also know
why we've then got three groups.

So why have participants without autism?

You need to have participants without
autism because they're a control group.

You always need to have
a control group as a baseline

whenever you do experiments.

Realistically, that's the best thing to do.

Because if you have a group that
do not have the neurological disorder,

or if you're doing caffeine and memory,
have no caffeine,

that gives you a baseline of what
theory of mind should look like,

or what memory should look like when
you're not using caffeine, things like that.

In this case, it's what theory
of mind should look like.

What level of theory of mind should you have?

We can use this to compare
to the other two groups,

and that tells us whether the other
two groups are abnormal in any way.

But why have participants
with Tourette’s Syndrome?

Tourette’s Syndrome
is a neurological disorder,

and it's characterized by things like tics

and sudden involuntary
movements and vocalizations.

So it's things like physical
bodily movements,

like the twitch of an arm.

You can sometimes see people
that have one with physical tics,

so it might be like
a facial spasm might be a tic,

or I've seen people before
that have tics in their limbs,

so it might be that there's a tic,
that arm goes in the air

and then it won't come
down for a little bit.

It's all involuntary.
They've got no control of that.

Or it could be vocal.

So often people think that people
with Tourette’s just swear,

and sometimes they do swear
but it's not just swearing.

Often, it's things which are
inappropriate for the moment.

So it could be things like swearing
or it could just say random words

but words that are relevant to that person.

So I don't know if anybody watches E4,
but there's a lady that presents for E4.

She does the-- like the talking bit
when you're introducing the next show.

And one of her tics is,
she says “thunder cats.”

So often, she'll go “thunder cats”
between things that she says.

It's not like a swear word,
but that's a tic, it’s involuntary.

She's got no control over that.

The reason why participants
with Tourette’s were chosen

was because they're similar to
autistic participants in a lot of ways.

These conditions,
they both affect social interaction.

and they're both
developmental disorders,

more males rather than females
have these disorders,

but neither one affects intelligence.

I think people have tried
to make comparisons before

with things like Down syndrome,
which can affect intelligence.

Whereas we know that high-functioning
autism and Asperger’s and Tourette’s

have no effect with
intelligence whatsoever.

We can't say that any differences
are based on intelligence,

just on these disorders.

Theory of mind should affect
only participants with autism

and not Tourette’s.

So by comparing the two groups,

we can see whether having
a lack of theory of mind

is characteristic of having autism
or being on the autistic spectrum

rather than just having any
neurological or developmental disorder.

So in this study, four tasks are completed.

Four tasks.

So we have a set of control tasks.

Control tasks, similar to a control group,
are looking for baseline measurements.

The control tasks here are to ensure
that the participants with autism

were lacking only theory of mind

and they're not lacking things
like basic cognitive functions,

like basic intelligences, basic abilities.

The two tasks are gender recognition
and basic emotion.

In the gender recognition tasks,
participants are looking at photos

and they're stating the gender
of the person in the photo.

The task controls for face perception,

perceptual discrimination,
and social perception.

In other words, none of these things
could affect whether they suggested

that they were male or female.

Then you've got your basic
emotion recognition task.

Again, they're looking at photos of faces,

and they're stating what basic
emotion the person was feeling,

identified by a psychologist called Ekman.

They had choices of
things like basic emotions

being happy, sad, fear,
anger, surprise, disgust.

They're checking whether
difficulties on the Eyes Task

were due to theory of mind
and that being in lack,

or difficulties with these basic
emotional recognition skills.

Those are the two control tasks.

And then you've got two experimental tasks.

After the control tasks are completed,

every participant in all three conditions
completed these two experimental tasks.

We've got the Eyes Task.

So the Eyes Task was
developed by Baron-Cohen,

and I'm going to tell you a bit more
about how that's developed.

This is the test that they developed
to see if it was suitable for adults.

It's a test of theory of mind
and Happé's Strange Stories.

Happé's Strange Stories
we've already talked about.

This was to compare the results
of the new Eyes Task

to see if there was a link between the two.

We know the Happé's Strange
Stories test for theory of mind,

but there is a bit of
a ceiling effect with it.

So what we're doing is,
we're taking this Eyes Task

in which we're saying
there's no ceiling effect,

it's suitable for adults.

So if participants struggle
with the Eyes Task,

and then they also struggle
with Happé's Strange Stories,

we can be fairly confident that these
two tests are testing the same thing.

So we know that they struggle
with Happé's Strange Stories,

which test theory of mind.

They're struggling with the Eyes Task,

so we can also assume that
that is testing theory of mind,

and that is known as concurrent validity.

If participants struggle with one task,

they should also struggle with another
task that tests the same construct.

Same idea.

To summarize what I've said so far,
you've got three groups:

high-functioning autism and Asperger’s;

you've got a Tourette’s group;
you've got a control group.

