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Teaching a Deictic Relational Repertoire to Children with Autism

Article in The Psychological Record · December 2014

DOI: 10.1007/s40732-014-0078-z

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Psychol Rec
DOI 10.1007/s40732-014-0078-z

ORIGINAL ARTICLE

Teaching a Deictic Relational Repertoire to Children with Autism

Marianne L. Jackson & Dena R. Mendoza &
Amanda N. Adams

# Association of Behavior Analysis International 2014

Abstract Perspective-taking skills are crucial for successful tasks, and researchers have suggested that deficits in ToM
social interactions and individuals with autism often have may be, at least in part, responsible for the social difficulties
great difficulty in this area. Recent research in the area of experienced by individuals with these diagnoses. For exam-
Relational Frame Theory has developed an analysis of deictic ple, Baron-Cohen et al. (1985) administered a ToM test
relations, thought to underlie perspective-taking. A few stud- known as the “Sally-Anne” task to children with autism,
ies have shown that performance on a deictic relations proto- children with Down syndrome, and typically developing chil-
col correlates with other measures of perspective taking, and dren. This task assessed understanding of false belief and
that deictic relations can be learned through operant condi- involved two dolls named Sally and Anne. Researchers pre-
tioning procedures. The current study examined the effects of sented a vignette to the children, in which Sally places a
increased deictic relational responding, on Theory of Mind marble in a basket and leaves the room. Anne enters the room,
scores, with children with autism. Five children with autism removes the marble from the basket, and places it in a box.
participated in this study, two of whom were designated as When Sally returns, the participants are asked to identify
control participants. The results suggest that the current form where Sally would look for the marble. Results showed that
of deictic relational training can be taught to children with children with autism had considerable difficulties with this
autism, but this may not be sufficient to change more gener- task, whereas children with Down syndrome and typically
alized perspective-taking skills, as measured by a Theory of developing children completed the task with relative ease.
Mind assessment. Subsequent research has shown that typically developing
children under 4 years of age generally had difficulty with
Keywords Perspective-taking . Autism . Deictic relations this task, but children over 4 years old performed significantly
better (Perner et al. 1987). In contrast, Baron-Cohen (1992)
showed that children with autism of various ages (12–
Perspective-taking was defined by Baron-Cohen (1995) as, 28 years), continued to have difficulty with this task, even
“the ability to think about other people’s thinking,” and it is once the false belief was revealed.
generally assumed to be a crucial aspect of many of our day- Howlin et al. (1999) developed a hierarchy of specific
to-day interactions with others (Baron-Cohen et al. 1985; levels of understanding that are believed to account for ToM
Flavell 2004). Much of the research in this area has invoked development. These levels ranged from simple visual
the concept of Theory of Mind (ToM), described as, “the perspective-taking to predicting actions on the basis of false
ability to impute mental states to oneself and to others” and belief. Each level represents increasing complexity and is
ToM skills are said to underlie our ability to interpret and dependent on adequate performance on all previous levels.
predict the behavior of others (Premack and Woodruff 1978). These five levels are also categorized as first-order false belief
Individuals with autism spectrum disorders (ASDs) have (levels 1 & 2), involving the simple attribution of a mental
generally demonstrated low levels of performance on ToM state to another person (Baron-Cohen 2004), and second-
order false belief (levels 3, 4, & 5), involving the more
M. L. Jackson (*) : D. R. Mendoza : A. N. Adams
complex understanding that a person can have mental states
Department of Psychology, California State University, Fresno, 2576
E. San Ramon Ave. M/S/ ST11, Fresno, CA 93740-8039, USA about another person’s mental states (Baron-Cohen et al.
e-mail: majackson@csufresno.edu 2004). Research has indicated that children diagnosed with
 Psychol Rec

