Journal of Deaf Studies and Deaf Education, 2016, 141–147 doi:10.1093/deafed/env058 Advance Access publication December 13, 2015 Empirical Manuscript
empirical manuscript
Empathy and Theory of Mind in Deaf and Hearing Children Candida C. Peterson University of Queensland Correspondence should be sent to Candida C. Peterson, School of Psychology, University of Queensland, Brisbane, Queensland 4072, Australia (e-mail: [email protected]).
Abstract Empathy (or sharing another’s emotion) and theory of mind (ToM: the understanding that behavior is guided by true and false beliefs) are cornerstones of human social life and relationships. In contrast to ToM, there has been little study of empathy’s development, especially in deaf children. Two studies of a total of 117 children (52 hearing; 65 deaf children of hearing parents) aged 4–13 years were therefore designed to (a) compare levels of empathy in deaf and hearing children, and (b) explore correlations of ToM with empathy in deaf and hearing groups. Results showed that (a) deaf children scored lower in empathy than their hearing peers and (b) empathy and ToM were significantly correlated for deaf children but not for the hearing. Possible reasons for these divergent developmental patterns were considered, along with implications for future research.
Empathy is fundamental to social cooperation and close relationships. In developmental psychology, empathy has been defined as “a vicarious affective response” (Feshbach, 1968, p. 133), “the ability to emotionally resonate with others’ feelings” (Jones, Happe, Gilbert, Burnett, & Viding, 2010, p. 1188) or, most commonly, as the experience of “an affective response more appropriate to someone else’s situation than one’s own” (Hoffman, 1987, p. 48). As such, empathy is a clearly conceptually distinct from cognitive perspective-taking, or theory of mind (ToM) which can be defined as a cognitive understanding of people’s thoughts, beliefs, and intentions. Indeed, empirical evidence shows that this is true not only behaviorally but also neurocognitively. For example, Shamay-Tsoory, Aharon-Peretz, and Perry (2009) conducted a neuroimaging study of adults with circumscribed brain damage to particular areas of the prefrontal cortex. Results revealed a double dissociation showing that empathic emotional contagion was localized in a different brain region from cognitive ToM. ToM is protypically assessed via standard inferential false belief tests (Wellman, Cross, & Watson, 2001) requiring predictions about how people with wrong information will behave. Most 3-year-olds fail these tests but most 5- to 6-year-old hearing children pass. By contrast, affective empathy emerges
considerably earlier, as seen in toddlers as young as 18 months becoming upset and attempting to comfort parents, peers, or infants who are in distress (Zahn-Waxler & Radke-Yarrow, 1990). In other words, whereas ToM involves “cool” cognition and abstract mental representation and takes 5 years or more to develop, empathy is fundamentally “hot,” emotionally charged and is present from as early as the second year of life. Methodologically, also, there is an important difference between the two. The assessment of ToM is straightforward since its operational definition is widely agreed to consist of (or at least include) success on laboratory false belief tests (Wellman et al., 2001). By contrast, assessing empathy is more complex. Techniques that have been used vary widely from study to study and operational definitions of the concept are somewhat inconsistent. Examples include (a) caregivers’ reports (e.g., Hudry & Slaughter, 2009), (b) direct behavioral observation in structured settings (e.g., by watching how the child being tested reacts when an experimenter feigns injury: Sigman, Kasari, Kwon, & Yirmiya, 1992) and (c) physiological reactivity to affect (e.g., changes in heart rate as a function of exposure to a film of someone being hurt: Sigman, Dissanayake, Corona, & Espinosa, 2003).
Received August 2, 2015; revisions received November 19, 2015; accepted November 21, 2015 © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
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The Link Between ToM and Empathy in Hearing Children In the case of typically developing hearing children, perhaps the most widely used is the first of these methods, namely reliance on the informed reports of observers who know the children well. Parents, peers, and teachers have many opportunities to observe children’s affective reactions to others’ distress and to notice their active efforts to offer comfort or alleviate the source of the upset. Thus, researchers can capitalize on this backlog of experience to obtain a picture of the child’s usual behavior in everyday social contexts that could potentially evoke empathy. Using this procedure, a number of studies have examined whether children’s cognitive ToM understanding correlates with their affective empathy. For example, using a peer nomination procedure, Astington and Jenkins (1995) defined empathy operationally as being kind and helpful to others who are upset. Preschool children who were named by classmates as frequently demonstrating this kind of empathy did not score any higher on false belief tests of ToM than those who were seen by peers as never or rarely empathic. Ford et al. (2011) used children’s own self-reports and likewise found no statistically significant correlation between 4-and 5-year-olds’ ToM test scores and their claims to experience empathic feelings (e.g., “seeing a child with no one to play with makes me sad.”) However, Peterson (2014) obtained different results using Roberts and Strayer’s (1996, p. 458) single-item global empathy measure. This measure offers a general description (“is empathic; generally sensitive and responsive to others’ emotions”) and caregivers report how true it is of their child. Peterson found that the ToM scores of typically developing children aged 3–12 years correlated significantly with their caregivers’ ratings on this global empathy measure, although age and verbal ability also contributed. Perhaps the direct and summative nature of Roberts and Strayer’s measure partly explains this positive result since Dadds et al. (2008) found no significant association between ToM (as reported by parents) and parents’ ratings of their children on multiple specific instances of empathy (e.g., “My child cries if he/she sees or hears another child crying.”) Overall, then, results of past research on hearing children appear somewhat mixed. Conceivably the nature of the empathy measure and/or ToM measures used and the age groups of the children may partly explain discrepancies among different studies’ results. Nevertheless, the question of whether ToM understanding is correlated with empathy in typical development is clearly not yet fully resolved. Further investigation of this issue will be useful and this is one of the subsidiary aims of the present study. Even more importantly, given that no known previous study has investigated whether deaf1 children’s empathy is correlated with their ToM understanding, this is a clear research need. In theory, the two might be unrelated to one another in deaf children. Or they might be closely related, perhaps even more so than in hearing children. Only empirical evidence can answer this intriguing question. Thus, exploring whether deaf children’s empathy correlates with their ToM understanding is a major goal of the present pair of studies. But first it will be useful to briefly review what is currently known about deaf children’s ToM understanding and about their empathy behavior via the previous research that has examined these two variables as separate entities.
Deaf Children’s Development of ToM and Empathy Considerable research over the past three decades has shown that many deaf children from hearing families are seriously
delayed in developing ToM understanding. In fact, these children often continue to fail false belief and other standard preschool ToM tests well into middle childhood and beyond (see Peterson, 2009 and Spencer, 2010, for reviews). Yet natively signing deaf children of deaf parents develop ToM understanding on the same early timetable as hearing children (e.g., Peterson & Siegal, 1999; Schick, deVilliers, deVilliers, & Hoffmeister, 2007; Peterson, Wellman, & Liu, 2005) implicating the sharing of conversation with family members via a mutually accessible language (either signed or spoken) in the timely mastery of ToM understanding (Peterson, Slaughter, Moore, & Wellman, in press; Peterson, Wellman, & Slaughter, 2012). Empathy in deaf children has been researched far less often than ToM. Indeed, a comprehensive literature search revealed only three studies that investigated individual differences in empathy among deaf children relative to hearing controls. The first, by Bachara, Raphael, and Phelan (1980) used a measure of empathy similar to Feshbach’s (1968) definition (above) but one that is somewhat controversial since, in other studies, the same test has also been dubbed a test of emotion understanding (e.g., Cutting & Dunn, 1999) or affective perspective-taking (e.g., Kurdek & Rodgon, 1975). In Bachara et al.’s version, children were exposed to affectively charged story vignettes (e.g., a boy gets lost in a shopping center) and attributions of emotions to self and the story protagonist were elicited. The sample, consisting of 21 deaf children aged 9–14 years from a bilingual (sign-plus-speech) residential school, scored below a 7-year-old hearing comparison group and, in absolute terms, had considerable difficulty empathizing with sadness and anger scenarios, responding incorrectly to these on between 30% and 40% of opportunities. In a similar vein, Wauters and Knoors (2008) found that deaf children scored lower than their hearing peers on a peer-nomination empathic helpfulness measure similar to Astington and Jenkins’ (1995: see above). The deaf children were also significantly less likely than hearing controls to engage in empathic helpfulness. The third study, by Ketelaar, Rieffe, Wiefferink, and Frijns (2013) compared young deaf children (mean age: 39 months) with cochlear implants (CI) to age-matched hearing children on two different measures of empathy. A problem for the interpretation of the study’s results was that the two empathy measures did not correlate significantly with one another for either the deaf group or the hearing group. Nevertheless, despite this, the authors were still able to validly conclude that these young deaf children were at least as empathic as their hearing peers. Specifically, a parent-report measure similar to that of many previous studies of hearing children (see above) showed that deaf and hearing children scored equally. On a behavioral observation measure, the deaf children spent even longer looking at an experimenter who was feigning distress than their hearing peers did. However, whether or not this reflected pure empathic sharing of the experimenter’s distress was unclear, especially since this behavioral measure did not correlate significantly with parent-reported empathy. Indeed, as the authors themselves pointed out, frequent looking at an adult’s face by deaf children with CI may have been due as much to reliance on visual cues for information access as to empathic distress. Nonetheless, irrespective of how these mixed findings of past research are interpreted, it is undeniable that the evidence so far on empathy in deaf children is very limited. Thus, further investigation of deaf children’s empathy relative to that of matched hearing groups’ is clearly needed. Examining this, together with studying possible links between empathy and ToM, are major goals of the present pair of studies.
