Research Proposal: Theory of Mind Intervention Study

The following post contains a research proposal for an intervention study that aims to improve theory of mind development for children with cochlear implants. This proposal is built off of a substantial collection of recent research that has investigated theory of mind development for children with cochlear implants.

Mental-State Conversation Training as a Method to Advance Theory of Mind Development in Children with Cochlear Implants

Danni Davis
University of Texas at Dallas




Children with cochlear implants (CI) have delayed Theory of Mind (ToM) development relative to their normal-hearing (NH) peers. Delays in ToM development have been shown to predict negative outcomes, such as peer problems, externalizing, and internalizing behaviors for these children. Research shows that children with CI are exposed to less mental-state based conversation than their NH peers. Mental-state conversation is predicted to effect ToM development because it exposes children to the subjective desires and beliefs held by other people. This study will measure the impact of mental-state conversation training for parents on ToM development for their child with cochlear implants.

Keywords:  cochlear implants, theory of mind, mental-state based conversation

Mental-State Conversation Training as a Method to Advance Theory of Mind Development in Children with Cochlear Implants

Children with cochlear implants (CI) develop Theory of Mind (ToM) later than children with normal hearing (NH). ToM development is clearly linked to language development, and past research has shown that children with communicative issues, such as autism spectrum disorder, language disorders, or deafness, have significant delays in ToM development (Peterson & Siegal, 2000). Although a cochlear implant enables a child to hear sounds, the auditory sounds are not the same as normal hearing and the child still experiences delays in ToM development (Ketelaar, Rieffe, Wiefferink & Frijns, 2012). It is important to examine and improve ToM development in children with CI in order to help with their socialization during the highly formative years of early childhood. Children with delayed ToM development are more likely than their peers to have internalizing problems, externalizing problems and peer relationship issues (Caputi, Lecce, Pagni, & Banerjee, 2012; Sharp, 2008).

A child’s exposure to social interaction and language with their parents is essential to ToM development. It has been shown that language is a precursor to full ToM development and that the richness of the language within the interaction is particularly important (Astington & Jenkins 1999). Recent research has shown that parents of children with CI participate in less effective turn-taking and less mental-state conversations than parents of children with NH (Morgan & Meristo & Mann & Hjelmquist & Surian & Siegal, 2013). Mental-state based conversation is important to ToM development because it exposes the child to the thoughts, desires, and beliefs of another person. This study will build off past research on ToM development for children with CI by assessing the child’s ToM development over time when their parents are exposed to intervention training aimed to improve mental-state based conversation.

Developing a Theory of Mind

Theory of Mind (ToM) is a skill developed in early childhood that enables children to understand and react to the thoughts, feelings, and emotions of oneself and of others (Premack & Woodruff, 1978). Understanding the subjectivity of people’s intentions, desires, and beliefs is essential to social functioning. Theory of Mind is acquired through a series of developmental accomplishments that happen in a predictable sequence. For example, children learn to understand the intentions of another person before understanding the desires of another person (Wellman & Liu, 2004).

One of the earliest ToM tasks, intention, develops during the first year of a child’s life before language development. Intention is the ability of a child to understand that other people want certain things. The accomplishment of this developmental task can be seen when the child can follow another person’s gaze or pointing gestures. In this stage of development, the child learns that gestures such as gaze or pointing signify another person’s attention toward a specific object. It has been shown that this stage of development is relatively consistent between NH children and children with CI. Researchers suspect that this finding is related to the lack of language required to accomplish this developmental task (Ketelaar, Rieffe, Wiefferink & Frijns, 2012).

Desire is one of the next ToM tasks. Children typically develop desire understanding between the ages of two and three. Desire understanding is when a child understands that another person may prefer one thing over another. For example, if a person likes to swim they would most likely prefer to go to a pool over a park to play. If a child is asked where the person would like to go to play, the child will correctly choose pool when they have achieved this ToM development task.

Belief understanding tends to follow desire understanding for ToM and develops around the age of four. Belief understanding is when a person understands that another person may have different thoughts based on their perspective of an environment. For example, if a person places a box of cookies in a cupboard, and the box of cookies is moved to another location when the person is out of the room, the person will still look for the box of cookies in the cupboard. Until a child develops belief understanding, they will incorrectly guess that the person will look in the new location for the cookies because they incorrectly assume the person has the same perception as them. There is evidence to support the idea that early exposure to language helps with ToM development tasks that follow understanding the intentions of another person (Colonnesi, Reiffe, Koops, & Perucchini, 2008).

