Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder in which an individual’s symptoms can vary from mild to severe. According to the most recent prevalence rates from the US Centers for Disease Control and Prevention (CDC), about 1 in every 54 individuals has ASD1. Although many theories exist about the pathology and causes of autism, such as genetic and environmental factors, ASD is a heterogeneous disorder without a specific known cause or cure. Language and intellectual impairments may or may not be characteristic of children with ASD, but the most significant challenges they face are difficulties communicating and interacting with others in social situations2. Early diagnosis and intervention (e.g., speech and language therapy, social cognitive behavioral intervention, etc.) targeting these social difficulties are especially critical if we wish to improve the social communication skills of children with autism, as well as help them build relationships, engage in activities with others, and be successful in school.
An important component of social communication and social interaction in children with ASD is theory of mind (ToM). ToM is the ability to reason about the thoughts and feelings of self and others, including the ability to predict what others will do or how they will feel in a given situation on the basis of their inferred beliefs3,4. Difficulties with ToM are thought to lead to impairments in social interactions among individuals with ASD. It has been argued that a diminished ability to interpret the beliefs, intentions, and emotions of others will undermine the individual’s ability to interact in ways that are generally considered appropriate and adaptive for a particular social context5. Individuals with ASD often have trouble interpreting or reading the verbal and non-verbal communications of others, specifically in social interactions6.
ToM abilities have been adopted as proxies to functioning level in ASD for several reasons: (1) the developmentally sequenced acquisition of ToM skills in childhood is well documented7,8; (2) ToM tests have been used in a variety of populations and cultures9–11; and (3) ToM deficits ostensibly underlie social communication impairments in ASD12–14. Additionally, general ToM assessment is internationally applicable in that ToM skills develop in roughly the same manner across the world15–17. ToM abilities have also been proposed as a potential severity index in ASD: better ToM is associated with improved behavior towards social rules18, better social interaction skills19,20, and increased language use21,22.
At a neural level, studies have established a ToM network involving the medial prefrontal cortex (mPFC), the posterior superior temporal sulcus (pSTS), the temporal parietal junction (TPJ), the precuneus, and the posterior cingulate cortex (PCC). More specifically, the mPFC is associated with mental state reflection; the pSTS is involved in inferring to other’s actions; and the TPJ with understanding beliefs and socially relevant information23–25. Individuals with ASD exhibit decreased activation and connectivity among these identified ToM regions, as well as decreased connectivity in the frontal-medial, frontal-parietal
and medial cerebellum anatomical networks23–25. The purpose of this study is to examine behavioral and neurobiological measures of emotions involving ToM, contributing to what is known about ToM markers at the brain and behavior levels that can distinguish those with and without ASD. In the review of the literature that follows, we discuss the development of emotion recognition as one aspect of ToM in neurotypical (NT) and ASD populations surrounding happiness, sadness, surprise, embarrassment and desire-based emotion. This includes a description of how emotion recognition has been tested and measured at both a behavioral and neural level in individuals with ASD.
1.1 Emotion Recognition in Neurotypical Development
One particular aspect of ToM, emotion recognition, plays a critical role in an individual’s ability to meaningfully engage in social communication and social interaction. Emotion recognition is the ability to discriminate between different facial expressions and is key to understanding empathy or the feelings of others. The present study focuses on three specific emotions (i.e., surprise, embarrassment, desire-based emotion) as they are critical aspects of ToM.