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Study 1 Method Participants A total of 61 Australian children aged 4–12 years took part in Study 1, in two groups. Group 1 consisted of 30 prelingually severely or profoundly deaf children of hearing parents. Their mean age was 9.69 years (range 5.92–12.92) and 17 were boys. They were recruited from specialist bilingual units that used both of speech and Auslan signing as instructional media. They were chosen to represent the broad age range across which empathy is seen to develop in hearing children which (Hoffman, 1987). Units were housed in government-funded primary schools and most of these children shared classroom and playground experiences with mainstream hearing children for at least a few hours each week. Twelve (40%) of them had a CI. Group 2, the hearing control group, was likewise chosen to represent the broad range of ages through which empathy is seen to develop (Hoffman, 1987) including not only preschoolers but also older children in primary school who might have additional impetus to develop empathic feelings via daily exposure to classroom peer groups in primary school. Because this broad age range was advantageous for an exploratory study of this nature, the goal was not to match groups narrowly by age but rather to use age as a statistical control variable where necessary in group comparison analyses. Hence Group 2 included some younger children likely to match the deaf group in levels of ToM understanding as well as a substantial proportion (64%) of older age-matched primary-schoolers who would have had a similarly extensive exposure to full-day contact with a classroom peer group as the deaf children in Group 1. Overall there were 31 hearing children aged 4.25–10.50 years (mean age: 6.78; 18 boys) recruited from government-funded preschools and primary schools located in neighborhoods with similar socioeconomic (SES) catchments to those of Group 1’s primary schools. All children had written parental informed consent and all families used English as their sole or primary language. No Group 2 child had any diagnosed disability and none in Group 1 had any disability apart from hearing loss. There was no significant gender difference between the groups, χ2(1) < 1, p = .920. However, there was a significant age difference, t(59) = 5.41, p < .001. On average the deaf children were 3 years older than the hearing group. Thus, ANCOVA was used to control for age when conducting statistical comparisons between groups (see Results below). Measures and Testing Procedure All children were tested individually at school by an experienced male experimenter on a three-task false belief battery. For deaf children in Group 1 a professionally qualified (certified at the highest proficiency level) Auslan interpreter assisted the main experimenter by translating all the experimenter’s speech into Auslan and children’s Auslan responses into speech. This bilingual approach was desirable since, despite preferring Auslan, many Group 1 children also had limited vocal and auditory skills. In a separate private session, the child’s main classroom teacher completed a published questionnaire rating-scale measure of the child’s observed level of empathy. Language ability was assessed for Group 1 using teachers’ ratings of signing ability whereas Group 2 took a standard receptive vocabulary test. (This latter was unsuitable for Auslan signers, as explained below). Tasks and scoring were as follows.
ToM tests ToM understanding was assessed with a three-item battery. The first two items consisted of Baron-Cohen, Leslie, and Frith’s (1985) two-task “Sally-Anne” procedure with a boy doll replacing the second girl doll. Briefly, on each trial, the girl put her marble into a basket and left. The boy moved the marble to a box (Task 1) or the experimenter’s pocket (Task 2). The girl returned and the test question was: “Where will she look for her marble?” followed by two control questions which had to be passed, along with the test question, to pass the task. The third item was a misleading contents false belief task, presented exactly as described by Wellman and Liu (2004) except that the misleading container was a crayon box concealing a toy car. There was a test question “What does the [naïve] boy think is in the crayon box?” and a control question. Both had to be passed to pass the task. A total false belief score (TFB) ranging from 0 to 3 was the sum of scores on the three false belief items. Language ability To assess language ability in Group 1, the child’s main classroom teacher (a fluent signer) rated each child’s signing production and comprehension ability on a 5-point scale ranging from: 1 = little or no skill, 2 = modest skills adequate for basic everyday communication, 3 = quite skilled, 4 = very highly skilled, to 5 = excellent signing skills. For Group 2, verbal mental age (VMA) was assessed with the Peabody Picture Vocabulary Test (PPVT: Dunn & Dunn, 2007), a standardized receptive vocabulary test based on picture pointing responses. This test was unsuitable for the deaf children owing not only to lack of norms for Auslan but also other problems including the numerous words with either completely iconic signs (e.g., a point at the knee for “knee”) or no discrete sign translation at all in standard Auslan dictionaries. Of course the use of different language tests for deaf and hearing children precluded direct comparison between the groups’ linguistic maturity. But this was not a goal of the present study. Instead, the present purpose for including linguistic skill in the design was simply as a conservative precaution to be able to control statistically (within deaf and hearing groups separately) for any possible confounding effect general language skill might have upon the predicted association between the focal variables (empathy and ToM). All Group 1 children had full language data available but PPVT scores were missing for five hearing children in Group 2 owing to school absences and teachers’ reluctance to schedule additional testing sessions late in the school year. Empathy Teachers rated each child’s empathy using a slightly adapted version of Roberts and Strayer’s (1996; see also Strayer & Roberts, 2004) global measure. On a six-point continuous scale from 0 = “not at all true of this child” through 1 = “ a little bit true of this child”, 2 = “somewhat true of this child”, 3 = “often true of this child”, and 4 = “very often true of this child”, to 5 = “almost always true of this child”, the teacher responded to the item “ Is empathic: generally sensitive and responsive to others’ feelings (e.g., offering comfort to a child who is in distress)”. This single item global empathy rating has been used extensively with hearing children by Roberts and Strayer’s (1996; see also Strayer & Roberts, 2004) and others. Comprehensive validation data from several studies of typically developing hearing children of similar age to the present sample (e.g., Roberts & Strayer, 1996) have suggested that, when used by experienced teachers, this single-item summative measure performs well in validation against other empathy indicators including multi-item scales and behavioral observations.
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Results and Discussion Table 1 shows children’s mean scores on the ToM and empathy measures along with data on age and language ability. A preliminary analysis showed that raw empathy scores did not differ significantly between the groups, t(59) = 1.72, p = .092. (A nonparametric Mann–Whitney U test showed the same, U = 339.50, p = .056). However, it will be recalled (see Method section above) that deaf and hearing children differed significantly in age. Given that the deaf children were an average of 3 years older their equivalent performance might nonetheless reflect some delay behind hearing children. Thus, to conservatively examine the effect of hearing status directly upon empathy scores while controlling statistically for this group age difference, an analysis of covariance (ANCOVA) was conducted with chronological age as the covariate. Results revealed a statistically significant main effect for hearing-status group, F(1, 58) = 7.23, p = .009 (with hearing children earning higher empathy scores than deaf children their age) and a significant age covariate effect, F(1, 58) = 4.66, p = .035, such that for both groups combined empathy increased significantly with age. (The same age increase in empathy was also true for each group individually: see Table 2). In interpreting this significant group contrast, it is important to bear in mind that individual differences within each group were wide. In fact, 30% of the deaf children earned the highest empathy scores of 4 or 5 (“very often” or “almost always” empathic) as did 41% of hearing children, a nonsignificant difference: χ2(1) = 1.49, N = 61, p = .222. But, at the same time, 40% of deaf children had low empathy scores (0, 1, or 2) as contrasted with only 10% of hearing children, χ2(1) = 7.56, N = 61, p = .006. In other words, even though deafness itself did preclude the development of high empathy, these categorical results confirmed the ANCOVA findings that deaf children were perceived by teachers as lower overall in empathy than their hearing peers. A parallel ANCOVA with ToM total scores as the dependent variable showed a significant group effect, F(1, 58) = 36.26, p < .001, and a significant effect of the age covariate, F(1, 58) = 28.67, p < .001. Hearing children outperformed the deaf children in ToM understanding, consistent with much past research (see Peterson, 2009 and Spencer, 2010, for reviews) and ToM increased with age in both groups. Considering the deaf children separately, there was a highly significant simple bivariate correlation between ToM and empathy, r(28) = .51, p = .004. However, it fell to nonsignificance once the effects of age and sign language skill were statistically controlled via partial correlation, r(26) = .31, p = .113. Comparisons of boys with girls via t-test revealed no significant gender differences in either empathy or ToM: both ts < 1.00, both ps > .30. Similarly, there were no significant differences in either empathy or ToM between the 12 deaf children with CIs and the 18 without, both ts .30. For the hearing children, there was no significant bivariate correlation between ToM and empathy, r(29) = .10, p = .593 nor was empathy significantly correlated with VMA or gender, both ps > or = .198. Thus, an independent link between ToM understanding on standard laboratory measures and children’s ability
to express empathy in their everyday social relations with peers and teachers at school was not apparent for hearing children. However, before drawing firm conclusions, replication with a fresh sample of deaf and hearing children and alternative measures of empathy and ToM is desirable. This was one goal of Study 2. Other aims included: (a) to test closely age-matched deaf and hearing groups, (b) to compare deaf children with versus without CI, and (c) to examine any effects of mainstream hearing schooling versus daily contact with signing peers in bilingual units on deaf children’s ToM and empathy.