autism have difficulty with first-order false belief tasks (Bar- and ToM performance. McHugh et al. developed a protocol to
on-Cohen et al. 1985; Leekham and Perner 1991; Perner et al. analyze perspective-taking in terms of three deictic frames and
1989; Reed and Peterson 1990; Swettenham 1996; used it to test participants of varying ages and abilities. The
Swettenham et al. 1996) and are often unable to engage in protocol consisted of 62 items (reduced from an original 256
the second-order false belief tasks (Howlin et al. 1999). relations) based on the type of deictic relations (I-you, here-
Developmental psychologists have generally shown that there, and now-then) across three levels of complexity (simple,
performance on these perspective-taking skills increase reversed, double reversed). The protocol was subsequently
around the age of 5 years and have assumed this to be due referred to as the Barnes-Holmes protocol. Data were collect-
primarily to biological processes of maturation. From this ed across five different age groups and showed high levels of
perspective it seems logical there would be relatively few accuracy across all participants over 5 years of age and rela-
studies on the amelioration of deficits in these skills; however, tively weaker performances for children below this age. Fur-
there have been a growing number of studies examining the thermore, data suggest a hierarchy of difficulty across relation
influence of experience in learning these skills. type; now-then relations were more difficult than here-there
The field of behavior analysis has paid relatively little relations, and both were more difficult than I-you relations. In
attention to the area of perspective-taking and ToM. This has addition, more errors were produced with reversed relations
largely been attributed to an objection to the use of the concept than simple relations confirming the increasing difficulty of
of ToM. Schlinger (2009) cites the lack of information on relational complexity. The authors point out the significant
what the organism actually does and the behavioral history overlap in performance with the traditional developmental
required, as main objections and argues that a more parsimo- literature on ToM.
nious explanation is possible within the field of behavior McHugh et al. (2006) used an approach similar to that of
analysis. A few behavioral researchers have investigated McHugh et al. (2004), but focused on tasks that were similar
methods to teach directly perspective-taking skills. For exam- to Level 5 ToM tasks. In addition, the authors included tests of
ple, LeBlanc et al. (2003) taught three children with autism to logical-not relations (e.g. not here – not there) due to the
pass variations of two commonly used perspective-taking involvement of this relation in false belief tasks. The results
tasks using video-modeling and reinforcement strategies. demonstrated that correct responding to the protocol increases
Two of the three participants subsequently passed the Sally- as a function of age and corresponds to performance of tradi-
Anne task, although no explicit teaching had occurred with tional ToM tests. Furthermore, there was no significant differ-
this test. Although this suggests some degree of generalization ence between standard deictic relations and those involving
of the perspective-taking skills taught, the authors suggest logical-not, suggesting an overlap in the behavioral processes
further research on generalization is warranted, particularly involved. This study provided further support of the RFT
with respect to everyday social situations. In addition, they approach to ToM.
suggest that researchers should focus on further development Rehfeldt et al. (2007) compared the performance of chil-
and testing of a behavioral explanation of perspective-taking. dren with high-functioning autism, or Asperger Syndrome
One such explanation has come from an approach known as (AS), to their typically developing peers on a modified version
Relational Frame Theory (RFT). of the Barnes-Holmes protocol. Participants with high-
Proponents of RFT suggest that human language and other functioning autism, or AS, showed increasing errors with
complex behavior, including perspective-taking, are a result of increasing levels of complexity, and the majority of errors
contextually controlled derived relational responses. These are were made at the reversed level of complexity. The second
learned through the processes of operant conditioning over experiment examined the possibility that deictic relational
multiple exemplars and result in various forms of generalized responding could be taught as operant behavior, and involved
operants. RFT contends that perspective taking is a form of two typically developing children. All types of simple rela-
generalized operant responding involving deictic relations tions were taught first, followed by reversed relations, and
(Barnes-Holmes et al. 2001; McHugh et al. 2004). The deictic then double reversed relations. Both participants mastered all
relations of I-you, here-there, and now-then are purported to complexity levels, involving all relation types. This study
be central to perspective-taking skills and are said to be demonstrated that reinforcement techniques could be used to
learned from a history of asking and responding to questions increase the performance, of typically developing children, on
such as, “What am I doing?” and “Where were you yester- the Barnes-Holmes protocol.
day?” According to RFT, the most effective means of estab- Weil et al. (2011) taught deictic relations to three typically
lishing perspective taking would be to teach these relations developing children using the Barnes-Holmes protocol, and
directly, rather than attempting to teach children to understand assessed any change in their performance on second-order
informational states as defined within ToM training programs. false belief tasks. All participants were able to reach a mastery
A study conducted by McHugh et al. (2004) was one of the criterion of 80 % correct on the protocol, and, as the partici-
first to investigate the relationship between deictic relations pants acquired the deictic relations at the reversed and double
Psychol Rec

reversed levels, scores on the false-belief tasks increased. comprehension skills to complete the task. For example they
Responding also generalized to untrained versions of ToM may have been asked, “If the sky is yellow and the sun is blue,
tasks. One notable limitation to this study was the possibility what color is the sky? What color is the sun?” As in Rehfeldt
of test/retest effects on ToM assessments. et al. (2007), participants who failed one or more of the three
Further research is required to examine the applicability of practice trials were excluded from the study. All participants
this finding to clinically relevant populations such as those were currently working with a token economy system and we
with ASDs. The participants in the Weil et al. (2011) study used a similar system to reinforce correct responses during
were typically developing children, within the age range when training.
performance on common ToM tests often increases. From a
behavior analytic viewpoint, these skills emerge through in- Setting
creasing exposure to relevant experiences and differential
reinforcement for performance (Baer 1970). Therefore, par- Three of the five participants (Charlie, Jerry, and Thomas)
ticipants in Weil et al.’s study may already have acquired a completed all sessions in a room in their home. The rooms
number of pre-requisite skills to allow the additional training used all contained a table, two chairs, and the research mate-
provided to produce changes in these global measures of rials. In addition the immediate area, around the table and
perspective-taking skills. Individuals with autism often con- chairs, was cleared and distractions were minimized. Two
tinue to show significant deficits on perspective-taking skills participants (Diego and Garfield), completed all sessions in a
measured by ToM tests, regardless of chronological age, research room containing a table, two chairs, and the research
suggesting that they may not have learned these pre-requisite materials. The setting remained consistent for each participant
skills though their everyday experiences. The purpose of this throughout the study. During each session, the experimenter
study was to replicate and extend the study by Weil et al. with and participant sat on opposite sides of the table unless the
participants diagnosed with autism. protocol stated otherwise and breaks were provided approxi-
mately every 20 min. Each session lasted between 30 to
60 min and was followed by a play activity of the child’s
Method choice. Sessions could be terminated upon the child’s request
at any time (although this never occurred).
Participants
Design
Five children, between the ages of 5 years and 6 years 1 month,
participated in the study and were recruited from behavioral Three of the participants were randomly assigned to an exper-
service providers in the local area. They all had a diagnosis on imental condition and two were assigned to a control condi-
the autism spectrum and this was confirmed by a file review tion (see Table 1). All participants completed pretests on all
upon completion of parental informed consent to participate. five levels of ToM and all three types of deictic relations (I-
In addition, we completed the Childhood Autism Rating Scale you, here-there, & now-then), across the three levels of com-
(CARS) at the beginning of the study. Specific participant plexity (simple, reversed, & double reversed), using a modi-
information is presented in Table 1. fied version of the Barnes-Holmes protocol (Weil et al. 2011).
Prior to the experiment, all participants completed three Participants earned reinforcement approximately every 5 min
practice trials similar to the format of those in the Barnes- for on-task behavior, regardless of the accuracy of responses.
Holmes protocol. These questions were of similar length but Following these baseline sessions, the three participants in
didn’t require perspective-taking skills and were conducted to the experimental condition completed training on all three
ensure that all participants had sufficient verbal types of frames at the simple level of complexity. All simple

