Neuropsychologia 43 (2005) 99–114

Theory of mind after traumatic brain injury夽

Helen Bibby, Skye McDonald∗
School of Psychology, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
Received 13 May 2003; accepted 28 April 2004

Abstract
This study investigated whether people with severe traumatic brain injury (TBI) demonstrate a specific impairment on tasks requiring
them to make inferences about others’ mental states (theory of mind tasks). Participants with severe TBI were compared to a healthy group
on verbal first-order and second-order theory of mind (ToM) tasks, non-verbal ToM tasks and on verbal and non-verbal tasks requiring them
to make general (non-mental) inferences (NMIs). The clinical group performed more poorly than controls on both ToM and NMI tasks.
This performance was not completely accounted for by the working memory or implicit language demands of the tasks. Multiple regression
analyses suggested that patients with TBI have a general weakness in inference-making that, combined with linguistic and working memory
limitations, impairs their performance on both non-verbal and second-order ToM tasks. However, a specific ToM impairment may underlie
their poor performance on verbal first-order tasks. Implications of this finding for the possibility of a separate cognitive module of ToM
are discussed, as well as for the rehabilitation of social deficits after TBI.
© 2004 Published by Elsevier Ltd.
Keywords: Mental-state; Inference; Lesion; Brain-damage; Cognitive; Module

1. Introduction 1.1. Theory of mind as a separate cognitive module

Human beings are social animals (Adolphs, 1999), and
social interaction requires complex, flexible behaviour
(Adolphs, 2001; Baron-Cohen et al., 1999). In order to man-
ifest this behaviour, social cognition is required (Adolphs,
2001). Social cognition (or social intelligence) has been
defined as the ability to interpret others’ behaviour in terms
of mental states, to conceptualise relationships between
oneself and others, and to use these concepts to guide one’s
own behaviour and predict that of others (Adolphs, 2001;
Baron-Cohen et al., 1999). It has been suggested that this
ability may be independent from general intelligence, with
different information processing demands (Adolphs, 2001;
Baron-Cohen et al., 1999).
夽 Data collection for this research was facilitated by a Discovery Grant
from the Australian Research Council. We gratefully acknowledge the
Liverpool Brain Injury Rehabilitation Unit, especially Anne Pfaff, the
Royal Ryde Rehabilitation Unit, especially Dr. Clayton King, and the
Westmead Hospital Brain Injury Unit, especially Dr. Joe Gurka, for access
to patients.
∗ Corresponding author. Tel.: +61-2-9385-3029; fax: +61-2-9385-3641.
E-mail address: s.mcdonald@unsw.edu.au (S. McDonald).
Despite its potential importance, the concept of social
cognition tends to be rather loosely defined (Adolphs,
2001). Perhaps for this reason, much of the research in
the area has focussed on one aspect of social intelligence,
namely “theory of mind” (ToM) (Happe, Brownell, &
Winner, 1999). ToM refers to the ability to think about other
people’s mental states (e.g. thoughts, beliefs, intentions and
desires) and use them to understand and predict others’
behaviour (Baron-Cohen et al., 1994; Mazza, De Risio,
Sudan, Roncone, & Casacchia, 2001; Rowe, Bullock,
Polkey, & Morris, 2001). It has been suggested that ToM
is a separate cognitive module, with an innate neural basis
(Happe et al., 1999; Happe, Malhi, & Checkley, 2001).
However, the specific mechanism and neural pathways of
ToM are not well understood (Happe et al., 2001) and its
identity as an innate module remains controversial (e.g.
Garfield, Peterson, & Perry, 2001).
According to Fodor’s original conceptualisation (1983)
a cognitive module is a domain specific inference-making
system that has a distinct neuroanatomical location, only has
access to information that is relevant to its computations,
and is independent of the diffuse central systems that govern
higher cognitive functions. Consequently, if ToM is modular
it should be possible to have specific ToM impairment with

0028-3932/$ – see front matter © 2004 Published by Elsevier Ltd.

