J Autism Dev Disord

DOI 10.1007/s10803-015-2576-5

BRIEF REPORT

Brief Report: Translation and Adaptation of the Theory of Mind

Xavier Estrada1 • Marta Aceña1 • Araitz Petrizan1 • Lurdes Duñó1 •

Ó Springer Science+Business Media New York 2015

Abstract The Theory of Mind Inventory is an informant Individuals with a deficit in ToM have difficulties to
measure designed to evaluate children’s theory of mind determine the intentions of others, to understand how their
competence. We describe the translation and cultural behavior affects others, and dealing with social reciprocity
adaptation of the inventory by the following process: (1) (Baker 2003).
translation from English to Spanish by two independent Mentalizing deficits have been described in different
certified translators; (2) production of an agreed version by pathologies of psychiatric (e.g., schizophrenia, attention
a multidisciplinary committee of experts; (3) back-trans- deficit with hyperactivity disorder, anorexia nervosa,
lation to English of the agreed version by an independent bipolar disorder, etc.) and neurological origin (e.g.,
translator; (4) discussion of the semantic, idiomatic, and Parkinson’s disease, Huntington Chorea, multiple sclerosis,
cultural equivalence of the final version; (5) elaboration of head injuries, etc.) or genetic diseases (e.g., Fragile X,
the final test; (6) pilot test on 24 representatives of the Turner syndrome, Prader-Willi syndrome, etc.) (Abu-Akela
autism spectrum disorders population and 24 representa- and Shamay-Tsoory 2011). However, more extensive
tives of typically developing children. The steps were research and development of ToM has focused on patients
conducted satisfactorily, producing the final version in affected by autism spectrum disorders (ASD) (e.g., Baron-
Spanish, which showed good psychometric properties. Cohen 2000; Baron-Cohen et al. 1985; Leslie 1987).
The development of this complex construct has gener-
Keywords Theory of mind
Social cognition
Autism ated a great variety of methods to assess ToM (Baron-
spectrum disorder
Assessment
Adaptation
Translation Cohen 2000; Sprung 2010), which, although useful to
assess concrete tasks, also have some limitations (Hutchins
et al. 2008; Hutchins et al. 2012). Most of the tasks follow
Introduction the same standard structure: a story in which the protago-
nist finds him/herself in a certain situation is presented to
Theory of mind (ToM) is the ability to attribute mental the participant. The participant must infer the state of mind
states—beliefs, intentions, desires, pretense, knowledge, of the protagonist or predict his/her behavior.
etc.—to oneself and others and to understand that other In spite of the great complexity and dimensionality of
people have beliefs, desires, and intentions that are dif- this construct, the traditional tasks (e.g., the Sally–Anne
ferent from one’s own (Premack and Woodruff 1978). task) are simply scored dichotomically (pass/fail). In con-
trast, the mindreading we all perform in our daily social
interactions is a highly complex phenomenon, involving
& Elena Pujals simultaneously attending to multiple social stimuli, such as
[email protected]
different people, the gaze, tone of voice, bodily gestures,
1
Neuropsychiatry and Drug Addiction Institute, Parc de Salut and situational aspects that can modulate the interaction,
Mar, Passeig Marı́tim n. 25-29, 08003 Barcelona, Spain and requiring different attributions to be assigned in par-
2
Department of Psychiatry and Forensic Medicine, Universitat allel. The correct appraisal of social situations requires
Autònoma de Barcelona (UAB), Bellaterra, Spain giving rapid responses; late reactions are considered