Study 2 Method Participants A total of 56 Australian children aged 5–13 years participated in Study 2, in two groups. Group 1 consisted of 35 prelingually severely or profoundly deaf children of hearing parents (mean age: 9.51 years; range: 5.67–13.33; 24 boys). Eighteen (51%) had a CI. A majority (n = 66%) were recruited from the same bilingual (sign + speech) specialist hearing impairment units as in Study 1, some in Study 2 (n = 10: 34%) were mainstreamed in hearing classes for all lessons (or all apart from weekly Auslan classes), thus making it possible to examine any effects of type of schooling within the deaf group. (Note that although some were from the same units as in Study 1 none of the children included in Study 2’s sample had taken part in Study 1, enabling a test of the replicability of Study 1 patterns with a completely fresh sample). Group 2, the age-matched hearing control group, had 21 hearing children aged 7.33–12.42 years (mean age = 8.75; SD = 1.26; 9 boys) recruited from government-funded primary schools located in neighborhoods with similar socioeconomic (SES) catchments to those of Group 1’s primary schools. There was no significant age difference between Groups 1 and 2, t(54) = 1.51, p = .130, nor was there a difference in gender balance, χ2(1) = 2.60, p = .107. All children in both groups had written parental consent. No child in either group had taken part Study 1 and none had a disability other than hearing loss. Measures and Testing Procedure The testing procedure was essentially the same as in Study 1 though the tasks were different. Children individually took a developmental ToM Scale (Wellman & Liu, 2004) in their preferred language (Auslan or spoken English for this sample) and their teachers supplied ratings on a different empathy measure than the one used in Study 1. Measures were: ToM Scale Wellman and Liu’s (2004) five-step ToM Scale was presented and scored exactly as described by Peterson et al. (2005). In brief, it includes five tasks presented either pictorially or with doll actors and props. They test a developmentally sequenced set of ToM concepts. In order from easiest to hardest these are: (a) diverse desires (DD: different people want different things), (b)
Table 1. Mean scores (and standard deviations) on key Study 1 measures
Group 1 (n = 30) Group 2 (n = 31) Note. ToM = theory of mind.
Empathy (0 to 5)
ToM total (0 to 3)
Age (years)
Language ability
2.97 (0.96) 3.35 (0.80)
1.60 (1.10) 2.35 (0.88)
9.69 (2.12) 6.78 (2.08)
Signing skill mean: 3.42 VMA mean: 7.31 years
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Table 2. Mean scores (and standard deviations) on key Study 2 measures Empathy (1 to 4)
ToM Scale total (0 to 5)
Age (years)
Sign language production skill (0–22)
2.94 (0.54) 3.48 (0.68)
2.54 (1.15) 4.48 (0.68)
9.51 (2.09) 8.75 (1.26)
19.40 (2.44) —
Group 1 (n = 35) Group 2 (n = 21) Note. ToM = theory of mind.
Table 3. Bivariate correlations (r values) for deaf children on key Study 2 measures Empathy
ToM Scale
Age
Sign language skill
Schooling with signing peers
— —
.34* —
−.07 .16
−.08 .29
.16 .39*
Empathy ToM Scale Note. ToM = theory of mind. *p < .05.
diverse beliefs (DB: different people can hold different potentially true beliefs), (c) knowledge access (KA: not seeing leads to not knowing), (d) false beliefs (FB: standard contents false belief test), and (e) hidden emotion (HE: people may conceal their true feelings by putting on a false facial expression). Each task had a control question which was required along with the test question to pass the task. Children earned a score of 0 to 5 for the number of tasks passed. Empathy Teachers were instructed to judge the truth of the statement “Seems to understand the feelings of others, demonstrates empathy” for that child relative to others the same age with or without hearing impairment. Response choices were: 4 = very true of this student all or most of the time; 3 = somewhat true of this student some of the time; 2 = somewhat false/often not true of this student; 1 = very false/almost never true of this student. Sign language skill For the deaf children only, a 22-item test of sign language production skill was administered, based on the Auslan adaptation (Johnston, 2004) of the British Sign Language skills test (Herman, Holmes, & Woll, 1999). Children were shown pictures of familiar objects (e.g., apple) and asked to give their signs. Scoring was strict. Fingerspelled, gestured, or incomplete signs and inexact signs for related items were all scored as incorrect. Raw (total correct) scores were used since no test norms were available. These ranged from 9 to 22 in this sample and just over half the children (57%) got 80% or more of items correct, indicating an adequate range of variation for statistical comparison with other variables. Testing procedure Some of the children with CI in Study 2 attended mainstream oral-only primary schools where they had little or no contact with any other deaf child. These children (like their peers with CI in the bilingual units described for Study 1) were currently learning Auslan and had been doing so since at least age 5. Some attended Auslan classes weekly with deaf pupils from other schools or classes, others were taught individually by adult Auslan instructors either in person or remotely via the Web. With or without CI, all Group 1 children had at least basic Auslan skills by the time we tested them and all but one child preferred to be tested with the assistance of a natively fluent Auslan interpreter via the bilingual method described in Study 1. The one child who did not was tested purely orally.
Results and Discussion Table 2 shows children’s mean scores on key Study 2 variables. A t test revealed a significant difference in teacher-rated empathy between the two groups, t(54) = 3.09, p = .003, and the same was true via a nonparametric Mann–Whitney U test, U = 235.00, p = .020. As in Study 1, hearing children displayed more frequent empathic behavior at school than deaf children their age, according to teachers. ToM understanding, as reflected in total ToM Scale steps mastered, likewise differed significantly between the groups in the expected direction, t(54) = 7.01, p < .001 (U = 59.00, p < .001). Only one deaf child (3%) passed all five ToM Scale steps, which was significantly fewer than the 12 children (57%) who did so in the hearing control group, χ2(1) = 18.76, N = 56, p .800. Thus at least for this sample of signing severely or profoundly deaf children of hearing parents aged 5–13 years with reasonably good Auslan skills (Table 2), having a CI in and of itself was not a strong influence on either empathic sensitivity to others’ affective states or cognitive appreciation of others’ states of mind. There were likewise no significant gender differences for deaf children on any measured variable, all ts ≤ 1.52, all ps > .135. Another variable of interest was type of school attended. Mainstream integration versus attendance at signing units allow for different amounts of contact with signing deaf peers at school. This might influence a deaf child’s development of empathy and/or ToM understanding via conversation and playground interaction in a shared communication medium (signing). To test this, a “schooling with signers” variable was created to reflect the amount contact with other signing deaf children available to the child during a typical week at school. On a 3-point scale, it ranged
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from 3 = “signing peer contact at least daily”, through 2 = “signing peer contact at least weekly”, to 1 = “no contact with deaf peers in normal school hours”. The bivariate product moment correlation for the full deaf sample (CI and non-CI combined) between this schooling variable and empathy was not statistically significant (Table 3). Importantly, however, having more contact with signing deaf peers at school was positively and significantly linked with total scores on the ToM Scale (Table 3). This result is consistent with much other research reviewed earlier in suggesting that conversational access to other signers can benefit deaf children’s ToM development via signed exchanges of thoughts and feelings with natively fluent conversational partners. A final subsidiary question of interest for Study 2 concerned ToM and empathy in hearing children. In Study 1 the association between the two had been nonsignificant for this group and the same was true in Study 2, r(19) = .22, p = .339. Thus, the finding of a significant independent association between the two variables for the deaf children in Study 2 was a unique pattern not echoed among age-matched hearing children (or, for that matter, hearing preschoolers: Astington & Jenkins, 1995).
