Autistic Spectrum Disorders 53Box 4.1The Sally-Anne story: a test of first-order ‘Theory of Mind’
The following story is enacted with puppets and props.
Sally has a marble. She puts it in a basket and then goes out. While Sally is
out, Anne decides to play a trick on Sally. Anne takes the marble out from the
basket and puts it in a box instead. Then Anne leaves. When Sally comes home,
she wants her marble. Where will Sally look for the marble?
Normal 3-year-oldsfail the test, saying that Sally will look in the box; they
know the marble is there and they find it hard to see that Sally does not.
Normal 4-year-oldspass the test, predicting that Sally will act on her false
belief and look in the basket.
Children withDown syndromeusually pass the Sally-Anne test if they have a
mental age of 4 or more (on verbal tests).
Autistic children, by contrast, usually fail the Sally-Anne test even when they
do have a verbal mental age of 4 or more. The minority of high-functioning
autistic individuals who do pass the Sally-Anne test nearly always fail more
complex tests of mentalising ability.primary psychological deficit in autism include an innate impairment in
the ability to become emotionally engaged with others and an impaired
ability to extract high-level meaning by synthesising diverse sorts of
information. However, none of these theories accounts satisfactorily for
the repetitive and stereotypied behaviours seen in autism, or for the low
IQ seen in the majority.
Treatment
The mainstays of treatment are appropriate educational placement and the
provision of adequate support for parents. Children with autism generally
do best in a well-structured educational setting where the teachers have
special experience of the condition. Early placement in specialised nursery
schools from the age of 2 or 3 years may be particularly beneficial.
Home- and school-based behavioural programmes can reduce tantrums,
aggressive outbursts, fears and rituals, as well as fostering more normal
development. However, extreme behavioural regimes involving expen-
sive one-to-one tutoring have not been shown to improve symptoms
or development any more than good quality moderately intense special
educational care. Many families welcome respite care. Membership of
a parents’ organisation may be helpful, providing access to newsletters,
conferences, telephone helplines and contact with other similarly affected
families. Structured social skills groups have been shown in trials to help;
speech and language therapy has not been rigorously evaluated but is often
reported by parents to be useful.
Standard antiepileptic medication is used to manage any associated
epilepsy. Psychotropic medication does not cure the core symptoms of