Introduction
Autism spectrum disorder (ASD) is a clinically heterogeneous condition that variably affects cerebral, cognitive, and social functioning, all of which are essential for daily life. Its prevalence has recently increased, internationally, to an estimated level of 1% to 1.5% of the child population (Bougeard et al. 2024; Zeidan et al. 2022). ASD typically manifests in early childhood, but persists across the lifespan, influencing almost all aspects of daily life, whether relational, academic, professional, of other. ASD affects boys more frequently than girls (Werling and Geschwind 2013). Their diagnosis is usually made as early as 18 and 24 months of age (Zeidan et al. 2022) based on the criteria of impaired social communication and abnormal behaviors (APA 2013; WHO 2018). Indeed, these autistic symptoms in both sex/gender groups are not invariable across time, but can intensify or recede to varying degrees over time in different age groups. Some cognitive theories (e.g., Baron-Cohen et al. 1985) explain ASD symptoms (e.g., impairments in social communication) by psychological factors, attributing them in particular to disorders of social cognition (e.g., mentalizing deficit) (Baron-Cohen et al. 1989; Happé et al. 2017; Isaksson et al. 2019; Tager-Flusberg 2007). Mentalizing (or theory of mind – ToM) is a neurocognitive construct whose cognitive aspects constitute one of its two main domains: cognitive vs. affective (Kalbe et al. 2010; Shamay-Tsoory 2007; Tager-Flusberg and Sullivan 2000). Cognitive mentalizing refers to the ability to infer cognitions (i.e., cognitive mental states: perceptions, intentions, beliefs, opinions, perspectives, etc.) to others or oneself (Charki et al. 2025). Empirical and clinical studies in this field have examined its normal functioning in typical individuals (Cassetta et al. 2018; Wellman et al. 2001) and pathological functioning in clinical populations, especially those with neurodevelopmental disorders (Isaksson et al. 2019; see Charki and Ettouzani, 2021 for review). Unlike affective mentalizing (or cognitive empathy), cognitive mentalizing has a specific neural circuit (Canu et al. 2024; Van Overwalle and Baetens 2009; Shamay-Tsoory 2007). It manifests atypically in several clinical categories including ASD (Cole et al. 2019; Fadda et al. 2024; Fishman et al. 2014; Kim et al. 2016). Numerous studies (e.g., Kimhi 2014) using various screening tasks, which measure cognitive reasoning in particular, have found that these individuals do indeed lack baseline abilities (first-order mentalizing; Bulgarelli et al. 2022) when compared to their neurotypical peers, who typically acquire them by the age of 4 or 5 years old (Wimmer and Perner 1983). The forms of naïve knowledge that individuals have about mental states, whether implicit or explicit and automatic or controlled (Frith and Frith 2012), are important for everyday social communication, but seem to be relatively deficient in children with ASD, suggesting that all forms of mentalizing, including explicit, automatic, and affective, are impaired (Altschuler et al. 2021; Rosenblau et al. 2015; Charki and Ettouzani 2024). Within this framework, deficits in mentalizing have been shown to be relatively characteristic of most people with ASD (Baron-Cohen 1989; Wellman et al. 2001). However, this social cognitive impairment cannot be confined to the child population, but can be present in different age groups; it often accompanies and appears in adolescence, youth and adulthood, or later (Baron-Cohen et al. 1997; Spek et al. 2010; Pedreño et al. 2017; Tehrani-Doost et al. 2020). Adolescents with ASD have significant difficulties in recognizing and understanding the mental states reflected in Strange Stories (White et al. 2009), Hinting Tasks (Sasson et al. 2020), or other tasks associated with first or second-order of cognitive reasoning (Bulgarelli et al. 2022). Empirical studies (Boucher 2012; Cassetta et al. 2018; Scheeren et al. 2013; Tager-Flusberg and Sullivan 1994) indicated that children with ASD-high functioning (ASD-Hf) or Asperger’s syndrome (see DSM-IV) without any noticeable verbal or cognitive impairments are able to pass false-belief tasks that reflect cognitive reasoning abilities, at both the first and second order. They scored on verbal reasoning and contextual tasks comparably to neurotypical children (Rosello et al. 2020; Scheeren et al. 2013). In adolescents, the detection and attribution of intentions showed similar performance to their neurotypical peers (Schütz et al. 2023). This has led some researchers to question whether ToM impairments are partial or universal across all individuals with ASD from different cultural backgrounds, or whether they only affect one component of mentalizing (cognitive, affective, spontaneous, etc.). On the local side, the study of mentalizing in its clinical dimension in the Arab-Moroccan context as well as in comparison with normal individuals, remains, to our knowledge, rare. In the current study, we limited our exploration to cognitive (and not affective; see Charki and Ettouzani 2024) mentalizing in ASD.