Table 1 Chronological Age

(CA), formal diagnosis, CARS Participant Experimental participants Control participants
scores, educational placement,
history of behavioral treatment, Charlie Diego Jerry Garfield Thomas
current hours of ABA treatment
CA 5-7 6-1 5-10 5-0 5-3
Diagnosis Autism Autism Autism PDD-NOS Autism
CARS Scores 27.5 17.5 30 33 27
Placement Regular K Regular 1st Homeschool Regular K Regular K
History of ABA 4 years 3 years 4 years 2 months 2 years
Current ABA 15 h/week 15 h/week 15 h/week 4 h/week 10 h/week
 Psychol Rec

relation types were randomly presented for a total of eight correct and incorrect responses for a total of 40 trials
trials per trial block. Correct responses were reinforced and (eight at each of the five levels). A total percentage
incorrect responses resulted in corrective feedback. This was correct was calculated by dividing the number of correct
repeated until the participant was able to respond correctly on responses by the number of correct plus incorrect re-
80 % or more of the trials, at which time training stopped at sponses. Again, trials on all presentations of the ToM
that level and a mastery probe was conducted on simple tests were unreinforced and unprompted. Reinforcement
deictic relations. If the participant was then able to respond was provided for on-task behavior, approximately every
at 80 % accuracy or better for the simple complexity probe, all 5 min.
levels of complexity on the Barnes-Holmes protocol and all
levels of ToM tasks were tested. Training then proceeded to Level 1 (simple visual perspective taking). This level
the next level of complexity. If the participant did not meet the assessed the understanding that different people can have
criterion for the mastery probe, another block of training was different views of the same situation. Participants sat on the
conducted. Training followed the same progression for all opposite side of the table from the experimenter and they
levels of complexity (i.e. reversed and double reversed) and were shown both sides of a card, with each side of the card
probes of all ToM levels and deictic relations were conducted showing a different picture (e.g., cat & shoe). The card was
upon mastered of each complexity level. The two participants placed between the participant and the experimenter such
randomly assigned to the control condition completed four that each person can see only one side and the other person
ToM probes and the initial Barnes-Holmes pretest. The four can only see the other side. The participant was then asked,
ToM probes were conducted approximately once a week for “What can you see?” and “What can I see?” in a varied
4 weeks to approximate the testing timeline of the experimen- order. Correct responses corresponded to the picture facing
tal participants. the participant or the experimenter, depending on the ques-
An ABACADA multiple probe design was used, with A tion, and required that both questions be answered
representing the delivery of pretest/probes, B representing the correctly.
training of simple relations, C representing the training of Level 2 (complex visual perspective taking). This level
reversed relations, and D representing the training of double assessed the participant’s understanding that people can
reversed relations. see the same thing differently. Again, the researcher sat
across the table from the participant and a large card with
Procedures a picture on it was placed on the table between the
researcher and the child so that the object depicted ap-
Upon completion of informed consent, a CARS assessment, pears upside down for one individual and the right way
and three verbal comprehension practice trials, participants up for the other. The researcher then asked the child,
completed a preference assessment. “When I look at the picture, is the horse the right way
up, or upside down?” and “When you look at the picture
Preference Assessments Preference assessments were con- is the horse the right way up or is it upside down?”
ducted using a Multiple Stimulus without Replacement Correct responses corresponded to the orientation of the
format (MSWO; Deleon and Iwata 1996). Several items picture from the child or experimenter’s perspective and
were presented to the participant simultaneously. The both answers had to be accurate to count as one correct
child was then instructed to choose an item and provid- response.
ed brief access to it. This item was then removed from Level 3 (seeing leads to knowing). This level tested the
the array and the remaining items were rearranged. This participant’s understanding that people only know things
procedure was repeated until all of the items had been that they have seen. An empty box, a doll, and various
chosen or the participant stopped responding. The pref- pairs of items were used during this level of testing and
erence assessment was repeated prior to each session each member of the pair was identical with the exception
and periodically throughout the session if needed. The of one aspect (e.g. may differ in size or color). Self-
most preferred item (first one chosen) was made avail- judgment and another’s judgment were tested at this level.
able as a back-up for the exchange of tokens (fake For self-judgment the researcher put one item (e.g. blue
money) and remaining items were used to reinforce block from the pair) into a box and asked the child either
on-task behavior. to watch, or keep their eyes closed. The researcher then
asked the child, “Do you know which block is in the
ToM Testing To assess any change in perspective-taking box?” and, depending on how the child answered, they
skills following training and testing on deictic relations, were then asked either “Why don’t you know which
participants completed tests on all five levels of ToM block is in the box?” or “How do you know which block
four times throughout the study. Data were collected on is in the box?” For another’s judgment, the researcher
Psychol Rec