doi:10.1016/j.neuropsychologia.2004.04.027
100 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
intact functioning in other areas (c.f. aphasias) (Foder, 1985)
or for ToM to remain intact in spite of severe intellectual
impairment (Moscovitch & Umilta, 1991).
Claims concerning the cognitive independence of ToM
are based upon a range of findings. Firstly, there are recent
findings of specific, acquired ToM impairments in patients
who have had a right hemisphere stroke (Happe et al., 1999),
frontal lobe surgery (Happe et al., 2001) and fronto-temporal
dementia (Lough, Gregory, & Hodges, 2001). Secondly,
ToM ability has been shown to develop during childhood in
a series of increasingly complex stages that are thought to
be universal across cultures and to occur within a narrow
time frame (Happe et al., 2001; Lough et al., 2001). Also,
the rate of development has been found to be relatively in-
dependent of level of intelligence (Fletcher et al., 1995) and
to have a genetic component that is independent of verbal
development (Hughes & Cutting, 1999).
Thirdly, research has demonstrated a selective impair-
ment of ToM while other functioning is relatively intact in
developmental disorders such as autism (Happe et al., 1999;
Stone, Baron-Cohen, & Knight, 1998). Conversely, there is
evidence of a selective sparing of ToM ability in some indi-
viduals with impaired general intellectual functioning, such
as William’s syndrome and Down’s syndrome (Happe et al.,
2001; Lough et al., 2001). It should be noted, however,
that this evidence has not gone unchallenged. Ozonoff,
Pennington, and Rogers (1991) claimed that deficits in ToM
in autistic individuals are caused by general impairments
in reasoning and strategy application. Furthermore, Zelazo,
Burack, Benedetto, and Frye (1996) found that low-
functioning adults with Down’s Syndrome performed worse
than normal children on several ToM tasks, and that their
performance was correlated with a test of mental flexibility.
In accordance with Fodor’s conceptualisation, neuro
anatomical specificity is another requirement for modu-
larity. Indeed, a considerable amount of evidence from
imaging studies has suggested that the frontal lobes are nec-
essary for this ability (Adolphs, 2001). Baron-Cohen et al.
(1994) found increased blood flow in the right orbito-frontal
cortex during recognition of mental state words and Goel,
Grafman, Sadato, and Hallett (1995) found activation of the
left temporal and left medial frontal lobe during a task re-
quiring mental state inferences. Fletcher et al. (1995) found
increased activation in the left medial prefrontal gyrus and
the posterior cingulate cortex when they compared normal
subjects’ performance on ToM stories to that on general
(non-mental) inference (NMI) stories and Gallagher et al.
(2000) found a similar activation pattern when they com-
pared normal subjects’ performance on ToM and NMI
cartoons. This evidence provides considerable support for
the role of the frontal lobes in ToM.
Localisation evidence via functional imaging studies is
strengthened considerably by the presence of convergent
findings from neuropsychological lesion studies (Happe
et al., 2001). A number of studies have investigated ac-
quired ToM deficits after frontal lobe damage, although not
all have demonstrated a specific impairment that is disso-
ciable from general inferential ability. For example, while
Stuss, Gallup, and Alexander (2001) found that frontal lobe
lesions resulted in impaired performance on visual perspec-
tive taking and deception tasks, they did not incorporate
NMI tasks. Similarly, Channon and Crawford (2000) found
that patients with left anterior lesions showed impaired
comprehension on ToM stories relative to those with other
lesions, but again, no NMI stories were used. Nevertheless,
a small number of researchers have reported a clear and
dissociable ToM impairment in patients with frontal lobe
damage. Rowe et al. (2001) studied neurosurgical patients
with unilateral frontal lobe lesions and found a specific im-
pairment on ToM tasks following both left and right hemi-
sphere damage, and Happe et al. (2001) found a deficit in
ToM stories and cartoons compared to NMI tasks in a single
patient who had undergone a bilateral surgical procedure
to cut the neuronal connections between the orbito-frontal
cortex and the mid-line thalamic nuclei. Therefore, some
evidence from lesion studies is consistent with imag-
ing research suggesting the role of the frontal lobes in
ToM.
Another line of evidence has implicated the right hemi-
sphere in ToM tasks. For example, Winner, Brownell, Happe,
Blum, and Pincus (1998) found that right-hemisphere
brain-damaged (RHD) patients’ performance on more
difficult (second-order) ToM tasks was fragile and vari-
able compared to a control group, while left-hemisphere
brain-damaged (LHD) patients’ performance on less ver-
bally demanding ToM tasks was not impaired. Given this
mixture of findings implicating both the frontal lobes and
the right hemisphere, it is possible that the most important
brain region for ToM is in fact the right frontal region. This
possibility is supported by the recent findings by Tranel,
Bechara, and Denburg (2002) that the right ventromedial
prefrontal cortex is related to social and emotional process-
ing impairments, while the left ventromedial prefrontal cor-
tex is not. Also, Stuss et al.’s study (2001, discussed above)
suggested that the right frontal lobe was particularly impor-
tant. Despite these findings there is not universal agreement
concerning a right frontal focus. Some of the research out-
lined above implicated the left frontal region rather than the
right (Channon & Crawford, 2000; Fletcher et al., 1995;
Goel et al., 1995), and while Surian and Siegal (2001) also
found that RHD patients performed worse on ToM tasks
compared to LHD patients, this only applied when the tasks
placed a demand on visuo-spatial processing.
In sum, while there is some evidence that is sugges-
tive of a separate cognitive module for ToM, the issue re-
mains controversial and more research is needed. While it
appears that ToM can be differentially impaired in devel-
opmental and acquired neurological disorders this requires
further clarification. Similarly, there is some evidence that
the frontal lobes are necessary for ToM ability, but the ex-
act region of these lobes that is involved is still a matter of
debate.
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
1.2. Theory of mind in traumatic brain injury
Given that ToM is an aspect of social cognition, it is
not surprising that a range of social deficits have been as-
sociated with ToM impairment. Specifically, a ToM deficit
has been linked to difficulties using gestures to affect how
others feel as well as taking account of others’ interests in
conversation (Fletcher et al., 1995), withdrawal from social
contact (Happe et al., 2001), insensitivity to social cues,
indifference to others’ opinions, poor foresight, egocen-
trism, lack of restraint and inappropriate affect (Rowe et al.,
2001), pedantic speech, inappropriate non-verbal commu-
nication and inability to follow social rules (Bowler, 1992),
and difficulty applying theoretical social knowledge to the
real situation (Stone et al., 1998). Furthermore, research has
suggested that impaired ToM may also be associated with
communication difficulties. In particular, it has been linked
to problems comprehending non-literal speech, such as sar-
casm, irony, humour and deceit (e.g. Channon & Crawford,
2000; Happe, 1993).
One group that has been found to demonstrate many of
the social and communication difficulties outlined above are
people who have sustained a severe traumatic brain injury
(TBI). Subjects with TBI have been shown to have impaired
social competence (Spatt, Zebenholzer, & Oder, 1997); to be
socially isolated (Lezak, 1995); and to have difficulties with
non-literal language (Dennis, Purvis, Barnes, Wilkinson,
& Winner, 2001; McDonald & Pearce, 1996; Winner et al.,
1998). They have also been described as having poor in-
sight, talkativeness and inappropriate expressions of affec-
tion (Santoro & Spiers, 1994); reduced empathy (Eslinger,
1998); lack of foresight, tact and concern (Lishman, 2001);
egocentrism and inappropriate levels of social interaction
(McDonald & Pearce, 1996); impaired understanding of
non-verbal signals (Lezak, 1995); and difficulty applying
social knowledge (Dimitrov, Grafman, & Hollnagel, 1996).
The overlap between these observations and the social dif-
ficulties thought to be associated with ToM deficits raises
the question of whether patients with severe TBI have im-
pairment in ToM. Furthermore, TBI often results in damage
to frontal areas in the brain (as well as temporal dam-
age and diffuse axonal injury) (Adams et al., 1985, 1989;
Levin et al., 1987). Given these two lines of evidence, i.e.
(1) poor social behaviour; (2) frontal lobe involvement,
the possibility that many people with TBI have impaired
ToM merits examination. The finding of a specific ToM
impairment in TBI would provide further evidence for the
modular nature of ToM. It would also have important im-
plications for the rehabilitation of social difficulties in this
group. Strategies to address a ToM deficit have been devel-
oped for people with Asperger’s syndrome (Attwood, 1998)
and schizophrenia (Sarfati, Passerieux, & Hardy-Bayle,
2000), and these might be adapted for patients with
TBI.
Existing research on ToM deficits in TBI is very lim-
ited, with many studies on acquired impairment of ToM
101
explicitly excluding TBI patients (e.g. Mazza et al., 2001).
In one of the few published reports that included subjects
with TBI, Stone et al., 1998 demonstrated a specific (i.e.
dissociable) impairment on more difficult ToM tasks (“faux
pas” tasks) in five TBI patients with bilateral damage to the
orbito-frontal cortex. However, Bach, Happe, Fleminger, and
Powell (2000) did not find evidence of a ToM deficit in a
TBI subject with acquired orbito-frontal damage and social
problems.
Santoro and Spiers (1994) assessed 10 adults after a
closed-head-injury and found that they had more difficulty
than non-head-injured adults on a video-based perspective
taking task, and Dennis et al. (2001) found that children
with severe closed head injury cannot answer questions
about the intentions of speakers who use non-literal lan-
guage. However, it is unclear from these latter studies that
TBI results in a specific impairment of ToM because nei-
ther of them compared performance on these tasks to that
on tasks requiring non-mental (e.g. physical) inferences
(NMI). Thus, the impaired performance might be due to
a more general impairment in inferential ability. A small
number of other studies found impaired ToM in subject
groups that included, but were not limited to TBI patients
(e.g. Channon & Crawford, 2000; Dimitrov et al., 1996),
but again these did not measure general inferential ability.
It is clear that further research is merited to examine the
possibility of a specific ToM deficit after TBI. Therefore, the
present study aimed to address two main questions: (1) Do
people with a severe traumatic brain injury (TBI) demon-
strate impairment on tasks requiring them to make inferences
about others’ mental states (theory of mind tasks) compared
to healthy controls? (2) Is this impairment independent of
the ability of people with TBI to make general (non-mental)
inferences?.
1.3. Alternative explanations of ToM task performance
It has been pointed out that performance on any cognitive
task reflects competence in the ability required to solve the
problem (in this case, ToM) and the possession of other cog-
nitive skills that are necessary but not sufficient for the task
(e.g. the ability to remember information, focus attention,
understand and answer questions, etc.) (Wellman, Cross, &
Watson, 2001). In terms of Fodor’s concept of modularity,
a ToM task may well tap into a separate cognitive module
