theory of mind and cerebral visual impairment...•developed by baron-cohen, leslie & frith...

TheoryofMindandCerebralVisualImpairment

SomereflectionswithJohnRavenscroftandAmandaLueck

Withthanksto

• AmandaLueck (Prof- Education)• GordonDutton (Prof- Ophthalmology• KarenGoodall (Dr- Psychology)• MartinToye (Dr- Psychology)• LeaHyvärinen (Prof– Ophthalmology)• HelenStClairTracy(ParentofchildwithCVI)• SimonHayhoe (Dr– Education)

Whatisthistalkabout……….?

• GoodQuestion

• MyideasandramblingsaboutCVIandTheoryofMind(TOM)andthenatureofrepresentation

• IwilllookatwhatisToM astryandconnectthistochildrenandadultswithCVI

• Imaybeentirelywrong– partiallywrong– partiallyright– entirelyright

• Buttheissueis– nooneknowsforsure– especiallyme!

TheNatureofRepresentation• “Whatisitliketobeabat”(Nagel1974)• Anorganismhasconsciousmentalstatesifandonlyifthereissomethingthatitisliketobethatorganism– somethingthatitislikefortheorganismtobeitself.

• themind-bodyproblemisnotjustalocalproblem,havingtodowiththerelationbetweenmind,brainandbehaviourinlivinganimalorganisms,butthatitinvadesourunderstandingoftheentirecosmosanditshistory.(Nagel,2012:P.3)

AQuestiontoJohnLocke

Amanbeingbornblindandhavingaglobeandacube,nighofthesamebigness,committedintohishand,andbeingtaughtortold,whichiscalledtheglobeandwhichthecube,soaseasilytodistinguishthembytouchorfeeling;thenboththingstakenfromhim,andlaidonatable.Letussupposehissightrestoredtohim;whetherhecould,byhissight,andbeforehetouchthem,knowwhichistheglobeandwhichthecube?Sowhetherhecouldnotreachthemthoughtheywereremoved20or1000feetfromhim?

• LetterfromWilliamMolyneux toJohnLocke,7thJuly1688.FromthecorrespondenceofJohnLocke,TheJohnLockeCollection,BodleanLibrary,OxfordUniversity.

• SpecialthankstoSimonHayhoetakenfromClassicPhilosophiesonBlindnessandCross-ModalTransfer,1688-2003InRavenscoft (2019)HandbookofVisualImpairment:SocialandCulturalResearch.Routledge.

AnAnswerforJohnLocke

• Whenhewasjustoutofthehospital,andhisdepressionwasbutoccasional,hewouldsometimesprefertousetouchalonewhenidentifyingobjects.Weshowedhimasimplelathe(atoolhehadwishedhecoulduse)andhewasveryexcited.WeshowedithiminaglasscaseattheScienceMuseuminLondon,thenweopenedthecasesothathecouldtouchit.Withthecaseclosed,hewasquiteunabletosayanythingaboutit,exceptthatthenearestpartmightbeahandle(whichitwas— thetransversefeedhandle),butwhenhewasallowedtotouchit,heclosedhiseyesandplacedhishandsonit,whenheimmediatelysaidwithassurancethatitwasahandle.Heranhishandseagerlyovertherestofthelathe,withhiseyestightshutforaminuteorso;thenhestoodbackalittle,andopeninghiseyesandstaringatit,hesaid:'NowthatI'vefeltitIcansee'

Gregory,RichardL..EyeandBrain:ThePsychologyofSeeing,PrincetonUniversityPress,1998

CVIWordCloud

WordstakenfromDisordersofthebrainandhowtheycanaffectvision.InA.H.Lueck&G.N.Dutton(Eds.),Visionandthebrain:Understandingcerebralvisualimpairmentinchildren(p.78-79).

TheoryofMindWordCloud

WordstakenfromSaxe,R.(2007).Theoryofmind.In TheOxfordHandbookofCognitiveNeuroscience.

KeyQuestionstoask• Howisperception(selfandofothers)tiedtocognitionforchildrenwhohaveCVI((inallofitsvaryingexpressions))

• CanTheoryofMind(ToM)tellusanythingaboutCVI?

• CanCVItellisanythingaboutToM?

