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C HAPTER S IXTEEN
Development of Social Understanding
in Children with Hearing Loss:
Implications for Audiologists
Mary Pat Moeller and Brenda Schick
Introduction
Communication requires more than knowledge of
grammar and the world; it also entails our understanding of social interaction. A key element contributing to communicative success is people knowledge;
that is, the ability to predict or explain others’
behaviors with reference to what others are thinking,
believing or feeling. Social reasoning ability often is
called mindreading or theory of mind (see Astington
1993). In general, it refers to our ability to make sense
of events around us by predicting or explaining
behavior based on the mental states of others and
ourselves. As an example, one of the authors was
driving to work recently and noticed a couple holding
hands and solemnly looking at a small garden plot on
the side of their home. Upon seeing this, the author
speculated that the couple recently buried a pet. It
may be the case that the couple were planning their
next planting season, but that explanation would not
match their somber mood and stance. Our ability to
make sense of events requires us to reason in relation
to how people typically think and feel. As adults, this
process is a constant part of social interaction (e.g., “I
wonder if I can convince my husband to go out for
dinner tonight;” or, “You need to consider how to
approach the subject so you won’t hurt her feelings”).
The body of literature on theory of mind has several
implications for children with hearing loss. This chapter begins with an explanation of theory of mind and
how it underlies social understanding, including
information about typical development. This is followed by a brief literature review that summarizes
what is known about theory of mind development in
children with hearing loss. Implications for support-
ing these children in gaining social cognitive skills
will be described. A case study will illustrate clinical
applications of theory of mind in program planning
for a deaf student.
What Does It Mean to Have a Theory
of Mind?
Since the 1980’s there has been a proliferation of
research in cognitive psychology dealing with children’s development of theory of mind (ToM) concepts.
In general, a theory of mind refers to an understanding that people, including themselves, have thoughts,
feelings, and desires. Some refer to this as a theory,
because it represents an integrated set of concepts
used to predict and explain behaviors. In the case of
theory of mind, children learn to predict and explain
human actions by considering mental states, such as
beliefs, desires, intentions and emotions (Astington
and Pelletier 1996; Astington and Jenkins 1999;
Perner 1991; Wellman 1990). For example, upon seeing dad try to take a bite of a plastic apple, a child
with a theory of mind reasons that either his dad is
teasing, or he mistakenly thinks that the plastic
apple is real. Such social reasoning is complex,
because it requires the child to simultaneously represent two separate beliefs (e.g., knowledge that the
fruit is fake [the true belief], and knowledge of dad’s
belief that it is real [a false belief]). Understanding
the relationships between beliefs and actions in the
real world requires a representational concept of the
mind. That is, children must figure out that people
act with regard to their beliefs about the world, not
with regard to the world directly (Bartsch and
Wellman 1995). Many developmentalists view these
representational changes in children’s thinking as a
major cognitive-linguistic achievement during the
preschool years. Social reasoning skills continue to
Address correspondence to: Mary Pat Moeller, Ph.D., BTNRH, 555 N.
30th Street, Omaha, NE 68131, [email protected] or Brenda
Schick, Ph.D., Associate Professor, Speech, Language, and Hearing
Sciences, 2501 Kittredge Loop Road, University of Colorado, Boulder,
CO 80309–0409, U.S.A. [email protected]
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mature throughout the school years, yet the understanding of false belief that typically develops around
four to five years is considered foundational (Flavell
and Miller 2000).
Astington (1993) explains that children’s discovery of the mind enables them to understand many
aspects of human social life, such as surprises,
secrets, tricks, mistakes and lies, that depend on the
ability to integrate the landscape of actions and the
landscape of consciousness (Bruner 1990). Acquisition
of a ToM transforms the way children are able to see
other people and to make sense of what they are
doing (Moore and Frye 1991). This becomes a powerful social tool, as it allows the explanation, prediction, and manipulation of the behaviors of others
(Astington 1993; Wellman 1990). Having an understanding of the mental states of others also supports
a child’s participation in communication and social
interaction. Development of a ToM likely provides
the basis for pragmatic language skills (i.e., using
language for social purposes, such as predicting what
a listener needs to know and using the right amount
of information to convey the idea clearly; BaronCohen 1988) and for the ability to read the emotions
of others (de Villiers, Hosler, Miller, Whalen and
Wong, 1997). Researchers and theorists have suggested that ToM may be linked with other social
developmental skills, such as awareness of traits
(Yuill
1993),
perspective-taking,
and
inferential reasoning about others (Flavell and Miller
2000; Pillow 1991).
Recently, investigators have explored the connections between ToM and literacy and some suggest
that theory of mind skills represent an aspect of literate thinking (Astington and Pelletier 1996; de
Villiers, Church, Giorano, Whalen and Hoffmeister
1999; Olson 1994). Astington and Pelletier (1996) contend that theory of mind concepts developed during
the preschool years provide a conceptual foundation
for metacognitive thinking processes that will be a
major focus of the school years. Children enter school
with theory of mind skills that allow intuitions about
what others are thinking and believing. When
teachers facilitate cognitively challenging discussions, children can elaborate their social reasoning
skills and make their understanding of the mind
explicit. This is important, because people knowledge
helps to guide children’s understanding of both
spoken and written discourse. For example, consider
the following passage from the Divine Secrets of the
Ya-Ya Sisterhood (Wells 1996).
“Vivi Abbot Walker knew she wasn’t supposed to be drinking, and she knew she
wasn’t supposed to be smoking. That is why,
after she’d cleared up the dinner things and
said good night to Shep, she felt a little thrill
as she stepped out onto the patio . . . ” (p. 63).
The fact that the protagonist plans to engage in
an activity she knows to be taboo is never explicitly
stated; it must be inferred from the paragraph. Without inferences about the character’s beliefs and intentions, the reader cannot understand her plan or
interpret her emotional responses. Only by reasoning
about the character’s internal states is the reader able
to understand the author’s intended meaning. Accurately decoding the words in the passage clearly is only
one step in the process of constructing its meaning.
Children must gain the skills of reasoning accurately
about others, with reference to their internal states.
Making accurate predictions or conclusions about the
behavior of others by considering their likely mental
states is essential for reading comprehension, socialization and problem solving in relation to others.
Even preschool books are filled with concepts that
require a theory of mind to fully comprehend (e.g.,
Little Red Riding Hood’s lack of awareness of the evil
intentions of the wolf; Wright-Cassidy et al. 1998).
In the next section, we will explore the development of children’s understanding of others and their
growing abilities to explain events with reference to
others’ mental states. This information has relevance
for audiologists, because children with hearing loss
who have hearing parents are known to experience
delays in theory of mind development. Such delays
may influence their socialization and pragmatic
communication skills.
Developmental Aspects of Theory of
Mind in Typically Developing
Children
Although many studies have focused on children’s discoveries about the mind around three and
four years of age, there is evidence that even young
infants demonstrate emerging social understanding
of others. This section provides a brief summary of
some developmental accomplishments in theory of
mind concepts from infancy through the school years.
For ease of reference, these developmental landmarks
are summarized in table 1.
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Many believe that the foundations of theory of
mind are established in infancy (around 9–12
months) when babies engage in joint attention routines and begin to use cues to determine the intentions of others. Infants in this age range consistently
look where the adult looks as cues to meaning, and
a
use adults as social reference points (e.g., looking
back and forth from mom to an object and smiling to
share the event; Baldwin and Moses 1994; Tomasello
2003). By 18 to 24 months, toddlers are beginning to be
able to read the communicative intentions of adults
(Carpenter, Akhtar and Tomasello 1998) and this
Table 1: Developmental achievements related to theory of mind in hearing children.