of ToM, but also require the involvement of other cognitive
modules and central systems.
It has been suggested that a deficit in one of these other
systems may underlie the impaired performance on ToM
tasks in young children (Foder, 1992), people with autism
(Bowler, 1992), people with schizophrenia (Langdon et al.,
1997) and patients with frontal lobe damage (Channon &
Crawford, 2000). This question must also be considered
in relation to TBI given that the disorder is heterogeneous
and associated with a range of cognitive deficits including
difficulties with pragmatic language (McDonald & Pearce,
102 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
1996), recall of information, working memory, attention and
executive functioning (Lezak, 1995).
1.3.1. Implicit language demands
One possibility for the poor performance of young chil-
dren on ToM tasks may be due to difficulties in under-
standing the purpose of the questions (Siegal, Carrington, &
Radel, 1996). This has led researchers to re-phrase the ques-
tions used (e.g. “where will John look for his kitten?” be-
comes “where will John look for his kitten first?” or “where
does John think his kitten is?” (Siegal et al., 1996; Wellman
et al., 2001). Siegal and coworkers (Siegal et al., 1996;
Surian & Siegal, 2001) argued that the impaired perfor-
mance of RHD patients on ToM tasks was attributable to the
pragmatic demands of the questions, and showed that using
more explicit questions enables this group to make correct
false-belief predictions. Similarly, Varley, Siegal, and Want
(2001) were able to show that a patient with severe apha-
sia retained theory of mind reasoning when they used a task
with significantly reduced verbal demands. Given that pa-
tients with TBI are known to have difficulties with pragmatic
language (McDonald & Pearce, 1996), it is important to ex-
amine their responses to both implicit and explicit questions
about mental states. An example of the kind of questions
used is shown below:
John puts his kitten in a box, and then leaves the room
while the kitten escapes and hides under a chair. When
he returns, he looks for his kitten in the box.
The implicit question would be “Why did John look for his
kitten in the box?” A more explicit question would be: “Why
did John think his kitten was in the box?” Each question
requires the same level of reasoning about mental states, but
one explicitly indicates that a response referring to mental
states is required.
1.3.2. Memory demands
ToM tasks would be expected to place a considerable load
on the memory of brain-injured participants. Researchers
have attempted to eliminate the possibility that memory
problems could account for an observed deficit in several
ways. Some have included a measure of prose recall in their
studies as a covariate (Rowe et al., 2001) and others have
incorporated a memory question after each task (Surian &
Siegal, 2001). An alternative approach is to leave the test
material in front of the subject while all questions are asked
(Channon & Crawford, 2000; Dennis et al., 2001). It has
been suggested that, in addition to reducing memory load,
the practice of providing test material in written as well
as verbal form increases participants’ attention to and en-
gagement with the activity (Kaplan, Brownell, Jacobs, &
Gardner, 1990).
1.3.3. Working memory demands
It has also been claimed that impaired performance on
ToM tasks may be attributable to working memory demands
(Stone et al., 1998). A number of studies have shown that
young children’s performances on ToM tasks are influenced
by working memory capacity (Butler, 1997; Gordon &
Olson, 1998; Hughes, 1998; Keenan, 1998, 2000), although
the evidence suggests that it is not the sole contributing
factor (Artuso, 2000; Tager-Flusberg, Sullivan, & Boshart,
1997). Notably, Davis and Pratt (1995) found that back-
wards, but not forwards, digit span was significantly related
to performance on false-belief tasks, even when age and
language ability were controlled. Subjects with TBI often
have impairments in working memory (Lezak, 1995), so the
possibility that this underlies observed impairments in ToM
tasks is important to address. Indeed, it has been proposed
that a weakness in working memory may underlie a broad
range of frontal lobe deficits (Kimberg & Farah, 1993), and
Stone et al. (1998) found that patients with dorsolateral
frontal lesions only had difficulty on those theory of mind
tasks that placed demands on working memory.
Therefore, the current study took alternative hypotheses
for impaired performance on ToM tasks into account by
incorporating both implicit and explicit questions, leaving
the test material in front of the subject while these questions
were asked, and examining how performance on ToM tasks
relates to working memory capacity.
1.4. Measuring theory of mind
A wide range of different approaches have been used to
assess ToM. These approaches have varied in terms of fac-
tors such as the subjects they were designed for (ranging
from normal adults to children with autism) and their capac-
ity to distinguish between different developmental levels of
ToM (e.g. first-order, second-order and applied uses of ToM
inferences).
1.4.1. False-belief stories
ToM ability is usually measured using false-belief tasks
(Fine, Lumsden, & Blair, 2001; Keenan, 1998), which mea-
sure the ability to understand that other people’s beliefs may
not match the true state of affairs (Stone et al., 1998). This
understanding normally develops at around 4 years of age
(Hughes & Cutting, 1999). A typical false-belief story de-
scribes an object being moved from one location to another
without a key character’s knowledge. The subject is then
asked to predict where that character will search for the ob-
ject (Tager-Flusberg et al., 1997). Other studies have used
a story where the main character has acted on a false-belief
and the subject is asked to explain his or her actions (e.g.
Channon & Crawford, 2000; Mazza et al., 2001). The latter
may be more appropriate for adult subjects, as it has been
suggested that the simplest false-belief tasks designed for
children may confuse adults because they expect more dif-
ficult questions (Siegal et al., 1996). Hughes et al. (2000)
found that most standard false-belief tasks have good reli-
ability, and Wellman et al., 2001 found that, despite varia-
tions, false-belief tasks are “essentially equivalent” (p. 679).
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
1.4.2. Second-order stories
In addition to the first-order false-belief stories described
above, a number of studies have included second-order ToM
stories (e.g. Lough et al., 2001; Rowe et al., 2001; Santoro
& Spiers, 1994; Stone et al., 1998). Second-order stories re-
quire the subject to demonstrate understanding of what one
person thinks another person believes (“Mary thinks that
John thinks. . . ”) (Bishop, 1993; Mazza et al., 2001). This
understanding normally develops at around 6 or 7 years of
age, and is claimed to underlie the ability to distinguish a
lie from a joke (Leekam & Prior, 1994; Sullivan, Winner, &
Hopfield, 1995). It has been suggested that performance on
more developmentally advanced ToM tasks provides an in-
dex of the severity of the deficit (with milder deficits picked
up by more challenging tasks) (Stone et al., 1998). Studies
haye found that some high functioning people with autism
can pass first-order tasks but will fail second-order ones
(Happe, 1993) and others have found that RHD patients’
ToM impairment is restricted to second-order tasks (Happe
et al., 1999; Winner et al., 1998). Hughes et al. (2000) re-
ported that second-order false-belief tasks have good relia-
bility.
1.4.3. Mental-state cartoons
While the majority of ToM research has focussed on story
tasks of the kinds outlined above, a small number of stud-
ies have also incorporated tasks with a non-verbal compo-
nent (e.g. Bihrle, Brownell, & Powelson, 1986; Gallagher
et al., 2000; Hughes & Cutting, 1999; Sarfati et al., 2000).
Frequently these studies use mental-state cartoons, where
to understand the cartoon you need an understanding of
a character’s false-belief (Fine et al., 2001; Happe et al.,
1999). Happe et al. (1999, 2001) reported that both RHD
patients and a patient treated with stereotactic anterior cap-
sulotomy showed consistent ToM deficits across story and
cartoon tasks, and Gallagher et al. (2000) found selective
activation of the same brain region when they compared
normal subjects’ performance on ToM stories and cartoons.
However, to date there does not appear to have been an ex-
amination of the performance of TBI subjects on non-verbal
ToM tasks.
1.4.4. Non-mental inference tasks
As discussed above, the current study was interested in
examining whether subjects with TBI show impairment on
ToM that is dissociable from a more general difficulty with
making inferences. A number of previous studies have in-
corporated stories and cartoons that require inferences to be
drawn about things other than mental states, such as phys-
ical causation, physical anomaly or breaking social norms
(Happe et al., 1999, 2001). Such tasks have been used in
a number of imaging studies (e.g. Fletcher et al., 1995;
Gallagher et al., 2000; Happe et al., 1996) and some le-
sion studies (Happe et al., 2001; Stone et al., 1998). Other
researchers have incorporated control questions into their
mental state tasks assessing understanding and recall of the
103
story (e.g. Bowler, 1992; Hughes & Cutting, 1999; Lough
et al., 2001) but these are not adequate as they do not require
inferences to be made (Stone et al., 1998).
Therefore, the current study used stories and cartoons
to examine ToM ability in adults with and without TBI in
verbal and non-verbal domains. It included first-order sto-
ries in which the main character has acted on a false-belief,
second-order stories in which the main character has acted
on a belief about a belief, and mental state cartoons that re-
quired an understanding of false-belief to be understood. Per-
formance on these ToM tasks was also compared to that on
NMI tasks (that required inferences to be drawn about things
other than mental states, such as physical causation, physi-
cal anomaly or breaking social norms) to examine whether
any impairment was specific to social reasoning. All tasks
were pilot-tested on normal adults to screen for errors, check
comprehensibility and to ensure the scoring criteria were
unambiguous.
1.5. Summary of aims
The present study aimed to address the following ques-
tions:
(1) Do people with a traumatic brain injury (TBI) demon-
strate an impairment on tasks requiring them to make
inferences about others’ mental states (theory of mind
tasks) that is independent of their performance on tasks
requiring them to make general (non-mental) infer-
ences?
(2) At what level of inference does this impairment mani-
fest? (first-order or second-order)
(3) Does this impairment apply to non-verbal tasks (car-
toons) as well as verbal ones (stories)?
(4) Is this impairment independent of working memory
deficits that may impact on the performance of such
tasks?
(5) Is this impairment independent of the nature of questions
(implicit or explicit) that are used to assess this ability?
2. Method
2.1. Participants
Fifteen outpatients (11 male, 4 female) with a mean age of
40.5 years (S.D. = 10.6) were recruited from three neurolog-
ical rehabilitation centres. All participants had suffered a se-
vere head injury resulting in posttraumatic amnesia (PTA) of
an average of 94.5 days (S.D. = 81.2). A chi-square analysis
indicated that the injury had significantly effected the distri-
bution among occupational categories of the patient group
(Cramer’s V = 0.838, P < 0.01), with the majority working
in skilled trade or sales/clerical positions before their injury,
and being unemployed or in volunteer positions afterwards.
Almost all patients had CT or MRI scans which showed
104 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114