• AreMirrorNeuronsimportantinthisstory?

TheoryofMind(Recap)

Whatis‘TheoryofMind’(ToM)?

• Term introduced by Premack and Woodruff (1978) • The ability to attribute mental states (thoughts,

beliefs, desires) to others, and to use this to predict and explain their behaviour.

• An innate cognitive module which gradually develops in childhood in typically developing children.

• Known as a ʻtheoryʼ because it involves a system of inferences about states that are not observable.

ToM canhelpusto…

Relatetoothers Empathise

Understandothers’intentions

Mislead ManipulateDeceiveExcludeothers

Predictlikelybehaviour

Correctothers’misunderstandings

Importanttothelifeofchildrenandotherswhohave

CVI

Perceptionsofothers’statesofminds:knowingwhatotherpeoplearethinking

• Akeysocialskillorability

• Multipleexamplesineverydaylife

• Necessaryforeffectivesocialfunctioning,otherwise:

• Mindblindness

• Relativelynewconcept:ToM describedinthe1970s/80s

• Morerecently,providesbridgebetweenchilddevelopment,educationand(social,cognitiveanddevelopmental)psychology

Whatis‘socialcognition’?The cognitive capacities that underlie the ability to interact socially – to understand and reason about other people, in terms of factors such as how people think, feel and react (see Hala, 1997; Tager-Flusberg & Sullivan, 2000).

Metarepresentational ability“The ability to represent the knowledge states (mental representations) of the self and others.”

(Goswami, 2008: 221).

HowCVImayaffectSocialCognition

• perceivethedirectionofsounds• seemovingobjects• understandthecompositionofcrowdedenvironments• takeinthefullenvironmentifthereisvisualneglect• watchsomethingbeingmovedifthereareissuessuchasapraxiaofgaze,smoothpursuitdifficulties

• holisticvsfocalprocessing• faceblindness• Inabilitytointerpretthelanguageconveyedbyfacialexpression• orientationinspace(i.e.,gettinglostinspacewhencannotperceiveandorganizelandmarks)

DevelopmentofToM intypicallydevelopingchildren

• Beginstodeveloparound3yearsofage

• Firmlyinplaceformostby4/5yearsofage.o Tager-Flushberg &Sullivan(2000)

• So…mostchildrenbyprimary1willhaveToM ability.

• But…somelaterthanothers

• Someearlierthanotherstoo…

FactorsthatinfluencehowearlyweachieveToM?

DifferencesinNeglected/LAC?

• Pears&Fisher(2005)studiedToM inchildreninfostercare(aged3-5yearsold)

• ChildreninfostercareweresignificantlylessabletopassToMtasksevenwhentakingaccountofageandintelligence.Deprivationappearstoplayarole.

• ArgueacaseforinterventionstotargetthesechildrentohelpToM andemotionunderstanding(whichtheyalsofoundimpaired)

• CVIandSocialDeprivation(Ravenscroft)

FactorsthatinfluencehowearlyweachieveToM?

CulturaldifferencesinToM?

• Consensusisno…ToM isuniversal

EG• Sabbagh etal.(2006)• StudiedEFandToM inAmericanandChinesepreschoolchildren.• ChinesechildrenbetteronEFtasksbutnotbetteronToM tasks.

FactorsthatinfluencehowearlyweachieveToM?

Siblings• Siblingeffectswelldocumented

o Zajonc (1983)NumberofsiblingscorrelateswithIQ

• Perner etal.(1994):ChildrenwithsiblingshavebetterToM• Ruffman etal.(1998):olderbutnotyoungersiblings?Why?...Lewisetal.(1996)– apprenticeship?

• Dunnetal.(1991)Mothers’narrativeisalsoimportanto Apprenticetomaternalsocialinteractionaswellassiblings?o Roleoflanguage(RoleofLanguageinCVI– speedofinput/processing/)

• Child’sowncharacteristicsimportanttoo

AttentionvPerceptionToM VCVI

• Sustainedattentionistheabilitytofocusononespecifictaskforacontinuousamountoftimewithoutbeingdistracted.

• Selectiveattentionistheabilitytoselectfrommanyfactorsorstimuliandtofocusononlytheonethatyouwantwhilefilteringoutotherdistractions.

