NADD Bulletin Volume VII Number 6 Article 1

Complete listing

How Social Stories Can Teach Parents to Respond to Their Children's Developmental Needs

Ian Gilmour


A parent with an intellectual disability already faces significant life challenges from the disability. Social cognition is dissociable from general intelligence and, clearly, an intellectual disability in and of itself is not an adequate predictor of poor parenting. As Whitman and Accardo (1993) elegantly state, " the capacity to nurture is not dependent on intelligence, for if intelligence alone predicted the ability to nurture, there would be no parents of normal intelligence guilty of child abuse or neglect" (p. 124).

Most research concerning parents with an intellectual disability has focused on training instrumental skills. Those studies are very clear in their conclusions that parents with a intellectual disability do improve parenting skills (Llewellyn, McConnell, Honey, Mays, & Russo, 2003; Feldman, 2004). However, parenting with an intellectual disability is affected by other factors such as poverty (Rimmerman, Botuck, Levy, & Royce, 1996), higher rates of psychiatric illnesses (Bongiorno, 1996), parents having a higher risk of having had neglectful or abusive experiences in their own childhood (Sobsey, 1994), higher risks of spousal abuse (Powers, Curry, Oschwald, & Maley, 2002), and lack of consistent supports (Ray, Rubenstein, & Russo, 1994). Ray and group (1994) found that one third of children of parents with an intellectual disability who were under three years of age had an identified disability. The number of children later in life who had an identified disability increased to two thirds. They also found that parents were often disengaged from services viewing them as threats to their autonomy. Finally, many parents struggled with general life stressors.

This paper will suggest that an important factor in supporting parents with an intellectual disability is to increase their abilities to respond to activations of their children's attachment systems as infants, and to assist them in moving towards a goal-directed partnership with their children. The paper will examine processes of social cognition, a neural and experiential system that allows human beings the ability to demonstrate the insight into their own mind and the minds of others. These skills underlie critical social processes such as empathy. This process, called among other names, theory of mind is defined by the Oxford psychologist, Simon Baron-Cohen, as a complex cognitive mechanism enabling an individual to formulate meta-representation, that is the ability to mentally depict the psychological states of others (Baron-Cohen et al., 1994). The development of a theory of mind has been related to attachment security (Fongay, Redfern, & Charman, 1997). Perry (1997) and Karmiloff-Smith (1998) have argued that a seriously compromised developmental process affects processes within the brain responsible for motivation, exploration, the abilities to categorize, sequence and output coherent behaviour.

This paper hypothesizes developmental disruptions in the life of some parents with an intellectual disability independent of the disability, due to social and biological factors that have disrupted developmental processes leading to a fully functioning theory of mind. This hypothesized effect would negatively impact the way in which the parents organize the meaning of social stimuli both from a perspective of a topology of salience (a system that organizes responses to the world) but also in the organization of emotions leading to the creation of somatic markers (a form of mental representation that short hand brain-body reactions to environmental events). all of which contribute to an inability to be aware of their child's needs and to be able to see their children as separate and possessing desires, beliefs and wishes that may conflict with their own. Finally the paper suggests different types of social cognitive interventions through the use of social stories and two techniques that are used with non-disabled individuals who also are challenged in their parenting abilities, Guidance Interaction (McDonough, 1993) and Wait-Watch-Wonder (Cohen et al., 1999).

Social Cognition

Adolphs (2001) commented on the importance of social cognition for development,

"The ability to recognize, manipulate, and behave with respect to socially relevant information requires neural systems that process perception of social signals and that connect such perception to motivation, emotion, and adaptive behavior. Social cognition guides both automatic and volitional behavior by participating in a variety of processes that modulate behavioral response: memory, decision-making, attention, motivation and emotion are all prominently recruited when socially relevant stimuli elicit behavior" (p. 231).

Humans are not born with a fully mature theory of mind; we go through a developmental process, aided by caregivers. This period of care giving allows us the time and experiences necessary to develop our capabilities for agency, intentionality, and mind

Malle (2002a) suggests that joint attention, an important early component of social cognition, begins the innate ability to imitate. By 14 months of age the infant has already achieved the growth of social cognitive abilities which allow him/her to parse human action streams into meaningful units of behaviour which are intentional and goal directed. This allows the child by 18 months of life to infer intentions even from unsuccessful surface behavior. By the age of two years, the child has a conceptual understanding of desires, and by age 3 years of beliefs, culminating by the age of 4 years in an understanding that others can hold false beliefs, which many consider the watershed of theory of mind development. At this point children understand that different people represent the world in different ways and therefore can believe or know different things.

Somatic Markers

Damasio (1994) has also argued that emotions are central in cognition. Damasio argues that there is no Cartesian separation of body and brain. He notes that "Nature appears to have built the apparatus of rationality not just on top of the apparatus of biological regulation, but also from it and with it" (p.128). In fact, Damasio suggests that purposeful and functional social action occurring in a moment-by-moment context could not take place without underlying emotional processes. Damasio makes a distinction between emotions which occur in the brain and a feeling which is a perception of the emotion occurring within the body.

Damasio suggests that there are two levels of emotions within human beings. The first type he labels primary emotions; these are innate and correspond to activation of the amygdala and limbic system. They are oriented to the biological survival of an organism and are evolutionary based.