Objectives and hypotheses
The main aim of this research was to investigate aspects of cognitive mentalizing in children with ASD and their neurotypically developing (TD) peers. In particular, we aimed to explore first- and second-order cognitive mentalizing in two samples of children: a clinical group and a control group. In addition, these cognitive aspects of mentalizing for both groups were examined with reference to the age variable. We predicted that children with ASD would have relatively low performances (as measured by the complexity of the test tasks) in first- and second-order cognitive mentalizing compared to neurotypical children. Additionally, we assumed that the higher the age of children with or without ASD, the higher their performance on cognitive reasoning would be.
Material and methods
Population
The study sample included 113 participants from Morocco: 67 children with ASD (53 boys and 14 girls) and 46 neurotypical children (30 boys and 16 girls), aged between 7 and 13 years, t(111) = 1.436, p ≥ 0.154). The ASD participants were recruited from integration centers run by autism associations in Morocco, taking into account the criteria of verbal skill and autism severity level – mild and moderate (range = 30-36, M = 32.43, SD = 2.13).
Participants with NTP were recruited from the school where they received their primary education. To comply with the objectives and ethics of the study, only children from both samples who expressed their willingness to participate, and with the consent of their parents, were recruited. In contrast, all children who refused to complete the pilot tests or refrained from doing so were excluded from the study. We also removed from the clinical sample all children on the severe autism spectrum whose symptom severity was greater than 36.5 on the CARS-2 scale or less than 29.5 on the same scale (being non-autistic), as well as those who could not express verbally. This is in order to obtain the verbal response of these individuals in cognitive reasoning tests that rely mainly on verbal language, as severely disordered individuals often do not have sufficient language abilities, which may prevent them from communicating verbally and answering the questions on the verbal tests of the study. Some descriptive data on children with ASD were published previously by Charki et al. (2025).
Clinical measures
Autism spectrum disorder
All autistic children who participated in this study were diagnosed with ASD according to the modern criteria defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Their diagnosis of autism was confirmed and their main symptoms were verified using the clinical interview and the Childhood Autism Rating Scale in its 2nd version (CARS-2; Schopler et al. 2010). The CARS-2 is an important clinical measure for the diagnosis of ASD, especially as it allows the clinician to quantify autistic symptoms (Schopler et al. 2010). In addition, it can provide a clear picture of the categorization and levels of symptoms associated with ASD, as a single category within neurodevelopmental disorders, from which the levels of intervention and assistance for the target group are determined (APA 2013). Consequently, this scale was adopted to quantitatively categorize the severity levels of autistic symptoms, in order to distinguish mild and moderate levels from a severe level of autism.
Cognitive aspects of mentalizing measure
Participants’ cognitive mentalizing abilities were assessed by false-belief tasks (first- and second-order). These are experimental paradigms involving short stories with pictures and questions to answer. False-belief tasks have been shown to be effective in assessing global mentalizing abilities. In this study, we used the following six false-belief tests: Four are simple tasks – Sally-Anne Test (Baron-Cohen et al. 1985), Anthony Test (Nader-Grosbois and Houssa 2016), Maxim and Chocolate Test (Wimmer and Perner 1983; Duval et al. 2011), Sebastian-Linda Test (Desgranges et al. 2013) – allowing the assessment of first-order cognitive mentalizing. The others are complex false-belief tasks – Fisherman-Diver Test and Mother-Son Test (Duval et al. 2011; Desgranges et al. 2013) – which assess second-order cognitive mentalizing abilities. These tests are culturally and linguistically modified in terms of context and Arabic language for Moroccan children (Charki 2023). They have been translated from English (or French) into Arabic using characters whose names are part of Moroccan culture and whose original test names have been replaced (e.g. Sally-Anne by Salma-Amale, etc.). The other second-order tasks (Fisherman-Diver Test and Mother-Son Test) have been translated into definitive Arabic. These assessment tasks were revised and corrected by linguists. They were then proposed to a committee of experts and professor-researchers in psychology who are fluent in English, French and the original Arabic. Finally, the committee accepted them and recommended a simple rectification of the final version of the proposed tasks. The internal reliability of all these false-belief tasks was consistently strong (Charki et al. 2025).