Table 1
Clinical features of the TBI patients
Subject number Cause of injury Injury site (CT or MRI scan) Time in PTA (days) Time post-injury (years)

1 MVA Right frontal 186 9.5

2 Assault Left temporal 120 9.5
3 MVA Bilateral fronto-temporal 16 5
4 Assault Bilateral fronto-temporal and parietal 196 14
5 MVA Left fronto-temporal and parietal 38 4
6 Fall Left temporal, parietal and occipital 10 1
7 Fall Bilateral frontal 11 3.5
8 MVA Right frontal and occipital 27 4
9 MVA – 140 14.5
10 MVA Right fronto-temporal 90 16
11 Assault Left frontal – 0.5
12 MVA Right frontal 140 3
13 Assault Right parietal 240 8.5
14 MVA Left frontal 14 2.5
15 MVA Right temporal – 8
Note: MVA = motor vehicle accident.

damage to a wide variety of brain regions. The majority had
frontal and/or temporal involvement. Clinical features taken
from the patients’ medical records are shown in Table 1.
At the time of testing, all patients were out of PTA.
Their stage of injury was at least 6 months post, but
in most cases was much longer, with the average time
post-injury being 7.4 years (S.D. = 4.9). As a result of
the long average duration post-injury, the available neu-
ropsychological data was sketchy for some patients, but
clinical records revealed that they did not have severe
amnesia, aphasia or agnosia, and that basic cognitive pro-
cesses were grossly intact. Their performances on standard
neuropsychological tests (where available) are shown in
Table 2.
Fifteen control subjects (10 male, 5 female) with a mean
age of 35.9 years (S.D. = 12.3) were recruited from the rel-
atives of brain-injured participants, the general community
and from advertisements placed at local social clubs and
job centres. They had no history of neurological problems
or severe head injury, and were chosen to be similar to the
brain-injured subjects in demographic characteristics. The
results of Student’s t-tests indicated that there were no sig-
nificant differences between control and traumatic brain in-
jury (TBI) groups for age (P = 0.372) or education level (P
= 0.711). Chi-square analyses indicated that there were also
no significant differences for gender (P = 0.5) or pre-morbid
occupation (P = 0.508). The demographic characteristics of
all participants are shown in Table 3.
2.2. Materials
2.2.1. Story tasks
Three types of stories were used, namely first-order the-
ory of mind (ToM) stories, second-order ToM stories and
general (non-mental) inference (NMI) stories. A total of 12
stories were given to all subjects—four of each type. Most
of the stories were drawn from previously published studies
(Bihrle et al., 1986; Fletcher et al., 1995; Gallagher et al.,
2000; Happe et al., 1999; Hughes et al., 2000; Mazza et al.,
2001; Rowe et al., 2001; Sullivan et al., 1995). Some were
adapted to ensure they were of roughly equivalent length. All
the NMI stories were of approximately equivalent length and
complexity to the ToM stories. Two were used by Gallagher
et al. (2000) and two were designed specifically for the cur-
rent study. Each story was 1–2 paragraphs long and de-
scribed characters involved in a range of activities, such as
household chores, organising a wedding, committing a rob-
bery or buying an ice-cream. The first-order ToM stories
related to a character’s lack of knowledge about a physi-
cal situation (e.g. a stolen cigarette, a practical joke). The
second-order ToM stories related to a character’s knowledge
(or lack of knowledge) about another character’s beliefs or
intentions (e.g. that a character had received a phone mes-
sage, a double bluff scenario). The non-mental inference
stories involved reasoning about physical cause and effect
(e.g. ice melting, driving around in circles).
Each story was individually presented to subjects in large
(16 point) font on A4 paper in a protective sheet. At the
same time, the story was read aloud. The story remained in
front of the subjects while four questions were asked. In the
case of the ToM stories the questions were:
(1) A general question implicitly requiring an inference to
be made about a character’s mental state. Subjects were
asked to explain the character’s words or actions, al-
though the reason behind these actions had not been di-
rectly stated in the story.
(2) A follow-up question explicitly asking about mental
states.
(3) Two further follow-up questions. These also explicitly
referred to mental states, but were presented in forced
choice format (yes or no). For each story, the correct
answer to one of the questions was yes and the other
no, so that the possibility of response bias could be
excluded.
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114 105

Table 2
Performance on standard neuropsychological tests
Test Subject scores

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

WAIS-III
Subtest ASS
Information 9 12 6 – 4 8 11 9 8 12 – 9 15 9
Similarities 6 9 7 – 6 1 11 4 11 10 – 4 12 7 8
Digit span 11 9 7 7 8 5 9 10 6 9 11 6 9 8 9
LNS 10 8 9 – – 6 12 5 – 8 – – 14 5 6
DS-C 7 7 4 – 4 5 13 – – 6 – 4 5 5 4
SS 6 7 5 – – 6 12 3 2 9 – 1 6 – 6
WTAR 116 101 101 – 119 – 104 110 87 92 – 102 121 100 113
WMS-III
Subtest ASS
LM1 5 7 8 – – 8 10 8 7 10 – 1 9 7 12
LM2 9 9 8 – – 9 12 8 9 9 – 2 10 9 12
Faces 1 8 10 6 – – 9 10 7 7 7 – 4 8 6 12
Faces 2 9 7 9 – – 7 10 9 5 8 – 3 10 10 12
VPA1 10 11 6 – – 10 14 5 9 5 – 2 12 6 9
VPA2 9 11 8 – – 11 13 4 8 5 – 3 11 5 10
REY CFT
Copy 21 26 23 – 28 31 30 12 – 26 – 22 34 – 23
Recall 5 14 4 – 7 22 18 2 2 19 – – 19 – 17
COWAT 29 35 21 27 11 24 56 39 25 40 35 16 37 28 29
WCST
Categories 2 – 0 – – 4 3 0 0 6 – 5 6 – 3
PE 46 – 10 – – – 26 72 11 – 20 9 – 5
CANTAB
Circ 0 0 0 – 0 – 0 0 0 2 – 2 0 – 2
Dim. total 68 68 94 – 96 – – – 127 72 – 96 68 – 87
Errors 30 13 25 – 24 – 12 32 43 13 – 30 11 – 21
Note: WAIS-III, Wechsler adult intelligence scale (3rd ed.); ASS, age scaled scores (X = 10; S.D. = 3); LNS, letter number sequencing; DS-C, digit
symbol coding; SS, symbol search; WTAR, Wechsler test of adult reading, estimated WAIS-III full intelligence quotient; WMS-III, Wechsler memory
scale (3rd ed.); LM, logical memory; VPA, verbal paired associates; CFT, complex figure test; COWAT, controlled oral word association test; WCST,
Wisconsin card sorting test (scoring criteria taken from manual); PE, perseverative errors; CANTAB, Cambridge neuropsychological test automated
battery; Circ, big/little circles; Dim., intra/extra dimensional shift.