There are also what Damasio calls secondary emotions, ones that occur in the brain and body and involve a complex interaction. Secondary emotions occur according to Damasio when a person begin a process of dealing with an event, and the subsequent evaluation of its social meaning. What is created is a distinct physiological response within the brain and body. The person's heart rate may increase, resulting in a flush on his face because greater blood flow. The endocrine system releases peptide modulators that arouse the immune system. The musculoskeletal system activated facial muscles that formed into an emotional expression that represented his evaluation of the event (fear, distress, danger) The overall effect of these linked reactions is a change in the homeostatic balance of the body (p. 135).

Damasio also discusses an alternate process known as an AS-IF loop, which by passes the brain-body changes of secondary emotions but still allows the person to rapidly compare past coping with current contingencies and apply the results to the current and similar event. The reactivation signals of the AS-IF loop (only sent to the somatosensory cortex) allow the person through the somatosensory areas to recall the original encoded experience. In essence the person can re-sense the original experience. It is a way for the person to make rapid decisions regarding social & environmental stimuli.

"Somatic markers," explains Damasio, "force attention on the negative outcome to which a given action may lead, and functions as an automated alarm signal" The function of the alarm system is multicomponented. It not only assists in the rejection of actions that would be punishing for him or her, but it also decreases the number of alternatives that a person needs to choose from. Damasio does not see it as a substitute for normal decision making but a means by which an individual can rapidly assess and decide on a course of action in the face of a threat or a reward. (p. 173) It is likely that somatic markers are involved in the creation of a topology of salience in which the person reacts to events.

Topology of salience

Ami Klin and associates have defined social cognition as a predisposition to social stimuli whereby a child actively attempts engagement in a process to make sense of the social environment (Klin, Jones, Schultz, & Volkmar, 2003). Klin et al. view this engagement as a dynamic process in which the interaction affects both the child and environment. Modification occurs in the child's functional abilities to make sense of the social environment. It focuses on how an organism is changed by interaction with the environment. Klin et al. refer to this as a "species-specific topology of salience (i.e. some things in the environment are more important than others" p. 348-9). Klin et al. note that in normative developmental processes children become adept at managing moment-to-moment social interactions occurring steadily within the environment. These experiences accumulate and involve a huge number of thoughts, feelings & actions. This storehouse of experience is formed, according to Klin et al., into maps of affective and cognitive knowledges. An individual will have paired these mapped knowledges to types of social stimuli that, as Klin et al. say, facilitates his or her ability to, "navigate the background environment according to the relative salience of each of the multitude of elements of a situation." The map that develops allows the person to "&ldots; make sense of the social environment and change itself as a result of this interaction&ldots;[this viewpoint produces a] &ldots;topology of differential salience" (i.e. some things in the environment are more important than others) (p. 348). Klin et al. summarise when they note:

"the vast complexity of the surrounding environment is greatly simplified in terms of a differential 'topology of salience' that separates aspects of the environment that are irrelevant&ldots;from those that are crucially important&ldots;Second, this topology of salience is established in terms of perceptually or cognitively guided actions subserving social adaptation. These principles imply, however, that the surrounding environment will be 'enacted' or recreated differently based on differences in predispositions to respond in a certain way" (p. 349).

A topology of salience arises from multiple and complex adaptive and non-adaptive interactions between the organism and the social environment. They suggest that the brain's somatosensory areas are involved in how people learn to predict future events by identifying aspects of the world which are salient to him or her given their innate role in survival. For example, Klin et al. suggest that social stimuli for an infant have a higher survival salience than inanimate stimuli. However, this may not hold true for individuals with atypical developmental experiences. An individual with an atypical topology of salience will have accumulated a store of social knowledges but likely has contextualized it in such a way that it is not helpful to him/her to align internal states with external demands or to flexibly apply rules or strategies. What has happened instead is that affective and cognitive knowledge is inefficiently matched, leading to social failures. These difficulties can be applied to a number of populations. For example, a person with ADHD would have a topology of salience that may be missing key mapped linkages between stored knowledge and social stimuli because of his or her difficulty in correctly perceiving non-verbal signals, especially those involved in emotional recognition. Cadesky, Mota, and Schachar (2000) found that children with ADHD were less accurate than controls in the recognition of emotional cues from pictures of facial expressions and recordings of voices. Similarly, Pollack, Cicchetti, Hornung, and Reed (2001) found that children who had been maltreated were less able than children without a maltreatment history to recognize emotional cues. It would be likely that some parents with an intellectual disability may not have formed an adequate topology of salience. An adequate topology of salience is also likely related to the development of self-regulation. Bechara et al. (1997) note that "&ldots;regulatory mental systems are not innate, but a product of the experience-dependent maturation of the orbitofrontal system which generates nonconscious biases that guide behavior before conscious knowledge does. Disruptions in developmental process leading to a theory of mind and an adequate topology of salience can and will have significant, long standing negative effects.

An Overview of Research on Parents with an Intellectual Disability

Feldman (2004) notes that research into parents with intellectual disability has suggested a number of potential risk factors for children.

"Children of parents with intellectual disabilities are at-risk for neglectful care that leads to health, developmental, and behavioural problems. Most of these problems can be traced to parenting skill deficiencies, rather than purposeful abuse or neglect. Many of these parents&ldots;lack critical knowledge and skills in providing adequate instrumental child-care, a safe home environment, proper nutrition, and nurturing interactions&ldots;Parents with ID also have difficulties in problem-solving recognizing and treating medical emergencies, and understanding basic child development information" (p. 17).