Age
Developmental Achievement
Author(s)
9–12 months
Infants engage in joint attention routines;
look at where adults look; begin to use cues
to determine intentions of others
Baldwin and Moses 1994
Tomasello 2003
18–24 months
Infants begin to read the communicative
intentions of others (this facilitates word
learning)
Carpenter, Akhtar and Tomasello 1998
18+ months
Toddlers engage in symbolic pretend play,
simultaneously representing the real and
imaginary object
Amsel and Smalley 2000; Lillard 1993
20–24 months
Toddlers begin to talk about desires (want,
like) and feelings
Bretherton and Beeghly 1982;
Dunn, Bretherton and Munn 1987
30+ months
Children begin to use words to talk about
the mind (think, know, remember)
Shatz, Wellman and Silber 1983
20 months –
4 years
Children progress through three stages in
talk about the mind:
1. Desire talk and desire-based reasoning
predominant
2. Desire talk and desire-based reasoning
still prominent, but child starts to talk
about thoughts and beliefs
3. Increased talk about thoughts and beliefs
and uses these to explain people’s actions
Bartsch and Wellman 1995
3 years
Children realize people can have different
desires; they understand that seeing means
knowing
Wellman and Liu 2004
4–5 years
Children understand that people can act on
the basis of what they believe rather than
based on reality (false belief)
Baron-Cohen, Leslie and Frith 1985;
Wimmer and Perner 1983.
∼4.5 to 5 years+ Children can judge how a person will feel
upon discovery of a mistaken belief; they
begin to understand that true feelings can be
masked
Wellman and Liu 2004
6–7 years
Perner and Wimmer 1985
Children understand second-order
representations (Joey thinks that Pam
knows that her brother ate her cake.)
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ability facilitates children’s word learning (Tomasello
2003). Young children learn language in the context
of social interaction; infants’ emerging social understanding underlies much of language learning.
Other early evidence of theory of mind skills
comes from toddler’s participation in pretend play.
Pretend (symbolic) play begins around 18 months of
age and involves some understanding on the part of
the child that a real object is being represented as
something else (Amsel and Smalley 2000; Lillard
1993.) Thus, the child simultaneously has two cognitive representations: the real object and the imaginary one. Children of this age also read the intentions
of adults or siblings who pretend that one object is
something else (Lillard 2002). Evidence shows that
children who pretend frequently also have advanced
theory of mind skills (Astington and Jenkins 1995;
Cutting and Dunn 1999; Hughes and Dunn 1997;
Youngblade and Dunn 1995). Pretend play involving
socialization may be a particularly rich context for
learning about the mind. In this context, children
engage in pretend representations, role taking and
negotiating with siblings (both of which may contribute to perspective-taking), and using language to talk
about thoughts and emotions (Hughes and Dunn
1997; Lillard 2002).
Other evidence of children’s developing understanding of the mind is when and how often they
begin to talk about internal states, like desires, feelings and thoughts. Studies show that typically developing children begin to talk about their own and other
people’s feelings toward the end of the second year of
life (Bretherton and Beeghly 1982; Dunn, Bretherton
and Munn 1987). However, children’s use of words to
talk about the thoughts and beliefs (i.e., know, think,
remember, wonder) develops later, beginning somewhere around two and a half years of age (Shatz,
Wellman and Silber 1983). Bartsch and Wellman
(1995) studied language samples from ten typically
developing preschool-aged children for evidence of
spontaneous talk about the mind, and found a progression of three phases in children’s use of mental
state language. In the earliest phase, young children
talked about desires (mostly want and like) and they
explained people’s actions and reactions with reference to desires (i.e., Joey hit his brother because he
wanted the toy). A second phase began around the
third birthday and was characterized by some talk
about beliefs and thoughts, but desire talk and desirebased explanations based were predominant. The
third phase emerged around age four, when children
increased their talk about the thoughts and beliefs of
others and used these to explain people’s actions
(Bartsch and Wellman 1995).
Bartsch and Wellman’s data (1995) also reveal
that preschool-aged children frequently talk about
the mind. Three-year-old children in their study
referred to mental states of others (e.g., saying want,
think or know) once in every 25 utterances. This
means that these children used such terms to talk
about people more than 100 times a day. This suggests that there is a pervasive mentalism in preschoolers’ everyday discourse.
As noted above, a major achievement or landmark in theory of mind development is the child’s
ability to understand that someone else can have a
false belief, which occurs at around age four to five
years (Baron-Cohen, Leslie and Frith 1985; Wimmer
and Perner 1983). The child’s achievement of an
understanding of false belief is commonly tested
using one of several classic tasks. Wimmer and
Perner, for example, developed what is termed an
“unexpected contents task.” In this task, the experimenter shows a child a candy box such as Smarties or
M and M’s. The child is asked, “What do you think is
in the box?” The child predictably answers, “Candy.”
The child then opens the box to discover that it contains a pair of scissors instead. The box is closed up
again and a peer (e.g., Joey) is brought into the room.
The original child is asked, “What will Joey think is in
the box?” In this standard unexpected contents task,
three-year-old children will insist that Joey thinks
scissors are in the box. Three-year-olds apparently
fail to understand that the other person’s beliefs may
be false. Four-year-olds, in contrast, will announce,
“Joey thinks it’s candy, but he’s wrong – it’s scissors.”
This finding has been replicated over many experiments using a variety of approaches and it appears to
be a fairly robust phenomenon (Wellman, Cross and
Watson 2001).
The role of parents and siblings is substantial in
developing a theory of mind. Studies have demonstrated that mothers who talk to their children about
the mind at early ages have children who later have
advanced theory of mind skills (Ruffman, Slade and
Crowe 2002; Jenkins, Turrell, Kogushi, Lollis and
Ross 2003). Parents of typically developing children
use more cognitive talk, as their children get older
(and presumably more competent in language and
thinking skills; Brown and Dunn 1991; Furrow,
Moore, Davidge and Chaisson 1992). Children whose
mothers and siblings talk about theory of mind con-
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cepts more typically do better at theory of mind tasks.
Ethnographic studies of Dunn and her colleagues
(Dunn, Brown and Beardsall 1991; Brown and Dunn
1991) demonstrate the role of daily family-child social
interactions (e.g., resolving conflicts between siblings,
symbolic play routines, reasoning-based explanations) in shaping children’s understanding of the
mind. Harris (1992) argues that it is not just the mention of mental states in families that fosters children’s
ToM development. Rather, it is the back and forth
shuttling from one viewpoint to another that makes a
difference. The rich exposure in this back and forth of
conversation may be difficult for children with hearing loss to access fully. Some parents may simplify
their language in response to a child’s language
delays, resulting in less overall exposure to talk about
the mind. Thus, reductions in the frequency and quality of exposure to mental state talk may be implicated
in theory of mind delays observed in children with
hearing loss.
Based on a comprehensive meta-analysis of the
developmental literature, Wellman and Liu (2004)
recommended the need to move beyond standard
false belief tasks to gain a comprehensive understanding of children’s emerging concepts of the mind.
They proposed a series of tasks that could be used to
assess a developmental sequence of theory of mind
accomplishments. These tasks were evaluated with
preschool children, and an age-related developmental
schedule emerged. For example, they showed that
before children understand false belief, they understand that people can have different desires (e.g., I
can want ice cream, but dad can want salad). They
also figure out that people who look in a box will know
what it contains and that not looking means not
knowing. Some mental state concepts that emerge
after false belief understanding include judging how a
person will feel when a mistaken belief is discovered
(e.g., How will teddy feel when he discovers his favorite snack box is filled with rocks, not Cheerios?), and
understanding that a person can be masking their
true feelings (e.g., a boy can be smiling when teased
but feel upset inside). Much is yet to be learned about
children’s understanding of the mind. Viewing the
process on a developmental continuum is a major step
forward in this enterprise.