• Alternatingattentionistheabilitytoswitchyourfocusbackandforthbetweentasksthatrequiredifferentcognitivedemands.

• Dividedattentionistheabilitytoprocesstwoormoreresponsesorreacttotwoormoredifferentdemandssimultaneously.Dividedattentionisoftenreferredtoasmulti-tasking.

• Attentionisacentralprocessandperceptionisnotpossiblewithoutattentionalprocesses.

• Thatmeansattentionprecedesperception.

• Attentionalprocessesservevariousfunctionsintheorganizationofourperceptionsandothercognitivefunctions.

• IfyoucannotattendthenthishassignificantimplicationsforToM

FactorsthatinfluencehowearlyweachieveToM?

PrecursorstoToM development?• Earlier/otherabilities?

• Cognitiveabilities?oCognitiveabilitiessuchasmemory,attention,inhibitionlinkedwithhowquicklyweachieveToM (Devine&Hughes,2014).SoundsabitlikeCVI

oParticularfocusonimportantroleofexecutive(frontallobe)functions– mediationofattention?SoundsabitlikeCVI

o EF>ToM>SocialBehaviour:whichEFsareimportant?

Assessing(ortestingfor)ToM• FalseBeliefTasks• ValueBeliefTasks• Desire-emotiontasks• NotownDesireemotiontasks• Ignorancetasks

WellmanandLiu(2004)ScalingofTheory-of-MindTasks.ChildDevelopment,Vol.75,No.2(Mar.-Apr.,2004),pp.523-541

FalseBeliefCommonly-usedassessmentofToM

• UnexpectedtransfertestoVariousversionsofthiskindoftask

oOriginalversion:SallyAnnTaskcf Maxi

• Deceptiveboxtask(unexpectedcontents)

SallyAnnTask• Ballplacedintobasketwhenboth

SallyandAnnpresent.

• AnnmovesballwhenSallyisoutoftheroom.

• DoesSallyknowwheretheballiswhenshereturns?

• PassResponse:No,Sallydoesnotknowandcheckswheresheleftit.

• FailResponse:Yes,Sallywillknowwheretheballisandwillcheckinnewlocation

SallyAnnTask

• DevelopedbyBaron-Cohen,Leslie&Frith(1985)o Prof. DameUta Frith>Prof. SimonBaron-Cohen

• OriginalstudyaimedtocomparesocialunderstandingofchildrenwithAutism,Down’sSyndrometohealthycontrolchildren.

Findings:• 85%oftypicalchildrenpassedToM task• 86%ofchildrenwithdown’ssyndromepassed• Around80%ofchildrenwithocularimpairmentpassed• Only20%ofchildrenwithautismpassed

DonotknowrechildrenwithCVI

BUT……………….

• Lowacuity,• Contrastsensitivity• Visualfielddeficits• Simultanagnosia• Prosopagnosia• Integrativeagnosia

Canallprecludeaccesstothevisualelementsofthescenerequiredtobothlearnandexhibittheoryofmindthroughthistypeoftesting.

Issueswiththetask

• Gopnik (1993);Gopnik &Astington (1988)

• Needmetacognitionfirst(thinkingaboutthinking)…needtothinkaboutwhatyouthinkfirst…necessarybeforethinkingaboutwhatsomeoneelsethinks. (thinkaboutdevelopingmetacognitionasapriorityinchildrenwithCVI??)

• AlisonGopnik:testsshouldbemoresimple

MetacognitionissueswithVIandCVI

• itmaybehardertoreadandgivesocialsignals• personalstylemaybelessempathic;• playwillbelesslikelytoincludepretence (thisisbecauseimaginative• playmaybedependentonunderstandingmentalstates);• learningmaybeproblematicatschool,partlybecauseoftheliteralinterpretationoflanguage,andbecauseofdifficultiesinadjustinglearntbehaviour tothecontext

(Pring,L.(2008) PsychologicalcharacteristicsofchildrenwithvisualimpairmentsLearning: memoryandimagery.BritishJournalofVisualImpairmentMay2008)

TheoryofMindandVisualImpairment(Ocular)

IthasbeenarguedinthepastthatvisionplayedacriticalroleinToM

AssuchChildrenwithVIweredelayedinacquiringToM

Minteretal(1998);Sonksen andDale,(2002);Korkmaz (2001)Greenetal(2004);Brambring andAsbrock (2010)

Explanation:individualshadlittleexperienceinsocialintegrationsandthereforenotlearntaboutothersmentalstates– couldn’tseesocialinteractionsandnotjudgegapbetweenexperienceandverbalinteraction(Dyck etal2004.