ToM Development for Children with CI

Children with CI have delayed ToM development apart from the first task of understanding intention. Longitudinal research is still needed to confirm that the development trajectory for children with CI is the same as children with NH. While most researchers make this assumption, it is possible that the path for ToM development is not only delayed, but follows a different trajectory (Wellman, 1990). There is some support for a difference in developmental trajectory based on age because of high cognitive flexibility within the brain that enables faster ToM development between the ages of three and six. Children who receive their first cochlear implant at an early age have better ToM development than children who receive a cochlear implant later (Sundqvist & Lyxell & Jonsson & Heimann, 2014). This unknown may have an impact on the relationship between mental-state conversations and ToM development for children with CI.

Research has shown that deaf children born to deaf parents do not have delays in ToM development and progress at the same rates as children with NH. This result is not surprising because deaf parents are expert communicators without verbal language. In this type of rich communication environment, the deaf child has access to mental-state based conversations with their parents that deaf children born to normal hearing parents do not have (Peterson & Siegal, 2000).  This finding supports the argument that ToM development is not directly related to a child’s ability to develop typical language skills. It suggests that something about the child’s environment is impacting ToM development.

When children enter preschool, the ToM developmental tasks of desire and belief have already been achieved by typically-developing children. This is not always the case for children with CI. The timing of this development may be of special importance because it coincides with the ages that children enter preschool and begin to interact in environments outside of the home. In social environments, such as preschool, negative outcomes associated with delayed ToM development can be especially problematic.

Current Proposal

The goal of this study is to assess changes in ToM development over time for children with CI when their parents participate in intervention training to improve the quantity and quality of mental-state based conversations with their child. This study will take a longitudinal approach to measuring ToM development for children before, during, and after mental-state based conversation training for their parents. This proposal hypothesizes that ToM will develop differently for children with CI when parents participate in mental-state conversation intervention compared to children with CI whose parents do not participate in the intervention.



The participants for this study will be parents and their child. The parents will participate in mental-state conversation training, activities with their child, and questionnaires. The child will participate in ToM development assessments and some mental-state conversation activities initiated by his or her parents. This study will recruit approximately 80 children between the ages of two and four. This age range is chosen because it overlaps with typical ToM development (Wellman & Liu, 2004). 20 of the children will be normal hearing, and 60 will have either a unilateral or bilateral cochlear implant. The ratio of participants with NH to participants with CI will enable there to be four groups with equal numbers of participants. Three of the groups will be comprised of children with CI. Children will be recruited through hospitals, counseling and rehabilitation services, or through after-school programs. This sampling method will be a productive way to get an unbiased sampling of children whose parents are already engaged in their child’s health and development at some level, which may increase the likelihood that parents will follow through with the training and activities required of this study. After the procedure details are finalized, this research will get approval by the university human subjects review board. All participants will be treated ethically. Informed consent will be obtained for parents participation in this study. Children will be asked to give verbal consent to participate.


This study will take a longitudinal approach to study the effects of an intervention activity on ToM development for children with CI. The intervention activity will be mental-state based conversation training for parents of children with CI. Children will be split into one of four groups: NH Control, CI Control, CI Low Treatment, and CI High Treatment. These groups will have repeated measures of ToM development taken at year zero, one, two, and three. Reference Table 1 for the proposed study setup.

The first step of the procedure will be to assess the ToM of all children to obtain a time-zero measurement for each child’s ToM development. Children will be randomly assigned to groups except for the NH Control Group. Parents selected for a treatment group will then begin the mental-state based conversation training specified by the treatment group they were placed in. Parents will follow the guidelines and activities from their training for one calendar year. During this time, they will keep a log that measures the consistency of their participation throughout the course of the year.

At the one-year mark, all children will repeat the ToM development evaluations. Also at year one, parents will have completed the training and activity sessions. The children from all groups will repeat ToM development testing at year two and year three. No controls will be put in place for repeated exposure to the same ToM tests. Because of the young age of these children, the one year window between testing should be sufficient to prevent any increase in testing scores due to repeat exposure. The longitudinal nature of this study has the potential to assist in the understanding of how intervention training may contribute to both short and long-term development.