Theory of mind understanding continues to
mature in the school years. A key developmental
accomplishment that has been empirically studied is
children’s ability to understand embedded or secondorder representations (i.e., Joey thinks that Pam
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knows that Bill ate her cake; Perner and Wimmer
1985). By six to seven years of age, children are able
to reflect on their own and others’ beliefs in this way,
which helps in taking the perspectives of others.
Astington and Pelletier (1996) emphasize the relevance of second-order concepts to everyday social
interaction. As adults, we often consider what someone believes about someone else’s actions or feelings
as we problem solve or socialize. Second-order understanding also is important for children’s understanding of lies, jokes, sarcasm and irony (Leekham 1991;
Winner and Leekham 1991). This level of understanding is essential to literacy and critical thinking.
To date, there has been little research focused on
relating theory of mind to academic development.
However, it seems clear that many of the pragmatic
functions of school discourse will be easier to manage
with well-developed theory of mind concepts. As
school years advance, students are expected at a minimum to interpret the perspectives and intentions
of others, adapt conversational strategies to the knowledge of the listener, form and revise beliefs about the
world, detect bias or prejudice in messages, provide
explanations, and negotiate in collaborative learning
settings. Theory of mind concepts and well-developed
language skills to talk about them may be prerequisite for engaging fully in these higher-order
thinking tasks (Astington and Pelletier 1996).
Developmental Aspects of Theory of
Mind in Children with Hearing Loss
There is ample research to show that theory of
mind development is delayed in children with a hearing loss who are from hearing families; table 2 summarizes much of the research. Deaf children with
hearing parents are delayed in development of theory
of mind concepts, as typically measured by false belief
understanding, in comparison to hearing peers and
deaf children with deaf parents. In the best-case
scenario, delays are estimated at two to three years in
comparison to typically developing children. However,
some studies have shown that some adolescent deaf
children have not attained the four-year-old achievement of an understanding of false belief. It should be
noted that many studies have used tasks that require
both comprehension and production of language,
which may easily mask underlying cognitive skills
(see table 2 for the type of task used in each study).
However, even studies that have used non-verbal or
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Table 2: Summary of main published studies on theory of mind in deaf children
Authors
Subjects
Primary
Questions
Gale 1995
11 signing deaf
children with
hearing parents
Group 1: 4;8 – 7
years
Group 2: 9;11 – 10;4
How do deaf children Nonverbal hide and
perform on verbal
seek task; standard
and nonverbal ToM verbal task
tasks?
Deaf children are delayed
in ToM skills. Older
children, but not younger
children passed ToM
tasks. Deaf children
performed similarly on
verbal and nonverbal
tasks.
Peterson and
Siegal 1995
26 signing deaf
children, all but 2
were from hearing
families
Ages 8 to 13 years
Does limited access
to conversation
result in impaired
theory of mind
development?
Standard verbal
tasks; modified
question format for
half of the subjects
Significant delays in
deaf children’s
understanding of false
belief (a 29% pass rate
reported). Delays were
similar to those observed
in groups of autistic
children. Results support
conversational access
account. 2 deaf children
of deaf parents were not
delayed. Language
abilities were not directly
measured.
How do hearing
children perform on
nonverbal tasks
measuring ToM?
Standard ToM tasks
and a nonverbal
sticker hiding game
(a seeing is knowing
task where child
must infer the
knowledge state of
an adult)
Hearing preschoolers
performed similarly on
verbal and nonverbal
tasks.
Same as above plus
movies designed to
elicit theory of mind
statements
Deaf children performed
comparably on verbal
and nonverbal forms of
false belief tasks. Deaf
children performed
better than hearing 3
year olds, but worse than
4 year olds on these
tasks, showing delays in
ToM performance.
Language and use of
language to explain
actions were best
predictors of ToM skills.
Gale, deVilliers, 20 three and four
deVilliers and
year olds with
Pyres 1996
normal hearing
23 Oral deaf children Do the linguistic
Ages 3;9 – 8;9
demands of the false
(median age = 6:3)
belief task mask deaf
children’s true
understanding?
Tasks
Findings and
Considerations
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Peterson and
Siegal 1997
Compared
performances of D/D,
D/H and autistic
children
Does limited access
to conversation
result in impaired
theory of mind
development?
Standard false belief Deaf children of deaf
tasks; False
parents perform better
photograph task
than D/H and autistic
children on ToM
tasks (although
children studied were
older than four years
of age). Concluded that
D/H children’s limited
access to signed
conversations at home
influenced ToM
development. Parental
signing skills were not
measured.
Steeds, Rowe
and Dowker
1997
22 deaf children
(“most” from hearing
families),
Ages 5;8 to 12:4
(X = 9;8)
Re-examination of
the claims of
Peterson and Siegal
(1995)
Two verbal false
belief tasks
Russell et al.
1998
32 deaf children
(30 D/H; 2 D/D)
Ages 4 – 16 years
Are there age related 1 standard verbal
improvements in
false belief task
ToM in deaf
children?
70% of the children
passed the false belief
tasks, presenting a
more positive picture
than initially reported
by Peterson and
Siegal (1995). Task
improvements and
greater exposure
to British Sign
Language were
related to improved
performance.
Deaf children were
delayed in ToM skills.
Age related changes
were observed, but not
until after 13 years of
age. Language skills
were not measured.
Authors concluded that
delays are related to
children’s limited early
exposure to talk about
the mind.
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Peterson and
Siegal 1999
102 children; 11 D/D
(6;6 – 12;8), 14 oral
children (hard of
hearing with losses
from moderate to
severe; 6;10 – 13;2),
34 D/H signers (5;6
– 12;8), 22 children
with autism
(6;2 – 13;9), 21
typically developing
preschoolers
(3;11 – 5;4)
Does limited access
to conversation
result in impaired
theory of mind
development?
3 standard verbal
false belief tasks
D/D, hard of hearing
and hearing children
performed similarly
and better than children
in D/H and autism
groups. Note that
the D/D, D/H and
oral children are
much older than the
hearing control group.
Results further
supported the role of
early dialogue in ToM
development.
deVilliers and
deVilliers 2000
27 Oral deaf children Relationship
X age = 7;0
between language
and ToM skills
Teacher ratings of
language abilities
Standard verbal
tasks;
Nonverbal task
requiring prediction
of surprise vs. not
surprised
Courtin 2000
155 deaf children
(37 D/D, 54 D/H
and 45 oral deaf)
Does early exposure 3 standard verbal
to sign language (in false belief tasks
this case French
Sign Language)
Ages 5 to 8 years;
promote the
39 hearing children, development of ToM
ages 4 to 6 years
skills? Does exposure
to sign language
advantage children
in perspective
taking?
Rhys-Jones and 20 deaf and 20
Ellis 2000
hearing adolescents
(11–16 years);
14 deaf and hearing
children (6 to 10
years)
Do deaf adolescents
have poorer social
reasoning than
hearing peers?
Oral deaf children are
significantly delayed in
ToM skills, measured by
verbal or less verbal
tasks. Thus, it is not just
the language of the task
that leads to delay.
Syntax, particularly
complement mastery,
predicts ToM skills.
D/D group close to ceiling
on false belief tasks
at age five. D/D
outperformed hearing
children (perhaps due to
SES differences in the
groups). Delays observed
in D/H and oral deaf
groups. Supports the
argument that early
exposure to a linguistic
system facilitates ToM
development.
Sequence pictures in Age effects were
a story and produce identified. Deaf
narratives
adolescents were
able to empathize
with and discuss the
mental states of
characters in sequence
stories.
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Marschark
et al. 2000
15 hearing students
(10.6 – 15.5)
Are deaf students
able to demonstrate
knowledge of the
mind in written
narratives involving
explanations of
behavior?
Create a spontaneous story about what
it would be like to be
picked up by a flying
saucer OR what it
would be like to live
in a new civilization
under the sea.
Only 2 deaf and 3 hearing
students made no
references to mental
states. Deaf students
aged 9 to 15 are fully
capable of attributing
mental states to
themselves and
others.