presented a doll (Sue) and then removed the doll from the questions; that they initially believed that the box
situation so that she was unable to see which item was contained candy, that before the box was opened they
placed in the box. The child was asked to place one of the believed it contained candy, that it actually contained
items in the box (e.g. pink ball) and the doll was brought pencils, and that Sue would also falsely believe that it
back up onto the table. The child was then asked, “Does contained candy.
Sue know which ball is in the box?” and “How does Sue
know it is the pink ball?” Correct responding at this level
required the child to respond accurately to the two self- Deictic Relations Baseline Tests/Probes All participants
judgment questions and the two other-judgment completed a pretest measuring of perspective-taking
questions. abilities, using a modified version of the Barnes-
Holmes protocol (Weil et al. 2011). Only the experi-
Level 4 (true belief). This level concerns the partici-
mental participants were exposed to deictic relations
pant’s understanding that people can hold true beliefs,
based on their experience, and that their action can be probes throughout the study. Pretests and probes ran-
domly presented all three deictic relations across all
predicted on the basis of this belief. To assess this we
three levels of complexity for a total of 18 trials (two
used a dollhouse with various items of toy furniture, a
doll, and a number pairs of different objects. The child of each relation type at each complexity level) in an
interspersed fashion. No feedback or programmed rein-
was given the following instruction:
forcement was provided contingent on responding, but
Let’s play a game with the dollhouse and Sue (the doll). reinforcement was delivered approximately every 5 min
for on-task behavior. Upon mastery of a particular com-
Look, there is a ball on the bed and there is a ball on the
plexity level, probes were conducted on all other com-
table. Here is Sue (Sue faces the researcher and the child
but away from the dollhouse). This morning Sue saw the plexity levels (trained and untrained). For example, if
simple relations were being trained, a mastery test for
ball on the bed. Sue did not see the ball on the table.
simple relations was conducted and probes of reversed
They were then asked four questions, a belief ques- and double reversed relations were also conducted.
tion (“Where does Sue think the ball is?”), a justifica-
tion question (“Why does she think it is on the bed?”), Deictic Relations Training The full version of the Barnes-
an action question (“Where will Sue go to get the Holmes protocol, as reported by McHugh et al. (2004)
ball?”), and another justification question (“Why will and used by Weil et al. (2011), was utilized for the
she go to the bed/table?”). A correct response at this training purposes. This consisted of 62 trials assessing
level required the child to report that the doll would go responding to the three types of deictic relations (I-you,
to the location where they originally saw the item and here-there, and now/then). There were a combination of
to respond correctly to all four questions. eight trial types: three trial-types assessing simple rela-
tions presented across eight trials (two trials for I-you,
Level 5 (false belief). This assesses the participant’s two trials for here-there, and four trials for now-then);
understanding that people can hold false beliefs three trial-types assessing reversed relations, presented
based on their experience and that they may act across 36 trials (eight I-you trials, 12 here-there trials,
on the basis of these beliefs. Both the Unexpected and 16 now-then trials); and two trial-types assessing
Contents Task and the Unexpected Transfer Task double reversed relations presented across 18 trials (six
were conducted with all participants. The Unexpect- I-you/here-there trials and 12 here-there/now-then trials).
ed Contents task presented the participant with a The researcher sat across the table from the partici-
familiar or clearly labeled container (e.g. a candy pant and read each statement to the participant (e.g., “I
box) and the participant was asked an initial belief have a red brick and you have a green brick.”). The
question, “What do you think is inside this box?” researcher then asked the participant two questions (e.g.,
They were then instructed to open the box, look at “Which brick do I have?” “Which brick do you have?”).
the contents and then close the box again. They Each of the trials consisted of one statement followed
were then asked three additional questions; a false belief by two questions and both had to be answered accu-
question (“Before we opened the box what did you think rately for it the trial to be scored as correct. No feed-
was in here?”), a reality question (“And what is really in back was given until both responses had been made and
here?”), and another’s belief question (“Sue comes in and participants responded vocally. Once a criterion of 80 %
looks at the candy box, what will she think is inside?”). In or higher was achieved across one session, a mastery
the candy box example, a correct response required the probe of simple relations along with a probe at the
participant to respond accurately to all of the four reversed and double reversed relations was presented.
 Psychol Rec

Fig. 1 Charlie’s performance on all types of deictic relations at each relations (squares), C represents training in reversed relations (circles),
complexity level. Condition A represents unreinforced probes (open and D represents training in double reversed relations (triangles)
shapes of respective complexity levels), B represents training in simple