General Discussion Empathic ability to perceive and affectively share other people’s feelings of pleasure or distress is at the heart of much of what is best in human social interaction. Feelings of empathy for others’ unhappiness can motivate compassionate communication as well as practical efforts to alleviate the distress. In adulthood, empathy can extend broadly and abstractly to selfless acts of devotion to humanity as a whole via the sacrifice of personal wellbeing in the service of the prevention of future human suffering. According to Zahn-Waxler and Radke-Yarrow (1990) “empathy is at the center of what it means to be fully human” (p. 108). They also noted that there are important individual differences in empathy even among young children. Throughout childhood some children display empathy more strongly and consistently than others their age do. Thus, it is important to study the correlates and predictors of these individual variations in empathy as a basis for future interventions to enhance this “fundamental building block of positive growth and development” (Zahn-Waxler & Radke-Yarrow, 1990, p. 110). Developmentally, empathy emerges in most children by age 2 and is deemed an essential ingredient in the growth of conscience and morality (Hoffman, 1987). Lay observers sometimes assume that children’s affective empathy is synonymous with a cognitive ToM-based understanding of others’ states of mind. However, past research has clearly shown that this is not the case for the hearing majority either during childhood (e.g., Astington & Jenkins, 1995) or in adulthood (e.g., Shamay-Tsoory et al., 2009). In fact, the two variables are not necessarily even significantly correlated with one another for hearing children. This was shown in several published studies reviewed earlier as well as in the present results from both studies. Indeed, neither Study 1 nor 2 revealed a significant correlation for the hearing groups between ToM and empathy despite collectively sampling across the entire childhood age range from preschool to upper primary school and using varied measures of both ToM and empathy. Intriguingly, the pattern we observed for deaf children from hearing families was different. The primary finding of the present pair of studies (which are perhaps the first to examine the link between ToM and empathy in deaf children) was the discovery of a significant association between ToM and empathy for deaf children only. Significant bivariate correlations emerged for the deaf groups in both studies. Furthermore, in Study 2, the association
remained statistically significant over and above age and language ability. The difference from the null results for hearing children is intriguing and clearly warrants further research. Restricted early access to family conversation about thoughts and feelings in hearing households where parents are not fluent signers is thought to contribute to the delayed ToM development seen in this and previous studies of deaf children in hearing families relative to natively signing deaf children of deaf parents (e.g., Peterson & Siegal, 1999). Empathy itself, being affective rather than cognitive and manifesting itself in toddlerhood before much opportunity for mentalistic conversation has arisen even in hearing families, is unlikely to depend on conversational access to others’ thoughts. However, it is possible that some of the more subtle aspects of the empathic communication of affective synchrony may require mentalistic conversational skills. If so, this could help to explain both why ToM is correlated with empathy for deaf children only and also the mutual links between empathy, ToM and signing ability in Study 1. Of course other explanations also possible and further study of both family conversation and empathy in deaf children is clearly warranted before firm conclusions can be drawn. It would be particularly useful to include deaf native signers in such future research, to use multiple converging measures of empathy and also to study ToM’s connections to empathy longitudinally. The other consistent and intriguing finding of the present pair of studies, namely that deaf children scored significantly lower in empathy than hearing children their age, also merits further study. Such a pattern echoes results of all known past published studies of empathy in school-aged deaf children, though not the results of one past study of deaf toddlers (Ketelaar et al., 2013) that, using a parent-report empathy measure, found no significant deaf-hearing contrast. Possibly toddlers, whether deaf or hearing, have yet to develop the kinds of empathic awareness and communication of shared feelings that, as suggested above, our teacher-observers may have been picking up on when reporting individual differences in their pupils’ empathic behavior at school. Alternatively, the parents of young children in Ketelaar et al.’s study may have been less objectively accurate in judging their own offspring’s empathy than teachers of the same children would have been. Experienced teachers like those we sampled have extensive observational and normative experience of a wide range of children to go on when rating any individual child. It would be useful in future research to compare parental and teacher ratings of the same individual. Also, future studies should address the methodological limitation of using third-party ratings rather than direct behavioral observations of children’s empathic affective responses. While teachers’ ratings have many strengths, they may fail to capture some key elements of the subjective affective experience of empathy, particularly in young children and those with hearing loss whose abilities to express their emotions in words may be sometimes be limited. Another potential methodological shortcoming of the present teacherrating procedure was the fact that teachers were inevitably aware of the child’s deafness when making their judgments. This could conceivably have introduced bias. However, it is important to note that this did not take the form of an unwillingness ever to assign a high empathy rating to a deaf child. In Study 1, a minority of children earned the highest possible empathy ratings (“always” or “almost always” empathic). Teachers’ frames of reference could also have swayed their judgments if their own particular past teaching experiences were primarily with deaf students versus mostly in mainstream hearing classrooms. However, again, our Study 2 data showed no overall difference in empathy ratings as a function of this schooling contrast. Nevertheless, additional study of empathy ratings by varied groups of teachers with varied
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backgrounds and experiences on varied empathy measures is clearly desirable in future to verify these patterns. Overall, then, the novel and intriguing findings of the present studies, including the finding of differences between deaf and hearing children in patterns of connection between empathy and ToM, clearly warrant further investigation. Beyond this, the centrality of empathy for friendship and harmonious social relations more generally strongly recommends future investigation into the growth, individual variation and correlates of empathy in deaf and hearing groups alike. Eventually, it is hoped results such research will supply a sound scientific basis for practical interventions on behalf of children who have empathic difficulties either with resonating to others’ emotional states and/or with the communication of this empathic awareness.
Note 1. The term “deaf” is used generically here to refer to people who share the physical condition of hearing loss, some of whom may self-identify as “deaf” and others as “hard-of-hearing.”
Conflicts of Interest No conflicts of interest were reported.
References Astington, J. W., & Jenkins, J. M. (1995). Theory of mind development and social understanding. Cognition and Emotion, 9, 151– 165. doi:10.1080/02699939508409006 Bachara, G., Raphael, J., & Phelan, W. (1980). Empathy development in deaf preadolescence. American Annals of the Deaf, 125, 38–41. Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a ‘theory of mind’? Cognition, 21, 37–46. Cutting, A., & Dunn, J. (1999). Theory of mind, emotion understanding, language, and family background: Individual differences and interrelations. Child Development, 70, 853–865. doi:10.1111/1467-8624.00061 Dadds, M. R., Hunter, K., Hawes, D. J., Frost, A. D., Vassallo, S., Bunn, P.,…Masry, Y. E. (2008). A measure of cognitive and affective empathy in children using parent ratings. Child Psychiatry and Human Development, 39, 111–122. doi:10.1007/s10578-007-0075-4 Dunn, L., & Dunn, D. (2007). PPVT-4: Peabody Picture Vocabulary Test. Minneapolis, MN: Pearson. Feshbach, N., & Roe, K. (1968). Empathy in 6- and 7- year-olds. Child Development, 39, 133–145. doi:10.1177/001316446802800326 Ford, R., Lobao, S., Macaulay, C., & Herdman, L. (2011). Empathy, theory of mind and individual differences. Journal of Experimental Child Psychology, 110, 626–646. doi:10.1016.jecp. 2011.06004 Herman, R., Holmes, S., & Woll, B. (1999). Assessing British Sign Language. Gloustershire, UK: Forest Bookshop. Hoffman, M. L. (1987). The contribution of empathy to justice and moral judgment. In N. Eisenberg & J. Strayer (Eds.), Empathy and its development (pp. 47–80). New York, NY. Cambridge University Press. Hudry, K., & Slaughter, V. (2009). Agent familiarity and emotional context influence the everyday empathic responding of young children with autism. Research in Autism Spectrum Disorders, 3, 74–85. Johnston, T. (2004). Assessment and achievement of proficiency in a native sign language within a sign bilingual program. Deafness Education International, 6, 57–81. Jones, A. P., Happe, F. G., Gilbert, F., Burnett, S., & Viding, E. (2010). Feeling, caring, knowing: Different types of empathy deficit
in boys with psychopathic tendencies and autism spectrum disorder. Journal of Child Psychology and Psychiatry, 51, 1188– 1197 doi:10.1111/j.1469-7610.2010.02280.x Ketelaar, L., Rieffe, C., Wiefferink, C., & Frijns, J. (2013). Social competence and empathy in young children with cochlear implants and normal hearing. Laryngoscope, 123, 518–523 doi:10.1002/lary.23544 Kurdek, L., & Rodgon, M. (1975). Perceptual, cognitive and affective perspective taking. Developmental Psychology, 11, 643–650. doi:10/1037/0012-1649.11.5.643 Peterson, C. C. (2009). Development of social-cognitive and communication skills in children born deaf. Scandinavian Journal of Psychology, 50, 475–483. doi:10.1111/j.1467-9450.2009.00750.x Peterson, C. C. (2014). Theory of mind and empathic behavior in children with autism spectrum disorders. International Journal of Developmental Neuroscience, 39, 16–21. Peterson, C. C., & Siegal, M. (1999). Representing inner worlds: Theory of mind in autistic, deaf, and normal hearing children. Psychological Science, 10, 126–129. doi:10.1111/1467–9280.00119 Peterson, C. C., Slaughter, V., Moore, C., & Wellman, H. M. (in press). Theory of mind and peer social skills for children with autism, deafness or typical development. Developmental Psychology. Peterson, C. C., Wellman, H. M., & Liu, D. (2005). Steps in theoryof-mind development for children with deafness or autism. Child Development, 76, 502–517. doi:10.1111/j.1467–8624 Peterson, C. C., Wellman, H. M., & Slaughter, V. (2012). The mind behind the message: Advancing theory-of-mind scales for typically developing children, and those with deafness, autism, or Asperger syndrome. Child Development, 83, 469–485. doi:10.1111/j.1467-8624.2011.01728.x Roberts, W., & Strayer, J. (1996). Empathy, emotional expressiveness, and prosocial behavior. Child Development, 67, 449–470 doi:10.2307/1131826 Schick, B., de Villiers, P., de Villiers, J., & Hoffmeister, R. (2007). Language and theory of mind: A study of deaf children. Child Development, 78, 376–396. doi:10.1111/j.14678624.2007.01004.x Shamay-Tsoory, S., Aharon-Peretz, J., & Perry, D. (2009). Two systems of empathy. Brain, 132, 617–627. doi:10.1036/awn279 Sigman, M. D., Dissanayake, C., Corona, R., & Espinosa, M. (2003) Social and cardiac responses of young children with autism. Autism, 7, 205–216. Sigman, M. D., Kasari, C., Kwon, J. H., & Yirmiya, N. (1992). Responses to the negative emotions of others by autistic, mentally retarded, and normal children. Child Development, 63, 796–807 doi:10.2307/1131234 Spencer, P. (2010). Play and theory of mind. In M. Marschark & P. E. Spencer (Eds.), The Oxford handbook of deaf studies & deaf education (pp. 407–424). New York, NY: Oxford University Press. Strayer, J., & Roberts, W. (2004). Empathy and observed anger and aggression in five-year-olds. Social Development, 13, 1–13. doi:10.1111/j.1467-9507.2004.00254.x Wauters, L. N., & Knoors, H. (2008). Social integration of deaf children in inclusive settings. Journal of Deaf Studies and Deaf Education, 13, 21–36. doi:10.1093/deafed/enm028 Wellman, H. M., Cross, D., & Watson, J. (2001). Meta-analysis of theory-of-mind development: The truth about false belief. Child Development, 72, 655–684. doi:10.1111/j.1467–8624.00304 Wellman, H. M., & Liu, D. (2004). Scaling of theory-of-mind tasks. Child Development, 75, 523–541. doi:10.1111/j.14678624.2004.00691.x Zahn-Waxler, C., & Radke-Yarrow, M. (1990). The origins of empathic concern. Motivation & Emotion, 14, 107–130. doi:10.1007/BF00991639
empirical manuscript
Empathy and Theory of Mind in Deaf and Hearing Children Candida C. Peterson University of Queensland Correspondence should be sent to Candida C. Peterson, School of Psychology, University of Queensland, Brisbane, Queensland 4072, Australia (e-mail: [email protected]).