Schick et al.
2000
176 deaf students;
86 orally educated
49 D/D using ASL
41 D/H using ASL
42 hearing
Ages 3;11 – 8;3
What aspects of
Standard verbal
language predict
false belief tasks, low
theory of mind skills? verbal false belief
tasks, descriptions of
movies designed to
elicit theory of mind,
and a range of
cognitive and
linguistic measures
D/D children are
comparable to hearing
peers, D/H children
delayed in theory of
mind. Results were
predicted by vocabulary
skills and the ability to
produce syntactic
complements.
Figueras-Costa 24 orally trained
and Harris
D/H children in
2001
two groups:
younger (4.7 – 6.5)
older (6.9 – 11.11)
Is impaired ToM
Verbal and
performance of deaf nonverbal tasks
children an artifact
of the weighty verbal
demands of the false
belief paradigm?
Deaf children were
delayed on both types
of tasks. Only the
older children performed
above chance. The
mean age for passing
ToM tasks was 8 years,
10 months.
Jackson 2001
Is there a
Standard false belief
relationship between tasks and receptive
receptive language
language measures
and ToM in deaf
children?
Language skills were
positively and
significantly correlated
with ToM performance.
Deaf children were
delayed in ToM compared
to language matched
hearing children.
Concluded that
properties specific to
language are required
for ToM development,
over and above
age-related experiences
and neuromaturation.
51 deaf children in
four groups: 11 D/D,
12 D/H using BSL.
14 D/H using TC.
14 oral deaf children
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Is there a difference
in early and latesigning children on
picture-based (low
verbal) ToM tasks,
and will a difference
disappear if
language and
spatial intelligence
abilities are
controlled?
Pick a picture to put
in a thought balloon
based on whether
or not a cartoon
character had seen
an event (Seeing =
knowing)
Native signing children
outperformed latesigning children on
pictorial tasks, even
when matched on
language and spatial
abilities. Language
abilities were related
to ToM. The authors
concluded that
conversational
interactions are
important to ToM
development.
Study 2:
39 deaf children. 21
late signers and 18
native signers
Do differences in
executive function
(ability to plan and
shift attention
flexibly during
problem solving)
explain the group
differences in
Study 1?
False photograph
test (nonmental
representation)
Tests of executive
function
Native signers
outperformed late
signers on ToM,
but not on False
photograph or
executive function
tests. Performances
cannot be explained
by differences in
executive functioning.
34 children with
hearing losses
> 65 dB, ages 5 to 10
years. all from
hearing homes,
“some signed and
some did not”
Examined the
effects of age and
expressive language
skills on ToM
development.
Parent self report
of signing skills.
Language
Proficiency Profile
(teacher rating
scale). 4 standard
theory of mind
tasks
Significant delays in
deaf children’s false
belief understanding.
Deaf children
approximately three
years delayed in ToM.
Age effects found.
Parents were unable
to sign 2/3 of the mental
vocabulary, but no
association was found
between parental
signing and children’s
ToM (note, however,
a restriction in range
in parental sign
skills).
Woolfe, Want
Study 1:
and Siegal 2002 60 deaf children,
ages 4 to 8 years. 40
late-signing (X = 6.8)
and 20 native
signing (X = 5.10)
Lundy 2002
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Moeller 2002
26 deaf child/hearing
mother dyads (4.3 to
9.11)
26 hearing child/
hearing mother
dyads (4.3 to 5.11)
Do hearing mothers
who sign discuss
mental states with
their young deaf
children? Are
maternal and child
language proficiency
related to ToM
skills?
Verbal and
nonverbal ToM
tasks. Explanation
of action tasks.
Videotaped
observations. child
and maternal
language measures
Child language and
maternal talk about the
mind were significantly
related to deaf children’s
ToM performance. Delays
identified in ToM
(although majority of 6–7
year olds passed).
Mothers with high
intermediate and
advanced signing skills
talked about the mind to
the same degree as H/H
dyads.
Woolfe et al.
2003
20 native signing
deaf children (ages
4 to 8 years) and
their siblings
Is quality of sibling
relationship
indicative of
effective
communication
about the world
and better ToM
abilities?
Referential
communication task
(barrier game) to
examine ease of
communicating
complex ideas.
Sibling Quality
Interview. ToM and
British Sign
Language Receptive
Tests
Results demonstrated a
link between the quality
of sibling relations and
ToM reasoning in
children who are native
signers.
Remmel 2002
Study 1
10 D/D children (7.4
to 10.9) and 16 D/H
children (5.6 to
11.8)
Tested various
theoretical positions
about ToM
development by
comparing groups of
D/D and D/H
children
Range of tasks
measuring ToM and
understanding of
how perception
leads to knowing.
D/H children performed
poorly relative to D/D
and hearing norms.
Performance related to
length of exposure to
sign language and
ASL proficiency.
Study 2
10 D/D children
(3.10 to 5.6)
18 hearing children
(3.9 to 5.6)
Do D/D children
perform comparably to hearing
age-mates on
various ToM and
perspective-taking
tasks?
Range of tasks
measuring false
belief, conceptual
perspective taking,
and knowledge about
visual perception.
Hearing children
outperformed D/D
children. Results
inconsistent with
Courtin’s (2000)
position, but support
Peterson and Siegal’s
(2000) position that
ToM depends on early
exposure to talk
about mental states.
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Table 2: Summary of main published studies on theory of mind in deaf children (continued)
Authors
Subjects
Primary
Questions
Tasks
Findings and
Considerations
Terwogt and
Rieffe 2004
21 deaf children
(11.3 to 12.10)
36 hearing children
(9.8 to 12.10)
What negotiation
strategies do deaf
children use in falsebelief situations?
(How to deaf and
hearing children
react to a scenario
in which a mother,
who is unaware of
a change in the
situation, threatens
to block the
fulfillment of the
child’s desire).
Children presented
with two scenarios
where providing
mother with missing
information would
help the child reach
his goal. Children
were asked what
they would say to
the mother.
Deaf children more often
failed to correct the
mother’s false belief.
Hearing children
typically left their own
desires implicit. Deaf
children kept stressing
their own desires as the
primary argument. Deaf
children more often
repeated arguments that
did not provide new
information.
low-verbal tasks have still found delays in development (Schick, Hoffmeister, de Villiers and de Villers
2000). In addition, many studies have used sign
language interpreters, which may have affected
children’s performance. However, it is reasonable to
conclude that many deaf children with hearing
parents enter school delayed in their theory of mind
understanding.
A child’s language skills are related significantly
to theory of mind development in hearing children
(Astington and Jenkins 1999) and in children with a
hearing loss (Schick et al. 2000; Moeller 2002). Children with better language skills, including the ability
to use complex grammar, have a better understanding of mental reasoning. de Villiers and de Villiers
(2000) assert that children’s mastery of advanced
syntax, specifically object complements (Mother knew
that her son was late getting home) underlies theory of
mind development. Peterson and Siegal (1995, 1997,
2000) contend that children’s early access to conversations about the mind promotes theory of mind
development. Obviously, language skills are a prerequisite to participation in discourse about the mind,
regardless of which aspect is most important.
Researchers continue to explore the relative contributions of child language and conversational access by
deaf children in relation to theory of mind
development.
In general, older deaf children perform better
than younger deaf children on ToM tasks, but several
studies suggest that age effects are mediated by language skills (Courtin 2000; Jackson 2001; Moeller
2002; Schick et al. 2000). In other words, simply getting older does not ensure that deaf children will master theory of mind concepts. It appears that children
must gain advanced language skills, in particular
language to talk about the mind (e.g., object complements, why clauses, mental verbs), if theory of mind
understanding is to grow (de Villiers, de Villiers,
Schick and Hoffmeister 2000). It is critical to measure
and control for language when exploring the relationships between theory of mind and age in groups of
deaf children.