However, TheoryofMindandVisualImpairment(Ocular Studies)• RecentStudies• Beeger etal2014,• Pijnacker etal2012,• Variousneuroimagingstudiessuggestthatbilateraltemporoparietal junction,medialprefrontalcortex,precuneus andanteriortemporalsulci suggestthatblindnessdoesnoteffectToM northedevelopmentofit.

• Sak Wernica (2015)NodifferenceswerefoundwithVIandSightedintheirfirst-orderandhigher-orderToM use.

• Butthestudyshowsthatpeoplewhoareblindmayunderstandotherpeople’sintentions,feelingsandbeliefs differentlythanpeoplewhoaresighted

“Combinedbehavioural,anatomicalandfunctionalbrainstudiesinsightedandincongenitallyblindindividualsareprovidingnovelinsightsontheeffectsof(lackof)visualexperienceonthedevelopmentandfunctioningofthehumanbrain.Agreatdealofthebraincorticalfunctionalarchitectureappearstobeprogrammedtooccurevenintheabsenceofanyvisualexperienceandabletoprocessnon-visualsensoryinformation,apropertythatcanbedefinedas supramodality”

• Ricciardi etal(2014)Mindtheblindbraintounderstandthesightedone!Isthereasupramodal corticalfunctionalarchitecture?Neuroscience&Biobehavioural Reviewes.Vol41,p64-77

OurView(OcularVisualImpairment)

• IsseemsthereisnolinkbetweenadelayedToM andOcularVisualImpairment

• ThinkofDanielKish– hasexcellentToM buthasnoeyes– butarewiredvisualbrain.

• Aredifferencesareduetotypeoftest?

• Dodifferenttesttypeactivatedifferentareasofthebrain?

• PerhapsthesedifferentareasresultsindifferencesbutnotadelayorabsenceofToM.

• PerhapsVisionsupramodality isresponsibleforpositiveresults?Whoknows?

ToM andCerebralVisualImpairment

• Verylimitedliterature

• Clearlyadifficultandneglectedfield

• Butlet’sexploreCVIinabitmoredetail

VisionInvolvesMoreThanTheEyes,and…..

VisionisProcessedinManyPartsoftheBrain

FROMSECRETLIFEOFTHEBRAIN:PBS

ButfirstaquickRecap

Analysingthevisualsceneandgivingattention

• Cooperationofthreeareasofbrain

1 Posteriorparietallobes:appraiseoverallvisualscene2 Temporallobes:recognise3 Frontallobes:mediatechoice

VisualFeaturesofCVI

Area of Damage Seen on MRI Scan Visual Features to Look For

Occipital LobesLeft occipital lobe ● Lack of visual field on the right side for

both eyesRight occipital lobe ● Lack of visual field on the left side for

both eyesBoth occipital lobes ● Impaired central visual functions of

acuity, contrast, and color● Lack of visual field on both sides (often

manifesting as visual field constriction)● Severe damage causes profound visual

impairment

ReprintedfromDutton,G.N.(2015).Disordersofthebrainandhowtheycanaffectvision.InA.H.Lueck&G.N.Dutton(Eds.),Visionandthebrain:Understandingcerebralvisualimpairmentinchildren(p.78-79).NewYork:AFBPress.

PosteriorParietalLobesLeft posterior parietal lobe

ü Intermittent lack of attention on the right sideü A tendency to miss people and events on the right sideü A tendency to bump into people and objects on the right side, especially when

upset or tiredü Reduced accuracy of visual guidance of movement of the right side of the bodyü A tendency to be left-handed (because this becomes the dominant hand)ü Weakness of the right side of the body (as a result of damage further forward in

the brain)ü Difficulties with spoken or written language (because the left parietal lobe

serves language)ü When drawing, the right side of the picture can be distorted

Right posterior parietal lobe● Significant lack of attention on the left side and intermittent lack of attention on the

right side (Ting et al., 2011)● People and events on the left side are frequently missed● People and objects on the left side are frequently bumped in to● A tendency to be right-handed● Weakness of the left side of the body

PosteriorParietalLobes(Both)

Both posterior parietallobes

(Severe damage affecting the

cortex, white matter, orboth)

● Inability to see more than one or two items in a visual scene at once (simultanagnosia), despite the requisite visual field.