If the participant met the criterion on the simple rela- correct answers required responses that were identical to the
tions mastery probe, a ToM probe was conducted. arrangements specified in the question. (e.g., “Yesterday you
Training of the reversed relations was then introduced were watching television, today you are reading. What were
in a similar fashion. If the participant did not meet you doing then?” [Watching television] “What are you doing
criterion on the simple relations probe, training resumed now?” [reading]). Although the object of the statements
until criterion of 80 % or better was achieved. If the changed across trials the complexity remained the same and
participant did not meet criterion across three sessions this was true of all subsequent complexity levels.
at any level, visual prompts (i.e., picture of a red brick) Reversed relations were trained next. All reversed trials
were used for one session. Prompting sessions required were randomly rotated across I-you, here-there, and now-
the participant to hold a picture (i.e., red brick) and the then frames and correct answers required the participant to
researcher to hold the other picture (i.e., green brick). reverse the arrangements specified in the question (e.g. “I have
The researcher then read each statement and question to a red brick and you have a green brick. If I was you and you
the participant. While reading the statement “If I was were me, which brick would I have?” [green] “Which brick
you and you were me” the researcher simultaneously would you have?” [red]).
switched pictures with the participant and the participant Double reversed relations were trained last and cor-
was directed to look at the pictures when answering the rect answers required the participant to reverse the I-you
questions. Once the participant met criterion (80 %) and here-there or here-there and now-then arrangements
with the use of prompts, training resumed without the specified in the question (e.g. “Yesterday you were
use of prompts. sitting there on the black chair, today you are sitting
Simple relations were trained first, randomly rotating be- here on the blue chair. If here was there and there was
tween simple I-you, here-there, and now-then frames and here and if now was then and then was now. “Where

Table 2 Summary of Charlie’s

percentage of correct responses ToM levels Pretest Probe 1 Probe 2 Post-test Change across study
for each ToM measure by level
and administration Level 1 50 % 38 % 50 % 50 % +0
Level 2 100 % 100 % 100 % 100 % +0
Level 3 0% 0% 0% 0% +0
Level 4 0% 38 % 25 % 38 % + 38
Level 5 13 % 13 % 25 % 13 % +0
Psychol Rec

Fig. 2 Diego’s performance on all types of deictic relations at each relations (squares), C represents training in reversed relations (circles),
complexity level; Condition A represents unreinforced probes (open and D represents training in double reversed relations (triangles)
shapes of respective complexity levels), B represents training in simple

would you be sitting now?” [blue chair] “Where would Results

you be sitting then?” [black chair]). Reversing two
relations resulted in the response being the same as Experimental Participants
the arrangement specified in the question.
Charlie Figure 1 shows Charlie’s performance on pretests,
Inter-Observer Agreement and Procedural Integrity A sec- training, probes, and posttests on simple, reversed, and double
ond observer independently collected data on 41 % of reversed relations. He scored below the mastery criteria on all
all sessions. An exact agreement method was used to of the pretests, but mastered simple relations after just one
calculate agreement, meaning that an agreement was session. He required 17 sessions to master reversed relations,
scored if both the researcher and the observer scored a with an additional prompted session (not reflected in the
trial in the same way, as either correct or incorrect. IOA graph) conducted after sessions three and nine, due to slow
was calculated by dividing the total number of agree- or halted acquisition rates. On the first mastery probe he failed
ments by the total number of agreements plus disagree- to meet the mastery criterion and a further four sessions of
ments, multiplied by 100. The percentage of agreement training on reversed relations were required to pass the mas-
across the study was 91 %, with a range of 85 %–96 % tery probe. Double reversed relations were mastered over six
across participants. Procedural integrity was evaluated sessions and all complexities passed the final mastery probe.
on 34 % of all testing and training trials and was None of the more complex relations met mastery criterion
92 % across all participants and conditions, with a without explicit training. Charlie’s ToM scores can be seen
range of 84 %–98 %. in Table 2. He passed level 2 at 100 % during the pretests and
throughout the study but failed all other levels, with minor
increases in level 4 skills. Overall there were no consistent or
Table 3 Summary of Diego’s percentage of correct responses for each
meaningful changes in ToM scores and training in deictic
ToM measure by level and administration relations change levels passed.

ToM levels Pretest Probe 1 Probe 2 Post-test Change across study Diego Figure 2 shows Diego’s performance on pretests, train-
Level 1 50 % 50 % 50 % 50 % +0 ing, probes, and post-tests on simple, reversed, and double
Level 2 63 % 50 % 50 % 50 % −13 reversed relations. Although he performed below the mastery
Level 3 13 % 36 % 0% 75 % +62
criterion on pretests, he mastered simple relations in just two
Level 4 25 % 50 % 38 % 38 % +13
sessions, reversed relations in five sessions, and double re-
Level 5 13 % 25 % 0% 13 % +0
versed relations in two sessions. He did not require any
prompted sessions or remedial training but was observed to
 Psychol Rec