An example of a first-order ToM story (adapted from
Hughes et al., 2000) is shown below:
Larry really likes drinking Coke, but he hates milk
and refuses to touch it. Larry has a brother, Jack, who
likes playing tricks on people. One day, Larry was
drinking some Coke when the phone rang. He put down
the can and went into the other room to answer the
phone. Meanwhile, Jack came in. He decided to play a
trick on Larry. He poured all the Coke out of the can,
and put milk in it instead. When Larry came back from
the phone he was thirsty. He went over to the can and
drank from it.
Implicit question: Why did Larry drink from the can?
Explicit question: What was Larry thinking about the can?
Forced choice questions:
Did he think the can had Coke in it?
Did he know Jack had put milk in the can?
The questions were always asked in order from least to
most explicit, to prevent cuing. For NMI stories, a similar
set of four questions was asked, but in this case the mental
states of the characters were irrelevant and the questions
concerned physical cause and effect. Examples of a NMI
story and a second-order ToM story are in Appendices A
and B with some sample responses.
2.2.2. Cartoon tasks
Two types of cartoon tasks were used, namely ToM and
NMI cartoons. A total of eight cartoons were given to
all subjects—four of each type. All cartoons were drawn
from previously published studies (Gallagher et al., 2000;
Happe et al., 1999). The ToM cartoons were based around
a character’s lack of knowledge about a physical situation1
(e.g. the presence of a monster, a practical joke). The NMI
1 None of the ToM cartoons required an understanding of one character’s
knowledge of another character’s beliefs or intentions, that is, they were
all first-order rather than second-order ToM tasks (Bishop, 1993; Mazza
et al., 2001).
106 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114

Table 3 ers (Happe, 1994; Happe et al., 1999). For both stories and
Demographics of the TBI patients and the control group cartoons, answers to implicit questions were scored out of
Continuous variable TBI patients Control subjects two. In the case of ToM tasks, subjects scored one point for
(mean (S.D.)) (mean (S.D.)) an adequate response, and a second point for the use of a
N per group 15 15 mental state term (e.g. thinks, wants, wishes, believes, etc.).
Age (years) 40.5 (10.6) 35.9 (12.3) For NMI tasks, subjects scored two points for an adequate
Education (years) 13.2 (2.5) 14.0 (2.4)
answer. All follow-up questions were allocated one point for
Categorical variable TBI patients Control subjects each correct answer.
percentage percentage
Gender 2.2.4. Working memory task
Male 73.3 66.7 All subjects were administered the Digit Span sub-
Female 26.7 33.3
test from the Wechsler adult intelligence scale (3rd ed.)
Pre-morbid occupation (WAIS-III) (Wechsler, 1997) which measures memory span
Professional/manager 28.6 26.7
for digits repeated forwards and backwards. Based on Davis
Sales/clerical 28.6 13.3
Skilled trade 35.7 40.0 and Pratt (1995), the current study used the longest span
Unskilled trade 7.1 13.3 of digits correctly repeated backwards as an absolute (un-
Unemployed 0.0 6.7 scaled) measure of subject’s ability to mentally manipulate
Post-injury occupation∗ information.
Professional/manager 6.7 N/A
Sales/clerical 13.3 2.3. Design and procedure
Skilled trade 0.0
Unskilled trade 0.0
Unemployed 46.7
The University of NSW ethics committee, as well as the
Volunteer 26.7 ethics committee of each participating rehabilitation centre
Student 6.7 approved the study. It was performed in accordance with
∗ Significant difference at P < 0.05.
the ethical standards laid down in the 1964 Declaration of
Helsinki. All subjects gave their informed consent prior to
cartoons were based around physical cause and effect (e.g. their inclusion in the study.
a shrinking potion) or a reference to a cultural concept (e.g. Subjects were each tested in a single session of 1–1.5 h.
three blind mice). Cartoons and stories were presented in randomised order.
Each cartoon was individually presented to subjects on The entire story or cartoon caption was repeated once if
A4 paper in a protective sheet. Subjects were allowed 10 s subjects requested it. No other assistance was given, and al-
to examine the cartoon. One ToM and one NMI cartoon though general encouragement was provided throughout the
included a brief caption. These were read to subjects at the session, no feedback was given about the correctness of an-
beginning of the ten-second period. The cartoons remained swers. All subjects with TBI and most controls were tested
in front of the subjects while four questions were asked. In individually, and their responses to questions were recorded
the case of the ToM cartoons the questions were: verbatim for subsequent scoring by the first author. Some
control subjects were tested in small groups of two or three
(1) A general question implicitly requiring an inference to
people. In this case, the procedure was identical, except that
be made about a character’s mental state. Based on
subjects wrote their own responses on a standard form once
Happe, Malhi, and Checkley (2001), subjects were asked
the story and questions had been read to them. After all sto-
to explain why each cartoon was funny.
ries and cartoons were presented, subjects were administered
(2) A follow-up question explicitly asking about mental
the working memory task. In the case of group administra-
states.
tions to control subjects, this task was given individually in
(3) Two further follow-up questions. These were presented
a separate room.
in the same forced choice format as the stories.
Again, the questions were always asked in order from
least to most explicit, to prevent cuing. For NMI cartoons, a 3. Results
similar set of four questions were asked, but in this case the
mental states of the characters were irrelevant and the infer- 3.1. Story tasks
ences concerned things such as physical cause and effect.
Examples of a ToM and an NMI cartoon are in Appendices A For each subject, total scores for first-order ToM,
and B with some sample responses. second-order ToM and NMI stories were calculated by sum-
mating scores across all questions. Fig. 1 presents the mean
2.2.3. Scoring total score for each type of story for subjects with and with-
The scoring system for implicit questions was adapted out TBI. A 3 (type of story) × 2 (TBI) analysis of variance
from Channon and Crawford (2000) and Happe and cowork- (ANOVA) was performed to examine the patterns of scores
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114 107

the main effect of cartoon, F(1,28) = 0.452, P = 0.5). There

was also no evidence that the pattern of differences be-
tween TBI subjects and controls varied across different car-
toon types (for the interaction effect, F(1,28) = 2.04, P =
0.16).

3.3. Comparison of stories and cartoons

To examine the effect of type of material (story or car-

toon), subjects’ scores on first-order ToM and NMI sto-
ries were compared to those on ToM and NMI cartoons
(second-order ToM stories were not included, as there
Fig. 1. Mean total score in story tasks for subjects with and without TBI. were no second-order inferences required in the ToM car-
toons). A 2 (type of material) × 2 (type of inference) × 2
(TBI) ANOVA revealed that, consistent with findings when
for the two groups. Subjects with TBI received significantly
stories and cartoons were considered separately, subjects
lower scores than control subjects (a main effect of TBI),
with TBI received significantly lower scores than control
F(1,28) = 8.312, P < 0.01, and story types differed appre-
subjects (a main effect of TBI), F(1,28) = 14.568, P <
ciably in the scores that subjects obtained on them (a main
0.01. This difference was greater for cartoons than for
effect of story), F(2,56) = 7.027, P < 0.01. However, there
stories (a significant interaction), F(1,28) = 10.942, P <
was no evidence that the pattern of differences between TBI
0.01, but there was no evidence that the type of inference
subjects and controls varied across different story types (for
(ToM or NMI) influenced it (for the interaction, F(1,28)
the interaction effect, F(2,56) = 0.283, P = 0.75).
= 5.208, P = 0.385). Further, scores on cartoons were
Follow-up tests of contrasts revealed that scores on
lower than scores on stories (a main effect of type of mate-
second-order ToM stories were significantly lower than
rial), F(1,28) = 118.129, P < 0.001. No other effects were
both first-order stories, F(1,28) = 12.963, P < 0.01, and
significant.
NMI stories, F(1,28) = 4.920, P < 0.05. There was no ev-
idence of a significant difference between first-order ToM
and NMI stories (F(1,28) = 1.200, P = 0.772). 3.4. Examining the impact of working memory

3.2. Cartoon tasks 3.4.1. Story tasks

In order to determine whether working memory medi-
ated the significant findings for ToM and NMI stories, a
Fig. 2 presents the mean total score (summated across
3 (type of story) × 2 (TBI) analysis of covariance (AN-
all question types) for each type of cartoon for subjects
COVA) was performed with subjects’ longest digit span
with and without TBI. A 2 (type of cartoon) × 2 (TBI)
backwards as a covariate. The main effect of TBI was re-
ANOVA revealed that, as with the stories, subjects with TBI
duced, but remained significant, F(1,27) = 6.53, P = 0.017
received significantly lower scores than control subjects (a
(previously 0.002). In other words, when working mem-
main effect of TBI), F(1,28) = 17.833, P < 0.001. How-
ory performance was controlled, subjects with TBI still per-
ever, there was no evidence that cartoon types differed ap-
formed significantly worse than control subjects on story
preciably in the scores that subjects obtained on them (for
tasks.