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socially inept, which may explain why some high-func- their degree of agreement with each statement at the
tioning patients with ASD present deficient social func- appropriate point along the continuum. Responses for each
tioning in spite of passing even advanced mentalizing tasks item are scored with a ruler (possible range = 0–20) and
(Slaughter and Repacholi 2003). This complexity is not averaged, with higher values reflecting higher certainty that
represented in the classic tasks to evaluate ToM. the target child possesses ToM knowledge of the surveyed
In spite of the fact that the classic tasks may correlate content. The following mentalizing skills are assessed by
with the observations of an individual’s social functioning the inventory: pretense, desire, and intentionality, distinc-
(e.g., Frith et al. 1994; Lalonde and Chandler 1995), the tions between appearance and reality, causes of emotions,
very nature of these tasks makes it very unlikely for the mental-physical distinctions, knowledge that seeing leads
social situations they describe to occur in real life (Ast- to knowing, first- and second-order thinking, visual per-
ington 2003; Klin et al. 2000). In the classic mentalizing spective-taking, affective recognition, empathy, social and
tasks, the interviewer asks the individual about unknown logical inference, comprehension and production of mental
characters, presenting a hypothetical situation that is usu- state terms and acts, the ability to understand humor, sar-
ally of little interest to the participant and that contains all casm, counterfactual reasoning, and the distinction
the necessary details for its resolution. Real life social between jokes and lies and knowing and guessing. The
situations take place in very different circumstances: the ToMI had adequate reliability and validity in both ASD
interactions occur in family environments of great emo- and typically developing children, showing a very high
tional significance for the individual (e.g., home, school), consistency (a = 0.98), estimated with Cronbach’s alpha
and involve one or more people from the environment (Hutchins et al. 2012). The measure performed well and
(e.g., teachers, parents, siblings, classmates) (Astington established strong test–retest reliability for short and long
2003). The individual will have to choose the necessary intervals, as well as convergent validity with scores on a
information to respond adequately to social situation. measure of receptive vocabulary (Peabody Picture Vocab-
Research conducted with high- functioning individuals ulary Test-4) and on a ToM task battery. Compared to
with autism show that they can pass standard tasks of false traditional measures, in the ToMI, responses are scored on
beliefs, but they have difficulties in day-to-day social a continuum, not dichotomically, it has no ceiling effect in
functioning, suggesting that they do not necessarily use individuals with ASD, and it is not affected by the child’s
these skills in their daily social interactions (Slaughter and situational or motivational factors, or by cognitive or lin-
Repacholi 2003). guistic factors. It also assesses a broad array of mentalizing
In individuals whose mentalizing abilities are relatively skills based on concrete examples of behaviors that occur
good, the traditional tasks, both standard and advanced in real life, not in artificial or laboratory conditions, thereby
measures, may present ceiling effects (Slaughter and reflecting the subject’s real functioning (Hutchins et al.
Repacholi 2003), as most of them were designed for use 2012, 2008). The instrument is administered to the
with children aged 4–6 years. patient’s parents or main caregivers. They are considered
Lastly, task administration is limited by the patient’s expert informants because, through their observation of
cognitive and linguistic abilities (Welman et al. 2001), daily situations, they accumulate considerable data about
excluding the possibility of studying children affected with the children’s social functioning and mentalizing abilities
non-verbal ASD or with limited cognitive and verbal skills. (Hutchins et al. 2008) and their skills, strengths, and dif-
Situational and motivational factors (Tager-Flusberg 1999) ficulties (Crais 1993; Prelock 2006; Prelock et al. 1999;
also interfere. It has been shown that correct performance of Shelton and Stepaneck 1994).
a mentalizing task can improve if it is associated with posi- The goal of this study is to adapt and validate the ToMI
tive reinforcement or if the participant engages actively in in the Spanish language spoken in the territory of Spain, in
the task (e.g., the participant is asked to choose the materials, order to apply this instrument to individuals with ASD and
the content, or the activity to carry out) (Beeger et al. 2003). assess their mentalizing abilities. In this article, we
In an attempt to address the broad variety of the ToM describe the first steps of its validation in Spanish, con-
construct and the limitations of the classic ToM tasks, sisting of the translation and cultural adaptation of the
Hutchins and colleagues developed a unique measuring inventory.
instrument: the Perception of Children’s Theory of Mind
Measure (Hutchins et al. 2008), the original instrument
from which derives the current Theory of Mind Inventory Methods
(ToMI; Hutchins et al. 2012). The instrument consists of 42
statements, accompanied by a response continuum of 20 Before beginning the process of adaptation and validation,
metric units anchored by Definitely not and Definitely with we contacted the authors of the original instrument,
a center point of Undecided. Caregivers are asked to mark Hutchins, Prelock, and Bonazinga, to obtain their consent.