Not surprisingly, deaf children who have deaf
families develop theory of mind skills much like their
hearing peers (Schick et al. 2000; Peterson and Siegal
1997, 1999). Studies comparing signing deaf children
with hearing parents (D/H) to signing deaf children
with deaf parents (D/D) demonstrated ageappropriate achievement of ToM skills in the D/D
group. This is understandable, given the early and
full access to language received by most children in
the D/D group. These findings underscore the benefits
of early access to language models and to participation in familial discussions of mental states for theory
of mind development. Both signing deaf children in
hearing families or children with significant hearing
losses who are learning orally are at risk to miss out
on social discourse that promotes understanding of
others’ minds (Moeller 2002). Conversational partici-
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pation may be reduced by the child’s language delays
as well as limitations in sign language use in the family. Deaf children with cochlear implants or hard of
hearing children with hearing parents may be
exposed to consistent language input, but noise, distance and reverberation may have a negative impact
on the magnitude or clarity of input over time. More
research focused on these latter two groups is needed.
There are a few studies that have examined theory of mind skills in deaf children in naturalistic tasks
or settings. For example, there are recent studies
exploring the use of theory of mind concepts in written language (Marschark, Green, Hindmarsh and
Walker 2000), narrative production (deVilliers and
deVilliers 2000; Rhys-Jones and Ellis 2000), tasks
where partners must communicate unseen information to each other (Woolfe, Want and Siegal 2003) and
problem solving situations (Terwogt and Rieffe 2004).
These studies represent a departure from experimental focus on false belief, with efforts to understand how theory of mind understanding influences
social and academic participation. However, the
results indicate that deaf children have difficulty with
theory of mind concepts beyond the traditional,
language-rich tasks that are used to assess false
belief understanding. Much more research is needed
to determine how and when deaf children recruit
knowledge of others to support socialization and
learning.
As with hearing children, mothers play a substantial role in how well deaf children develop a theory of mind. Moeller (2002) explored the extent to
which hearing parents of signing deaf children were
able to talk to their children about the mind. Mothers
and their signing deaf children were videotaped
interacting in three contexts designed to elicit mental
state talk. Child language skills and theory of mind
skills were assessed and interactive language
samples were used to measure how much the
mothers referred to theory of mind concepts. Results
showed that mothers with high intermediate to
advanced signing skills frequently talked to their
children about the mind. In fact, these mothers talked
to their deaf children to the same degree as a control
group of hearing/hearing dyads. However, mothers
with limited signing skills rarely talked about the
mind and were lacking in knowledge of signs to reference such topics. The extent to which mothers talked
about the mind was significantly related to children’s
theory of mind skills, after controlling for the effects of
other variables. Clearly, the quality of language input
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from parents can affect a deaf child’s development of a
theory of mind.
Many gaps exist in our knowledge about children
with hearing loss and theory of mind. In general,
many studies have included heterogenous populations of children, with varying degrees of hearing loss,
communication approaches, and family backgrounds.
This limits the generalizability of some results. Further, some specific populations of children have been
insufficiently addressed. For example, although some
children with cochlear implants have participated in
studies, few studies have included focused and wellcontrolled groups of these children. Because of the
heterogeneity within groups of children with hearing
loss, subject populations need to be well described, so
that individual differences may be understood.
Within groups of children with cochlear implants, age
of implantation, generation of device, and language
abilities are obvious variables that need to be controlled for meaningful interpretation of outcomes.
Children who receive hearing aids or cochlear
implants early and are successful users may have
better conversational access than signing deaf children in hearing families. If this is the case, these children should acquire theory of mind concepts closer to
typical ages. Empirical research is needed to further
explore this hypothesis. Remmel, Peters and Sawyer
(2004) recently studied a range of theory of mind
skills in a well-controlled group of 30 children who
had cochlear implants and age-appropriate language
skills. Although mild delays were identified relative
to chronological age, the children’s theory of mind
skills were considered to be excellent relative to
“hearing age” (length of time post implantation).
Their findings suggest that early cochlear implantation has positive effects on theory of mind development. These results are in contrast to Peterson (in
press) who found no differences in false belief understanding in children with cochlear implants and those
with conventional hearing aids. However, the students in Peterson’s study had delayed language skills.
Few studies have addressed the theory of mind abilities of children with mild and moderate hearing loss.
Such research may further illuminate the relative
contributions of language and conversational access
on theory of mind development in children with
hearing loss. Additional studies of naturalistic
interactions (parent-child, sibling-child, teacherchild) are needed to guide clinical practice recommendations targeted at improved social skills in these
children.
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Implications for Working with
Children and Families
How can this body of literature be applied in
pediatric audiological practice? Audiologists have
long been aware that some children with hearing loss
in their caseloads experience subtle difficulties with
socialization and/or pragmatic communication skills.
Sometimes parents report that their children have
difficulty empathizing with others or considering
alternative viewpoints. Their children may lack
finesse or flexible strategies in social problem solving
situations or may miss or misunderstand subtle
classroom rules. It is also true that many children
who are deaf or hard of hearing have more difficulty
learning to read at an age-appropriate level. The literature on theory of mind development helps us put
these common challenges in a fresh and specific context. Theory of mind concepts are central for children’s learning, not only in socialization, but also in
reading comprehension, literate thinking and higher
order reasoning. It is of value for audiologists to be
aware of this foundational area in children’s socialcognitive development, and its relevance to social,
communicative and academic growth.
In daily clinical management, it is important to
recognize that children with hearing loss, especially
those in hearing families, are at risk for delays in
theory of mind concepts. Delays often are related to
the children’s language deficits, in particular the use
of language to talk about internal states (thoughts,
feelings, beliefs, desires) and the application of this
language to reason and problem solve (deVilliers and
deVilliers 2000; Moeller 2002; Schick et al. 2000). It
takes effort to ensure that the child with hearing loss
has access to the ongoing dialogue among family
members. Due to the effects of distance, noise and
reverberation, some of the natural exposure to talk
about the mind in the family may be lost or
incomplete. Families should be reminded of the
importance of including children with hearing loss in
everyday discourse, especially talk about varied
viewpoints, thoughts, beliefs and feelings.
Several practical recommendations can support
families in their interactions with children with hearing loss. First of all, families should be encouraged to
explicitly talk to their young children about thoughts,
desires, beliefs and feelings during natural interactions with their children. As an initial step, families
should be encouraged to use terms to make reference
to the mind (see table 3). Recall that typically develop-
ing two and one half year olds use mental state verbs
in spontaneous talk (Bretherton and Beeghly 1982;
Dunn, Bretherton and Munn 1987). Some families
who have children with hearing loss artificially limit
their talk to the immediate, concrete context (landscape of immediate action) in an effort to “teach”
language. When this occurs, families should be
advised to begin to expose the child to a wider range
of ideas, including mental terms, in the context of
daily social interactions. For example, families can be
encouraged to shift the emphasis of their talk during a daily routine like setting the table. Instead of
focusing on labels (“Here’s a spoon. Put the spoon
next to the plate”), they can focus on relational messages like, “Oops, we forgot Johnny’s spoon! He’ll
think he can eat with his fingers. I wonder how that
will work!? The food is too hot. What do you think we
should do?” By adding demonstrations and facial
expression, the language concepts can be contextually
supported and understood by the child. Parents can
be encouraged to talk about how people’s beliefs and
feelings affect what they do (e.g., “Your brother can’t
play now. He is in a hurry. He is worried he will be
late for practice.”)
Moeller (2002) found that parents with limited
signing skills tended to talk about concrete,
perceptually-based topics during pretend play with
their signing deaf children (e.g., talking about colors
and counting objects in the immediate setting). In
part, this resulted from reduced knowledge of sign
vocabulary and limited sign language fluency. Sign
language teaching lessons for parents need to include
both vocabulary and strategies for providing cognitively and socially rich stimulation. In addition,
parents may need support to view their children as
capable thinkers, who will benefit from varied and
challenging language input. Parents may need
encouragement to raise expectations for what the
child can understand within supportive contexts.