3.4.2. Cartoon tasks

In order to determine whether working memory medi-
ated the significant findings for ToM and NMI cartoons, a
2 (type of cartoon) × 2 (TBI) ANCOVA was performed,
using the same covariate as for stories. The same pattern
seen with the stories emerged, i.e. the main effect of TBI
was reduced, but remained significant, F(1,27) = 16.628
(previously 168.033), P < 0.001. Interestingly, in contrast
to the story condition, when longest digit span backwards
was a covariate a significant main effect for type of car-
toon emerged, F(1,27) = 5.534, P < 0.05. This indicated
that, when the subjects’ ability to mentally manipulate in-
Fig. 2. Mean total score in cartoon tasks for subjects with and without formation was controlled, a difference between scores on
TBI. ToM and NMI cartoons was revealed, such that scores
108 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114

Table 4 Table 5
Mean total score for each type of question for NMI, first order ToM and Mean total score for each type of question for NMI and ToM cartoons
second order ToM stories for subjects with and without TBI for subjects with and without TBI
Group Story Type of Mean total Group Cartoon Type of Mean total score
question score (to 1 question (to 1 decimal place)
decimal place) TBI patients NMI Implicit 2.4
TBI patients NMI Implicit 6.4 Explicit 5.1
Explicit 4.9 Forced choice 4.7
Forced choice 6.3
ToM Implicit 2.1
First order ToM Implicit 5.6 Explicit 4.0
Explicit 5.6 Forced choice 6.1
Forced choice 7.3
Control subjects NMI Implicit 5.1
Second order ToM Implicit 4.1 Explicit 6.1
Explicit 4.0 Forced choice 7.3
Forced choice 6.9
ToM Implicit 3.8
Control NMI Implicit 6.7 Explicit 5.7
subjects Forced choice 7.1
Explicit 6.1
Forced choice 7.3
Subjects’ scores on forced choice questions were re-coded
First order ToM Implicit 7.1
Explicit 6.5 using Reid’s (1977) formula2 to adjust for guessing. The
Forced choice 7.7 analyses outlined above were then repeated, with the re-
Second order ToM Implicit 5.8
sults being consistent with those obtained for the unadjusted
Explicit 5.6 scores.
Forced choice 7.3
3.5.2. Cartoon tasks
For each subject, total scores for their responses to im-
on ToM cartoons were significantly lower than on NMI plicit, explicit, and forced choice questions were calculated
cartoons. for each type of cartoon. Table 5 presents the mean total
score for each type of question for NMI and ToM cartoons
3.5. Examining the impact of language demands for TBI and control subjects. A 2 (type of cartoon) × 3
(type of question) × 2 (TBI) ANOVA revealed that, as for
3.5.1. Story tasks stories, the subjects’ scores differed significantly depending
For each subject, total scores for their responses to im- on what type of question was used (a main effect of ques-
plicit, explicit, and forced choice questions were calculated tion type), F(2,56) = 78.586, P < 0.001, and that the differ-
for each type of story. Table 4 presents the mean total score ence between scores on types of cartoons was influenced by
for each type of question for each type of story for TBI and the type of question being asked (a significant interaction),
control subjects. A 3 (type of story) × 3 (type of question) × F(2,56) = 5.137, P < 0.01. Once again there was no evi-
2 (TBI) ANOVA revealed that subjects’ scores differed sig- dence that the pattern of differences between TBI subjects
nificantly depending on what type of question was used (a and controls varied across different types of question (for
main effect of question type), F(2,56) = 39.350, P < 0.001, the interaction, F(2,56) = 1.381, P = 0.26). No other main
and that the difference between scores on types of stories effects or interactions were significant, apart from the main
was influenced by the type of question being asked (a signif- effect of TBI, which has been discussed above.
icant interaction), F(4,112) = 39.350, P < 0.001. There was Follow-up tests of contrasts revealed that scores on forced
no evidence that the pattern of differences between TBI sub- choice questions were significantly higher than on explicit
jects and controls varied across different types of question questions, F(1,28) = 19.47, P < 0.001, and scores on ex-
(for the interaction effect, F(2,56) = 1.702, P = 0.19). No plicit questions were significantly higher than on implicit
other main effects or interactions were significant, apart from questions, F(1,28) = 5.732, P < 0.05. Furthermore, for im-
the main effect of TBI, which has been discussed above. plicit and explicit questions, scores on ToM cartoons were
Follow-up tests of contrasts revealed that scores on forced lower than NMI cartoons, but for forced choice questions,
choice questions were significantly higher than on implicit scores on NMI cartoons were lower than ToM cartoons.
questions, F(1,28) = 37.597, P < 0.001, and scores on im- As with the stories, subjects’ scores on forced choice
plicit questions were significantly higher than on explicit questions were re-coded using Reid’s (1977) formula to ad-
questions, F(1,28) = 5.732, P < 0.05. Furthermore, the dif- 2 S = 1/2(n − 1)[n(R + B/n) + (n − 1)Q − Q2 /(R + B/n)] where S is
ferences between second-order ToM and other types of sto- the adjusted score, n the number of choices per question, R the number
ries were larger for implicit questions than for forced choice of correct answers, B the number of omitted questions and Q the total
questions. number of questions.
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
just for guessing. The analyses outlined above were then re-
peated, with the results generally being consistent with those
obtained for the unadjusted scores. However, one additional
effect was found. Specifically, when scores on forced choice
questions were adjusted for guessing, the pattern of differ-
ences between TBI subjects and controls was found to vary
across different types of question (a significant interaction),
F(1,28) = 6.981, P < 0.05. Follow-up tests of contrasts re-
vealed that the difference between TBI subjects and controls
was greater for forced choice questions than explicit ques-
tions.
3.6. Further examination of the contribution of inferential
ability to ToM
To further explore the relative contribution of inferential
and working memory ability in explaining the variance in
performance on theory of mind tasks, a number of multiple
regression analyses (MRAs) were conducted.
3.6.1. First-order ToM stories
A stepwise MRA was conducted taking presence of TBI,
scores on NMI stories, and performance on the working
memory task (longest digit span backwards) as predictor
variables for the criterion variable of scores on first-order
ToM stories. TBI was the only significant predictor, adjusted
R2 = 0.175, F(1,29) = 7.136, P < 0.05 for the model, β
= 0.366. Thus, working memory ability and ability to make
non-mental inferences about stories did not explain a sig-
nificantly greater amount of the variance in first-order ToM
story performance above that accounted for by presence of
TBI.
3.6.2. Second-order ToM stories
A stepwise MRA was conducted taking presence of TBI,
scores on NMI and first-order ToM stories, and perfor-
mance on the working memory task as predictor variables
for the criterion variable of scores on second-order ToM
stories. Scores on the working memory task and on NMI
stories were significant predictors, adjusted R2 = 0.326,
F(2,29) = 8.011, P < 0.01 for the model (for longest digit
span backwards, β = 0.478, P < 0.01; for NMI stories,
β = 0.364, P < 0.05). Thus, presence of TBI and ability
to make first-order ToM inferences did not explain a sig-
nificantly greater amount of the variance in second-order
ToM story performance above that accounted for by ability
to mentally manipulate information and ability to make
non-mental inferences.
3.6.3. ToM cartoons
A stepwise MRA was conducted taking presence of TBI,
scores on NMI cartoons, and performance on the working
memory task as predictor variables for the criterion vari-
able of scores on ToM cartoons. Scores on both the working
memory task and on NMI cartoons were significant predic-
tors, adjusted R2 = 0.351, F(2,29) = 8.842, P < 0.01 for the
109
model (for NMI cartoons, β = 0.548, P < 0.01; for longest
digit span backwards, β = 0.341, P < 0.05). Thus, presence
of TBI did not explain a significantly greater amount of the
variance in ToM cartoon performance above that accounted
for by ability to mentally manipulate information and ability
to make non-mental inferences.
3.7. Examination of the contribution of chronicity of lesion
to performances after TBI
To explore whether the length of time since injury im-
pacted on TBI subjects’ performances on theory of mind
tasks, two further multiple regression analyses (MRAs) were
conducted.
3.7.1. Story tasks
An MRA was conducted using the Enter method, taking
scores on first-order ToM, second-order ToM and NMI sto-
ries as predictor variables for the criterion variable of time
elapsed after injury. The resulting model was not significant
(F(3,11) = 1.22, P = 0.348). Adjusted R2 = 0.045. In other
words, there was no evidence that chronicity of lesion im-