Fig. 3 Jerry’s performance on all types of deictic relations at each relations (squares), C represents training in reversed relations (circles),
complexity level; Condition A represents unreinforced probes (open and D represents training in double reversed relations (triangles)
shapes of respective complexity levels), B represents training in simple

provide his own verbal prompts during training. For exam- In summary, all three participants in the experimental con-
ple, during reversed relation training, he said, “black is here, dition were shown to increase their scores on the Barnes-
blue is here, switch it,” using his hands accordingly and Holmes protocol using standard operant procedures. This
crossing them over to represent the reversal. He did not did not seem to result in any substantial or consistent increases
master any of the complexities until relevant training was in ToM scores, for any of these participants.
provided and maintained the mastery level on all complex-
ities at the post-test. Diego’s ToM scores can be seen in Control Participants
Table 3. He did not pass any of the levels during the pretest
and performed similarly on posttests. His performance in- The remaining participants were exposed to pretests on the
creased by 62 % on level 3, although this change was Barnes-Holmes protocol and four ToM assessments. Garfield’s
extremely variable throughout testing. Overall, Diego scores on the deictic relations were as follows: 67 % correct on
showed no consistent changes in ToM scores before, during, simple relations, 33 % on reversed relations, and 67 % on
or after deictic relations training. double reversed relations. Thomas’ scores were 73 %, 33 %,
and 67 % for simple, reversed, and double reversed relations
Jerry As shown in Fig. 3, Jerry’s pretest scores did not meet respectively. Their four ToM assessments were administered
the mastery criterion, and he did master all levels of complexity once per week for 4 weeks (to approximate the spacing of ToM
with relevant training. Similar to Charlie’s data, Jerry only tests for the experimental participants). Garfield’s scores on the
required one session to master simple relations, but required ToM assessments can be seen in Table 5 and Thomas’ can be
15 sessions to master reversed relations, with an additional seen in Table 6.
prompted session (not reflected in the graph) conducted after
sessions four and nine, due to slow or halted acquisition rates.
He then required six sessions to reach the mastery criterion on
Table 4 Summary of Jerry’s percentage of correct responses for each
double reversed relations, but failed the subsequent mastery ToM measure by level and administration
probe and an additional three sessions were required. He then
met mastery criterion on all post-tests. Jerry’s. ToM scores are ToM levels Pretest Probe 1 Probe 2 Post-test Change across study
shown in Table 4. Jerry scored at or below chance levels during Level 1 50 % 50 % 50 % 50 % +0
the pretests on all levels except level 2, on which he scored
Level 2 88 % 100 % 100 % 100 % +12
88 %. He scored 100 % on all subsequent level 2 probes and on
Level 3 50 % 13 % 25 % 13 % −37
the post-test. His performance on level 3 deteriorated by 37 %
Level 4 0% 0% 0% 0% +0
over the course of the study, and the remaining levels showed
Level 5 25 % 13 % 50 % 25 % +0
no consistent change from pre- to post-tests.
Psychol Rec

Garfield’s ToM scores remained similar from pretest to Table 6 Summary of Thomas’ percentage of correct responses for each
ToM measure by level and administration
posttest with the exception of level 2 which increased from
38 % to 100 %. Other levels showed minor variations through- ToM levels Pretest Probe 1 Probe 2 Post-test Change across study
out, but no consistent change. Thomas passed level 2 at pretest
and post-test, but failed all other levels and they remained Level 1 50 % 50 % 50 % 50 % +0
relatively unchanged across the course of the study. In general, Level 2 88 % 75 % 88 % 100 % +12
the ToM scores of the control participants did not change with Level 3 13 % 0% 13 % 13 % +0
repeated exposures across the course of the study. Level 4 0% 25 % 13 % 0% +0
Level 5 25 % 13 % 38 % 25 % +0

There are a few possible interpretations of this finding; one

Discussion might be that these deictic relations are unrelated to ToM skills
but we would argue that this is unlikely given the overlapping
This study was the first study to demonstrate that children with involvement of I-you, here-there, and now-then relations across
autism could learn to pass the Barnes-Holmes protocol using assessments, and the existing research on this topic. Another
common operant procedures. This supports existing research explanation may be that this repertoire is more difficult to teach
in the area of RFT suggesting that deictic relations can be to individuals with ASD using the standard Barnes-Holmes
taught and are learned through multiple exemplar training protocol. Rehfeldt et al. (2007) noted some difficulties that
across relation type and increasing complexity. Furthermore, may be specific to individuals with autism compared to studies
probes conducted throughout the study suggest that perfor- using individuals without a diagnosis of autism. Our data con-
mance on each complexity level did not increase until directly firm their findings that participants with a diagnosis of autism
trained. This lends support to the claim that such a repertoire made more errors at the reversed level of complexity than at the
emerges from a history of being reinforced for responding simple level, confirming that this is a more complex form of
relationally to the frames of I-you, here-there, now-then, and relational responding at the reversed level of complexity
that each represents a functionally distinct operant (McHugh (McHugh et al. 2004). However, participants had fewer errors
et al. 2004; Rehfeldt et al. 2007; Weil et al. 2011). Despite at the double reversed level relative to the reversed level and
increased performance on deictic relations, performance on requiring more trials to meet the mastery criterion at that level
ToM tests did not change significantly for any of the experi- (Table 7). It seems that the double reversed level would entail a
mental participants. This suggests that training on the Barnes- more complex form of relational responding than the reversed
Holmes protocol was not sufficient to produce generalized level as answers at the double reversed level of complexity
changes in perspective-taking ability as measured by the ToM required the participants to simultaneously reverse the I-you
tests. Results of repeated ToM tests for the control participants and here-there or here-there and now-then arrangements speci-
demonstrate that this alone was not sufficient to produce any fied in the question. Fewer training trials on double reversed
consistent increase in scores or levels passed. This lends relations suggest that the participants were not responding rela-
weight to the validity of Weil et al.’s results as it suggests that tionally at the double reversed level, as suggested by Rehfeldt
test/retest effects were not responsible for increased scores on et al. This could be because correct responding resulted in the
ToM tests. Findings from control participants further suggest initial order specified, or merely echoing the initial statement.
that neither the passage of time nor everyday experiences of We attempted to minimize this testing through the use of ran-
perspective taking were sufficient to increase ToM skills for domly rotated questions from previously mastered levels of
any of the participants. complexity during post-instructional probes (Weil et al. 2011).
It may be necessary to develop further procedures to ensure that
Table 5 Summary of Garfield’s percentage of correct responses for each
ToM measure by level and administration Table 7 Number of training sessions to meet mastery criterion at each
complexity level
ToM levels Pretest Probe 1 Probe 2 Post-test Change across study
Participants Simple Reversed Double reversed
Level 1 50 % 50 % 36 % 63 % +13
Level 2 38 % 50 % 100 % 100 % +62 Charlie 1 21 3
Level 3 25 % 25 % 0% 25 % +0 Diego 2 5 2
Level 4 0% 0% 0% 0% +0 Jerry 1 15 9
Level 5 38 % 13 % 25 % 38 % +0 Total per complexity level 4 41 14
 Psychol Rec