Descriptions for the different study treatment groups, methods, and measures are shown below. The purpose of different groups is to begin to understand the quantity of mental-state conversation training and practice that is needed to have an impact on ToM development in children with CI. The methods and measures have been chosen because they have been well-received within the scientific community and have already been thoroughly vetted through other recent studies involving ToM, cochlear implantation, or deafness.

Treatment Description. If participants are selected for a treatment group, they will be exposed to mental-state based conversation training. This training will be broken out into different sections: a lecture-style class, a parent group practice class, and weekly home assignments.

The lecture-style class will be a 2-hour training class that describes ToM development and its dependence on language skills. Parents will be exposed to the concepts of turn-taking and mental-state based conversation. The lecture will provide information on relevant research and scientific support for the importance of this type of communication toward ToM development. After completing the lecture class, parents will then participate in a 4-hour parent group practice class, which consists of in-class instruction and practice structuring conversations to include mental-state descriptions. In-class practice will include workbook style independent work and interactive exercises with other parents. At the end of both training sessions, parents will be given reference materials, a participation log, and children’s books/videos that make heavy use of mental-state conversations. The parents will be instructed to spend a certain amount of time per week practicing mental-state conversations with their child and a specified amount of time per week exposing their children to the children’s books/videos. The amount of time spent on these activities will be determined based on the treatment group the parents have been assigned to. The participation log will be used to record the hours of activities completed per week.

For this study the treated participants will be a part of either the Low Treatment or High Treatment group. Details between the different treatment groups are described below and included in Table 2.

Low Treatment. The Low Treatment group will require less parental involvement and participation. The goal of this group is to disseminate information as quickly as possible and to give parents minimal weekly tasks that focus on facilitating mental-state environments for their child. The parents will spend 1-hour per week actively practicing mental-state conversations with their child and 3-hours per week exposing them to the children’s books and videos.

High Treatment. The High Treatment group will require more substantial parental involvement. The goal within this group will be to try to improve mental-state conversation training with a more thorough and time intensive approach. The parents will spend 2-hours per week practicing mental-state conversations with their child and 6-hours per week exposing their children to the children’s books/videos. In addition, the parents and child will participate in a 1-hour conversation training session each month to practice interacting with each other and to receive feedback from instructors.  It is possible that the time commitment required from this group may be problematic, and a structured reward system may be needed to ensure participation in the study.

Measures. Multiple measures will be collected to assess a child’s ToM development. A child’s understanding of intention for ToM development will not be measured in this study because this ability typically develops before children are using language, and it has been shown to have a similar development trajectory between children with NH and children with CI (Ketelaar, Rieffe, Wiefferink & Frijns, 2012).

Desire. A child’s understanding of desire for ToM development will be measured with Common and Uncommon-Desire Tasks (Rieffe, Meerum, Koops, Stegge, & Oomen, 2001). For the Common-Desire Task, the child will be shown a picture card of a more and less desirable food item (ex. broccoli and ice cream). They will first be asked which item they like to eat. Afterwards, a boy character will be introduced who likes the same food as the child. The child will be asked to point to the picture card with the food the boy would prefer to eat by using the test question “Which food will the boy pick?” The Uncommon-Desire Task will follow the same structure except the boy character will prefer to eat the food that the child did not select. Two control questions “Does the boy like [food A]?” and “Does the boy like [food B]?” will also be asked. The child will be given one point for each correct answer. If all questions are answered correctly the child will receive a score of 3. This scenario will be repeated three times for both the Common-Desire and Uncommon-Desire Tasks. The mean score for the Common-Desire and Uncommon-Desire task will be used for analysis.

Belief.  A child’s understanding of belief for ToM development will be measured with the False-Belief Task (Sundqvist & Ronnberg, 2010).  This task will have two characters, a boy named John and his mother. John will put a box of cookies in a blue cupboard and then leave the room. While John is away, his mother will move the cookies to a yellow cupboard across the room. John will return to the room and the child participant will be asked the test question “Where will John look for the cookies?” and two control questions: “Where are the cookies?” and “Where did John put the cookies when he went away?” Children will receive one point per correct response.

Controls. In addition to common controls (ex. gender, SES), this study will control for child age, age of first CI, child non-verbal intelligence, child language skills, any other disabilities for the child, and parent language skills. It is important to pick up any sample variation that may be related to the age or language abilities of the child or parent. Language skills are one of the characteristics known to have significant variation between children with delayed ToM development compared to typically developing children.