General research positions on people with an intellectual disability parenting

1.People with an intellectual disability (ID) are not inherently poor parents but, rather, are have poor social support networks and have parenting skill deficiencies, both of which when remediated allow individuals to parent successfully (adapted from Aunos, Goupil, & Feldman, 2003).

2.The second position argues incapacity that put children at risk, due to an disability that endangers the child's health, safety and intellectual and emotional development

3.A third position argues that controlling for disability there is a systemic discrimination where parents with an ID are over-represented in child welfare cases

Skill deficits

Aunos et al. (2003) also provided a brief review of what could be characterized as 3 research directions regarding parents with an ID:

Emotionally-related-research appearing in the 1980s and early 1990s described parents with an ID often failing to provide necessary stimulation in terms of emotional and cognitive development. They often lived in environments which were neither enriching nor often safe. Parents with an ID often did not always respond sensitively or consistently to their children's needs. Parents appeared confused and had trouble in making and carrying out adequate care decision about their children, and as having difficulties making decisions regarding their parenting role

Parenting difficulties as skill deficits-a second line of research focused on training parents with an ID to teach instrumental parenting skills that would as described by Aunos et al., (2003) "increase the chances of satisfactory care and child development" (p. 66).

Social factors-a third line of research that explored additional factors that would decrease a parent's ability to care for children is the social support hypothesis. This described increased social supports to reduce stress and be able to provide more focused care to their children. A supportive social network could, it was hypothesized, "model more effective parenting behaviours and problem-solving strategies as well as offer emotional and practical support to these parents" (p. 66). A corollary to the supportive social network hypothesis is the 'benefactor.' This is one individual, important to the life of the parent with an ID who can provide "nonjudgmental type of support" (p. 66). Related to this are examination of: a) parents' physical and mental health, b) history, c) socio-economic status, d) family functioning, e) child characteristics, and, f) social factors in influencing parenting and adaptive abilities

Primarily incapability due to intellectual disability

Lynch and Bakely, (1989) in their review of literature regarding parents with an ID report concerns such as:

1.Learning problems




Their review suggested that the majority of identified concerns about the parenting style of people with an ID focused on discipline and instrumental care:

a.Disciplinary strategies were described as punitive, inappropriate for the child's age, and ineffectual

b.Children were not fed appropriate food, were left without supervision, and were given no stimulation...

c.Within the home there were unsafe conditions in which the child could harm themselves or others

d.Problems encountered typically were attributed to the parent's cognitive characteristics associated with their disability rather than to negative intent." (p.27)

Primarily discriminatory practices

Kirschbaum (2000) has suggested that there is evidence to suggest that there may be an active prejudice that minimizes the ability of parents with intellectual disabilities to adequately care for their children. A review of case law in the USA does suggest an apparent ongoing bias against parents with an ID in judgments in favour of the parent without an ID.

Booth (2000) summarizes evidence regarding a lack of support for the parenting efforts of people with an ID as:

1.Parents with [intellectual disabilities] are disproportionately represented in care proceedings.

2.They are less likely than other parents to have received support in their parenting - or to have received inadequate support - before care proceedings are initiated.

3.They are at risk of having their parental responsibility terminated on the basis of evidence that would likely be dismissed if brought against parents without a disability.

4.They are likely to have their competence as parents judged against stricter criteria or harsher standards than other parents.

5.They are more likely to have their children removed and their parental rights terminated.

6.They are disadvantaged in the child protection and court process by rules of evidence and procedure, ability to understand complex issues, and inadequacies in support services.

7.They are less likely to receive support in correcting the conditions leading to termination.


Linking social cognition and attachment theory

Adolphs (2001) points out that social cognition is highly correlated with emotion and its expression within an attachment relationship. Disruption of the development of a theory of mind can be affected by insensitive or destructive care giving that creates an emotional separation between the child and his or her primary caregiver. Malle (2002b) also points out the developmental danger when a child mentally separates from their caregiver-a disconnection encompassing attention and emotion-a result that can inhibit the child's ability to engage in vicarious learning, to benefit fully from instructional learning, to be able to interpersonal connect with others, and to engage in adequate social information processing. Ironically, the ultimate effect is a profound lack of sensitivity to their own mental life-as Malle says "the child becomes a mystery to himself, and with that is unable to adequately form mental representations that would allow him to infer about & interpret about the behaviours of others" (Malle, 2002b, 268-269).

Neural development is interactive with the environment in a use-dependent manner. Certain types of experiences are more optimal and lead to better outcomes. For example, development of the child can be affected by developmental status, the presence in the caregiver of an unresolved trauma or grief, poverty, caregiver psychopathology, an early onset childhood disorder such as ADHD (Kazdin, Kraemer, Kessler, Kupfer, & Offord, 1997; Cicchetti, 1994). Sroufe et al. (1999) reports that "a cumulative history of maladaptation will be more pathogenic than a single early period of poor functioning, with pathology ever more likely the longer a maladaptive pathway has been followed&ldots;[and]&ldots;change itself will be predictable in light of changes in stress and/or support (p. 2-3).