Happiness is considered to be the easiest recognized emotion while sadness is associated with the most negative affective reactions among the NT population26. Meta-analyses have found that the processing of emotional faces is associated with increased activation in a number of visual, limbic, TPJ and prefrontal areas, where happy and sad faces specifically also activate the amygdala27. Surprise conveys a sense of novelty or unexpectedness and most research indicates that accurate recognition of surprise will happen around the preschool years or even later among the NT population28. One functional magnetic resonance imaging (fMRI) study suggests that rapid recognition of surprised faces is associated with greater brain activities in the right postcentral gyrus and left posterior insula29.Embarrassment is often described as a ’self-conscious’ emotion that is associated with a feeling of shame or awkwardness around some action or statement30–33. Experiencing ’embarrassment’ does suggest some level of self-awareness that an ’expected’ behavior in a social context was unmet34–39. Embarrassment is evoked during negative evaluation following norm violations and supported by a fronto–temporo–posterior network. It often recruits greater anterior temporal regions, representing conceptual social knowledge40. Desire-based emotion recognizes the relationship between getting what you want and feeling happy and not getting what you want and feeling sad or disappointed. Thus, desire-based emotion can lead to positive emotions or negative emotions, depending on a fulfilled or unfulfilled desire41,42. There is abundant evidence that around the age of two, NT children understand desire-based emotion and can accurately predict emotional consequences when another’s desire and the situational outcome are known (i.e., others are judged as ‘happy’ if the outcome was wanted and ‘sad’ if it was not)43.
1.2 Emotion Recognition in ASD
Children with ASD have impairments in social interaction often due to a lack of understanding of emotions and the minds of others, as well as difficulty attending to social cues (e.g., gaze, facial expressions, body postures, etc.)44. Some studies have found that children with ASD use the lower part of the face to determine one’s facial expression and often ignore or have difficulty identifying negative facial affects evident near the eyes (e.g., distress, fear) as early as the age of three44. However, other studies suggest that children with ASD have trouble recognizing emotions from the lower part of the face compared to NT children44. There is a wealth of behavioral evidence showing that recognition of even more early developing emotions like happiness and sadness are impaired in individuals with ASD45–47. On the other hand, there is evidence of intact recognition of happiness in some individuals with ASD48 as well as a ‘happy advantage’ as recognition of happiness within ASD groups tends to be better than recognition of other emotions49–53. Better recognition of happiness is also associated with greater social competence49. The recognition of negative emotions including sadness is generally found to be impaired in ASD44,53–55. Poor accuracy during sadness recognition tasks is associated with higher symptom severity and poorer adaptive functioning in individuals with ASD56.
Research has also demonstrated that during face recognition tasks, individuals with ASD show activity in brain areas typically related to the object perception pathway in NT individuals57,58, suggesting that individuals with ASD may be compensating for a lack of functionality in the core and extended face perception pathways by recruiting regions comprising more general object perception networks. This may explain why ASD individuals perform reasonably well on some behavioral tasks involving emotional face processing59, perhaps by adopting a compensatory strategy.
The fusiform gyrus (FG), the superior temporal sulcus (STS), and the amygdala have been implicated in the aberrant neuropathology of ASD during face processing. In general, there is evidence for atypical patterns of brain activity in the form of hypoactivation of the FG, STS, amygdala and the occipital lobes, alongside hypoconnectivity of the FG in individuals with ASD. In addition, individuals with ASD demonstrate hypoactivation and hypoconnectivity in areas of the face perception network, including the inferior frontal gyrus (IFG)60, ITG (inferior temporal gyrus)60, and middle frontal gyrus (MFG)57. These results demonstrate that atypical brain activation during emotional face perception is not restricted to the core face perception pathway, but also extends to other cortical areas related to executive functions such as attentional control and inhibition. Taken together, these findings suggest that atypical face perception in ASD is mediated by other factors in addition to pure visual perception.
The neural mechanisms underlying the interpretation of basic emotions such as happy and sad faces in ASD are well studied. Although most studies have reported decreased amygdala activation during emotional face processing (e.g., angry and fearful), one study has found greater right amygdala activation in the ASD group compared to the NT group when processing happy and sad faces60–66. Specifically, there was a greater positive functional connectivity between the right amygdala and ventromedial prefrontal cortex to happy faces but less positive functional connectivity between the right amygdala superior/medial temporal gyri67. Other studies also found that the ASD group showed greater bilateral activation in the amygdala, vPFC and striatum comparing to the NT group68. Due to high variability across fMRI studies, other brain regions have also been identified, but overall reduced brain activities when processing happy faces are observed in ASD groups67,69,70. The literature has also found consistent results that the ASD population is more sensitive to sad faces. When processing sad faces, ASD groups tend to show greater activation relative to control groups in the amygdala, vPFC, putamen, and striatum, and younger adolescents show greater activation than older adolescents68,70. However, one study found decreased activities in mPFC among the ASD group when processing sad faces68.