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Subsequently, the following process of translation and Spanish. A few modifications of the original version were
adaptation of the ToMI was carried out: (1) translation carried out, mainly concerning the idiomatic equivalence
from English to Spanish by two independent certified and the experimental or cultural equivalence, which
translators, one of them a Ph.D. in psychology; (2) pro- involves peculiar idioms, phrases, or words of certain
duction of an consensual version by a multidisciplinary cultures. As the ToMI assesses advanced mentalizing skills
committee of experts that included two psychiatrists, two such as meta-linguistic skills, which include the non-literal
psychologists, and a nurse specialized in child and juvenile use of language like sarcasm, irony, humor, and wordplay,
mental health, all of them native Spanish speakers and these items had to be adapted specifically to the Spanish
fluent in English; (3) back-translation to English of the language spoken in the territory of Spain. The main items
agreed version by an independent certified translator; (4) subject to this process are shown in Table 1. The complete
discussion of the semantic, idiomatic, and cultural equiv- version of the ToMI is presented in Appendix.
alence of the final version of the questionnaire by a mul-
tidisciplinary committee of experts to ensure that the Pilot Test Results
translation retains the meaning of the original English
version (5) elaboration of the final text; (6) pilot test in Caregivers of the individuals with ASD reported that the
order to assess item comprehension, guidelines to complete inventory was easy to fill out. The items were considered to
the questionnaire, and the questionnaire format, as well as be understandable, and no relevant errors in its adminis-
to perform a preliminary statistical analysis and assess its tration were produced.
reliability. For patients with ASD, the values of the ToMI ranged
For the pilot study, we administered the ToMI to the between 8.47 and 19.7 (M = 13.29, SD = 3.54). For the
caregivers of n = 24 patients diagnosed with ASD at fol- normally developing population, the ToMI values ranged
low-up in the Mental Health Center for Children and Youth from 12.62 to 19.67 (M = 16.4, SD = 2.22). The group
of Sant Martı́ Nord (Barcelona). On the basis of the clinical differences in the composite score of the ToMI were sig-
interview and the administration of supplementary assess- nificant (p = 0.006).
ment instruments such as the Autism Diagnostic Interview- Internal consistency was assessed using Cronbach’s
Revised (ADI-R; Rutter et al. 2003) and the Autism alpha which resulted in a very high estimate of consistency
Diagnostic Observation Schedule (ADOS; Lord et al. of content (a = 0.96).
1999), the diagnoses of the patients according to DSM-IV-
TR criteria were: Autistic Disorder (n = 7), Asperger
Syndrome (n = 6), and Pervasive Developmental Disabil- Discussion
ity-Not Otherwise Specified (n = 11). The children were
20 males (83.3 %) and 4 females (16.7 %), who ranged in The process of translation and adaptation described herein
age from 4 to 14 years (M = 8.38, SD = 2.931). All of the led to the production of the Spanish version of the ToMI,
children were characterized as verbal (uses language in a an instrument that assesses ToM as it is conceived in the
variety of ways to communicate with others) according to literature, that is, a broad and multifaceted construct.
parents’ reports. It is important to point out the linguistic specificity of
For the control sample of normally developing indi- this instrument. The ToMI includes items that assess meta-
viduals, we chose n = 24 controls matched in age and sex pragmatic skills such as sarcasm, irony, sayings, and puns.
with the clinical sample, from a school in the region. We These uses of language are subject to relevant cultural
ensured the absence of general psychopathology in this factors. The adaptation is made in the Spanish language
group through the concomitant administration of the Child spoken in the territory of Spain, so most of the items are
Behavior Checklist—CBCL (Achenbach and Rescorla not suitable for Spanish-speaking patients from other ter-
2001). We ruled out the existence of ASD through the ritories such as Latin America. Due to this characteristic of
administration of the Social Communication Questionnaire the instrument and to its great utility to assess mentalizing
(SCQ; Rutter et al. 2005). tasks, it is currently being translated to other varieties of
Spanish, such as the Mexican and Chilean dialects, and
other languages (see the web site of the original instrument
Results www.theoryofmindinventory.com).
In the statistical analysis performed in the present study,
Results of the Translation Process the inventory displays good internal consistency (Cron-
bach’s alpha = 0.96), comparable to that observed in the
All the steps of the translation process were conducted study of Hutchins et al. (2012), which was a = 0.98. This
satisfactorily, producing the final version of the ToMI in latter study applied the ToMI to n = 104 caregivers of

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Table 1 Original version and final version in Spanish of the items subject to discussion in the cultural adaptation
Item Original version Version in Spanish
no.

2 If it were raining and I said in a sarcastic voice ‘‘Gee, it looks like a Si estuviera lloviendo y yo dijera con una voz sarcástica, ‘‘Jolı́n,
really nice day outside’’, my child would understand that I didn’t qué tiempo tan bueno hace’’, mi niño/a comprenderı́a que yo
actually think it was a nice day realmente no pensaba que hacı́a buen tiempo
13 If I said ‘‘Let’s hit the road!’’ my child would understand that I Si yo dijera ‘‘¡Levantemos el vuelo!’’ mi niño/a comprenderı́a que
really meant ‘‘Let’s go!’’ yo realmente querı́a decir ‘‘¡Vámonos!’’
36 If I said ‘‘What is black, white and ‘read’ all over? It’s a Si yo dijera ‘‘Oro parece. Plata no es. >Qué es? ¡Plátano!’’ mi niño/
newspaper!’’ my child would understand the humor in this play a comprenderı́a el humor en este juego de palabras
on words