And you've got four tasks that they're doing:

You've got gender recognition,
basic emotion, Eyes Task,

and Happé's Strange Stories.

The first two are control;

the second two are theory of mind
or experimental tasks.

So the Eyes Task.

We'll go through how
the Eyes Task worked.

In this test of theory of mind,

they looked at black-and-white
photographs of eyes for 3 seconds.

So there's 25 pairs
of black-and-white eyes.

They were 10 by 15 centimeters.
Each was displayed for 3 seconds.

Now, with each photo,
two words appeared:

one was a target word
and one was the foil word.

The target word was
the accurate description

of how the person was feeling.

If the person was feeling
happy in that photo,

the target word might have been “happy.”

The foil word is incorrect.

The foil word (usually the opposite)
might have been “sad.”

Participants were asked:

“Which word best describes what
this person is thinking or feeling?”

Participants had to choose
what they thought was the correct word

before moving on to
the next eyes photograph.

They're looking and it for 3 seconds,

and they’ve got to pick between
the target and the foil word.

There's an example of what it looked like.

So which word describes
what this person is best feeling?

Friendly or hostile?

When it came to choosing the photos,

we needed to make sure that this
was a valid test and it's free of bias.

So all these photos were
collected from magazines.

We have four judges, so two male
judges and two female judges

that looked at each photograph

and decided on the target
and the foil word for each one.

Now, to make sure again that this
is valid and that there's no bias,

what we do is, we've tested this
on a panel of eight other people.

So they had to further agree
on which word was the target

and which word was the foil,

They were checking that the task
was an appropriate level,

that the words used
(both the target and foil)

are understandable and that they match.

So this improves the validity of that task.

There's a couple of examples there
of pairs of words that we use.

So friendly or hostile, sad thought/
happy thought, calm/anxious,

sympathetic/unsympathetic,
concerned/unconcerned.

Just a few examples.

When the groups had
taken part in these tests,

they found that in the control tasks,

all the participants in
the autism and Asperger’s group

scored highly in the control task,

suggesting that they had
basic cognitive functioning.

In other words, on these control tasks,

there'd be no difference between
the autistic and Asperger’s group

compared to the normal adults
and the adults with Tourette’s.

But the group that has
high-functioning autism or Asperger’s

made significantly more errors on
the [Happé's] Strange Stories task

than either of the other groups.

When they're being asked questions
about the [Happé's] Strange Stories,

if you're in that high-functioning
autism Asperger’s group,

you're making more errors.

Now, when it came to the Eyes Task,

what we did was, we took the mean score
(the mean number that they got correct).

The mean score on the Eyes Task for adults
with autism or Asperger’s, was 16.3;

compared to normal people, which was 20.3;

and adults with Tourette’s, which was 20.4.

The mean score for adults with Tourette’s

was not significantly
different from normal adults,

but both were significantly higher

than those with high-functioning
autism or Asperger’s.

Now, remember, another question
that Baron-Cohen wanted to answer

was whether there was any basis
to the commonly held belief

that females were better than males
at mind reading or using theory of mind.

Using the results from the control
group only, (so from the normal group),

they got the following results.

The mean score on the Eyes Task
is that the normal males scored 18.8;

and the normal females scored 21.8.

Normal females performed significantly
better than normal males on the Eyes Task.

But the normal males were
still significantly better

than the group with high-functioning
autism and Asperger’s.

Normal males don't have as good a level
of theory of mind as normal females,

but they've still got a
better level of theory of mind

than those in the high-function
autism and Asperger’s group.

Now, within the autism and Asperger’s group,

there was no significant correlation
between IQ and performance on the task.

We know it's completely separate from IQ.

It's just to do with having autism
or being on the autistic spectrum.

On Happé's Strange Stories,

no participants with Tourette’s
syndrome made any errors;

but those with autism and Asperger’s were
significantly impaired, making many errors.

So this study concludes that adults with
autism had difficulty on the Eyes Task

and made errors on the Strange Stories.

This suggests that adults,
as well as children with autism,

find it difficult to attribute
theory of mind to others,

so they lack theory of mind, in other words,

struggle to understand things
from other people's perspectives.

Contrary to previous research with adults,
these results seem to provide evidence

that adults with autism or Asperger’s
do possess an impaired theory of mind.

Unlike things like the Sally Anne test,
which says that adults with Asperger’s

can pass a second-order theory of mind test,
the same as a 6-year-old normal child.

This is suggesting, well, actually,

they've still got an impaired
theory of mind level here.

As some of the high-function
autism and Asperger’s group

hold university degrees and
were all of normal intelligence,

it is reasonable to suggest
that theory of mind deficits

are independent of general intelligence.

That is the study by Baron-Cohen.

In your next lesson, what we are
going to do is, I'll check your notes.

There's quite a lot of information here,
so you should have made quite thorough notes,

and I'm also going to go through
the study with you again,

and we're going to evaluate the study.