In order to examine the hypothesis, that Theory of Mind development for children with CI can be altered with parental mental state based conversation training, a mixed repeated measures ANOVA will be conducted.

The specifics of the analysis used for this study will be finalized based on the number of participants and the quality of data collected. Based on our sample, we will determine if only one treatment group should be used to have high quality statistical results.

Results and Discussion

The Results section of this study will follow traditional structure and formatting. Details about the data and analysis will be discussed in detail with supporting tables and graphs as needed. Any unusual findings will be reported.

The Discussion section of this study will evaluate and interpret the results with emphasis on the relation to the study’s hypothesis. For this work, it will be highly relevant to reflect on the realistic application of mental-state conversation training to populations larger than the study group. Growth in the scientific communities’ knowledge about improving ToM development has wide-spread, real world applicability that will be both valuable and exciting to share with the greater community.


Astington, J. W., & Jenkins, J. M. (1999). A longitudinal study of the relation between language and theory-of-mind development. Developmental Psychology, 35, 1311-1320.

Caputi, M., Lecce, S., Pagni, A., & Banerjee, R. (2012). Longitudinal effects of Theory of Mind on later peer relations: The role of prosocial behavior. Developmental Psychology, 48, 257 – 270.

Colonnesi, C., Reiffe, C., Koops, W., & Perucchini, P. (2008). Precursors of a theory of mind: A longitudinal study. British Journal of Developmental Psychology, 26, 561 -577.

Ketelaar, L., Rieffe, C., Wiefferink, C. H., & Frijns, J. M. (2012). Does hearing lead to understanding theory of mind in toddlers and preschoolers with cochlear implants. Journal of Pediatric Psychology, 37(9), 1041 – 1050.

Morgan, G., Meristo, M., Mann, W., Hjelmquist, E., Surian, L., & Siegal, M. (2013). Mental state language and quality of conversational experience in deaf and hearing children. Cognitive Development, 29, 41 – 49.

Peterson, C. C., & Siegal, M. (2000). Insights into theory of mind from deafness and autism. Mind & Language, 15(1), 123 – 145.

Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences, 1, 515-526.

Rieffe, C., Meerum, M. T., Koops, W., Stegge, H., & Oomen, A. (2001). Preschoolers’ appreciation of uncommon desires and subsequent emotions. British Journal of Developmental Psychology, 19, 259-274.

Sharp, C. (2008) Theory of Mind and conduct problems in children: Deficits in reading the “emotions of the eyes.” Cognition and Emotion, 22, 1149 – 1158.

Sundqvist, A., Lyxell B., Jonsson R., & Heimann, M. (2014). Understanding minds: Early cochlear implantation and the development of theory of mind in children with profound hearing impairment. International Journal of Pediatric Othorhinolaryngology, 78, 538 – 544.

Sundqvist, A. & Ronnberg, J. (2010). Advanced theory of mind in children using augmentative and alternative communication. Communication Disorders, 31, 86 – 97.

Wellman, H. M. (1990). The child’s theory of mind. Cambridge, MA: MIT Press.

Wellman, H. M., & Liu, D. (2004). Scaling of theory of mind tasks. Childhood Development, 75, 523-541.



Table 1

Proposed Study Setup

ToM Assessment
Group Participants (Children) Year 0 Year 1 Year 2 Year 3
NH Control 20 with NH # # # #
CI Control 20 with CI # # # #
Low Treatment 20 with CI # # # #
High Treatment 20 with CI # # # #

# = ToM scores that will be measured with the proposed study

Note: This is the proposed setup for the study. Details may change if stronger statistical results are needed or if participants drop out or need to be excluded from a group.




Table 2

Treatment Group Details

Activity Low Treatment High Treatment
Lecture-style Class 2 hrs. 2 hrs.
Parent Practice Class 4 hrs. 4 hrs.
Home Practice 1 hr./week 2 hrs./week
Home Materials 3 hrs./week 6 hrs./week
Parent/Child Practice Class 1 hr./month


Note: The Low Treatment and High Treatment group will participate in the same Lecture-style Class and Parent Practice class. The Home Practice and Home Materials instructions, books, and videos for both groups will be the same but the weekly hours will be different. The Low Treatment group will not participate in the Parent/Child Practice Class.