All of these factors could and do create situations in which it is difficult for parents to parent sensitively. The paper will outline literature concerning parents with an intellectual disability and then discuss attachment theory and profile an application of attachment theory developed by Pamela Crittenden (1994) that behaviourally describes the effect on children of types of dysfunctional parenting styles.

Attachment theory

John Bowlby (1969; 1972; 1981) in his seminal theory of attachment suggested that instinctive behaviours, as an organism evolves from primitive, reflexive, fixed action patterns become incorporated into complex hierarchies of behaviour. His work anticipated later research into neural states detailing how a person adapts drives (innate organization of the brain) in reaction to changing environmental circumstance, which, according to Damasio (1994), increase the chances of survival by an organism

Attachment as Bowlby conceptualized it is a biologically influenced process, which protects an infant from danger and meets the infant's comfort and physical needs. His great insight was that instinctive behaviours in complex organisms are capable of goal-correcting actions. The ability to use goal-correcting actions means that an individual is able to consciously change how and why behaviours occur. This means that we have a system of control that is flexible rather than rigidly innate and overly deterministic as is the case in less complex organisms

However, he cautioned that flexibility also meant that these processes require continuity and if the goal correcting, adaptive transformations are disrupted, there is a high risk of a corresponding disruption of the child's developmental pathways-a child's exploration of themselves and their environment relies on qualities of social interaction from the caregiver to their infant that are sensitive and responsive to the child's needs and earliest signals.

The stability of attachment status

Vondra et al. (2001) found that a child's attachment classification clearly influenced current and later assessments of his or her ability to engage in emotional and behavioural regulation. Attachment status appears to have a life-long influence; Sameroff and Emde (1989) have suggested that a person's attachment system disturbed in early life is a likely "probabilistic" marker for some type of later psychopathology. Sameroff (1989) noted that even in cases where an individual has achieved changes that diminish the chances of psychopathology, the individual would still be at-risk for potential reactivation of these issue. However, on a more hopeful note, Sroufe et al. (1999), in a review of literature pertaining to attachment status and the risk of psychopathology, found that positive changes in developmental course were best predicted by increased stability of social support for the primary caregiver (p 3). Similarly, Seigel (2001b) has said that the most robust predictor of a child's attachment behaviour is not necessarily the events their early life, but, as the child matures, how he or she come to make sense of early relationship experiences. However this process (the application of social cognitive processes) is enhanced if the parent has him or herself made sense of their own childhood experience and has insights into how their past has influenced his or her development as an adult (Main & Hesse, 1990). As a child grows, the relationship between him or her and the parents becomes increasingly bi-directional in that each influences the others' behaviour (Crittenden, 1992). Bowlby (1969) and Ainsworth, Blehar, Waters, and Wall (1978) discussed age related stages within the development of parent-child attachment relationships with the last stage being one of shared responsibilities within interactions. What is widely agreed among researchers is that a poor attachment status increases the possibilities of serious disruptions within a child's developmental processes (Perry, 1997; 2002).

Behavioural descriptions of attachment patterns

Crittenden (1994) has argued that "&ldots;at the close of infancy, infants who are labeled secure have learned the. predictive and communicative value of many interpersonal signals; they have made meaning of both ion and affect. Avoidant infants, on the other hand, have learned to organize their behavior without being able to interpret or affective signals; that is, they have made sense of cognition but not affect. Ambivalent infants have been reinforced for affective or but have not learned a cognitive organization that reduces the inconsistency of their mothers' behavior. Thus, secure infants are competent with both cognitive and affective models; that is, they are balanced with regard to source of information" (p. 371).

Securely attached children have had the developmental opportunity to become self-regulated by the model of self regulation provided to them by their parent. They have been able to progress through age related stages of attachment development creating with their parents a goal-attainment partnership (Ainsworth et al., 1978). These successes are in sharp contrast to children who have an attachment status which have avoidant or ambivalent features.

Children with a rejecting/interfering parent

Avoidance is a survival strategy employed by children to prevent rejection by what Crittenden calls an interfering caregiver. These children grapple with two issues as they develop social cognitive abilities (Crittenden, 2001). Their active goal is to protect him or herself from caregiver anger, interference and rejection. Behavioural avoidance is slowly replaced with a psychological one (p. 377). This allows the child to interact on an instrumental level by inhibiting emotions that would signal a need or wish for closeness with the parent. The child will interact instrumentally but avoid affective displays and behaviours. Crittenden suggests that the child has learned that affect is a dangerous commodity leading to punishing consequences. Cognitions are safe in that they allow for self-control that helps manage parental-child interactions and thus has highly reinforcing consequences. It is an escape strategy that mitigates parental reactions. Crittenden suggests that this style of interaction matches the preferences of the parent who has few strategies for managing emotional closeness. This type of parent-child relationship could be characterized as cold social cognition where relationships are carefully constructed.

Children with a withdrawn parent

Children who have a parent who is withdrawn also construct using cold social cognition. These children have learned that the most efficient means of gaining and maintaining parental attention is to use constructed affective displays. Crittenden notes that children have mastered the ability of inhibiting their own emotions and substituting false affect attractive to their parents between 18 and 24 months. It becomes the child's responsibility to assure the parent that they will not make demands that would make the parent uncomfortable. Both Bowlby and Crittenden have identified this behaviour as compulsive caregiving whose function is to increase the parent's interest in interacting with the child. Crittenden uses the term non-contextual joy to describe displays of false affect (p. 378). Behaviourally the child signals non-contextual joy through a variety of non-verbal means: facial expression (incomplete: smiles, crooked smiles, smiles while turning away) and in the rate and intensity of the affective display (the flow in the exchange of affect is sudden, very brief, and out of context). When the child succeeds in gaining the parent's attention he or she might well become inhibited and limit the interaction (p.378).

