Mind blindness, or difficulty seeinganother persons perspec

Mind blindness, or difficulty seeing
another person's perspective, underpins
much ofthe social difficulty of autisnn.
Interventions that open children's eyes to
others' points of view show promise for
improving their social functioning.
BY BRIDGET MURRAY LAW
40 APRIL 2014 | THE ASHA LEADER
FAST READ: How can we help
children on the autism spectrum
better connect with others?
Researchers iiave wrestled with this
question and identified strategies
targeting understanding of pronouns,
emotions and sociai si<iiis. But no one
method wins out. What's clear is that
each child needs ongoing assessment
and tailored interventions tied to real-
life struggles.
TAGS: AUTISM SPECTRUM DISORDER,
THEORY OF MIND, SOCIAL SKILLS
IT'S AUTISM AWARENESS MONTH | BIT.LY/AUTISM-
MONTH 41

Charlie* is not having a good day. At all. The puffy-faced 5-
year-old, who bears a strong resemblance
to little "Mikey" of Life cereal fame, didn't want to come to
social skills group in the first place. But
his mother made him. Even after he bawled, wailed and clearly
made it known that he needed to finish
watching his favorite movie, "Cars." Needed to not be dragged
out on this cold, snowy February day.
But drag him out she did.
Now here he is in this strange room with the two other kids he
doesn't really know and the train set
he can play with only if he's allowed to by this nice-enough-
but-kind-of-demanding lady-—this "Ms.
Lauren," who insists that he say her name and look her in the
eyes. And who now says he has to share
all the trains he worked so hard to grab from the box before the
others did.
Why would he ever do that?
We can't know for sure that this is what Charlie
was thinking during speech-language pathologist
Lauren Civiello's weekly social skills group. But
it's a best approximation of his perspective on a
group that's ultimately meant to help him learn to
understand others' perspectives.
Seeing the world from another's point of view
is hard enough for neurotypical children—let's
face it, it's a struggle even for some neurotypical
adults—but for a child on the autism spectrum

it's possibly the toughest skill to grasp. It also
underlies much of the social difficulties inherent
in autism, as pioneering autism researcher Simon
Baron-Cohen and his team showed in the 1980s in
their "theory of mind" studies.
As a refresher, theory of mind refers to the
ability to recognize what you know, believe and
feel—and, very importantly—to understand that
others' knowledge, beliefs and feelings differ from
your own. What Baron-Cohen famously showed
in a 1985 study, published in Cognition (bit.ly/
cohen-tom), is that children on the spectrum fail
what's known as "the Sally-Anne" test at much
higher rates than age-matched neurotypical peers
and peers with Down syndrome. In this test, the
doll Sally places a marble in a basket and leaves
the room. The doll Anne then moves the marble
from the basket to a box. Lxperimenters ask
children to guess where Sally will look for the
marble when she returns to the scene.
The correct answer is in the basket, because
Sally doesn't know that Anne moved it. But the
vast majority of children with ASD say the box,
because they're not thinking of the situation
from Sally's point of view. For SLPs, who are
obviously concerned with language and social
pragmatics, developing these children's "other
awareness" is key to treatment success, says
Patricia Prelock, University of Vermont professor
of communication sciences and disorders and
2013 ASHA president, whose research focuses on
theory of mind (see sources online).

So how do you get a child like Charlie to see
that hoarding the trains means denying enjoyment
to his 5-year-old peers Eric* and James*? SLPs
and other developmental experts have investigated
that question over the past 30 years and identified
a number of effective approaches to teaching
perspective-taking. These approaches target
understanding of pronouns, emotions and social
skills (see sidebars).
But no one method trumps any other, notes
Prelock, and there's no surefire way to convey
this concept. What's critical, she says, is that the
SLP assess the child's current theory-of-mind
functioning, then tailor a set of interventions
Tackling the
Pronoun Problem
Mastering pronouns—the basic language
of self versus others—can be a steep
climb for children on the autism spectrum.
When confronted with a question that
requires pronouns in the answer, some
children fall back on echolalia, repeating
the last several words they heard instead
of responding conversationally. For
example, say an adult poses the question.
"Whose coat is that? Is that your coat or
my coat?" A child with poor pronoun
understanding might echo back, "Your
coat or my coat?"
Modeling by adults is one way to
show children how pronouns work, says

