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ABSTRACT
Background: This study focused on the linguistic consequences of damage to Theory of Mind (TOM) in patients after Traumatic Brain Injury (TBI). It was designed to extend a previous study that tested the consequences of TOM impairment (aTOMia) on referring abilities in right-hemisphere damaged patients.
Aims: To explore whether aTOMia in patients with TBI affects their use and comprehension of various referring expressions (definite and indefinite noun phrases, proper names and pronouns).
Methods and Procedures: We identified individuals with TOM impairment (aTOMia) in a group of 15 TBI patients using a battery of six types of TOM task. We then tested two groups of TBI patients: participants with aTOMia and participants without aTOMia, compared to a control group of non brain-damaged participants. Four TOM-related language tasks assessed their ability to vary the use of referring expressions according to the knowledge of the discourse partners.
Outcomes and Results: Five of the participants showed TOM impairment (aTOMia), whereas ten showed intact-TOM ability. The two groups did not differ according to most neuropsychological measures, or on grammatical performance. On the TOM-related language tasks the participants with aTOMia performed consistently worse than the participants with TBI and intact-TOM, and the control group.
Conclusions: Individuals after TBI do not form a homogenous group regarding their TOM abilities. Some patients show TOM-related language impairment, and should be considered for language evaluation and treatment focusing on aspects of language that depend on TOM ability.
Acknowledgments
We thank Ilil Dayan for her help in the data collection and Mali Gil for her support throughout the study. We also thank Naama Friedmann for the fruitful discussions concerning the research.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. In Balaban et al. (Citation2016b) the battery used included two additional categories. One of them (surprise) was removed because it introduced situations that were later evaluated as very common (surprise party/trip) that might be reasoned about in reference to individual personal experience. Accordingly, they were not sensitive to TOM difficulties compared with the other higher order categories. The second category (empathy) was removed because it tested very similar aspects as the second order story. In the current application of the battery we introduced two different stories to test second order false belief instead of two questions on one story in the original version. In the original version, we used one story to reduce the cognitive load of presenting two scenarios. In later discussion, we thought that an unequal number of questions about each story might create a different type of cognitive load in itself. Accordingly, in the current version we equated the number and type of questions presented for each scenario. We compared the scores of the control group that were tested in Balaban et al. (Citation2016b) to the control group of the current study on each category of the aTOMia battery that was used in the current study, using Mann Whittney non-parametric comparison. There was no significant difference on any of the categories (false belief – U = 84, p = .5; second order false belief – U = 73, p = .6, Instruction – U = 67, p = .2; faux pas – U = 72, p = .3; gaps of knowledge – U = 84, p = .5; mental cartoons – U = 79, p = .4).
2. Five of the six categories included a justification question (Why do you think that.?) for each of the two items. Justifications were not elicited in the first order false belief items because it was not a part of the traditional task.
3. Two of the items included C-command relations between constitutes. For more about the well-preserved syntactic abilities of patients with right brain damage and aTOMia see Balaban, Belletti, et al. (Citation2016).
4. A one-way ANOVA comparing age and education in the three groups of participants (with aTOMia, with intact-TOM, and control) did not reveal any significant difference between groups (p > .05). Most importantly, there was no difference between the two groups of TBI patient – with aTOMia and without aTOMia.
5. The Mann-Whitney non-parametric test and the Crawford and Howell’s t-test, reported above, are two different measures that complement one another – the first is used for group analysis and the second for individual analysis.
6. This analysis complements and elaborates the coding applied on the aTOMia battery (as described on the Method section), by analysing the type of justification produced by the participants. Importantly, testing of high order TOM abilities must rely on justifications, because we cannot infer from a yes/no correct answer whether the participant considered the state of mind of others in her reflection on the question. For that purpose, the participant should show explicit reflection on the thoughts or state of knowledge of others – by providing a justification. This has been introduced to the literature in the pioneering paper by Perner and Wimmer (Citation1985) and it is considered standard procedure at least since Happé’s seminal paper (Citation1994).
7. The verb “enjoy” is considered a mental verb because it denotes a subjective inner world experience (as opposed, for example, to “laugh” or “give” that denote behaviour).