Children with an inconsistent parent

Children whose bids for attention and nurturance are met with parental behaviours that alternate response of anger, nurturance and ignoring also tend to reject hot social cognition, since they are unable to predict when an emotional display would engender aggression or intent to harm from a parent or have no effect at all in securing nurturance. As infants these children lack parent-mediated self-soothing routines needed to deal with emotional cascades. However, Crittenden notes, by the time they would begin in a preschool they know that the signals they send to their parents and other adults must be unambiguous to motivate the adult to attend to their needs, desires, and wishes. These are children who seem to have a limited range of affective expression.

Growing developmental competence associated with a theory of mind allows the child to develop to main strategies for survival. The first is coercive behaviour and the second is coy behaviour. Both strategies function to secure behavioural responses from a parent with an inconsistent caregiving style that range from nurturance to environmental control to disarming aggression. The child uses coy behaviour as a strategy to quickly deescalate the parent's anger. Anger and coercion on the other hand are applied by the child reading the emotional state of the parent and judging when he or she would be vulnerable to this type of approach. Patterson (1982) has written extensively on the types of coercive behaviours that parents and children caught in a cycle of aversiveness display to each other and the effects on relationship processes. Crittenden notes that the application of these strategies is a highly risky proposition for the child.

Changing Parenting Practices

The question of what is salient for a parent with an intellectual disability may be influenced, as Malle (2002a) has pointed out by a damaged social cognitive system. Malle states that "People with a deficient theory of mind&ldots; lack the network of concepts that would allow them to interpret with ease and swiftness the meaning of this information." Malle (2002b) notes that the connections between mental states and behaviour leads to two outcomes-- "intentional action, which is caused by the agent's intention and decision, and unintentional behavior, which can be caused by internal or external events without the intervention of the agent's decision." Changing the parent's topology of salience while at the same time hopefully changing somatic markers creates abstract tasks which can be approached using positive behavioural methods.

Before commencing intervention it is important to understand and incorporate what the parent knows and what the parent knows and can actually apply successfully. Questions such as these may be useful in formulating an initial approach: a) What is their social knowledge base, and their ability to assign meaning which is culturally normative? b) What did they experience as children? c) What kind of life experiences have they had? d) What is the level of their instrumental skill? e) What is their current ability to assign social meaning to environmental events? f) how does that ability or lack of ability impact on the choices they make and why do they potentially reject other choices that would more adaptive for their child? g) What resources are available and which ones need to be created? and h) In short, what constitutes their topology of salience applied to their life and their children?


Core social skills that need to be taught to the parent

To accomplish this skill training has to be individualized to the parent's unique needs, and the emotional and cognitive ability of the parent(s) to understand, and requires the integration of a variety of positive behavioural and social communication techniques that target cognitions, emotions, and social-communication skills. It is essential to identify and build on demonstrated behaviour or verbal language that would help the parent(s) have an early sense of success and competence so that they are more likely to collaborate on new problem- solving skills. All of this is to clearly explain the instrumental behaviours which are missing and which can be taught through the use of social stories-for example, the critical need to support the child's developmental of non-verbal and verbal social and positive social interactions. To accomplish this, these parents must talk and interact more with their children to create models of varied models of social language (comments, protests) that they can use to influence their own self-regulation and impact the environment. To be able to do that they will likely need to be taught how to do it. Critically important is responsiveness and encouragement of joint attention so that actions, objects, gestures, words, and events can become connected to the child's social environmental experiences. Feldman has suggested that parents who use a variety of language forms and who use developmentally appropriate language tend, according to the research, to produce better rates of language development for their children.

Parents will need to learn to recognize and verbally discuss his or her frustration-they need to possess a rudimentary vocabulary of emotions. They will need to identify and verbally discuss which aspects of either the environment or his or her reaction to it is frustrating (a rudimentary awareness of interactional outcomes between him- or herself and the environment). They will have to have functional and meaningful strategies to counter automatic thoughts (i.e., 'I'm stupid or bad') in such a way that these thoughts do not contribute to misinterpretation of the social intent of others within interactions.

If these instrumental skills are taught, then it is more likely that the parent will be able to gain some greater insight into their own mind and that will promote their ability to recognize and respond to their child's social perspective. It should be easier for him or her to act appropriately in response to their child's social intentions and displays of agency. These two skills underlie the parent's ability to express empathy either verbally or nonverbally in a variety of situations and within conditions of low frustration tolerance. These skills also provide a basis for the parent to develop a theory of self that helps him or her decode and apply varied the social meanings to self, others, and environmental events is the key component in flexible social skills

It could well be that parents with an intellectual disability, like parents who fail to respond to their children's attachment systems, have specific deficits in understanding their children's mental state concepts (beliefs, knowledge, desires, and intentions) ,the lack of which handicap their ability to understand themselves and others. Although the parents might well pass a false belief test, their continuing actions, represented in all categories of the parent with ID literature suggests in day to day, moment to moment interactions, their ability to recognize and respond to their children is often limited.