Hannah Dostal, an assistant professor
of literacy education at the University
of Connecticut She and Jessica Lester,
42 APRIL 2014 | THE ASHA LEADER
accordingly and periodically assess treatment
effectiveness. And by effectiveness, she means how
well children perform in real social situations.
"What the literature has struggled with is that
kids can do well on these interventions and strategies
in the clinical setting but then they struggle in real
social situations because the skills don't generalize,"
says Prelock. "That's why, no matter what
intervention we use, it should always be tied to a real
situation the child is actually dealing with."
See beyond me
For any treatment to work, it first needs to meet
children where they are developmentally, Prelock
notes. There's no way a child can grasp the
complexities of others' perspectives without first
mastering joint attention—being able to look where
another is pointing and directing others similarly—
and mastering some language basics.
Typically developing children master joint
attention by 12 to 18 months and have a solid
handle on pronouns by age 3. Children with ASD
follow the same general pattern, but it's significantly
delayed by a year, two years or more, depending on
the autism severity. Again, says Prelock, it comes

back to assessment. If testing reveals that the child
struggles with joint attention, that's the place to start
treatment (see sources online).
an assistant professor of inquiry
methodology at Indiana University, have
worked with SLP Kellie Ellenbaum on
crafting "Perspective Speak," a five-phase
pronoun program for children with ASD
that—at least in the beginning—involves
two adults working with the child.
In phase one, which focuses on self, one
adult might ask the child to choose a food.
The other adult stands behind the child
and, pretending to be the child, answers:
"I want applesauce." The child repeats
this phrasing until he or she can use this
modeled language.
The rest of the program's phases
tackle other pronouns, including
possessive pronouns, and the language of
perspective shifting. "You don't need to
necessarily do this one phase at a time,"
says Ellenbaum of the method. "Ability to
learn fluctuates day to day with these kids,
and it's likely that they will go back and
forth between phases quite a bit before
they really get it. But it's a good guideline."
For more specifics on the approach, see
Ellenbaum's Pediastaff blog post at bit.ly/
perspectivespeak.

IT'S AUTISM AWARENESS MONTH BIT.LY/AUTISM-
MONTH 43
Next it's key to establish understanding and use
of pronouns, says SLP Tracy Magee, a colleague
of Lauren Civiello's at Spectrum Pediatrics in
Alexandria, Va. There are countless pronoun-
building approaches, ranging from highly structured
programs like "Perspective Speak" (see sidebar on
page 42) to simple, unstructured play. For example,
Magee holds tea parties with her children with ASD
because pouring and serving pretend tea and food
requires heavy pronoun use: your cup, my cup, his
plate, her plate and so forth.
Charlie turns the trains over and over in his hands,
as Ms. Lauren waits for him to hand some of them
to Eric and James. He balks, his face registering
bewilderment, consternation.
"Eric will be sad if you don't share those trains,"
says Ms. Lauren. "And so will James."
"And you want them to be happy, don't you?"
Get happy
Happy. It's so simple for most of us to define, if not
to feel. But for children on the spectrum, recognizing
and labeling this and other emotional states is
far from easy. Due to what Baron-Cohen dubbed
"mind blindness," they battle to discern their own
emotions, let alone read those of others.

"I have a client who, if you ask him to show you
happy, will show you a strange devilish look," says
Bethesda, Md.-based SLP Laura Rubinoff, who
specializes in teaching perspective-taking skills. "He
just doesn't have the self-awareness to demonstrate
the emotion."
Because it typically takes visuals to engage children
on the spectrum, she uses videos and computer
animations to help teach emotions. Baron-Cohen's
computer-animated library of emotions (featuring
"Harry Potter" actor Daniel Radcliffe, bit.Iy/
emotion-coach) is a good starting point, she says.
And the music video of Pharrell Williams' exuberant,
up-tempo "Happy" also tops her list of tools. In it,
a diverse group of actors depict the sunny emotion
in seemingly every nonverbal way possible—as
Williams sings, "clap along if you know what
happiness is to you," they spin, finger-snap, play air
guitar, jump, skip, smile, laugh, boogie and fling
their arms up to the skies (bit.ly/happy-video).
"After we watch the video, the children think
of other words that convey a whole continuum
of happy—glad, feeling fine, content, delighted,
thrilled, elated, ecstatic, beaming," says Rubinoff.
"We then rewind the video and study how the people
in the video use their body and facial expressions to
express 'happy.'"
From happy, Rubinoff moves on to "sad" and
"mad," covering the wide array of associated words
and body language.
Selected cards and apps also work well for teaching