The following transcript, taken from Moeller’s
(2002) dissertation, illustrates this process unfolding
during pretend play involving a hearing mother signing with her seven-year-old deaf son. The child suggested that they use tinker toys to make a bear that
can bend over and catch fish.
Mom: You are good at thinking of how to
put things together.
Mom: You can see it in your mind without
having a picture.
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Table 3: Internal state terms identified in previous studies of children’s mental state discourse
Furrow
et al. 1992
Shatz et al. 1983
Brown, Donelan-McCall and
Dunn 1996; Tager-Flusberg
1992
Emotive themes (Dunn,
Brown, and Beardsall 1991;
Tager-Flusberg 1992)
think
think
Used terms in the first two
columns and added:
know
know
learn
remember
guess
other
remember
guess
mean
real
reason
doubt
forget wish
pretend figure
dream believe
bet
understand
hope suppose
trick
lie
secret
confuse
have in mind
curious
surprise
idea
make believe
realize
angry
bad
shy
tired
better
calm
fun
good
happy
hate
like
love
mad
sad
scared
surprise
upset
wonder
Mom: Mommy needs a picture.
Mom: What about the head {points out a
problem to solve}?
Mom: It keeps falling falling falling.
Child: No no . . . so bear can look down and
catch the fish {explains his
reasoning}.
Mom: Ah hah, now it can get fish for breakfast {clarifies that she understands
his solution}?
Mom: Maybe this will be a fish body and a
tail?
Child: Hmmm maybe that can be head and
this body.
Child: Pretend like this is little wing arm for
swimming.
Mom: Uh huh the fin helps it swim.
Child: Mom that bear baby has big sharp
nail and mommy has closed sharp
claws.
Mom: Do you know why they have sharp
nails and claws {prompts his thinking about the world}?
Child: The mom has sharp big claws to dig a
worry
hole for home then close her claws
then go to sleep.
This example shows that both partners contributed actively to the negotiation of meanings. Such
interaction gives the child opportunities to compare
his thoughts with his mother’s. Knowledge of the
world is brought to the context to support interpretation and the mother comments on the mind and
encourages reasoning about events. Successful families engage the child actively in discussions that
promote insight about the mind. It is not solely a matter of how the parents talk or sign to the child. Rather,
they view the child as an active constructor of meaning, who benefits from negotiation of meanings and
exposure to increasingly abstract ideas as “food for
thought.”
Audiologists may want to remind parents that
much of our thinking is unspoken or implicit. When
we lose our keys, we think to ourselves, “Now where
was I when I last had them? I wonder if I should
retrace my steps or call my husband for the extra
set?” Children with hearing loss may benefit when
parents purposely “think out loud” in the presence of
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their children. In a recent workshop, parents were
given background on the importance of talking to
children about the mind and then they were given
role-play scenarios to practice. Sets of cards were
passed out and family members discussed what they
could say in response to the stated situation. For
example, one card stated, “You are waiting in a long
line of traffic that is not moving. Your child is anxious
to get to MacDonald’s. What do you say?” Several
parents initially responded that they would simply
tell the child, “We have to wait.” Following discussion, ideas were elaborated, to include statements
like, “I don’t know why the traffic isn’t moving. I
wonder if there was an accident. It is hard to be
patient when we don’t know what’s happening.” Many
families report that it is not intuitive for them to talk
out loud about implicit ideas in this way. Families
need opportunities to learn about the value for their
child of mental state talk and they need chances to
practice the use of this form of language stimulation.
Schick (2004) outlined strategies parents can use
to promote Theory of Mind concepts when reading
stories with children. She stressed that it is important to help family members understand that shared
reading is a good context for giving children insight
to the mind. Reading involves the thoughts and
motivations of story characters. Stories provide
opportunities to learn about other people’s thoughts
and emotions and to compare those with our own
experiences. By comparing our own reactions,
thoughts and feelings to those of the character, we
understand ourselves better and we learn that not
everyone thinks like we do. Reading provides an
opportunity to explore words that describe thoughts
and feelings. Some stories help children understand
that people change their minds, based on responses
to other people or events, which helps children see
how people learn from experience and alter their
thinking. Importantly, reading can be used to discuss how what we think and feel causes our
behavior. Parents can point out the causes of characters’ behaviors and discuss with the child whether
the response was wise or not. Families can be guided
in the use of thought-provoking strategies during
story telling to promote talk about the mind. For
example, at a recent workshop, parents were asked
to talk about what they could say in response
to storybook pictures. In response to a classic story
like Goldilocks and the Three Bears, parents were
prompted to move beyond labeling and action
descriptions to talk about the landscape of the mind.
Questions like, “Did Goldilocks know who lived in
the house?” and “When the bears came home, how
did they know someone had been there?” were modeled and practiced.
In working with families, we have found it useful
to organize recommended strategies in the form of a
simple acronym, T-H-I-N-K. Each letter represents a
recommended language stimulation principle, as
follows:
T – Talk about typically unspoken thoughts
and feelings.
H – Help children expand vocabulary related
to thinking, feeling and problem solving.
I – Identify inferences the child is making
and comment on them.
N – Nurture imagining and thinking using
question prompts and models.
K – Knowledge is key. Help children make
connections between storybooks and
experiences in everyday lives to build
knowledge of others.
These strategies are important for children at all
ages. With older children, social problems can become
an opportunity to discuss and compare alternate perspectives on potential causes and solutions. In the
next section, a brief case illustration is used to
demonstrate how theory of mind deficits can be
identified and addressed in program planning for an
adolescent.
Management Strategies for a Student
with Theory of Mind Deficits
P. A. was a 16-year-old who presented with profound, bilateral sensorineural hearing loss and
craniofacial anomalies, related to Goldenhar Syndrome. Medical history included long-term use of a
tracheostomy tube, multiple reconstructive surgeries
and cochlear implantation. This student discontinued
use of hearing aids and the cochlear implant due to
limited functional benefit from these devices. He used
sign language for communication at home and in
school. He attended public school programs (where he
was the only deaf student) and his academic skills
were in the average to above average range. His
future plans included post-secondary education in
computer engineering. He was referred for communication evaluation to aid in transition planning. The
parents and school expressed concerns for P.A.’s
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performance in the area of socialization with
language (Pragmatics).
Traditional evaluation measures do not address
theory of mind skills. Yet, deficiencies in this area
may contribute to social and academic difficulties for
older students, and therefore constitute a priority for
assessment and intervention. The examiner used
diagnostic teaching activities to explore P.A’s theory
of mind skills. P.A. was asked to explain Norman
Rockwell illustrations that require insight to the
thoughts and feelings of characters for full understanding. For example, he was asked to explain
in writing what was happening in the picture below:
P.A.’s initial response was unrelated to the character’s reactions to discovering a Santa suit in his
dad’s drawer. In fact, he stated, “He broke something
(an inference that seems to be based on the child’s
facial expression).” After discussion of the scene and
use of question prompts, he wrote, “It looks like he
found Santa Claus clothes and he thought that his
father is the Santa Claus who give out the presents.”
Further question prompting focused on prediction of
225
the child’s emotional responses resulted in the
answer, “He was shocked and upset when he found
Santa clothes because he thought that the Santa
Claus is real.” P.A. possessed the language to express
mental state concepts, but he did not typically use
this language or consider the emotional and mental
perspectives of others when interpreting events. He
needed support to apply his knowledge of others in
social situations. It was positive to note that he could
be prompted to connect beliefs with emotional
responses. More emphasis on this type of reasoning
was recommended for his program.