Introducing Social Stories as a Means of Assigning New Meaning to Social Stimuli

The idea is to help him or her by using a non-intrusive, social cognitive cue that helps the parent reorganize what he or she knows and apply it to the current situation. Social stories (Gray, 1996) have been most often used in interventions for people with autism spectrum disorders. They help children understand the social perspective of others. Social stories can be used in two related ways: Social stories can act as a major support in establishing social meaning. Salience of attention is one of the ways the parent makes sense of the world around them, and the parents' inappropriate salience may reveal deficits in their underlying social knowledge. Misdirected salience may be one explanation why a parent with an intellectual disability has difficulty understanding a rapidly moving developmental context with its demands for flexibility and shifts in thinking, feeling and behaviour. Changing how the parent attends to environmental elements most prominent for him or her. Social stories help formulate new cues and signals providing more appropriate parenting behaviours.

Social stories are designed to help the parent understand, predict, and anticipate the future. Social stories can do this by helping the parent hold critical information leading to a new coping response within working memory long enough to organize behaviour across a span of time and within a time sequence. According to Barkley (1998), this ability contributes to achieving hindsight and forethought. Since social stories focus on enhancing verbal and non-verbal language, they are extremely useful in adding to the individual's basic information-processing abilities (e.g., perception, memory, sequential processing, use of meta-cognitive strategies, rule learning, speed of processing). They provide the parent with salient strategies easily included within their current behavioural repertoire.

Thought bubbles

Thought bubbles cards are a sophisticated way of acknowledging & explaining to parents their own and their children's feeling and thinking states. They can help to translate them from abstract language to concrete symbols, which still retain the intention of abstract notion. They can be used to normalize, for the person, his or her feelings and thoughts, juxtaposing them with the feeling and thoughts of others. This assists in the development of clear communication process between the person and children while potentially offering an appropriate escape without the use of problematic communication behaviours. They translate, for the person, the social intentions and perspectives of others.

These act as a "picture-in-the-head strategy" for the person (Wellman et al., 2002). They allow the therapist and person to gain information about the thoughts in others. Some intriguing experiment have been carried out where manikins have a picture inserted into a slot in the head (Swettenham, Baron-Cohen, Gomez, & Walsh, 1996; McGregor, Whiten, & Blackburn, 1998). Experimenters suggested to the children with ASD that when they look at an object it creates a type of picture in their heads. Results tentatively indicated that this training technique might contribute to a modest increased ability to apply mental states by children to others. Wellman et al. (2002) extended the picture-in-the-head metaphor to thought bubbles. They define thought bubbles as:

"&ldots;Thought bubbles arguably provide a particularly natural or effective way of depicting thoughts pictorially, one which could come to aid autistic individual's reasoning about people, behavior, and mental states. In particular, thoughts are representational mental states and thought-bubbles depict a person's thoughts in a straightforward representational fashion, as pictures."

Results indicated that children were able to answering questions on a false belief covering both behavioural actions and in imputing thoughts to characters that demonstrated a rudimentary grasp of social cognition over pretest conditions. They suggested that not only were the thought bubbles useful in teaching the specific information needed to pass the false belief test but also that thought bubbles might assist in generalizing social cognitive skills.

With parents with an intellectual disability thought bubbles could be used to challenge faulty logic or automatic thoughts & responses. For example does the child cry because she is bad or because she needs to have her diaper changed? Feldman (2004) indicated the use of visuals (pictures, diagrams, videos) have been found to be an effective teaching tool with instrumental behaviours of parents with an ID.

Using New Strategies Taught In Social Stories As Neutralizing Routines For Inadequate Parenting Practices

The intention of a change in both the probability of applying a topology of salience may well be accomplished by neutralizing the influence of environmental SD made salient by the presence of a distal setting event (also referred to as an establishing operation), so that both are neutralized. Horner, Day, and Day (1997) discuss the use of neutralizing routines as a means of reducing the "&ldots;value of reinforcers that are associated with problem behavior" (p. 602). Horner et al. go on to say that: "The use of neutralizing routines is most practical if the initial establishing operation occurs at a point temporally distant from the discriminative stimulus for problem behavior. Given that a functional assessment identifies (a) the problem behavior, (b) stimuli that set the occasion for the problem behavior, and (c) preceding establishing operations for problem behavior, then one element of an intervention may be to insert a neutralizing routine between the occurrence of the establishing operation and presentation of the discriminative stimulus. The function of the neutralizing routine is to reduce the reinforcing value of consequences associated with problem behavior" (p. 602).

Wait-Watch-Wonder and Interaction Guidance

A second class of intervention that can also utilize social stories and thought bubbles is using infant mental health techniques such as Wait-Watch-Wonder and Interaction Guidance. Watch-Wait-Wonder (Muir, 1992) is a technique which teaches parents to shift communication from meeting only personal and instrumental goals to formats that match his or her needs with the needs of their children within a social interaction. The parent learns to read the emotional state of their child, to be attentive to signs of distress (emotional upset, frustration, physical hurt, etc.), and to respond promptly, warmly, and in a reassuring manner. It creates new responses because the parent learns to wait for a response and to develop listening skills, and to employ pragmatic social communication skills such as turn taking and asking for clarification.