emotions, says Magee. SLPs can use them to act out
emotions and inject game-playing fun. For example,
Magee uses "Alligator" apps targeting emotion
identification (free for download at bit.ly/emotions-
app)—the child guesses emotions shown on people's
faces by clicking on a choice of words.
Depending on the child's ASD severity and verbal
levels, Magee also uses language-boosting board
games and simple narrative stories to teach the "who,
what, when, where, why" of emotions. For example,
in the book "Taking a Bath With the Dog and
Other Things That Make Me Happy," the child will
identify what the protagonist is feeling (blue), why
she is feeling that way (wallowing in the blueness),
and how she can feel better (think of things that
make her happy).
Structured activities aside, Magee recommends
turning everyday moments into teaching
opportunities. "Like if the child bumps their knee,
it's saying, 'Oh that must feel bad, you must feel
sad.' And the same goes for parents: labeling those
emotions and using those moments."
Ms. Lauren is still trying to convince Charlie to
share his trains with Eric and James, both hard at
work piecing together the tracks. They sit side by
side as they place them, singing the same song in
unison: chugga chugga choo choo, chugga chugga
choo choo.
"How about if Eric and James ask you nicely to
share the trains?" Ms. Lauren asks Charlie.
Charlie hunches over the trains, possessively. How

come everyone always wants to take his stuff???
Eric turns to him, trying to make eye contact.
"Charlie, may I please have one of your trains to put
on the tracks?"
Long pause.
Staring at the floor, Charlie reluctantly hands a
train to Eric, his bad day continuing
Make others happy
The tension between Charlie and the others in the
room couldn't be more obvious, but what's causing
it? In short, Charlie lags behind the other two in
understanding a key aspect of theory of mind, which
is that "what I do (my behavior) affects the happiness
of those around me."
Civiello keeps this behavior-emotion link in her
44 APRIL 2014 THE ASHA LEADER
back pocket: She uses it constantly. During snack
time, she asks Eric how his mother will feel when she
learns he tried peanut butter and celery for the first
time. "Happy!" he proclaims. She smiles and claps
her approval. "And I'm happy you tried it, too!" she
says, prompting a squirmy smile in return.
But remember what happened when she tried the
"make someone else happy" approach with Charlie?
He was unaffected, holding his trains close until
coerced to hand them over. Meanwhile, in stark

contrast, Eric and James sang the "chugga chugga
choo choo" song together and cooperatively built the
track—with no help from Charlie.
In Civiello's view, the difference in their actions
mostly comes down to this: Charlie doesn't realize
that his behavior affects the happiness of others.
Eric and James, though also on the autism spectrum,
are making this realization.
"They get that it's not just about their own little
bubbles," says Civiello of Eric and James. "I really
see a difference in how they interact with other kids.
They've come a long way in six months of social
skills group."
Key to her success with them, she believes,
is tailored social skills treatment and ongoing
assessment, what Patty Prelock considers the staples
of successful perspective-taking treatment. SLPs can
choose from any number of tests to gauge a child's
other awareness (for example. The Theory of Mind
Inventory, www.theoryofmindinventory.com, or
the Theory of Mind subscale of The Developmental
Neuropsychological Assessment-II, bit.ly/nepsy-2).
In the case of Eric and James, it helps, also, that
they attend social group sessions more regularly than
Charlie does and have play dates together. This gives
them more chances to interact in the real world, to
really get into a rhythm with one another. A year
ago, they never would have shared their trains and
train track pieces so readily—they play together so
much better now, Civiello says.
Train tracks laid, the three boys try tbem out, one

at a time. "Go, Charlie! Co, Charlie! Co!!" Eric
and James cheer. And go Charlie does. Because
finally, finally his moment has arrived: the moment
of train wheels hitting tracks, red train going round
and round, up and down as he pushes it. But then
Ms. Lauren calls for clean-up. She'd said before that
this was the last round of turns, but Charlie wants
to run his train again. When he sees the other boys
dismantling the tracks, he loses it. He bursts into
tears and hurls his trains into the toybox so hard that
Ms. Lauren flinches. While the other boys high-five
Ms. Lauren on the way out, Charlie leaves in tears.
Civiello admits that it's hard to see a child like
Charlie have a bad day, to repeatedly suffer for
not getting his way despite her best efforts to
ease the bumps. (Just one example: She uses a
picture schedule to help with transitions.) But she's
optimistic because ... well, because being upbeat is
Programs Tiiat Target Social Skills
A deficit in social skills is one of the hallmarks of autism
spectrum disorder—and
also one that can be addressed through systematic treatment.
Speech-language
pathologists have been on the forefront of developing such
programs, including these
three well-known ones:
Social Thinking. Pioneered by SLP
Michelle Garcia Winner, this program
is geared for high-functioning children
on the spectrum and, according to
its website, targets how their own
social minds work—why they and
others react and respond the way

they do; how their behaviors affect
the way others perceive and respond
to them; and how this affects their
own emotions and relationships.
Among the goals are for participants
to recognize that they and others have
different perceptions and abilities
to process social information and
to become more socially adaptive.
For more specifics, see www.
socialthinicing.com.
Sociai Stories. Initially conceptualized
by educational consultant and former
teacher Carol Gray as a way to teach
children a script for appropriate
behavior, the social story has since
been widely adopted by SLPs and
others as a behavior modification tool.
Typically the story is an amalgam of
pictures and words describing how
the child can, say, handle unexpected.
unwelcome events or manage conflid
with others. For more on social stories^
see on.asha.org/sociai-story and i
bit.ly/gray-soclal.
Sociai Communication/Emotionai
Regulation/Transactionai Support.
(SCERTS). Developed by SLPs Barry '
Prizant, Amy Wetherby and Emily
Rubin, and occupational therapist ¡
Amy Laurent, this program addresses
social communication and emotional
regulation. Key components ofthe
program include peer and adult |

modeling, a supportive environment
and child-initiated communication. For
more specifics, see www.scerts.corni
Sociai Skiiiograpiiy. SLP Laura ^
Rubinoff draws on Garcia Winner's
Social Thinking approach and Albert.'
Bandura's social learning theory by '
pairing SLPs with improvisational
46 APRIL 2014 THE ASHA LEADER
part of her job. She's confident that
if Charlie comes to sessions more
regularly, he'll work through the
suffering and learn.
"Kids learn best from other kids,
from the experiences they have with
them," says Civiello. "So I really
push them socially. Sometimes they
leave here a little upset, and that's
OK. That's life."
Because when she sees children like
Eric and James demonstrate the skills
she teaches, it makes all the bad days
worth it.
"I hear them say things like, 'That
hurts my feelings,' or 'Tattling on
friends makes them feel bad,' and
I feel so good. Because I know I've
done my job." 9

Bridget Murray Law is managing editor of
The ASHA Leader.
•[email protected]
*T/?e names of the children in this
story have been changed to protect
their privacy.
Q Find sources for this article at
leader.pubs.asha.org.
actors to model emotions and
conversational skills for small
groupsof elementary and middle
school students. The children learn
about—and practice—using eye
gaze rules, taking turns, sharing
topics and responding to facial
expressions and body language.
Rubinoff rounds out the acting
demonstrations with "video
modeling" of social skills using
clips from TV shows such as "The
Literals" and "Sesame Street"
and movies such as "Frozen" and
"Toy Story." Learn more at bit.ly/
social-skillography.
Editor's note: ASHA does not endorse
particular programs, products or
procedures related to the treatment of
autism spectrum disorder.
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ASHA Board of Directors elections open April 23
and close May 29 at 3 p.m. Eastern time.
/atch for special coverage on the candidates
in the May issue of the leader.
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*^n HEARING
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Learn more about the candidates at
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IT'S AUTISM AWARENESS MONTH BIT.LY/AUTISM-
MONTH 47
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