● Inability to use vision to guide movement, accurately despite sometimes having clear three-dimensional vision

● Inability to give attention to more than one or two things atonce.

● Noise or conversation can make the child lose visualattention.

● Inability to move the eyes from one target to another at will, despite ability to move the eyes.

● Profound lack of ability to see moving targets is common.● Lack of lower visual field below the horizontal midline.

TemporalLobes

Left temporal lobe ● Impaired object recognition (objectagnosia); color recognition may beused to compensate.

● Impaired shape recognition (shapeagnosia).

● Difficulty learning the shapes of letters (alexia).

Right temporal lobe ● Impaired face recognition (prosopagnosia).● Impaired ability to see meaning in facial

expressions.● Difficulty being orientated (may be

profound) and navigating known environments (topographic agnosia).

BothTemporalLobes

Bothtemporal lobes ● Combinationoftheimpairedabilitiesdescribedfortheleftandrighttemporallobes(integrative agnosia).

● Difficultyknowingthelengthandorientationoflines,orsizeof objects.

● Impairedvisualmemory(oftenwithrelianceonauditorymemoryandlanguageability).

AsDutton,Chokron,LittleandMcDowell(2017)say

“Theposteriorparietallobesthusreconfigurevisualinformationreceivedviathedorsalstreamfromtheoccipitallobesandfromthemiddletemporallobesthatprocessmovingimagery.Theycreatethenonconscious virtual,dynamicthree-dimensionalpictorialandauditory, mentalemulationofthestructureofoursurroundingsthatenablesustomoveaccuratelywithoutcollisionandinjury”

WealsoknowfromPre-termChildren……

• Childrenbornextremelypretermareatriskofvisualprocessingproblemsrelatedtobraindamage.

• Damageinvisualpathwayscanremainundetectedbyconventionalmagneticresonanceimaging(MRI)andfunctionalconsequencescannotalwaysbepredicted.

• Delaysinprocessingvisualinformationcanbeidentifiedinchildrenbornextremelypreterm.Thedelaysmightbeascribedtodeficitsinneuronalconnectivityinvisualpathwaysatamicrostructurallevel.

Pel etal(2016)Earlyidentificationofcerebralvisualimpairmentsininfantsbornextremelypreterm.DEVELOPMENTALMEDICINE&CHILDNEUROLOGY,Vol58Issue10,p1030-1035

Dutton’sworktellsus

• Childrenbornpretermareatriskofdisorderedtemporalprocessingofvisualinformation.

• Whetheritistheperceptionandinterpretationofrapidchangesinfacialexpression(contributingtoacquisitionoftheoryofmind);

• theabilitytomatchone'smovementstothemovingvisualscenetonavigateinacrowdortocatchaball;

• ortheabilitytofindandfollowsomeoneinamovinggrouporrecognizetheirmovements – allmaybeimpairedbydeficientvisuotemporalprocessing.

• Rapidsequentialimagecaptureandprocessingisneededtopickupthenuancesofsocialinteraction,whiletemporalimagesummation,whichengagesbothcerebralandcerebellarfunction,isrequiredtodifferentiatetheflowingimagesofarunningorwalkingperson.

AndwealsoknowfromworkinCerebralPalsy

• MoreworkonthisthanonchildrenwithCVI

• Adegboye etal2017.HighersocialandemotionaldifficultieswerefoundinthedystonicCPgroupcomparedtothecontrolgroup.NonverbalparticipantswithdystonicCPwerefoundtopresentwithgreatersocialimpairmentandlowerToM abilitythantheirverbalcounterparts.Emotionalregulationandhyperactivityandattentionaldifficulties(HAD)significantlypredictedToM abilityandsocialdifficulties.LowerGrossMotorFunctionClassificationSystem(GMFCS)levelandIQalsocontributedtodifferencesinToM ability.