Interaction guidance (McDonough, 1993) focuses on two important goals: a) to teach the person to recognize their response patterns to others and the consequences of those behaviours, on himself and others. Secondly, b) it provides a rational that helps him recognize and respond to the distress of others around him, and to allow them to respond to his distress. Interactional Guidance should be seen as a directive method in which the parent would be coached from the videotape and given "homework" assignments in increasingly unstructured social situations to practice and reinforce learning accomplished during the session. First parents are taught how to position his or her body in such a way that he or she has face-to-face interactions with the child. The parent is also taught to project affect that is positive and inviting. Then they work and practice on emotional recognition and in projecting affective expression

Paired with social stories these two techniques, which have proven very useful with parents without an intellectual disability who had severe problems in parenting their children, may well be an effective means by which a parent with an ID can make changes in their topology of salience. This change implies a change in how information is understood (ascribed meaning) as well as how it may be organized within the person's neural/visceral/emotional systems. This has significant implications for helping the person identify and challenge the antecedents in their life which act as a discriminative stimuli for actions in response to their children, as well as changing setting events which also change the quality of their responses to their children. This might be an inadvertent action by the child or some other environmental event which occasions specific emotions and/or cognitions dramatically changing their responses to the action-the example that comes to mind is unresolved grief or trauma from earlier experiences unknowingly to the parent changes their behaviour (Main & Hesse, 1990).


This paper has suggested new means of conceptualizing the difficulties that some parents with an intellectual disability face in parenting their children. It suggests that social cognition is an important factor in this new conceptualization. Understanding the parents' topology of salience and their ability to see their children as separate from them is critical information in understanding why these parents act as they do. Adapting Crittenden's developmental-maturational model of attachment may be a means by which interventionists could draw early inferences about the style of parenting and its effect on their child. Finally it proposes a series of interventions to teach new social cognitive skills to these parents.





Adolphs, R. (2001). The neurobiology of social cognition. Current Opinion in Neurobiology, 11, 231-239.

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Lawrence Erlbaum.

Anous, M., Goupil, G., & Feldman, M. (2003). Mothers with intellectual disabilities who do and do not have custody of their children. Journal of Developmental Disabilities, 10, 65-80.

Barkley, R. A. (1998). How should attention deficit disorder be described? Harvard Mental Health Letter, 14 (8), 8.

Baron-Cohen, S., Ring, H., Moriarty, J., Schmitz, B., Costa S., & Ell, P. (1994). Recognition of mental state terms: Clinical findings in children with autism and a functional neuroimaging study of normal adults. The British Journal of Psychiatry, 165, 640-649.

Bechara, A., Tranel, D., & Damasio, H. (2000) Characterization of the decision-making deficit of patients with ventromedial prefrontal cortex lesions. Brain, 12, 2189-2202.

Booth, W. (2000). Parents with learning disabilities need support. Nursing Times, 23, 41.

Bongiorno, F. P. (1996). Dual diagnosis: Developmental disability complicated by mental illness. Southern Medical Journal, 89, 1142-1146.

Bowlby, J. (1969). Attachment and loss (Vol. 1. Attachment). New York: Basic Books.

Bowlby, J. (1973). Separation. New York: Basic Books.

Bowlby, J. (1980). Attachment and loss (Vol. 3. Loss). New York: Basic Books.

Cadesky, E. B., Mota, V. L., & Schachar R. J. (2000). Beyond words: How do children with ADHD and/or conduct problems process nonverbal information about affect? Journal of the American Academy of Child & Adolescent Psychiatry, 39, 1160-1167.

Cicchetti, D. (1994). Integrating developmental risk factors: Perspectives from developmental psychopathology. In C. A. Nelson (Ed.), Threats to optimal development: Integrating biological, psychological, and social risk factors (pp. 285-325). Hillsdale, NJ: Lawrence Erlbaum Assoc.

Cohen, N. J., Muir, E., Parker, C. J., Brown, M., Lojkasek, M., Muir, R., et al. (1999). Watch, Wait and Wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal, 20, 429-451.

Crittenden, P. M. (1992). Quality of attachment in the preschool years. Development and Psychopathology, 4, 209-241.

Crittenden, P. (1994). Attachment and psychopathology. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, developmental, and clinical perspectives. (p. 367-406). Hillsdale, NJ: The Analytic Press.

Crittenden, P. M. (2001). Organization, alternative organizations, and disorganization: Competing perspectives on the development of endangered children. Contemporary Psychology, 46, 593-596.

Damasio, A. R. (1994). Descartes' Error: Emotion, reason, and the human brain. New York: Grosset/Putnam.

Feldman, M. A. (2004). Self-directed learning of child-care skills by parents with intellectual disabilities. Infants and Young Children, 17, 17-31

Fongay, P., Redfern, S., & Charman, T. (1997). The relationship between belief-desire reasoning and a projective measure of attachment security (SAT). British Journal of Developmental Psychology, 15, 51-61.

Gray, C. (1996). Teaching children with autism to "read" social situations. In K. Quill (Ed.), Teaching students with autism: Methods to enhance learning, communication, and socialization (pp. 219-242). New York: Delmar Publishers.

Horner, R. H., Day, H. M., & Day, J. (1997). Using neutralizing routines to reduce problem behaviors. Journal Of Applied Behavior Analysis, 30, 601-614.

Karmiloff-Smith, A. (1998). Development itself is the key to understanding developmental disorders. Trends in Cognitive Sciences, 2, 389-398.