patients with ASD. The sample of patients with ASD The development of the ToMI is a great advance in the
included a large proportion of patients diagnosed with study of mentalizing skills. Its good psychometric proper-
Autistic Disorder (55 %), and the rest were diagnosed with ties detected in different studies (Hutchins et al. 2012,
PDD-NOS (22.2 %), and with Asperger Syndrome 2008) reveal the ToMI to be a valid and reliable instrument
(21.5 %). Of the total assessed patients, 32.5 % of them that can be used in assistential clinical practice or in
were considered non-verbal or with limited verbal skills. research as an alternative to the traditional ToM tasks. This
The values obtained for the ToMI ranged between 1.1 and is a simple and easy-to-use instrument, which includes a
19.95 (M = 10.8, SD = 4.5). In our sample of patients wide variety of mentalizing abilities and can be used in
with ASD, the ToMI scores were higher (M = 13.29, ASD population without having to take the patient’s lin-
SD = 3.54). This difference could be explained by the guistic or cognitive abilities into account. In addition, it is
differences in the two samples. In our ASD sample, the particularly sensitive in the detection of difficulties in
proportion of patients with a diagnosis of Autistic Disorder patients with relatively good meta-representation skills, so
is lower (29.2 %), and all of the patients included in the it could be useful as a screening instrument to detect
sample were considered to be verbal. These features can patients suffering from ASD.
influence the clinical severity of the sample, so a greater In patients with ASD, the identification through the
mentalizing capacity and higher scores in the ToMI are to ToMI of specific deficits in certain mentalizing abilities
be expected. could have important implications in their treatment,
The present study assesses the psychometric properties allowing the development of more individual intervention
of the ToMI instrument in a Spanish sample for the first plans that are better adapted to the specific needs of each
time. In addition to showing good internal consistency, the patient.
ToMI score was significantly lower in individuals with
ASD compared with normally developing population, Acknowledgments The authors would especially like to thank the
participant families for their valuable collaboration, the valuable time
indicating some concurrent validity. However, new studies they spent completing the questionnaires, without which the present
are needed to provide temporal stability (test–retest relia- study of adaptation and validation would not have been possible.
bility) and evidence of validity, for example, the relation-
ship of the instrument with other standardized measures of Author contribution EP conceived of the study, participated in its
design and coordination and drafted the manuscript; XE, MA and LD
mentalization in Spanish population (convergent validity). participated in the design and interpretation of the data; SP, AP, JM,
Likewise, for the complete validation of the ToMI to the LMM and VP participated in the design and coordination of the study
Spanish population, the ASD and normally developing and performed the measurement; EC participated in the design of the
samples should be expanded in a subsequent study, and study and performed the statistical analysis; SB conceived of the study,
and participated in its design and coordination and helped to draft the
factor analysis should be conducted to replicate the results manuscript. All authors read and approved the final manuscript.
observed in the original study of Hutchins et al. (2012).
The study of mentalizing skills in psychiatry has been an
object of study of great interest, especially in patients suf- Appendix: Inventario de la Teorı́a de la Mente
fering from ASD (e.g., Baron-Cohen 2000; Baron-Cohen (ToMI)
et al. 1985; Leslie 1987), because the deficit in ToM skills
has been considered a key symptom in these patients. The 1. Mi niño/a comprende que cuando alguien se pone una
traditional measures of mentalizing skills have important chaqueta, probablemente es porque él/ella tiene frı́o.
limitations (Hutchins et al. 2012, 2008), so the development 2. Si estuviera lloviendo y yo dijera con una voz
of new instruments is an imperative clinical need. sarcástica, ‘‘Jolı́n, qué tiempo tan bueno hace’’, mi

