Social communication in autism spectrum disorder not improved by Theory of Mind interventions.

Abstract

This review examines whether interventions based on the Theory of Mind cognitive model improve social communication in people with autism spectrum disorder (ASD). Theory of Mind is the ability of an individual to understand the thoughts, beliefs and feelings of others and involves skills such as joint attention (the ability to share a focus of interest with another), emotional recognition and imitation. The Theory of Mind cognitive model for ASD suggests that Theory of Mind is a deficit in individuals with ASD.1 No evidence that Theory of Mind interventions improve social skills and communication in individuals with ASD.2 Twenty-two randomised and quasi-randomised studies were included in the review, consisting of a total of 695 participants, with sample sizes ranging from 10 to 61 individuals with a diagnosis of autism, atypical autism, Asperger's syndrome or a Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) based on the Internal Classification of Diseases, 10th Revision, Diagnostic Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) or 5th Edition (DSM-5)3-5. The studies included in the review used interventions specifically designed to teach Theory of Mind and its precursor skills, such as joint attention, recognising emotions from faces or pictures and imitation skills. Control groups were mainly offered ‘treatment-as-usual' or were wait-list participants. The primary outcomes of the review were communication and social function. A study included individuals ranged from 17 months to 52 years of age, with less than half of the studies (9) focusing on preschool-aged children alone (range 1–5 years). Four studies involved both preschoolers and early primary-school aged children (range 3–8 years), while the remainder included individuals aged 6–15 years (7) or participants aged ≥16 years (2). There was a preponderance of male participants, reflecting the higher prevalence of ASD in men. Most studies included both genders, but four studies included only men, and another four studies did not specify gender. Most studies were conducted in the USA (9), with others studies originating from the UK (5), Europe (4), Australia (2) and Asia (2). The individuals studied had a range of intellectual abilities. Studies included individuals with normal intelligence only (10), low-range intellectual ability only (9) and a range of intellectual ability (3). The majority of the studies matched their intervention and control groups according to chronological age and intellectual ability. One study grouped participants according to normal IQ or associated intellectual disability. Different outcome measures were used between studies. Five studies targeted Theory of Mind specifically as the primary outcome. Most studies (17) focused on Theory of Mind precursor skills and the outcome measures of these studies were grouped into emotional recognition (7), joint attention and social communication (9) and imitation skills (1). The frequency and duration of intervention varied between studies. The shortest total intervention period was 30 min/day for eight consecutive days. The trial with the highest intervention intensity provided 2.5 h of therapist contact time in a classroom setting, with each session occurring for 4 days a week over a 6-month period. One study assessed the effect of a parent-implemented intervention consisting of 30 min every day for between 4 and 12 months, average duration 7 months. The majority of trials in the review were not able to demonstrate blinding of participants or study personnel, because of the therapist-led behavioural-based interventions carried out. Only six studies adequately described allocation concealment. Fourteen studies reported outcome assessment blinding, although in some instances it was unclear as to whether the blinding was adequate. One study was deemed to achieve full-blinding during the intervention, as the intervention was carried out using a DVD rather than a therapist. Three studies had a high risk of bias because of incomplete outcome data. Social interaction outcomes were available from 11 studies, but studies used different standardised measures and reported mixed positive and negative findings for improvement. Only six studies reported communication outcomes and again found mixed positive and negative findings for improvement; one study reported expressive language improvements, which were not sustained at 4-year follow up. ‘So doctor, what do we do now that we know our child has autism?' is the usual question asked of paediatricians after families receive this diagnosis. There is much said and written about the importance of very early diagnosis, and therefore early intervention, to improve the lives of children with autism. Some claim that ‘cures' can occur if a particular type of intervention commences as soon as the diagnosis is made, especially before 2 years of age. This recently published Cochrane Collaboration systematic review has examined interventions based on the Theory of Mind cognitive model. What is Theory of Mind? At age 4 years, most typically developing children can imagine how someone else might be thinking, feeling and what their beliefs and thoughts might be. This skill depends on infants and toddlers having developed skills of joint attention (the ability to share a focus of interest with another), recognising emotions from faces and learning to imitate others. Dyadic joint attention (two people sharing) occurs in young babies of 6 months. Triadic joint attention (the ability to coordinate gaze and attention between another person and objects) occurs in babies by 9 months. Theory of Mind has been described as one of the underpinning deficits for autism. However, there is discordance as to whether all children with autism are lacking Theory of Mind.6 This raises the question of the appropriateness and usefulness of Theory of Mind interventions in individuals with autism, in which Theory of Mind skills are present. Theory of Mind deficits have also been described in individuals with other conditions, such as social communication disorders, attention-deficit hyperactivity disorder (ADHD), schizophrenia and developmental language disorders.7 In turn, it is unknown whether similar Theory of Mind based interventions can be applied to these individuals. Many have also observed that Theory of Mind ability varies amongst otherwise functional individuals. What is the review's conclusion? There is no good evidence that teaching ‘Theory of Mind' skills alone helps the individual to develop social cognition beyond the environment in which it is taught or maintain the skill over time. The individuals studied did not develop pragmatic (socially functional) language skills or friendships in real life after undergoing the intervention. These findings are consistent with a recent systematic review from the US.8 Equally important, the authors did not find adverse effects from any of the interventions, but mostly because the studies assumed there was unlikely to be harm and did not explicitly look for it. In Australia, what intervention children with autism receive depends on local accessibility and availability of specialist and generic early and educational interventions. Parental beliefs about what is best for their child are also important. There are varied sources of advice on managing the communication difficulties and social skills challenges experienced by children with ASD. The controversies about what constitutes best practice in an environment with insufficient evidence only increases complexity for parents and care-givers, as they try to make decisions that often require substantial time and financial investment. It is interesting to note that a recent qualitative study from the UK, which involved parents and their children with neuro-disability, including children with autism, highlighted communication, emotional well-being, pain, mobility, independence/self-care, mental health, social activities and sleep as key outcomes to be addressed in health service provision. In addition, behaviour, toileting and safety were important factors identified by parents involved in the study.9 The National Institute for Health and Care Excellence guidelines on the management and support of children with autism has adopted a similar framework, with an emphasis on good professional-patient-carer communication models, individually tailored patient-centred care, ease of access to all necessary services and adequate training of health, educational and social services professionals. These guidelines go further to highlight the importance of consistency across all health and social services in the provision of individualised care for children with ASD, the need to prioritise interventions that enhance effective communication skills between children with ASD and their carers, proactive management of anticipated periods of transitions and co-existing co-morbidities and the need to offer siblings and families of children with ASD holistic short-term and long-term supports based on their reported needs and goals.10 This suggests that we need to change both our research focus and the way we make recommendations, so we can provide answers to questions that parents of children with ASD view as important.