Contrary to early-developing emotions (e.g., happy, sad, mad, scared) that are responses to situations, recognizing surprise among children with ASD appears to lag behind. Knowing that understanding one’s own and others’ desires, beliefs and values is a particular area of deficit for children with ASD, it is not unexpected they would be challenged in their ability to make sense of the concept of ’surprise’30,45–47. Desire-based emotion plays an important role when understanding and empathizing with others’ thoughts and feelings43,71–75. In general, the understanding of desire among children with ASD is very limited and they often are unable to generalize their understanding without explicit instruction and support in social contexts30. Surprise and desire-based emotions have only been examined at a behavioral level in individuals with ASD and little is known about their neural correlates. Children with ASD may show an emotional response of embarrassment, although to a lesser degree than their NT peers. Further, they seldom recognize embarrassment or express their experiences in situations of embarrassment. Often, they miss social gaffes where what is said is perceived as an inappropriate comment in a social context30,36,76–81. Embarrassment has been studied at a neural level only among adults with ASD, with evidence suggesting altered circuitry in the mPFC, ACC, IFG, TPJ/pSTS, posterior cingulate cortex (PCC), and amygdala32,33,40.
1.3 Purpose of the Study
Although ToM has been studied for decades, it still remains a challenging research area due to its multi-faceted composition. Although the neural mechanisms underlying ToM have been examined, few brain-based studies include children with ASD. Thus, a greater understanding of the brain-behavior connections associated with ToM in children will provide researchers a potential link between the biological mechanisms of ToM and behavioral characteristics. It will help lead to more efficient diagnostic processes and prognostic indicators for special populations like children with ASD. To facilitate increased understanding of this linkage, the current study will emphasize emotion recognition ToM with a specific focus on less well-studied and more complex emotions (i.e., surprise, embarrassment, and desire-based emotion). Surprise and embarrassment are particularly difficult for children with ASD to recognize52,56. While desire-based emotions are easier for children with ASD to recognize, their understanding of these emotions is delicate and often requires explicit descriptions.
The current study is the first to examine the neural correlates of selected ToM constructs including desire-based emotions and more complex emotions (surprise, embarrassment) to establish connections between behavior and brain activities in children with ASD (i.e., 7 to 14 years old). We used The Theory of Mind Inventory-2 (ToMI-2)82 and The Theory of Mind Task Battery (ToMTB)83 to establish the behavioral patterns and identify differences between ASD and NT groups in their understanding of these less well-studied and complex emotions. We developed two novel fMRI tasks to identify brain regions associated with the recognition and processing of these emotions. Although our primary interest was in the neural response to recognition of more complex emotions requiring ToM (i.e., embarrassment and surprise), happy and sad faces were also included to provide a comparison with previous literature investigating recognition of basic emotions. We established brain activation patterns in both groups to further probe brain deficits and neural compensation mechanisms being adopted by the ASD group. Specifically, we expected to see altered brain activity patterns among the ASD group in brain regions involved in the ToM neural network (e.g., mPFC, pSTS, cingulate cortex, and TPJ). Building upon findings from previous studies, the present study provides a deeper and more systematic understanding of the brain-behavior connections associated with ToM. This knowledge may lead to both behavioral and neural pathways for examining the impact of intervention research to achieve more normalized social performance. Such research might also help predict those brain-behavior profiles of children most likely to benefit from specific ToM or social cognitive based interventions, emphasizing the importance of interventions delivered at the cognitive level to bridge behavior with brain function84.