Kazdin, A. E., Kraemer, H. C., Kessler, R. C., Kupfer, D. J., & Offord, D. R. (1997). Contributions of risk-factor research to developmental psychopathology. Clinical Psychology Review, 17, 375-406.

Klin, A., Jones, W., Schultz, R., & Volkmar, F. (2003). The enactive mind, or from actions to cognition: lessons from autism. Philosophical Transactions of the Royal Society of London, 358, 345-360.

Kirshbaum, M. (2000). A disability culture perspective on early intervention with parents with physical or cognitive disabilities and their infants. Infants and Young Children, 13 (2), 9-20.

Llewellyn, G., McConnell, D., Honey, A., Mayes, R., & Russo, D. (2003). Promoting health and home safety for children of parents with intellectual disability: A randomised controlled trial. Research in Developmental Disabilities, 24, 405-431.

Main, M., & Hesse, E. (1990). Parent's unresolved traumatic experiences are related to infant disorganized status: Is frightening and/or frightened parental behavior the linking mechanism? In M. Greenberg, D. Cicchetti, & M. Cummings (Eds.), Attachment in the preschool years. (p. 161-182). Chicago: University of Chicago Press.

Malle, B. F. (2002a). Folk theory of mind: Conceptual foundations of social cognition. In Hassan, Uleman, & Bargh (Eds.), The new unconscious. New York: Oxford University Press.

Malle, B. F. (2002b).The relation between language and theory of mind in development and

evolution. In T. Givón & B. F. Malle (Eds.), The Evolution of language out of pre-language. (pp. 263-282). New York: John Benjamins Publisher.

McDonough, S. (1993) Interaction guidance: Understanding and treating early infant-caregiver relationship disturbances. In C. H. Zeanah (Ed.), Handbook of infant mental health (pp. 414-426). New York: The Guilford Press.

McGregor, E., Whiten, A., & Blackburn, P. (1998). Teaching theory of mind by highlighting intention and illustrating thoughts: A comparison of their effectiveness with three-year-olds and autistic subjects. British Journal of Developmental Psychology, 16, 281-300.

Muir, E. (1992). Watching, waiting, and wondering: Applying psychoanalytic principles to mother-infant intervention. Infant Mental Health Journal, 13, 319-328.

Patterson, G. R. (1982). Coercive family processes. Eugene, OR: Castalia.

Perry, B. D. (1997). Incubated in terror: Neurodevelopmental factors in the 'Cycle of Violence.' In J. Osofsky (Ed.), Children, youth and violence: The search for solutions. (pp. 124-148). New York: Guilford Press.

Perry, B. D. (2002). Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brain and Mind, 3, 79-100.

Pollack, S. D., Cicchetti, D., Hornung, K., & Reed, A. (2001). Recognizing emotion in faces: Developmental effects of child abuse and neglect. Journal of Developmental Psychology, 36, 679-688.

Powers, L. E., Curry, M. A., Oschwald, M., & Maley, S. (2002). Barriers and strategies in addressing abuse: A survey of disabled women's experiences. Journal of Rehabilitation, 68, 4-13.

Ray, N. K., Rubenstein, H., & Russo, N. J. (1994). Understanding the parents who are mentally retarded: Guidelines for family preservation programmes. Child Welfare League of America, 73, 725-743.

Rimmerman, A., Botuck, S., Levy, J. M., & Royce, J. (1996) Job placement of urban youth with developmental disabilities: Research and implications. Journal of Rehabilitation 62, 56-64.

Sameroff, A. (1989). General systems and the regulation of development. In M. Gunnar & E. Thelen (Eds.), Minnesota symposia in child psychology (Vol. 22) (pp. 219-235). Hillsdale, NJ: Erlbaum.

Sameroff, A., & Emde, R. (1989). Relationship disturbances in early childhood. New York: Basic Books.

Siegel, D. J. (2001a). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, "mindsight," and neural integration. Infant Mental Health Journal, 22, 67-94.

Siegel D. J. (2001b). Memory: An overview, with emphasis on developmental, interpersonal, and neurobiological aspects. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 997-1011.

Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities. Baltimore: Paul H. Brookes Publishing Co.

Sroufe, L. A., Carlson, E. A., Levy, A. K., & Egeland, B. (1999). Implications of attachment theory, developmental psychopathology. Development and Psychopathology, 11, 1-13.

Swettenham, J., Baron-Cohen, S., Gomez, J. C., & Walsh, S. (1996). What's inside a person's head? Conceiving of the mind as a camera helps children with autism develop an alternative theory of mind. Cognitive Neuropsychiatry, 1, 73-88.

Vondra. J. I., Shaw, D. S., Swearingen, L., Cohen, M., & Owens, E. B. (2001). Attachment stability and emotional and behavioral regulation from infancy to preschool age. Developmental Psychopathology, 13, 13-33.

Wellman, H. M., Baron-Cohen, S., Caswell, R., Gomez, J. C., Swettenham, J., Toye, E., et al. (2002). Thought-bubbles help children with autism acquire an alternative to a theory of mind. Autism, 6, 343-63.

Whitman, B. Y., & Accardo, P. J. (1993) The parent with mental retardation: Rights, responsibilities, and issues, Journal of Social Work & Human Sexuality, 8, 123-136.

For further information: