FASD and Theory of Mind (ToM): A Brief Review for Professionals

Fetal alcohol spectrum disorder (FASD) is a life-long disorder resulting from the person’s mother consuming alcohol during pregnancy (Coggins, Timler, & Olswang, 2007). Often characterized by a nuanced clinical profile, FASD can include a range of cognitive, social, and adaptive impairments (Howell et al., 2006; Jacobson & Jacobson, 1999). Cognitive impairments can manifest in executive functioning, attentional control, affective regulation, and short- and long-term memory problems along with poor performance on measures of standardized intelligence (Coles et al., 2002; Connor et al., 2000; Mattson et al., 1996; Rasmussen, 2005; Willford et al., 2006). Social impairments can include deficits in verbal and non-verbal abilities, recognition of social cues, interpersonal skills, as well as broader social information processing (Coggins, 1997; Cone-Wesson, 2005; Greenbaum, Stevens, Nash, Koren, & Rovet, 2009; Kodituwakku, 2007; Streissguth and Giunta, 1988). Adaptive impairments are typically observed with learning disabilities, decision-making, and anticipating or understanding the consequences of actions along with underachievement in school and work settings (Howell et al., 2006; Kerns et al., 1997; Kilchenmann, Thomas, Molteno, Dodge, Meintjes, Jacobson, & Jacobson, 2012; Streissguth and Giunta, 1988).

These cognitive, social, and adaptive impairments of FASD are often exacerbated by the environmental context experienced throughout childhood (Kilchenmann, Thomas, Molteno, Dodge, Meintjes, Jacobson, & Jacobson, 2012). For instance, individuals with FASD are disproportionately more likely to experience insecure attachment with their primary caregiver, which can result in dysfunctional caregiving, maternal drinking, and poverty (Coggins, Timler, & Olswang, 2007). Such a lack of positivity or nurturance in combination with FASD places the individual at risk for an array of secondary disabilities and conditions (Rasmussen, Talwar, Loomes, & Andrew, 2008). Of growing concern, is the stunted emergence of important cognitive and social skills like theory of mind (Coggins, Timler, & Olswang, 2007).

Theory of Mind

Theory of mind is the capacity to recognize and comprehend the mental states (i.e., thoughts, feelings, and desires) of one’s self and others along with the ability to understand that these mental states vary across individuals (Lindinger et al., 2016; Rasmussen, Wyper, & Talwar, 2009; Stone et al., 1998). Such information can be used, in turn, to predict the future actions and reactions of people (Baron-Cohen et al., 1994; Milders et al., 2006). Although several hypotheses have been proposed by researchers, the causal mechanisms underlying the development of theory of mind remain unclear (Astington, Harris, & Olson, 1988; Hale & Tager-Flusberg, 2003; Timler, Olswang, & Coggins, 2005). That said, much of the development in theory of mind occurs during early childhood, with the lion’s share emerging around the age of 4 years old (Rasmussen, Wyper, & Talwar, 2009).

Theory of mind plays an important role in social information processing, communication, and social behavior (Baron-Cohen et al., 1999; Channon & Crawford, 2000; Happé et al., 2001; Kilchenmann et al., 2012). For instance, deficits in theory of mind have been linked to poor social skills among children (Thomas et al., 1998; Lindinger et al., 2016). Further, the onset of theory of mind skills has been associated with cognitive abilities including working memory, attentional control, and language abilities (Keenan, 2000; Gordon & Olson, 1998; Rasmussen, Wyper, & Talwar, 2009). In light of these and other observations, researchers have concluded that the ability to successfully navigate social interactions is intrinsically linked to theory of mind skills (Baron-Cohen et al., 2001; Lindinger et al., 2016).

FASD and Theory of Mind

The hallmark symptoms of FASD could directly contribute to the maldevelopment of theory of mind skills (Coggins, 1997; Kodituwakku et al. 1997; Lindinger et al., 2016). FASD’s cognitive impairments are often characterized by executive functioning deficits, whereas executive functioning plays a critical role in the development of theory of mind (Carlson, Moses, & Breton, 2002; Hughes, 1998). This has been observed across a range of tasks that measure executive functioning (Rasmussen, 2005; Rasmussen & Bisanz, 2009; Rasmussen, Wyper, & Talwar, 2009). Further, children who have suffered maltreatment, which is particularly common among those with FASD, are prone to deficits in theory of mind (Cicchetti, 2004; Cicchetti, Rogosch, Maughan, Toth, & Bruce, 2003; Coggins, Timler, & Olswang, 2007). Lastly, individuals with both FASD and theory of mind deficits struggle with social information processing, communication, and interpersonal relationships. 

Although more research is needed, there is a growing literature that is beginning to establish the presence of theory of mind deficits among those with FASD. Foremost among this research are studies utilizing false-belief tasks (Coggins, 1997; Kodituwakku et al., 1997). These tasks require the participant to predict the actions of a character based on the character’s inaccurate knowledge of a situation (de Villiers & de Villiers, 2000). Coggins (1997) reported that school-age students with FASD struggle immensely with false-belief tasks. Similar struggles have been observed in youths with FASD on other theory of mind tasks like the Reading the Mind in the Eyes task (Kilchenmann, Thomas, Molteno, Dodge, Meintjes, Jacobson, & Jacobson, 2012). Here, a participant must recognize the affective state of another person based on an image of their facial expression. These findings have led some researchers to conclude that social impairments may be at the nexus of FASD and deficits in theory of mind (Timler, Olswang, & Coggins, 2005).

Recommendations for Further Study 

As this brief article highlights, deficits in theory of mind are an area of serious concern among individuals with FASD. This warrants innovative and sophisticated research in at least five areas. First, the establishment of evidence-based practices in the screening, assessment, and treatment of youths and adults with FASD and theory of mind deficits must be a priority. Second, etiological research is needed to tease apart the causal influences of prenatal alcohol exposure versus other potential causal factors in the emergence of theory of mind deficits in individuals with FASD (Lindinger et al., 2016). Third, at a broad level, more needs to be known about how theory of mind deficits impacts adults with FASD. Fourth, research should explore the role of theory of mind deficits in the antisocial behaviors (e.g., inappropriate sexual behaviors) of those with FASD. Fifth, a greater understanding of the consequences of theory of mind deficits on criminal justice-involved individuals with FASD from arrest to incarceration is needed. This should include important questions such as if these individuals are at a greater risk for suggestibility and confabulation during questioning or incompetency to stand trial. A strong program of research across these areas offers hope for improving short- and long-term outcomes in individuals with FASD and theory of mind deficits.

20 Essential Take-Away Points

1. FASD persists across the lifespan.
2. FASD is caused in an infant by their mother consuming alcohol during pregnancy. 
3. FASD can include a range of cognitive, social, and adaptive impairments. 
4. FASD’s cognitive impairments can impact executive functioning, attentional control, affective regulation, and memory. 
5. FASD’s social impairments can include verbal and non-verbal abilities, recognition of social cues, and interpersonal skills.
6. FASD’s adaptive impairments may be observed in learning disabilities, decision-making, and understanding the consequences of actions.
7. FASD symptoms are exacerbated by exposure to poor environmental contexts (e.g., insecure attachment, maternal drinking, and poverty). 
8. Theory of mind is the capacity to recognize and comprehend the mental states (i.e., thoughts, feelings, and desires) of one’s self and others.
9. Theory of mind is essential in predicting the future actions and reactions of people.
10. Theory of mind typically emerges during early childhood between the ages of 2 and 6 years old.
11. Theory of mind is critical in social information processing, communication, and social behavior.
12. FASD could inhibit the development of theory of mind skills. 
13. Executive functioning could be the common thread between FASD and theory of mind.
14. Theory of mind deficits appear common among individuals with FASD.
15. Research with false-belief and Reading the Mind in the Eyes task confirm the presence of theory of mind deficits among youths.
16. Assessment approaches that utilize integrated performance in real- time hold promise among youths with FASD.
17. Interactive and dynamic assessment approaches that mirror real-life situations could demonstrate higher validity and utility in children with FASD and theory of mind deficits.
18. Interventions should try to enhance the ability to recognize and understand how different people can possess contradictory perspectives.
19. Innovation in the area of FASD treatment could be inspired by research on other disorders like autism, which are also characterized by theory of mind deficits.
20. There are wide-ranging opportunities for research to better understand the relations between FASD and theory of mind.

Author Biography:

Jerrod Brown, Ph.D., is an Assistant Professor, Program Director, and lead developer for the Master of Arts degree in Human Services with an emphasis in Forensic Behavioral Health for Concordia University, St. Paul, Minnesota. Jerrod has also been employed with Pathways Counseling Center in St. Paul, Minnesota for the past seventeen years. Pathways provides programs and services benefiting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS) and the Editor-in-Chief of Forensic Scholars Today (FST). Jerrod has completed four separate master’s degree programs and holds graduate certificates in Autism Spectrum Disorder (ASD), Other Health Disabilities (OHD), and Traumatic-Brain Injuries (TBI). Jerrod has published numerous articles and book chapters and recently co-edited the book, Forensic Mental Health: A Source Guide for Professionals (Brown & Weinkauf, 2018) with Erv Weinkauf. Email address: [email protected]