Theory of Mind in Children with Fetal Alcohol Spectrum Disorders

Background Theory of mind (ToM) refers to the ability to understand and make inferences about other people's intentions, feelings, and beliefs. Although children with fetal alcohol spectrum disorders (FASD) are known to have deficits in social‐cognitive function, little is known about ToM in FASD. Methods ToM ability was assessed using a developmentally sensitive ToM battery, including the reading the mind in the eyes (RME) test, a measure of mental inferential ability that has been found to be impaired in other clinical populations. IQ and executive function (EF) were assessed as potential mediating variables. The battery was administered to 63 children (aged 9 to 11 years) from Cape Town, South Africa, whose mothers had been prospectively recruited during pregnancy. Children with fetal alcohol syndrome (FAS; n = 8) and partial FAS (PFAS; n = 19), as well as nonsyndromal heavily exposed children (n = 17), were compared to children born to abstaining or light drinkers (n = 19) from the same community. Results No FASD group differences were found on the less challenging ToM tasks. By contrast, children with FAS and PFAS performed more poorly than controls on a more challenging ToM task, the RME test. A continuous measure of prenatal alcohol exposure (PAE) was more sensitive than FASD diagnosis in that it was related to 4 higher‐order ToM measures, particularly the ability to attribute mental states assessed on RME. IQ only partially mediated the effect of exposure on RME performance, and these effects were not mediated by EF. Hence, the data suggest that these ToM measures tap into a specific alcohol‐related social‐cognitive deficit that does not merely reflect poorer EF. FASD diagnosis and PAE were each also related to RME after control for attention deficit/hyperactivity disorder. Conclusions These findings suggest that deficits in higher‐order ToM function may play a significant role in the social‐cognitive behavioral impairment in FASD. Fetal alcohol spectrum disorders (FASD) diagnosis and prenatal alcohol exposure were each related to deficits on the Reading the Mind in the Eyes task, indicating a deficit in affective information processing, even after control for the child IQ, executive function, and Attention Deficit/Hyperactivity Disorder. These findings suggest that deficits in higher‐order theory of mind function, specifically mentalizing through eye expression, may play a significant role in the behavioral impairment often described clinically in