Abstract Empathy (or sharing another’s emotion) and theory of mind (ToM: the understanding that behavior is guided by true and false beliefs) are cornerstones of human social life and relationships. In contrast to ToM, there has been little study of empathy’s development, especially in deaf children. Two studies of a total of 117 children (52 hearing; 65 deaf children of hearing parents) aged 4–13 years were therefore designed to (a) compare levels of empathy in deaf and hearing children, and (b) explore correlations of ToM with empathy in deaf and hearing groups. Results showed that (a) deaf children scored lower in empathy than their hearing peers and (b) empathy and ToM were significantly correlated for deaf children but not for the hearing. Possible reasons for these divergent developmental patterns were considered, along with implications for future research.
Empathy is fundamental to social cooperation and close relationships. In developmental psychology, empathy has been defined as “a vicarious affective response” (Feshbach, 1968, p. 133), “the ability to emotionally resonate with others’ feelings” (Jones, Happe, Gilbert, Burnett, & Viding, 2010, p. 1188) or, most commonly, as the experience of “an affective response more appropriate to someone else’s situation than one’s own” (Hoffman, 1987, p. 48). As such, empathy is a clearly conceptually distinct from cognitive perspective-taking, or theory of mind (ToM) which can be defined as a cognitive understanding of people’s thoughts, beliefs, and intentions. Indeed, empirical evidence shows that this is true not only behaviorally but also neurocognitively. For example, Shamay-Tsoory, Aharon-Peretz, and Perry (2009) conducted a neuroimaging study of adults with circumscribed brain damage to particular areas of the prefrontal cortex. Results revealed a double dissociation showing that empathic emotional contagion was localized in a different brain region from cognitive ToM. ToM is protypically assessed via standard inferential false belief tests (Wellman, Cross, & Watson, 2001) requiring predictions about how people with wrong information will behave. Most 3-year-olds fail these tests but most 5- to 6-year-old hearing children pass. By contrast, affective empathy emerges
considerably earlier, as seen in toddlers as young as 18 months becoming upset and attempting to comfort parents, peers, or infants who are in distress (Zahn-Waxler & Radke-Yarrow, 1990). In other words, whereas ToM involves “cool” cognition and abstract mental representation and takes 5 years or more to develop, empathy is fundamentally “hot,” emotionally charged and is present from as early as the second year of life. Methodologically, also, there is an important difference between the two. The assessment of ToM is straightforward since its operational definition is widely agreed to consist of (or at least include) success on laboratory false belief tests (Wellman et al., 2001). By contrast, assessing empathy is more complex. Techniques that have been used vary widely from study to study and operational definitions of the concept are somewhat inconsistent. Examples include (a) caregivers’ reports (e.g., Hudry & Slaughter, 2009), (b) direct behavioral observation in structured settings (e.g., by watching how the child being tested reacts when an experimenter feigns injury: Sigman, Kasari, Kwon, & Yirmiya, 1992) and (c) physiological reactivity to affect (e.g., changes in heart rate as a function of exposure to a film of someone being hurt: Sigman, Dissanayake, Corona, & Espinosa, 2003).
Received August 2, 2015; revisions received November 19, 2015; accepted November 21, 2015 © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
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The Link Between ToM and Empathy in Hearing Children In the case of typically developing hearing children, perhaps the most widely used is the first of these methods, namely reliance on the informed reports of observers who know the children well. Parents, peers, and teachers have many opportunities to observe children’s affective reactions to others’ distress and to notice their active efforts to offer comfort or alleviate the source of the upset. Thus, researchers can capitalize on this backlog of experience to obtain a picture of the child’s usual behavior in everyday social contexts that could potentially evoke empathy. Using this procedure, a number of studies have examined whether children’s cognitive ToM understanding correlates with their affective empathy. For example, using a peer nomination procedure, Astington and Jenkins (1995) defined empathy operationally as being kind and helpful to others who are upset. Preschool children who were named by classmates as frequently demonstrating this kind of empathy did not score any higher on false belief tests of ToM than those who were seen by peers as never or rarely empathic. Ford et al. (2011) used children’s own self-reports and likewise found no statistically significant correlation between 4-and 5-year-olds’ ToM test scores and their claims to experience empathic feelings (e.g., “seeing a child with no one to play with makes me sad.”) However, Peterson (2014) obtained different results using Roberts and Strayer’s (1996, p. 458) single-item global empathy measure. This measure offers a general description (“is empathic; generally sensitive and responsive to others’ emotions”) and caregivers report how true it is of their child. Peterson found that the ToM scores of typically developing children aged 3–12 years correlated significantly with their caregivers’ ratings on this global empathy measure, although age and verbal ability also contributed. Perhaps the direct and summative nature of Roberts and Strayer’s measure partly explains this positive result since Dadds et al. (2008) found no significant association between ToM (as reported by parents) and parents’ ratings of their children on multiple specific instances of empathy (e.g., “My child cries if he/she sees or hears another child crying.”) Overall, then, results of past research on hearing children appear somewhat mixed. Conceivably the nature of the empathy measure and/or ToM measures used and the age groups of the children may partly explain discrepancies among different studies’ results. Nevertheless, the question of whether ToM understanding is correlated with empathy in typical development is clearly not yet fully resolved. Further investigation of this issue will be useful and this is one of the subsidiary aims of the present study. Even more importantly, given that no known previous study has investigated whether deaf1 children’s empathy is correlated with their ToM understanding, this is a clear research need. In theory, the two might be unrelated to one another in deaf children. Or they might be closely related, perhaps even more so than in hearing children. Only empirical evidence can answer this intriguing question. Thus, exploring whether deaf children’s empathy correlates with their ToM understanding is a major goal of the present pair of studies. But first it will be useful to briefly review what is currently known about deaf children’s ToM understanding and about their empathy behavior via the previous research that has examined these two variables as separate entities.
Deaf Children’s Development of ToM and Empathy Considerable research over the past three decades has shown that many deaf children from hearing families are seriously
delayed in developing ToM understanding. In fact, these children often continue to fail false belief and other standard preschool ToM tests well into middle childhood and beyond (see Peterson, 2009 and Spencer, 2010, for reviews). Yet natively signing deaf children of deaf parents develop ToM understanding on the same early timetable as hearing children (e.g., Peterson & Siegal, 1999; Schick, deVilliers, deVilliers, & Hoffmeister, 2007; Peterson, Wellman, & Liu, 2005) implicating the sharing of conversation with family members via a mutually accessible language (either signed or spoken) in the timely mastery of ToM understanding (Peterson, Slaughter, Moore, & Wellman, in press; Peterson, Wellman, & Slaughter, 2012). Empathy in deaf children has been researched far less often than ToM. Indeed, a comprehensive literature search revealed only three studies that investigated individual differences in empathy among deaf children relative to hearing controls. The first, by Bachara, Raphael, and Phelan (1980) used a measure of empathy similar to Feshbach’s (1968) definition (above) but one that is somewhat controversial since, in other studies, the same test has also been dubbed a test of emotion understanding (e.g., Cutting & Dunn, 1999) or affective perspective-taking (e.g., Kurdek & Rodgon, 1975). In Bachara et al.’s version, children were exposed to affectively charged story vignettes (e.g., a boy gets lost in a shopping center) and attributions of emotions to self and the story protagonist were elicited. The sample, consisting of 21 deaf children aged 9–14 years from a bilingual (sign-plus-speech) residential school, scored below a 7-year-old hearing comparison group and, in absolute terms, had considerable difficulty empathizing with sadness and anger scenarios, responding incorrectly to these on between 30% and 40% of opportunities. In a similar vein, Wauters and Knoors (2008) found that deaf children scored lower than their hearing peers on a peer-nomination empathic helpfulness measure similar to Astington and Jenkins’ (1995: see above). The deaf children were also significantly less likely than hearing controls to engage in empathic helpfulness. The third study, by Ketelaar, Rieffe, Wiefferink, and Frijns (2013) compared young deaf children (mean age: 39 months) with cochlear implants (CI) to age-matched hearing children on two different measures of empathy. A problem for the interpretation of the study’s results was that the two empathy measures did not correlate significantly with one another for either the deaf group or the hearing group. Nevertheless, despite this, the authors were still able to validly conclude that these young deaf children were at least as empathic as their hearing peers. Specifically, a parent-report measure similar to that of many previous studies of hearing children (see above) showed that deaf and hearing children scored equally. On a behavioral observation measure, the deaf children spent even longer looking at an experimenter who was feigning distress than their hearing peers did. However, whether or not this reflected pure empathic sharing of the experimenter’s distress was unclear, especially since this behavioral measure did not correlate significantly with parent-reported empathy. Indeed, as the authors themselves pointed out, frequent looking at an adult’s face by deaf children with CI may have been due as much to reliance on visual cues for information access as to empathic distress. Nonetheless, irrespective of how these mixed findings of past research are interpreted, it is undeniable that the evidence so far on empathy in deaf children is very limited. Thus, further investigation of deaf children’s empathy relative to that of matched hearing groups’ is clearly needed. Examining this, together with studying possible links between empathy and ToM, are major goals of the present pair of studies.
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Study 1 Method Participants A total of 61 Australian children aged 4–12 years took part in Study 1, in two groups. Group 1 consisted of 30 prelingually severely or profoundly deaf children of hearing parents. Their mean age was 9.69 years (range 5.92–12.92) and 17 were boys. They were recruited from specialist bilingual units that used both of speech and Auslan signing as instructional media. They were chosen to represent the broad age range across which empathy is seen to develop in hearing children which (Hoffman, 1987). Units were housed in government-funded primary schools and most of these children shared classroom and playground experiences with mainstream hearing children for at least a few hours each week. Twelve (40%) of them had a CI. Group 2, the hearing control group, was likewise chosen to represent the broad range of ages through which empathy is seen to develop (Hoffman, 1987) including not only preschoolers but also older children in primary school who might have additional impetus to develop empathic feelings via daily exposure to classroom peer groups in primary school. Because this broad age range was advantageous for an exploratory study of this nature, the goal was not to match groups narrowly by age but rather to use age as a statistical control variable where necessary in group comparison analyses. Hence Group 2 included some younger children likely to match the deaf group in levels of ToM understanding as well as a substantial proportion (64%) of older age-matched primary-schoolers who would have had a similarly extensive exposure to full-day contact with a classroom peer group as the deaf children in Group 1. Overall there were 31 hearing children aged 4.25–10.50 years (mean age: 6.78; 18 boys) recruited from government-funded preschools and primary schools located in neighborhoods with similar socioeconomic (SES) catchments to those of Group 1’s primary schools. All children had written parental informed consent and all families used English as their sole or primary language. No Group 2 child had any diagnosed disability and none in Group 1 had any disability apart from hearing loss. There was no significant gender difference between the groups, χ2(1) < 1, p = .920. However, there was a significant age difference, t(59) = 5.41, p < .001. On average the deaf children were 3 years older than the hearing group. Thus, ANCOVA was used to control for age when conducting statistical comparisons between groups (see Results below). Measures and Testing Procedure All children were tested individually at school by an experienced male experimenter on a three-task false belief battery. For deaf children in Group 1 a professionally qualified (certified at the highest proficiency level) Auslan interpreter assisted the main experimenter by translating all the experimenter’s speech into Auslan and children’s Auslan responses into speech. This bilingual approach was desirable since, despite preferring Auslan, many Group 1 children also had limited vocal and auditory skills. In a separate private session, the child’s main classroom teacher completed a published questionnaire rating-scale measure of the child’s observed level of empathy. Language ability was assessed for Group 1 using teachers’ ratings of signing ability whereas Group 2 took a standard receptive vocabulary test. (This latter was unsuitable for Auslan signers, as explained below). Tasks and scoring were as follows.
ToM tests ToM understanding was assessed with a three-item battery. The first two items consisted of Baron-Cohen, Leslie, and Frith’s (1985) two-task “Sally-Anne” procedure with a boy doll replacing the second girl doll. Briefly, on each trial, the girl put her marble into a basket and left. The boy moved the marble to a box (Task 1) or the experimenter’s pocket (Task 2). The girl returned and the test question was: “Where will she look for her marble?” followed by two control questions which had to be passed, along with the test question, to pass the task. The third item was a misleading contents false belief task, presented exactly as described by Wellman and Liu (2004) except that the misleading container was a crayon box concealing a toy car. There was a test question “What does the [naïve] boy think is in the crayon box?” and a control question. Both had to be passed to pass the task. A total false belief score (TFB) ranging from 0 to 3 was the sum of scores on the three false belief items. Language ability To assess language ability in Group 1, the child’s main classroom teacher (a fluent signer) rated each child’s signing production and comprehension ability on a 5-point scale ranging from: 1 = little or no skill, 2 = modest skills adequate for basic everyday communication, 3 = quite skilled, 4 = very highly skilled, to 5 = excellent signing skills. For Group 2, verbal mental age (VMA) was assessed with the Peabody Picture Vocabulary Test (PPVT: Dunn & Dunn, 2007), a standardized receptive vocabulary test based on picture pointing responses. This test was unsuitable for the deaf children owing not only to lack of norms for Auslan but also other problems including the numerous words with either completely iconic signs (e.g., a point at the knee for “knee”) or no discrete sign translation at all in standard Auslan dictionaries. Of course the use of different language tests for deaf and hearing children precluded direct comparison between the groups’ linguistic maturity. But this was not a goal of the present study. Instead, the present purpose for including linguistic skill in the design was simply as a conservative precaution to be able to control statistically (within deaf and hearing groups separately) for any possible confounding effect general language skill might have upon the predicted association between the focal variables (empathy and ToM). All Group 1 children had full language data available but PPVT scores were missing for five hearing children in Group 2 owing to school absences and teachers’ reluctance to schedule additional testing sessions late in the school year. Empathy Teachers rated each child’s empathy using a slightly adapted version of Roberts and Strayer’s (1996; see also Strayer & Roberts, 2004) global measure. On a six-point continuous scale from 0 = “not at all true of this child” through 1 = “ a little bit true of this child”, 2 = “somewhat true of this child”, 3 = “often true of this child”, and 4 = “very often true of this child”, to 5 = “almost always true of this child”, the teacher responded to the item “ Is empathic: generally sensitive and responsive to others’ feelings (e.g., offering comfort to a child who is in distress)”. This single item global empathy rating has been used extensively with hearing children by Roberts and Strayer’s (1996; see also Strayer & Roberts, 2004) and others. Comprehensive validation data from several studies of typically developing hearing children of similar age to the present sample (e.g., Roberts & Strayer, 1996) have suggested that, when used by experienced teachers, this single-item summative measure performs well in validation against other empathy indicators including multi-item scales and behavioral observations.
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Results and Discussion Table 1 shows children’s mean scores on the ToM and empathy measures along with data on age and language ability. A preliminary analysis showed that raw empathy scores did not differ significantly between the groups, t(59) = 1.72, p = .092. (A nonparametric Mann–Whitney U test showed the same, U = 339.50, p = .056). However, it will be recalled (see Method section above) that deaf and hearing children differed significantly in age. Given that the deaf children were an average of 3 years older their equivalent performance might nonetheless reflect some delay behind hearing children. Thus, to conservatively examine the effect of hearing status directly upon empathy scores while controlling statistically for this group age difference, an analysis of covariance (ANCOVA) was conducted with chronological age as the covariate. Results revealed a statistically significant main effect for hearing-status group, F(1, 58) = 7.23, p = .009 (with hearing children earning higher empathy scores than deaf children their age) and a significant age covariate effect, F(1, 58) = 4.66, p = .035, such that for both groups combined empathy increased significantly with age. (The same age increase in empathy was also true for each group individually: see Table 2). In interpreting this significant group contrast, it is important to bear in mind that individual differences within each group were wide. In fact, 30% of the deaf children earned the highest empathy scores of 4 or 5 (“very often” or “almost always” empathic) as did 41% of hearing children, a nonsignificant difference: χ2(1) = 1.49, N = 61, p = .222. But, at the same time, 40% of deaf children had low empathy scores (0, 1, or 2) as contrasted with only 10% of hearing children, χ2(1) = 7.56, N = 61, p = .006. In other words, even though deafness itself did preclude the development of high empathy, these categorical results confirmed the ANCOVA findings that deaf children were perceived by teachers as lower overall in empathy than their hearing peers. A parallel ANCOVA with ToM total scores as the dependent variable showed a significant group effect, F(1, 58) = 36.26, p < .001, and a significant effect of the age covariate, F(1, 58) = 28.67, p < .001. Hearing children outperformed the deaf children in ToM understanding, consistent with much past research (see Peterson, 2009 and Spencer, 2010, for reviews) and ToM increased with age in both groups. Considering the deaf children separately, there was a highly significant simple bivariate correlation between ToM and empathy, r(28) = .51, p = .004. However, it fell to nonsignificance once the effects of age and sign language skill were statistically controlled via partial correlation, r(26) = .31, p = .113. Comparisons of boys with girls via t-test revealed no significant gender differences in either empathy or ToM: both ts < 1.00, both ps > .30. Similarly, there were no significant differences in either empathy or ToM between the 12 deaf children with CIs and the 18 without, both ts .30. For the hearing children, there was no significant bivariate correlation between ToM and empathy, r(29) = .10, p = .593 nor was empathy significantly correlated with VMA or gender, both ps > or = .198. Thus, an independent link between ToM understanding on standard laboratory measures and children’s ability
to express empathy in their everyday social relations with peers and teachers at school was not apparent for hearing children. However, before drawing firm conclusions, replication with a fresh sample of deaf and hearing children and alternative measures of empathy and ToM is desirable. This was one goal of Study 2. Other aims included: (a) to test closely age-matched deaf and hearing groups, (b) to compare deaf children with versus without CI, and (c) to examine any effects of mainstream hearing schooling versus daily contact with signing peers in bilingual units on deaf children’s ToM and empathy.
Study 2 Method Participants A total of 56 Australian children aged 5–13 years participated in Study 2, in two groups. Group 1 consisted of 35 prelingually severely or profoundly deaf children of hearing parents (mean age: 9.51 years; range: 5.67–13.33; 24 boys). Eighteen (51%) had a CI. A majority (n = 66%) were recruited from the same bilingual (sign + speech) specialist hearing impairment units as in Study 1, some in Study 2 (n = 10: 34%) were mainstreamed in hearing classes for all lessons (or all apart from weekly Auslan classes), thus making it possible to examine any effects of type of schooling within the deaf group. (Note that although some were from the same units as in Study 1 none of the children included in Study 2’s sample had taken part in Study 1, enabling a test of the replicability of Study 1 patterns with a completely fresh sample). Group 2, the age-matched hearing control group, had 21 hearing children aged 7.33–12.42 years (mean age = 8.75; SD = 1.26; 9 boys) recruited from government-funded primary schools located in neighborhoods with similar socioeconomic (SES) catchments to those of Group 1’s primary schools. There was no significant age difference between Groups 1 and 2, t(54) = 1.51, p = .130, nor was there a difference in gender balance, χ2(1) = 2.60, p = .107. All children in both groups had written parental consent. No child in either group had taken part Study 1 and none had a disability other than hearing loss. Measures and Testing Procedure The testing procedure was essentially the same as in Study 1 though the tasks were different. Children individually took a developmental ToM Scale (Wellman & Liu, 2004) in their preferred language (Auslan or spoken English for this sample) and their teachers supplied ratings on a different empathy measure than the one used in Study 1. Measures were: ToM Scale Wellman and Liu’s (2004) five-step ToM Scale was presented and scored exactly as described by Peterson et al. (2005). In brief, it includes five tasks presented either pictorially or with doll actors and props. They test a developmentally sequenced set of ToM concepts. In order from easiest to hardest these are: (a) diverse desires (DD: different people want different things), (b)
Table 1. Mean scores (and standard deviations) on key Study 1 measures
Group 1 (n = 30) Group 2 (n = 31) Note. ToM = theory of mind.
Empathy (0 to 5)
ToM total (0 to 3)
Age (years)
Language ability
2.97 (0.96) 3.35 (0.80)
1.60 (1.10) 2.35 (0.88)
9.69 (2.12) 6.78 (2.08)
Signing skill mean: 3.42 VMA mean: 7.31 years
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Table 2. Mean scores (and standard deviations) on key Study 2 measures Empathy (1 to 4)
ToM Scale total (0 to 5)
Age (years)
Sign language production skill (0–22)
2.94 (0.54) 3.48 (0.68)
2.54 (1.15) 4.48 (0.68)
9.51 (2.09) 8.75 (1.26)
19.40 (2.44) —
Group 1 (n = 35) Group 2 (n = 21) Note. ToM = theory of mind.
Table 3. Bivariate correlations (r values) for deaf children on key Study 2 measures Empathy
ToM Scale
Age
Sign language skill
Schooling with signing peers
— —
.34* —
−.07 .16
−.08 .29
.16 .39*
Empathy ToM Scale Note. ToM = theory of mind. *p < .05.
diverse beliefs (DB: different people can hold different potentially true beliefs), (c) knowledge access (KA: not seeing leads to not knowing), (d) false beliefs (FB: standard contents false belief test), and (e) hidden emotion (HE: people may conceal their true feelings by putting on a false facial expression). Each task had a control question which was required along with the test question to pass the task. Children earned a score of 0 to 5 for the number of tasks passed. Empathy Teachers were instructed to judge the truth of the statement “Seems to understand the feelings of others, demonstrates empathy” for that child relative to others the same age with or without hearing impairment. Response choices were: 4 = very true of this student all or most of the time; 3 = somewhat true of this student some of the time; 2 = somewhat false/often not true of this student; 1 = very false/almost never true of this student. Sign language skill For the deaf children only, a 22-item test of sign language production skill was administered, based on the Auslan adaptation (Johnston, 2004) of the British Sign Language skills test (Herman, Holmes, & Woll, 1999). Children were shown pictures of familiar objects (e.g., apple) and asked to give their signs. Scoring was strict. Fingerspelled, gestured, or incomplete signs and inexact signs for related items were all scored as incorrect. Raw (total correct) scores were used since no test norms were available. These ranged from 9 to 22 in this sample and just over half the children (57%) got 80% or more of items correct, indicating an adequate range of variation for statistical comparison with other variables. Testing procedure Some of the children with CI in Study 2 attended mainstream oral-only primary schools where they had little or no contact with any other deaf child. These children (like their peers with CI in the bilingual units described for Study 1) were currently learning Auslan and had been doing so since at least age 5. Some attended Auslan classes weekly with deaf pupils from other schools or classes, others were taught individually by adult Auslan instructors either in person or remotely via the Web. With or without CI, all Group 1 children had at least basic Auslan skills by the time we tested them and all but one child preferred to be tested with the assistance of a natively fluent Auslan interpreter via the bilingual method described in Study 1. The one child who did not was tested purely orally.
Results and Discussion Table 2 shows children’s mean scores on key Study 2 variables. A t test revealed a significant difference in teacher-rated empathy between the two groups, t(54) = 3.09, p = .003, and the same was true via a nonparametric Mann–Whitney U test, U = 235.00, p = .020. As in Study 1, hearing children displayed more frequent empathic behavior at school than deaf children their age, according to teachers. ToM understanding, as reflected in total ToM Scale steps mastered, likewise differed significantly between the groups in the expected direction, t(54) = 7.01, p < .001 (U = 59.00, p < .001). Only one deaf child (3%) passed all five ToM Scale steps, which was significantly fewer than the 12 children (57%) who did so in the hearing control group, χ2(1) = 18.76, N = 56, p .800. Thus at least for this sample of signing severely or profoundly deaf children of hearing parents aged 5–13 years with reasonably good Auslan skills (Table 2), having a CI in and of itself was not a strong influence on either empathic sensitivity to others’ affective states or cognitive appreciation of others’ states of mind. There were likewise no significant gender differences for deaf children on any measured variable, all ts ≤ 1.52, all ps > .135. Another variable of interest was type of school attended. Mainstream integration versus attendance at signing units allow for different amounts of contact with signing deaf peers at school. This might influence a deaf child’s development of empathy and/or ToM understanding via conversation and playground interaction in a shared communication medium (signing). To test this, a “schooling with signers” variable was created to reflect the amount contact with other signing deaf children available to the child during a typical week at school. On a 3-point scale, it ranged
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from 3 = “signing peer contact at least daily”, through 2 = “signing peer contact at least weekly”, to 1 = “no contact with deaf peers in normal school hours”. The bivariate product moment correlation for the full deaf sample (CI and non-CI combined) between this schooling variable and empathy was not statistically significant (Table 3). Importantly, however, having more contact with signing deaf peers at school was positively and significantly linked with total scores on the ToM Scale (Table 3). This result is consistent with much other research reviewed earlier in suggesting that conversational access to other signers can benefit deaf children’s ToM development via signed exchanges of thoughts and feelings with natively fluent conversational partners. A final subsidiary question of interest for Study 2 concerned ToM and empathy in hearing children. In Study 1 the association between the two had been nonsignificant for this group and the same was true in Study 2, r(19) = .22, p = .339. Thus, the finding of a significant independent association between the two variables for the deaf children in Study 2 was a unique pattern not echoed among age-matched hearing children (or, for that matter, hearing preschoolers: Astington & Jenkins, 1995).