A second diagnostic teaching activity involved
role-play of peer dialogue over the TTY. P. A. was
asked to invite a friend over to play a new game on his
Play Station 2. The clinician took on the role of the
friend. The conversation proceeded well until perspectives were at odds and negotiation was necessary.
The interaction proceeded as follows:
P.A.:
Friend:
P.A.:
Friend:
P.A.:
Friend:
P.A.:
Friend:
P.A.:
Friend:
Figure 1. Norman Rockwell 1956 (By permission, Rockwell
Foundation).
a
P.A.:
I just got new game for ps2. wanna
come over and play with me?
Well I gotta finish my homework, but
I could come in about an hour. Will
that work?
Hey don’t worry about homework,
you can finish it later tonight or in
school tomorrow. Just come over and
we’ll have fun.
My mom says she will ground me if I
leave my homework until later
tonight. I will hurry and then I will
be over okay?
Bring your homework here.
Awesome idea. I can’t figure the
math assignment out. Do you think
you could help me with it?
I just finish that assignment, you
can copy my homework.
But if I copy it, I won’t learn it and
there is a test next week!
You can still understand how I do
my assignment. There’ll be review
sheet for test so you can just do it
yourself.
But what I would really like is just a
little help with one problem. Can you
help me and then we can play all we
want?
Alrightalrightalright, just come over.
You’re waste my time. See you.
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Friend: Sorry about wasting your time. I
didn’t mean to hurt your feelings.
P.A.:
That’s ok, I have a bit of temper.
Friend: Okay . . . I’ll see you soon.
P.A.:
Bye.
This student became upset during the conversation when his partner continued to disagree with
him. He appeared to focus on his own agenda/goals,
and had difficulty making adjustments to take into
account the situation/needs of the friend. He will
benefit from emphasis on learning to take into
account the perspective of others and learning to use
higher-order language functions, such as negotiation.
He also needs support to identify and express his
own feelings as a way to successfully cope in various
social situations. Exploration of this student’s
insights into others and his ability to apply this
information to social reasoning revealed several key
intervention priorities that were relevant to transition planning.
Summary
Children make important strides in the preschool
and school age years in understanding of mental
concepts, like thoughts, beliefs and feelings. These
developments in social cognition allow children to
mindread in a host of circumstances, which helps
them to understand events in the world and supports
socialization with others. As children mature, theory
of mind skills become integrated in literate thinking,
allowing them to understand what they read and consider abstract ideas in relation to people and the
world. Although much is yet to be learned about children’s understanding of the mind, it is well established that early experiences in pretending and
engaging in discussions about the mind facilitate
learning. For several reasons, many children with
hearing loss who have hearing parents experience
delays in this area of social reasoning. Audiologists
should be aware of this developmental literature,
because they are in a position to guide families in the
use of language stimulation strategies to promote
children’s theory of mind skills.
References
Amsell, E., and Smalley, J.D. 2000. Beyond really and
truly: Children’s counterfactual thinking about pretend and possible worlds. In E. Riggs and P. Mitchell
(eds.), Reasoning and the mind (pp. 12–147). Hove,
UK: Psychology Press.
Astington, J.W. 1993. The child’s discovery of the mind.
Cambridge, MA: Harvard University Press.
Astington, J.W., and Jenkins, J.M. 1995. Theory of mind
and social understanding. Cognition and Emotion 9:
151–165.
Astington, J.W., and Jenkins, J.M. 1999. A longitudinal
study of the relation between language and theory of
mind development. Developmental Psychology 35:
1311–1320.
Astington, J. W., and Pelletier, J. 1996. The language of
mind: Its role in teaching and learning. In D. R. Olson
and N. Torrance (eds.), The handbook of education
and human development: New models of learning,
teaching and schooling (pp. 593–619). Cambridge,
MA: Blackwell Publishers, Ltd.
Baldwin, D. A., and Moses, L. M. 1994. Early understanding of referential intent and attentional focus: Evidence from language and emotion. In C. Lewis and P.
Mitchell (eds.), Children’s early understanding of
mind: Origins and development. Hillsdale, NJ:
Erlbaum.
Baron-Cohen, S. 1988. Social and pragmatic deficits in
autism: Cognitive or affective? Journal of Autism and
Developmental Disorders 18: 379–402.
Baron-Cohen, S., Leslie, A., and Frith, U. 1985. Mechanical, behavioral and intentional understanding of picture stories in autistic children. British Journal of
Developmental Psychology 4: 113–125.
Bartsch, K., and Wellman, H. 1995. Children talk about
the mind. New York: Oxford University Press.
Bretherton, I., and Beeghly, M. 1982. Talking about
internal states: The acquisition of an explicit theory of
mind. Developmental Psychology 18: 906–921.
Brown, J., Donelan-McCall, N., and Dunn, J. 1996. Why
talk about mental states? The significance of children’s conversations with friends, siblings, and
mothers. Child Development 67: 836–849.
Brown, J., and Dunn, J. 1991. ‘You can cry, mum’: The
social and developmental implications of talk about
internal states. British Journal of Developmental
Psychology 9: 237–256.
Bruner, J. 1990. Acts of meaning. Cambridge, MA:
Harvard University Press.
Carpenter, M., Akhtar, N., and Tomasello, M. 1998.
Sixteen-month-old infants differentially imitate
intentional and accidental actions. Infant Behavior
and Development 21: 315–330.
Courtin, C. 2000. The impact of sign language on the
cognitive development of deaf children: The case of
r
t
u
P
Development of Social Understanding in Children with Hearing Loss: Implications for Audiologists
theories of mind. Journal of Deaf Studies and Deaf
Education 5: 266–276.
Cutting, A. L., and Dunn, J. 1999. Theory of mind,
emotion understanding, language, and family background: Individual difference and interrelations.
Child Development 70 (4): 853–865.
de Villiers, P. A., Church, J., Giorano, R., Whalen, M.,
and Hoffmeister, R. 1999. Reference to mental
states in the written narratives of deaf children: The
contribution of English syntax and ASL skills. Paper
presented at the 14th Annual Conference on Issues in
Language and Deafness, Omaha, NE.
de Villiers, P. A., and de Villiers, J. G. 2000. Linguisitic
determinism and the understanding of false beliefs.
In P. Mitchessl and K. Riggs (eds.), Children’s reasoning and the mind (pp. 191–228). Hove, UK:
Psychology Press.
de Villiers, P. A., de Villiers, J. G., Schick, B., and Hoffmeister, R. 2000. Theory of mind development in
signing and non-signing deaf children: Impact of sign
language on social cognition. Paper presented at the
Theoretical Issues in Sign Language Research
Conference, Amsterdam.
de Villiers, P. A., Hosler, B., Miller, K., Whalen, M., and
Wong, J. 1997. Deaf children reading other people’s
emotions: Scripts, desires and knowledge states.
Poster presented at the Conference for the Society of
Research in Child Development, Washington, D.C.
Dunn, J., Bretherton, I., and Munn, P. 1987. Conversations
about feeling states between mothers and their young
children. Developmental Psychology 23: 132–139.
Dunn, J., Brown, J., and Bearsdsall, L. 1991. Family talk
about feeling states and children’s later understanding of others’ emotions. Developmental Psychology 27
(3): 448–455.
Figueras-Costa, B., and Harris, P. 2001. Theory of mind
development in deaf children: A nonverbal test of
false-belief understanding. Journal of Deaf Studies
and Deaf Education 6: 92–102.
Flavell, J., and Miller, P. 2000. Social cognition. In W.
Damon (Series ed.) and D. Kuhn and R. Siefler (eds.),
Handbook of child psychology, Vol. 3, Cognition,
perception and language. New York: Wiley.
Furrow, D., Moore, C., Davidge, J., and Chaisson, L. 1992.
Mental terms in mother’s and children’s speech:
Similarities and relationships. Journal of Child
Language 19: 617–631.