pacted on performances on the story tasks. β and P values
for each predictor variable are shown below:
Predictor variable β P
Total score for first-order ToM stories 0.039 0.893
Total score for second-order −0.340 0.275
ToM stories
Total score for NMI stories 0.545 0.110
3.7.2. Cartoon tasks
An MRA was conducted using the Enter method, taking
scores on ToM and NMI cartoons as predictor variables for
the criterion variable of time elapsed after injury. The result-
ing model was not significant (F(2,12) = 0.556, P = 0.588).
Adjusted R2 = −0.068. In other words, there was no evi-
dence that chronicity of lesion impacted on performances on
the cartoon tasks. β and P values for each predictor variable
are shown below:
Predictor variable β P
Total score for ToM cartoons 0.204 0.511
Total score NMI cartoons −1.013 0.311
4. Discussion
4.1. Theory of mind in traumatic brain injury
The present study aimed to determine whether people
with severe TBI demonstrate impairment on tasks requir-
ing them to make inferences about other’s mental states
(ToM tasks) compared to tasks requiring them to make gen-
110 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
eral (non-mental) inferences (NMIs). The performance of
subjects with and without TBI was compared for first and
second-order verbal ToM tasks, non-verbal ToM tasks and
for verbal and non-verbal NMI tasks. Initial analyses re-
vealed that subjects with TBI performed more poorly than
control subjects on all tasks, and that the nature of the in-
ference made in each task (mental state or non-mental in-
ference) did not effect the size of this discrepancy. This
would seem to suggest that subjects with TBI have a gen-
eral impairment in the ability to make inferences, rather
than a specific deficit in ToM ability. The observed deficits
in inference-making are consistent with reports of impaired
reasoning and problem solving in this group (Lezak, 1995).
However, follow-up multiple regression analyses (MRAs)
suggest that the explanation of a general inference-making
impairment in TBI subjects is not adequate to explain all
the results. Specifically, while subjects’ performance on
second-order ToM stories and ToM cartoons was signifi-
cantly predicted by inference-making ability (and working
memory performance), these abilities were not significant
predictors of subjects’ performance on first-order ToM sto-
ries. This raises the possibility that people with TBI may
also have a specific ToM impairment underlying their poor
performance on verbal first-order tasks. This finding is con-
sistent with a number of previous studies that have claimed
to have identified a ToM impairment in subjects with TBI.
Most of these studies (Channon & Crawford, 2000; Dennis
et al., 2001; Dimitrov et al., 1996; Santoro & Spiers, 1994)
have not included an index of general inferential ability in
their design. Thus, the current study increases confidence in
their claims and illustrates the importance of including such
an index in future research. Evenso, despite the apparent
independence of first-order ToM and general inferencing,
both types of tasks were performed poorly. Therefore, it
remains unclear as to whether the first-order ToM perfor-
mance was, indeed, indicative of a specific weakness or
continued to reflect broader deficits that were simply not
tested in this study.
4.2. Impact of task demands on ToM performance
4.2.1. Working memory demands
As noted above, working memory ability was found to be
a significant predictor of both non-verbal and second-order
verbal ToM performance in all subjects. Thus, it is clear that
many ToM tasks do involve working memory. This is gener-
ally consistent with Davis and Pratt (1995), who found that
backwards digit span was significantly related to children’s
performance on false-belief tasks.
However, verbal first-order ToM performance was not sig-
nificantly predicted by working memory ability in the current
study. Furthermore, the differences between control and TBI
subjects on both ToM and NMI tasks were found to remain
after working memory performance was controlled. Thus,
working memory ability does not completely explain the im-
pairment seen by the TBI group. This finding differs from
that of Stone et al. (1998), who found that subjects with dor-
solateral frontal lesions had difficulty with only those ToM
tasks that placed demands on working memory ability. How-
ever, their finding only applied to patients with dorsolateral
damage—it did not hold for the orbito-frontal group. Thus,
it is unsurprising that a similar finding was not obtained for
the heterogenous TBI group in the current study.
Further information about the role of working memory in
non-verbal tasks was provided by the finding that when back-
wards digit span was held constant, a significant difference
between types of cartoon emerged such that ToM cartoons
scored lower than NMI cartoons. This suggests that the NMI
cartoons were more taxing on working memory than ToM
cartoons, and that some other factor besides working mem-
ory caused ToM cartoons to be performed more poorly. This
factor could be the same general ToM ability thought to un-
derlie the verbal first-order ToM task although, once again,
the possibility that some, as yet untested cognitive domain
is responsible requires examination. For the cartoon tasks,
additional abilities that could impact on TBI performance
include humour comprehension and spotting visual details,
and these could be examined in future research.
4.2.2. Implicit language demands
The language demands of the questions were significantly
related to performance on both ToM and NMI tasks for all
subjects. In general, subjects performed better when ques-
tions were more explicit.3 Furthermore, when implicit ques-
tions were asked, all subjects performed more poorly on
non-verbal ToM and second-order verbal ToM tasks com-
pared to NMI tasks, but this pattern was diminished or re-
versed when forced choice questions were asked. Thus, it
is clear that performance on ToM tasks is influenced by the
language demands of the tasks. This is consistent with re-
search emphasising the importance of language for ToM de-
velopment in children (e.g. Garfield et al., 2001).
Despite the relationship between language and ToM out-
lined above, there was little evidence that the language de-
mands of the questions influenced the size of the difference
between the TBI and control groups. The only exception
to this was the finding that, once scores on forced choice
questions were adjusted for guessing, the difference between
TBI subjects and controls on cartoon tasks was greater for
forced choice questions than for free-response explicit ques-
tions. This may be due to that fact that TBI subjects guessed
more frequently on the forced choice questions, thus the
adjustment formula reduced their scores more significantly
3 Surprisingly, in the case of story tasks, implicit questions were an-
swered better than free-response explicit questions while forced choice
explicit questions were the easiest for subjects. This finding did not apply
to the cartoon tasks. It was observed that many subjects’ answers to im-
plicit questions about the stories (“Why did he/she do that?”) included a
complete answer to the free-response explicit question (“What was he/she
thinking?”), and it may be that some subjects were confused about what
was required for the second answer, believing they needed to provide
additional information and thus failing to give a one-point response.
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
than those of the control group. Regardless of this, there is
certainly no evidence that language ability consistently ex-
plains the weaker performance of the TBI group. This find-
ing contrasts to those of Siegal and coworkers (Siegal et al.,
1996; Surian & Siegal, 2001) who found that subjects with
RHD were able to make accurate false-belief predictions if
the need to infer the question’s meaning was removed. This
discrepancy may be due to the different patient groups con-
sidered in the studies, or it could be because of the different
types of false-belief tasks employed (prediction versus ex-
planation). Further research would be needed to determine
which of these is the case.
4.3. Implications of results for the modularity of ToM
According to Foder (1983), a cognitive module is a do-
main specific inference-making system that is independent
of other modules and of the diffuse central systems that gov-
ern higher cognitive functions. The findings of the current
study have implications for the debate about the modular
nature of ToM. Hughes (1998) claimed that correlations be-
tween performance on false-belief tasks and other abilities
(such as language or working memory) suggest that ToM is
not a separate cognitive module (i.e. it is not independent of
other modules or systems). However, this claim misses the
distinction between a task and the conceptual ability it in-
dexes. If some of the systematic variance in false-belief task
performance cannot be explained in terms of other cognitive
skills, it may be due to an independent ToM module.
Given the findings outlined in the current study, the poor