• Caillies etal(2012)“ResultsclearlyindicatethatchildrenwithCPencounterproblemswithrecursiveToM [secondorderfalsebelieftasks] andironycomprehension”

• Dahlgrenetal(2010)“CPchildrenperformedworsethanmatchednonCPcontrols”

• Falkman etal(2005) ”therearechildrenwithcerebralpalsywhofailtosolvetheoryofmindtasksirrespectivelyoftheverballoadingofthetasks”

• Lietal(2014)“Impairedtheoryofmindinthechildrenwithcerebralpalsyisreported”

Thissuggests

• IfChildrenwithCPinadditiontothosewhoarebornpre-term(before28weeksgestation)appeartohavedifficultywithToM development

• ItjusthastobethecasethatChildrenwithCVIhavedifficultywithToM – doesn’tit???

• (eventhoughthereisno[asyet]concreteresearchevidenceforthis)

Solutions

• SowhatdoesthismeanforPractitioners

MaybehelpcanbefoundthroughMirrorNeurons(Galleseetal.,1996;Rizzolattietal.,1996;RizzolattiandFadiga,1998;RizzolattiandCraighero,2004).

https://garfield.com/comic

ReallyInterestingStudy

• Ricciardi etal2009.DoWeReallyNeedVision?HowBlindPeople“See”theActionsofOthers.JournalofNeuroscience 2009, 29 (31) 9719-9724;

• CongenitallyBlindParticipantsN=8Meanage44Norecollectionofanyvisualexperience+congenitalglaucoma(n =5),retinopathyofprematurity(n =1),andcongenitalopticnerveatrophy(n =2).

• 14SightedParticipants

• FMRI

• Presented20actionand10environmentalsounds• MotorPantomimetask(participantstobevirtuallyhandedobjects/tools)

• PresentedalsowithMoviesandSound

• themirrorsystemcandevelopintheabsenceofsightandcanprocessinformationaboutactionsthatisnotvisual.

• congenitallyblindindividualsshowedactivationinapremotor–temporoparietal corticalnetworkinresponsetoaurallypresentedactions,andthisnetworkoverlappedwiththemirrorsystembrainareasfoundinsightedsubjects.

• Studieshavealsorevealedthatindividualswithnovisualexperiencerelyonsupramodal brainareaswithintheventralanddorsalextrastriatecortex,

Andsoifallofthisis“true”/“Correct”?????

• Ifmirrorneuronsareactivatedbyauditory(andthereissomeargumentfortactile)informationthenweagreewithvanDijk andothersthatusingtheMirrorNeuronSysteminalearningprogramfor(young)childrenwithdevelopmentaldelayorsensoryimpairment(s)opensnewperspectivesforsuccessfulhabilitationanddevelopmentofatheoryofmind.

Whatdoesthismeantothepractitioner

(1) prolongfacialexpressionswhilefacingthechild,(Mirroringtheface)(2) complementingemotionsthroughsimplesalientlanguage;(activationofmirroring)(3) speakclearlyaboutthechild'sexperiences,,prolongingexplosiveconsonants

(activiation ofmirroring)(2)chooseslow-movingunclutterededucationalmaterial;(activationofmirroring)(3)minimizevisualclutter,(whatareyoumirroring)(5)identifyandcaterforanyassociatedperipherallowervisualfieldimpairment;(cannotmirrorwhatyoucannotsee)(6)keepbackgroundnoisetoaminimum,especiallywhentalking;(Whatisbeingmirrored)

Dutton,2016,LueckandDutton2016etc………….

BacktoRepresentation

• WellIdonotknow“Whatitisliketobeabat”(Nagal,1974)

• Butwearebeginningtounderstandwhatform,functionandkindofmentalrepresentationchildrenwithcerebralvisualimpairmenthave

• Andtheevidenceleadsustosuggestthatthereisadeficitofatheoryofmindbutthatdeficitcanperhapsbereducedandevenoverturned.

• Butmoreresearchonthisisdefinitelyneeded.

Thanks

• Thankyouforindulgingmyramblings

• Ifyouwouldliketocommentorenhancethistalkinanywayletmeknow

• john.ravenscroft@ed.ac.uk

• BTWReferencesareavailableIjusthaven’taddedthemtothepowerpoint yet.Sorry.