Gale, E. 1995. Language and theory of mind in signing
deaf children. Unpublished master’s thesis, Smith
College, North Hampton, MA.
Gale, E., de Villiers, P. A., de Villiers, J., and Pyers, J.
a
227
1996. Language and theory of mind in oral deaf
children. In Proceedings of the Boston University
Conference on Language.
Harris, P.L. 1992. From simulation to folk psychology: The
case for development. In M. Davies and T. Stone
(eds.), Folk psychology (Vol. 3). Cambridge, MA:
Blackwell Publishers.
Hughes, C., and Dunn, J. 1997. Understanding mind and
emotion: Longitudinal associations with mental-state
talk between young friends. Developmental Psychology 34: 1026–1037.
Jackson, A.L. 2001. Language facility and theory of mind
development in deaf children. Journal of Deaf
Studies and Deaf Education 6: 161–176.
Jenkins, J.M., Turrell, S.L., Kogushi, Y., Lollis, S., and
Ross, H.S. 2003. A longitudinal investigation of the
dynamics of mental state talk in families. Child
Development 74: 905–920.
Leekham, S.R. 1991. Jokes and lies: Children’s understanding of intentional falsehood. In A. Whiten (ed.),
Natural theories of mind: Evolution, development and
simulation of everyday mindreading (pp. 159–174).
Oxford, England: Blackwell.
Lillard, A. 1993. Pretend play skills and the child’s theory
of mind. Child Development 64: 348–371.
Lillard, A. 2002. Pretend play and cognitive development.
In U. Goswami (ed.), Blackwell handbook of childhood cognitive development (pp. 188–205). Oxford,
England: Blackwell Publishing.
Lundy, J. 2002. Age and language skills of deaf children
in relation to theory of mind development. Journal of
Deaf Studies and Deaf Education 7: 41–56.
Marschark, M., Green, V., Hindmarsh, G., and Walker, S.
2000. Understanding theory of mind in children who
are deaf. Journal of Child Psychology and Psychiatry
41: 1067–1073.
Moeller, M.P. 2002. Mother’s mental state input and
theory of mind understanding in deaf and hearing
children. Unpublished doctoral dissertation. University of Nebraska-Lincoln.
Moore, C., and Frye, D. 1991. Children’s theories of mind:
Mental states and social understanding. Hillsdale,
NJ: Lawrence Erlbaum.
Olson, D. 1994. The world on paper. Cambridge: Cambridge University Press.
Perner, J. 1991. Understanding the representational
mind. Cambridge, MA: MIT Press.
Perner, J., and Wimmer, H. 1985. “John thinks that Mary
thinks that . . . ” Attribution of second order beliefs by
5- to 10-year-old children. Journal of Experimental
Child Psychology 39: 437–471.
r
228
a
t
u
P
A Sound Foundation Through Early Amplification
Peterson, C. C., and Siegal, M. 1995. Deafness, conversation and theory of mind. Journal of Child Psychology
and Psychiatry 36: 459–474.
Peterson, C. C., and Siegal, M. 1997. Domain specificity
and everyday biological, physical, and psychological
thinking in normal, autistic, and deaf children. New
Directions for Child Development 75: 55–70.
Peterson, C. C., and Siegal, M. 1999. Representing inner
worlds: Theory of mind in autistic, deaf, and normal
hearing children. American Psychological Society 10:
126–129.
Peterson, C. C., and Siegal, M. 2000. Insights into theory
of mind from deafness and autism. Mind and Language 15: 123–145.
Peterson, C. C. in press. Theory of mind development in
oral deaf children with cochlear implants or conventional hearing aids. Journal of Child Psychology
and Psychiatry.
Pillow, B. H. 1991. Children’s understanding of biased social
cognition. Developmental Psychology 27: 539–551.
Remmel, E. 2002. Theory of mind development in signing
deaf children. Unpublished doctoral dissertation.
Stanford University.
Remmel, E., Peters, K., and Sawyer, A. 2004, May. Theory
of mind and language development in children with
cochlear implants. Poster presented at the annual
convention of the American Psychological Society,
Chicago, IL.
Rhys-Jones, S., and Ellis, H. 2000. Theory of mind: Deaf
and hearing children’s comprehension of picture stories and judgments of social situations. Journal of
Deaf Studies and Deaf Education 5: 248–265.
Ruffman, T., Slade, L., and Crowe, E. 2002. The relation
between children’s and mothers’ mental state language and theory-of-mind understanding. Child
Development 73: 734–751.
Russell, P.A., Hosie, J.A., Gray, C.D., Scott, C., Hunter, N.,
Banks, J., and MacCaulay, M. 1998. The development of theory of mind in deaf children. Journal of
Child Psychology and Psychiatry 39: 903–910.
Schick, B. 2004. Theory of mind and early language
development; Theory of mind and reading. In
S. Watkins (ed.), The SKI-HI Curriculum, Volume II
(pp. 2116–2140). Hope, Inc: North Logan, Utah.
Schick, B., Hoffmeister, R., de Villiers, P. A., and de
Villiers, J. 2000. Theory of mind development in signing and non-signing children: The impact of language
on social cognition. Paper presented at the 7th Conference on Theoretical Issues in Sign Language
Research, Amsterdam.
Shatz, M., Wellman, H., and Silber, S. 1983. The acquisi-
tion of mental verbs: A systematic investigation
of first references to mental states. Cognition 14:
301–321.
Steeds, L., Rowe, K., and Dowker, A. 1997. Deaf children’s
understanding of beliefs and desires. Journal of Deaf
Studies and Deaf Education 2: 185–195.
Tager-Flusberg, H. 1992. Autistic children’s talk about
psychological states: Deficits in the early acquisition
of a theory of mind. Child Development 63: 161–172.
Terwogt, M. M. and Rieffe, C. 2004. Deaf children’s use of
beliefs and desires in negotiation. Journal of Deaf
Studies and Deaf Education 9 (1): 27–38.
Tomasello, M. 2003. Constructing a language: A usagebased theory of language acquisition. Cambridge,
MA: Harvard University Press.
Wells, R. 1996. The divine secrets of the ya-ya sisterhood.
New York, NY: Harper Collins.
Wellman, H. 1990. The child’s theory of mind. Cambridge,
MA: Bradford Books.
Wellman, H. W., Cross, D., and Watson, J. 2001. Metaanalysis of theory-of-mind development: The truth
about false belief. Child Development 72: 655–684.
Wellman, H. W. and Liu, D. 2004. Scaling of theory of
mind tasks. Child Development 75(2): 523–541.
Wimmer, H., and Perner, J. 1983. Beliefs about beliefs:
Representation and constraining function of wrong
beliefs in young children’s understanding of deception. Cognition 13: 103–128.
Winner, E., and Leekham, S. 1991. Distinguishing irony
from deception: Understanding the speaker’s secondorder intention. British Journal of Developmental
Psychology 9: 257–270.
Woolfe, T., Want, S., and Siegal, M. 2002. Signposts to
development: Theory of mind in deaf children. Child
Development 73: 768–778.
Woolfe, T., Want, S., and Siegal, M. 2003. Siblings and
theory of mind in deaf native signing children. Journal
of Deaf Studies and Deaf Education 8 (3): 340–347.
Wright Cassidy, K., Ball, L. V., Rourke, M. T., Stetson
Werner, R., Feeny, N., Chu, J. Y., et al. 1998. Theory
of mind concepts in children’s literature. Applied
Psycholinguistics 19: 463–470.
Youngblade, L.M., and Dunn, J. 1995. Individual differences in young children’s pretend play with mother
and sibling: Links to relationships and understanding of other people’s feelings and beliefs. Child Development 66:1472–1492.
Yuill, N. 1993. Understanding of personality and dispositions. In M. Bennett (ed.), The development of social
cognition: The child as a psychologist. New York:
Guilford Press.