Fig. 4 Percentage of errors by relation type, combined across complexities, for each participant during pretests

participants are learning to respond relationally to double re- met the mastery criterion on a given complexity level while
versed relations and not simply to learn to echo the original still making consistent errors on a particular relation type. The
statements in these questions. current training protocol does not require the participants to
Similar to the results of Weil et al. (2011), all participants meet mastery criteria for each relation type individually, only
responded with more errors on the now-then relations, than on on the complexity level as a whole. Being that these deictic
the here-there relations and the I-you relations, at the simple relations are encompassed throughout ToM tasks, this could
and reversed levels of complexity. This remained consistent be one reason why consistent increases were not shown in
for all participants during pretests and training procedures (see ToM scores for these participants. It may be that individuals
Figs. 4 and 5). At the double reversed level of complexity all with ASDs require a more rigorous training procedure, train-
participants responded with more errors at the here-there/now- ing all simple I-you relations to mastery, then training all
then relations compared to the I-you/here-there relations, simple here-there relations to mastery, and finally training all
which also remained consistent from baseline through training simple now-then relations to mastery, then following the same
with the exception of Diego. Given that all trial types were progression at the reversed and double reversed levels. In
trained and assessed within one complexity level, these pat- addition, a stricter mastery criterion may be needed, perhaps
terns of errors raise the possibility that participants may have including a fluency component. Future research should

Fig. 5 Percentage of errors by relation type (combined across complexities), for each participant during training
Psychol Rec