performance of TBI subjects on verbal first-order ToM
tasks does not appear to be adequately accounted for by
inferential, working memory or language ability. It was not
related to chronicity of lesion, and it is unlikely to be due
to the general memory demands of the task, because these
were minimised. Further, it cannot be attributed to demo-
graphic differences such as gender, age or education level,
as there were no significant group differences. Thus, a clear
contendor for the poor ToM performance was not found,
other than poor ToM itself. Nevertheless, the case for mod-
ularity could have been more strongly made had a clear
distinction been observed between (impaired) first-order
ToM ability and (intact) general inference ability. This was
not the case. Nor did this study address all cognitive skills
that may potentially impact upon performance on ToM and
other inferencing tasks. In particular, there was no index
of attention or executive functioning—other than working
memory—despite the fact that both areas are commonly
disturbed in patients with severe TBI (Lezak, 1995).
Importantly, the role of executive function in ToM has
been examined in a variety of populations although with
mixed results. Some researchers have found that executive
functioning is associated with ToM development in children
(Hughes, 1998; Wellman et al., 2001). In such cases the in-
hibitory control aspect of executive functioning was specifi-
cally related to children’s ToM performance (Hughes, 1998).
111
This is more relevant to predictive false-belief tasks (“where
will he look for the doll?”) than tasks that require explana-
tion (“why did he look there?”). In studies of children with
autism, Ozonoff et al. (1991) found that executive function-
ing was related to ToM performance, while Tager-Flusberg
et al. (1997) failed to do so. Similarly, while researchers such
as Channon and Crawford (2000) found a relationship be-
tween executive functioning and ToM ability in adults with
damage to the frontal lobes, others have failed to do so (Bach
et al., 2000; Lough et al., 2001; Rowe et al., 2001; Varley
et al., 2001). Clearly, the relationship between ToM perfor-
mance and executive functioning remains controversial. In
order to further the argument that ToM is indeed modular,
the findings of the current study suggesting the presence of
a specific ToM deficit need to be replicated in further studies
that consider the impact of executive functioning and other
cognitive skills not tested in this study.
4.4. Conclusion and implications
In conclusion, this study found that patients with se-
vere TBI performed more poorly than controls on both
NMI and ToM tasks. Further analysis of the data sug-
gests that patients with TBI have a general weakness
in inference-making that impairs their performance on
non-verbal and second-order verbal ToM tasks. However,
they may also have a specific ToM deficit that impairs their
performance on verbal first-order ToM tasks. Their weaker
performance on first-order ToM was not correlated with
general inference ability, and was not completely accounted
for by working memory ability, or the language demands
of the tasks, although there is evidence that each of these
factors contributed to their performance on some of these
tasks. None-the-less, a clear distinction between a lack of
competence on first-order ToM tasks on the one hand and
normal general inferencing ability on the other was not
found. Thus it remains to be determined whether a specific
ToM deficit can be observed relative to other tasks with
comparable (non-mentalising) processing demands. The
findings of the current study have implications for the de-
bate about the modular nature of ToM, and, if replicated in
further studies that consider the impact of other cognitive
skills such as executive functioning, would add support for
the claim that ToM ability is a separate cognitive module.
Finally, the findings of the current study have implications
for the rehabilitation of social impairments after TBI. The
study suggests that a range of factors may impact on TBI
patients’ social performance, including inferential ability,
language comprehension, working memory capacity, ToM
ability and possibly an understanding of humour. This sug-
gests that, rather than simply applying an existing reha-
bilitation program to train ToM ability (such as those that
have been developed for people with Asperger’s syndrome
(Attwood, 1998) and schizophrenia (Sarfati et al., 2000), re-
habilitation of social deficits after TBI requires a compre-
hensive individual assessment to determine which factors are
112 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
impacting on that individual’s difficulties. Treatment should
be tailored to address and/or compensate for those factors
that are identified.
Appendix A. Examples of stories and responses
A.1. Second-order ToM task (adapted from Sullivan et al.,
1995)
John and Mary are in the park when they see an ice-cream
truck. Mary would like to buy an ice-cream but has no money
with her. The ice-cream man tells her to go home and get her
money because he will be staying in the park all day. Mary
goes home and John stays in the park. Then the ice-cream
man tells John he is moving to the church. He drives off and
John goes home. On his way to the church the ice-cream man
meets Mary and tells her where he is going. They arrange
to meet at the church so Mary can buy her ice-cream. Later
John goes to Mary’s house. Her sister says she has gone to
buy ice-cream. John goes to look for her in the park.
Implicit question: Why does John look for Mary in the
park?
Sample 2-point response: “Because he does not know
she met the ice-cream man who told her to go to the
church“.
Sample 1-point response: “Because the ice-cream man
moved after she left the park”.
Sample 0-point response: “He does not really want to find
her”.
Explicit question: What was John thinking when he
looked for her in the park?
Sample correct response: “That she did not know the
ice-cream man moved”.
Sample incorrect response: “He must have decided to play
at the park instead”.
Forced choice questions: Does he think Mary will be at
the park?
Correct response: Yes.
Does he know that Mary knows where the ice-cream
truck is?
Correct response: No.
A.2. NMI story (developed for this study)
Betty has been making arrangements for her wedding. She
is very happy about the sculpture she has organised for the
head table at the reception—a big, glittering swan carved
out of ice.
On the morning of the wedding the weather looks perfect.
But as the day continues it gets hotter and hotter, and people
in the church look sweaty and uncomfortable. Just before
the ceremony the reception centre calls Betty to warn her
that the air-conditioning unit has broken down, but they are
installing fans to cool off her guests when they arrive.
The ceremony goes smoothly, and everyone drives to the
reception in good spirits. When they arrive, the room looks
beautiful and everyone praises Betty’s taste. But when she
goes to sit down at the head table, the table-cloth is soaking
and all the napkins are soggy. There is a big puddle on tile
floor.
Implicit question: Why is there so much water on the head
table?
Sample 2-point response: “Because the heat melted the
ice sculpture of the swan”.
Sample 0-point response: “Must have been because ev-
eryone was sweating so much”.
Explicit question: What effect would the broken
air-conditioner have had?
Sample correct response: “Made the room hot so the swan
melted”.
Sample incorrect response: “It might have leaked on the
table”.
Forced choice questions: Did the air-conditioner leak on
the table?
Correct response: No.
Did the heat melt the swan?
Correct response: Yes.
Appendix B. Examples of cartoon and responses
B.1. ToM cartoon (adapted from Gallagher et al., 2000):
Implicit question: Why is this cartoon funny?
Sample 2-point response: “Because he does not know the
piano is about to fall on his head”.
Sample 1-point response: “He is looking at the stool, but
the piano is about to fall”.
Sample 0-point response: “It is not funny”.
 H. Bibby, S. McDonald / Neuropsychologia 43 (2005) 99–114
Explicit question: What is the man thinking?
Sample correct response: “Where did the stool come
from?”
Sample incorrect response: “He is wondering how the
stool got there before the piano”.
Forced choice questions: Is he thinking about the chair?
Correct Response: Yes.
Is he thinking about the piano?
Correct response: No.
B.2. NMI cartoon: (adapted from Gallagher et al., 2000):
Implicit question: Why is this cartoon funny?
Sample 2-point response: “Because it is the Leaning
Tower of Pisa and they are throwing away the straight
towers”.
Sample 0-point response: “The towers are phallic”.
Explicit question: What are models of?
Sample correct response: “Leaning Tower of Pisa”.
Sample incorrect response: “Some kind of joy-stick for a
computer”.
Forced choice questions: Are some models thrown away
because they are not “leaning”?
Correct response: Yes.
Are some models thrown away because they are not
straight?
Correct response: No.
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