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niño/a comprenderı́a que yo realmente no pensaba que 19. Mi niño/a comprende que las personas no siempre
hacı́a buen tiempo. dicen lo que piensan porque no quieren herir los
3. Mi niño/a se da cuenta cuando alguien necesita ayuda. sentimientos de los demás.
4. Mi niño/a comprende que cuando alguien dice que 20. Mi niño/a comprende la diferencia entre mentiras y
tiene miedo de la oscuridad, no querrá entrar en un bromas.
cuarto oscuro. 21. Mi niño/a comprende que si dos personas miran el
5. Mi niño/a comprende que las personas pueden mismo objeto desde un punto de vista diferente, verán
equivocarse con respecto a lo que otras personas el objeto de diferentes formas.
desean. 22. Mi niño/a comprende que las personas a menudo
6. Mi niño/a comprende que cuando las personas tienen pensamientos sobre los pensamientos de otras
fruncen el ceño, se sienten diferentes de cuando personas.
sonrı́en. 23. Mi niño/a comprende que las personas a menudo
7. Mi niño/a comprende la palabra ‘‘pensar’’. tienen pensamientos sobre los sentimientos de otras
8. Si yo dejara mis llaves encima de la mesa, me personas.
marchara del cuarto y mi niño/a cogiera las llaves y 24. Mi niño/a comprende si alguien hace daño a otro a
las metiera en un cajón, él/ella comprenderı́a que propósito o por accidente.
cuando yo volviera, el primer sitio donde buscarı́a mis 25. Mi niño/a se da cuenta cuando los demás se sienten
llaves es donde las dejé. felices.
9. Mi niño/a comprende que para saber lo que hay en 26. Mi niño/a puede jugar a que un objeto es un objeto
una caja sin marcar, tienes que ver o te tienen que diferente (por ejemplo, hacer como que un plátano es
contar lo que hay en esa caja. un teléfono).
10. Mi niño/a comprende la palabra ‘‘saber’’. 27. Mi niño/a se da cuenta cuando un interlocutor no está
11. Las apariencias pueden engañar. Por ejemplo, cuando interesado.
ven una vela en forma de una manzana, algunas 28. Mi niño/a comprende que cuando yo muestro miedo,
personas asumen primero que el objeto es una la situación es insegura o peligrosa.
manzana. Cuando tienen la oportunidad de exami- 29. Mi niño/a comprende la palabra ‘‘si’’ cuando se
narla más de cerca, la gente tı́picamente cambia de emplea hipotéticamente, como en la frase ‘‘Si yo
parecer y decide que el objeto realmente es una vela. tuviera el dinero, me comprarı́a una casa nueva.’’
Si mi niño/a estuviera en esta situación, comprenderı́a 30. Mi niño/a comprende que cuando una persona usa sus
que no era el objeto lo que habı́a cambiado, sino sus manos como un pájaro, la persona no cree realmente
ideas sobre el objeto. que sus manos sean un pájaro.
12. Si yo enseñara a mi niño/a una caja de cereales llena 31. Mi niño/a sabe inventarse historias para conseguir lo
de galletas y le preguntara ‘‘>Qué pensarı́a que que él/ella desea.
contiene la caja alguien que no hubiera mirado 32. Mi niño/a comprende que en un juego de escondite, no
dentro?’’, mi niño/a dirı́a que otra persona creerı́a quieres que te vea la persona que te tiene que buscar.
que hay cereales dentro de la caja. 33. Mi niño/a comprende que cuando una persona prom-
13. Si yo dijera ‘‘¡Levantemos el vuelo!’’ mi niño/a ete hacer algo, significa que la persona debe hacerlo.
comprenderı́a que yo realmente querı́a decir 34. Mi niño/a puede ponerse en el lugar de otras personas
‘‘¡Vámonos!’’. y comprender cómo se sienten.
14. Mi niño/a comprende que las personas pueden mentir 35. Mi niño/a comprende que cuando alguien comparte
con la intención de engañar a los demás. un secreto, no debes contárselo a nadie.
15. Mi niño/a comprende que cuando alguien hace una 36. Si yo dijera ‘‘Oro parece. Plata no es. >Qué es?
‘‘suposición’’ significa que está menos seguro/a que ¡Plátano!’’ mi niño/a comprenderı́a el humor de este
cuando ‘‘sabe’’ algo. juego de palabras.
16. Mi niño/a comprende que cuando alguien piensa 37. Mi niño puede mostrarme cosas.
sobre una galleta, en realidad no puede oler, comer, o 38. Mi niño/a puede prestar atención cuando yo le
compartir esa galleta. muestro algo.
17. Mi niño/a comprende que las personas pueden sonreı́r 39. Mi niño/a comprende la palabra ‘‘creer’’.
incluso cuando no se sienten felices. 40. Cuando alguien nos cae bien, es probable que
18. Mi niño/a comprende la diferencia entre un amigo que interpretemos su conducta de forma positiva y cuando
está tomando el pelo a alguien de forma agradable y no nos gusta, es probable que interpretemos su
un matón que está burlándose de alguien de forma conducta más negativamente. Mi niño/a comprende
desagradable. que nuestras ideas y/o opiniones previas sobre los

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demás pueden influenciar nuestra forma de interpretar Hutchins, T. L., Bonazinga, L., Prelock, P. A., & Taylor, R. S. (2008).
sus conductas. Beyond false beliefs: The development and psychometric
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