examine the effects of meeting mastery criteria at all three needed, the results suggest a number of future research ques-
levels of complexity and within all relation types, on ToM tions addressing some adaptations to the Barnes-Holmes pro-
scores, for children with autism. tocol that may produce more generalized outcomes for chil-
Another possible explanation for the lack of impact of dren with autism.
deictic relations training on ToM skills is to consider it simply
as a failure in generalization. The Barnes-Holmes protocol
provides multiple exemplar training, as the object or activity
used varies across trials, but this variation may not be suffi-
cient for children with autism given the common difficulty References
with generalization (Schreibman 2000). Inclusion of more
naturalistic test questions or in situ training on the deictic Baer, D. M. (1970). An age-irrelevant concept of development. Merrill-
relations may remedy this issue. Furthermore, individuals Palmer Quarterly of Behavior and Development, 16, 238–245.
may need to be taught not only how to respond correctly to Barnes-Holmes, Y., Barnes-Holmes, D., & Cullinan, V. (2001).
Education. In S. C. Hayes, D. Barnes-Holmes, & B. T. Roche
deictic relations, but when to use these skills in everyday (Eds.), Relational frame theory: Apost-Skinnerian account of human
situations. language and cognition (pp. 181–195). New York: Plenum.
Finally, it may be that children with autism are defi- Baron-Cohen, S. (1992). Out of sight or out of mind: another look at
cient in other skills relevant to ToM performance. For deception in autism. Journal of Child Psychology and Psychiatry,
33, 1141–1155.
example, McHugh et al. (2006) discussed the relevance Baron-Cohen, S. (1995). Mindblindness: An essay on autism and theory
of logical-not relations to ToM tasks (especially false of mind. Cambridge: Bradford Books, MIT Press.
belief tasks). These relations are not directly trained using Baron-Cohen, S. (2004). Theory of mind and autism: A fifteen year
the Barnes-Holmes protocol and it may be necessary to review. In S. Baron-Cohen, H. Tager-Flusberg, & D. Cohen (Eds.),
Understanding other minds: Perspectives from developmental cog-
provide explicit training in these types of relations. The nitive neuroscience (2nd ed.). Oxford: Oxford University Press.
complexity of the questions used in common ToM tasks Baron-Cohen, S., Leslie, A. M., & Firth, U. (1985). Does the autistic child
should also be considered. Verbal comprehension was have a ‘theory of mind?’. Cognition, 21, 27–43.
only assessed for questions used in the Barnes-Holmes Baron-Cohen, S., Tager-Flusberg, H., & Cohen, D. (2004).
Understanding other minds: Perspectives from developmental cog-
protocol but similar tests were not conducted on compre- nitive neuroscience (2nd ed.). Oxford: Oxford University Press.
hension of the questions used in the ToM tests. ToM tests DeLeon, I. G., & Iwata, B. A. (1996). Evaluation of a multiple-stimulus
involve questions about where the character may look for presentation format for assessing reinforcer preferences. Journal of
the item and why the characters would respond a particu- Applied Behavior Analysis, 29(4), 519-533. doi:10.1901/jaba.1996.
29-519.
lar way. Participants might have difficulties understanding Flavell, J. H. (2004). Theory of mind development: retrospect and pros-
and responding to these types of questions. Similarly, pect. Merrill-Palmer Quarterly, 50, 274–290.
questions about what the character “knows” or “thinks” Howlin, P., Baron-Cohen, S., & Hadwin, J. (1999). Teaching children
require a pre-experimental history of responding correctly with autism to mind read: A practical guide. Chichester: Wiley.
LeBlanc, L. A., Coates, A. M., Daneshvar, S., Charlop-Christy, M. H.,
to these terms. Everyday scenarios may involve increas- Morris, C., & Lancaster, B. M. (2003). Using video modeling and
ingly complex questions in more abstract forms. In addi- reinforcement to teach perspective-taking skills to children with
tion, prior research had discussed the role of joint atten- autism. Journal of Applied Behavior Analysis, 36, 253–257.
tion in ToM tests. Individuals with ASDs have also dem- Leekham, S., & Perner, J. (1991). Does the autistic child have a
metarepresentational deficit? Cognition, 40, 203–218.
onstrated deficits in the area of joint attention, and this McHugh, L., Barnes-Holmes, Y., & Barnes-Holmes, D. (2004).
has been widely recognized as a necessary pre-requisite Perspective-taking as relational responding: a developmental pro-
for accurate performance on ToM tests (Warreyn et al. file. The Psychological Record, 54, 110–135.
2005). Future research should investigate these and other McHugh, L., Barnes-Holmes, Y., Barnes-Holmes, D., & Stewart, I.
(2006). Understanding false belief as generalized operant behavior.
pre-requisite skills necessary for correct performance on The Psychological Record, 56, 341–364.
ToM and other perspective-taking tasks. Perner, J., Leekam, S., & Wimmer, H. (1987). Three year olds’ difficulty
In summary, this was one of only a few studies teaching with false belief. The case for a conceptual deficit. British Journal of
deictic relations using the Barnes-Holmes protocol and only Developmental Psychology, 5, 125–137.
Perner, J., Frith, U., Leslie, A. M., & Leekam, S. (1989). Exploration of
the second study to involve children with autism. Moreover, it the autistic child’s theory of mind: knowledge, belief, and commu-
was the first study to assess the effects of this on ToM scores nication. Child Development, 60, 689–700.
for children with autism. The results of this study did not Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a theory
confirm that training on the standard Barnes-Holmes protocol of mind? Brain and Behavior Sciences, 1, 515–526.
Reed, T., & Peterson, C. (1990). A comparative study of autistic
would lead to changes in ToM scores (thought to be indicative subjects’ performance at two levels of visual and cognitive
of more general perspective-taking skills) for children with perspective taking. Journal of Autism and Developmental
autism. Although replication with additional participants is Disorders, 20, 555–568.
 Psychol Rec

Rehfeldt, R. A., Dillen, J. E., Ziomek, M. M., & Kowalchuk, R. K. Swettenham, J., Baron-Cohen, S., Gomez, J. C., & Walsh, S. (1996).
(2007). Assessing relational learning deficits in perspective-taking What’s inside a person’s head? Conceiving of the mind as a camera
in children with high-functioning autism spectrum disorder. The helps children with autism develop an alternative theory of mind.
Psychological Record, 57, 23–47. Cognitive Neuropsychiatry, 1, 73–88.
Schlinger, H. D. (2009). Theory of mind: an overview and behavioral Warreyn, P., Roeyers, H., Oelbrandt, T., & De Groote, I. (2005).
perspective. The Psychological Record, 59, 435–448. What are you looking at? Joint attention and visual
Schreibman, L. (2000). Intensive behavioral/psychoeducational treat- perspective-taking in young children with autism spectrum
ments for autism: research needs and future directions. Journal of d i s o r d e r. J o u r n a l o f D e v e l o p m e n t a l a n d P h y s i c a l
Autism and Developmental Disorders, 30, 373–378. Disabilities, 17(1), 55–73.
Swettenham, J. (1996). Can children with autism be taught to understand Weil, T. M., Hayes, S. C., & Capurro, P. (2011). Establishing a deictic
false belief using computers? Journal of Child Psychology and relational repertoire in young children. The Psychological Record,
Psychiatry, 37, 157–165. 61, 371–390.

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