General Discussion Empathic ability to perceive and affectively share other people’s feelings of pleasure or distress is at the heart of much of what is best in human social interaction. Feelings of empathy for others’ unhappiness can motivate compassionate communication as well as practical efforts to alleviate the distress. In adulthood, empathy can extend broadly and abstractly to selfless acts of devotion to humanity as a whole via the sacrifice of personal wellbeing in the service of the prevention of future human suffering. According to Zahn-Waxler and Radke-Yarrow (1990) “empathy is at the center of what it means to be fully human” (p. 108). They also noted that there are important individual differences in empathy even among young children. Throughout childhood some children display empathy more strongly and consistently than others their age do. Thus, it is important to study the correlates and predictors of these individual variations in empathy as a basis for future interventions to enhance this “fundamental building block of positive growth and development” (Zahn-Waxler & Radke-Yarrow, 1990, p. 110). Developmentally, empathy emerges in most children by age 2 and is deemed an essential ingredient in the growth of conscience and morality (Hoffman, 1987). Lay observers sometimes assume that children’s affective empathy is synonymous with a cognitive ToM-based understanding of others’ states of mind. However, past research has clearly shown that this is not the case for the hearing majority either during childhood (e.g., Astington & Jenkins, 1995) or in adulthood (e.g., Shamay-Tsoory et al., 2009). In fact, the two variables are not necessarily even significantly correlated with one another for hearing children. This was shown in several published studies reviewed earlier as well as in the present results from both studies. Indeed, neither Study 1 nor 2 revealed a significant correlation for the hearing groups between ToM and empathy despite collectively sampling across the entire childhood age range from preschool to upper primary school and using varied measures of both ToM and empathy. Intriguingly, the pattern we observed for deaf children from hearing families was different. The primary finding of the present pair of studies (which are perhaps the first to examine the link between ToM and empathy in deaf children) was the discovery of a significant association between ToM and empathy for deaf children only. Significant bivariate correlations emerged for the deaf groups in both studies. Furthermore, in Study 2, the association
remained statistically significant over and above age and language ability. The difference from the null results for hearing children is intriguing and clearly warrants further research. Restricted early access to family conversation about thoughts and feelings in hearing households where parents are not fluent signers is thought to contribute to the delayed ToM development seen in this and previous studies of deaf children in hearing families relative to natively signing deaf children of deaf parents (e.g., Peterson & Siegal, 1999). Empathy itself, being affective rather than cognitive and manifesting itself in toddlerhood before much opportunity for mentalistic conversation has arisen even in hearing families, is unlikely to depend on conversational access to others’ thoughts. However, it is possible that some of the more subtle aspects of the empathic communication of affective synchrony may require mentalistic conversational skills. If so, this could help to explain both why ToM is correlated with empathy for deaf children only and also the mutual links between empathy, ToM and signing ability in Study 1. Of course other explanations also possible and further study of both family conversation and empathy in deaf children is clearly warranted before firm conclusions can be drawn. It would be particularly useful to include deaf native signers in such future research, to use multiple converging measures of empathy and also to study ToM’s connections to empathy longitudinally. The other consistent and intriguing finding of the present pair of studies, namely that deaf children scored significantly lower in empathy than hearing children their age, also merits further study. Such a pattern echoes results of all known past published studies of empathy in school-aged deaf children, though not the results of one past study of deaf toddlers (Ketelaar et al., 2013) that, using a parent-report empathy measure, found no significant deaf-hearing contrast. Possibly toddlers, whether deaf or hearing, have yet to develop the kinds of empathic awareness and communication of shared feelings that, as suggested above, our teacher-observers may have been picking up on when reporting individual differences in their pupils’ empathic behavior at school. Alternatively, the parents of young children in Ketelaar et al.’s study may have been less objectively accurate in judging their own offspring’s empathy than teachers of the same children would have been. Experienced teachers like those we sampled have extensive observational and normative experience of a wide range of children to go on when rating any individual child. It would be useful in future research to compare parental and teacher ratings of the same individual. Also, future studies should address the methodological limitation of using third-party ratings rather than direct behavioral observations of children’s empathic affective responses. While teachers’ ratings have many strengths, they may fail to capture some key elements of the subjective affective experience of empathy, particularly in young children and those with hearing loss whose abilities to express their emotions in words may be sometimes be limited. Another potential methodological shortcoming of the present teacherrating procedure was the fact that teachers were inevitably aware of the child’s deafness when making their judgments. This could conceivably have introduced bias. However, it is important to note that this did not take the form of an unwillingness ever to assign a high empathy rating to a deaf child. In Study 1, a minority of children earned the highest possible empathy ratings (“always” or “almost always” empathic). Teachers’ frames of reference could also have swayed their judgments if their own particular past teaching experiences were primarily with deaf students versus mostly in mainstream hearing classrooms. However, again, our Study 2 data showed no overall difference in empathy ratings as a function of this schooling contrast. Nevertheless, additional study of empathy ratings by varied groups of teachers with varied
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backgrounds and experiences on varied empathy measures is clearly desirable in future to verify these patterns. Overall, then, the novel and intriguing findings of the present studies, including the finding of differences between deaf and hearing children in patterns of connection between empathy and ToM, clearly warrant further investigation. Beyond this, the centrality of empathy for friendship and harmonious social relations more generally strongly recommends future investigation into the growth, individual variation and correlates of empathy in deaf and hearing groups alike. Eventually, it is hoped results such research will supply a sound scientific basis for practical interventions on behalf of children who have empathic difficulties either with resonating to others’ emotional states and/or with the communication of this empathic awareness.
Note 1. The term “deaf” is used generically here to refer to people who share the physical condition of hearing loss, some of whom may self-identify as “deaf” and others as “hard-of-hearing.”
Conflicts of Interest No conflicts of interest were reported.
References Astington, J. W., & Jenkins, J. M. (1995). Theory of mind development and social understanding. Cognition and Emotion, 9, 151– 165. doi:10.1080/02699939508409006 Bachara, G., Raphael, J., & Phelan, W. (1980). Empathy development in deaf preadolescence. American Annals of the Deaf, 125, 38–41. Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a ‘theory of mind’? Cognition, 21, 37–46. Cutting, A., & Dunn, J. (1999). Theory of mind, emotion understanding, language, and family background: Individual differences and interrelations. Child Development, 70, 853–865. doi:10.1111/1467-8624.00061 Dadds, M. R., Hunter, K., Hawes, D. J., Frost, A. D., Vassallo, S., Bunn, P.,…Masry, Y. E. (2008). A measure of cognitive and affective empathy in children using parent ratings. Child Psychiatry and Human Development, 39, 111–122. doi:10.1007/s10578-007-0075-4 Dunn, L., & Dunn, D. (2007). PPVT-4: Peabody Picture Vocabulary Test. Minneapolis, MN: Pearson. Feshbach, N., & Roe, K. (1968). Empathy in 6- and 7- year-olds. Child Development, 39, 133–145. doi:10.1177/001316446802800326 Ford, R., Lobao, S., Macaulay, C., & Herdman, L. (2011). Empathy, theory of mind and individual differences. Journal of Experimental Child Psychology, 110, 626–646. doi:10.1016.jecp. 2011.06004 Herman, R., Holmes, S., & Woll, B. (1999). Assessing British Sign Language. Gloustershire, UK: Forest Bookshop. Hoffman, M. L. (1987). The contribution of empathy to justice and moral judgment. In N. Eisenberg & J. Strayer (Eds.), Empathy and its development (pp. 47–80). New York, NY. Cambridge University Press. Hudry, K., & Slaughter, V. (2009). Agent familiarity and emotional context influence the everyday empathic responding of young children with autism. Research in Autism Spectrum Disorders, 3, 74–85. Johnston, T. (2004). Assessment and achievement of proficiency in a native sign language within a sign bilingual program. Deafness Education International, 6, 57–81. Jones, A. P., Happe, F. G., Gilbert, F., Burnett, S., & Viding, E. (2010). Feeling, caring, knowing: Different types of empathy deficit
in boys with psychopathic tendencies and autism spectrum disorder. Journal of Child Psychology and Psychiatry, 51, 1188– 1197 doi:10.1111/j.1469-7610.2010.02280.x Ketelaar, L., Rieffe, C., Wiefferink, C., & Frijns, J. (2013). Social competence and empathy in young children with cochlear implants and normal hearing. Laryngoscope, 123, 518–523 doi:10.1002/lary.23544 Kurdek, L., & Rodgon, M. (1975). Perceptual, cognitive and affective perspective taking. Developmental Psychology, 11, 643–650. doi:10/1037/0012-1649.11.5.643 Peterson, C. C. (2009). Development of social-cognitive and communication skills in children born deaf. Scandinavian Journal of Psychology, 50, 475–483. doi:10.1111/j.1467-9450.2009.00750.x Peterson, C. C. (2014). Theory of mind and empathic behavior in children with autism spectrum disorders. International Journal of Developmental Neuroscience, 39, 16–21. Peterson, C. C., & Siegal, M. (1999). Representing inner worlds: Theory of mind in autistic, deaf, and normal hearing children. Psychological Science, 10, 126–129. doi:10.1111/1467–9280.00119 Peterson, C. C., Slaughter, V., Moore, C., & Wellman, H. M. (in press). Theory of mind and peer social skills for children with autism, deafness or typical development. Developmental Psychology. Peterson, C. C., Wellman, H. M., & Liu, D. (2005). Steps in theoryof-mind development for children with deafness or autism. Child Development, 76, 502–517. doi:10.1111/j.1467–8624 Peterson, C. C., Wellman, H. M., & Slaughter, V. (2012). The mind behind the message: Advancing theory-of-mind scales for typically developing children, and those with deafness, autism, or Asperger syndrome. Child Development, 83, 469–485. doi:10.1111/j.1467-8624.2011.01728.x Roberts, W., & Strayer, J. (1996). Empathy, emotional expressiveness, and prosocial behavior. Child Development, 67, 449–470 doi:10.2307/1131826 Schick, B., de Villiers, P., de Villiers, J., & Hoffmeister, R. (2007). Language and theory of mind: A study of deaf children. Child Development, 78, 376–396. doi:10.1111/j.14678624.2007.01004.x Shamay-Tsoory, S., Aharon-Peretz, J., & Perry, D. (2009). Two systems of empathy. Brain, 132, 617–627. doi:10.1036/awn279 Sigman, M. D., Dissanayake, C., Corona, R., & Espinosa, M. (2003) Social and cardiac responses of young children with autism. Autism, 7, 205–216. Sigman, M. D., Kasari, C., Kwon, J. H., & Yirmiya, N. (1992). Responses to the negative emotions of others by autistic, mentally retarded, and normal children. Child Development, 63, 796–807 doi:10.2307/1131234 Spencer, P. (2010). Play and theory of mind. In M. Marschark & P. E. Spencer (Eds.), The Oxford handbook of deaf studies & deaf education (pp. 407–424). New York, NY: Oxford University Press. Strayer, J., & Roberts, W. (2004). Empathy and observed anger and aggression in five-year-olds. Social Development, 13, 1–13. doi:10.1111/j.1467-9507.2004.00254.x Wauters, L. N., & Knoors, H. (2008). Social integration of deaf children in inclusive settings. Journal of Deaf Studies and Deaf Education, 13, 21–36. doi:10.1093/deafed/enm028 Wellman, H. M., Cross, D., & Watson, J. (2001). Meta-analysis of theory-of-mind development: The truth about false belief. Child Development, 72, 655–684. doi:10.1111/j.1467–8624.00304 Wellman, H. M., & Liu, D. (2004). Scaling of theory-of-mind tasks. Child Development, 75, 523–541. doi:10.1111/j.14678624.2004.00691.x Zahn-Waxler, C., & Radke-Yarrow, M. (1990). The origins of empathic concern. Motivation & Emotion, 14, 107–130. doi:10.1007/BF00991639