Scoring
For scoring, each correct answer to one of the two questions involved in the proposed task (memory and reality questions) takes a score of 2 points, 1 point for a correct answer to only one question, and 0 points for two incorrect answers. The total score for correct answers, obtained by the participant in all tasks, is 12 points (8 points in 1st-order tasks and 4 points in 2nd-order tasks), while participants who answered all questions incorrectly are given the score zero (Charki et al. 2025).
Statistical analysis
Descriptive statistical analyses (means and standard deviations) were used to describe participants’ total scores in the false-belief tests. The distribution of scores on cognitive aspects of mentalizing between groups was verified using Shapiro-Wilk and found to be abnormal. In this framework, the Mann-Whitney test was used to test for differences in cognitive mentalizing performance (first- and second-order) between the ASD and neurotypical groups. Regression analyses were used to evaluate the associations between the age variable and the cognitive aspects of mentalizing in children from both groups.
Results
Children with ASD showed lower cognitive mentalizing performance than neurotypical children. They obtained scores (M = 5.49, SD = 2.23), relatively judged to be above average, on first-order false-belief tasks, and very weak scores (M = 1.01, SD = 1.24) on second-order false-belief tasks and mixed cognitive mentalizing (M = 6.51, SD = 2.94). However, neurotypical children scored higher on both first- (M = 8, SD = 0) and second-order (M = 3.87, SD = 0.5) false-belief tasks and mixed cognitive mentalizing tasks (M = 11.87, SD = 0.5). The percentage of correct results in the first- and second-order false belief or mixed tasks was 68.63%, 25.25%, and 54.25% for the ASD group, and 100%, 98.92% and 98.93% for the TD group. The difference in performance between groups of children in cognitive mentalizing was statistically significant (first- [U = 437, Z = –7.186, p < 0.001], second-order [U = 95, Z = –8.905, p < 0.001], mixed tasks [U = 106, Z = –8.674, p < 0.001]) (Table 1, Fig. 1).
Association between age variable and aspects of cognitive mentalizing in children with ASD and neurotypical pees
The age variable was not associated with cognitive mentalizing performance for either the ASD group (1st-order: B = 0.093, β = 0.072, p > 0.563; 2nd-order: B = 0.114, β = 0.16, p > 0.196; mixed tasks: B = 0.207, β = 0.122, p > 0.988) or the control group (2nd-order: B = 0.034, β = 0.078, p > 0.604).
The results indicate that age differences between the ASD group and the neurotypical group have no impact on their performance in cognitive mentalizing (Table 2).
Discussion
Our study explored the cognitive mentalizing abilities of children with ASD in comparison with neurotypical children on the basis of false-belief paradigms (1st- and 2nd-order). Statistical comparisons confirm some of our hypotheses. They indicate that children with ASD performed very poorly in cognitive mentalizing (2nd-order) compared with their neurotypical peers. Although their performance in mentalizing was weak and significantly lower than that of neurotypical children, they showed above-average performance in first-order mentalizing. At this level, the results report that these children have developed some of the basic mentalizing skills (basic ToM) that are fully acquired in children with normal development by age 4 or 5 (Miller 2009; Wimmer and Perner 1983). Our results are consistent with numerous studies (Isaksson et al. 2019; Sanna and Blanc 2018; Schwartz-Offek et al. 2022) finding that the majority of individuals with ASD show intact cognitive mentalizing skills (e.g., first-order at age 7 or older) and their performance in these is comparable to that of neurotypical children (see Baldimtsi et al. 2020; Bowler 1994; Philpott et al. 2012). In fact, these mental abilities are developed behind the relevant stage of their typical development (Hoogenhout and Malcolm-Smith 2014; Frith and Firth 2012). On the other hand, they have very poor performance in second-order cognitive mentalizing; they present notable difficulties in mentalizing, particularly when they find themselves in circumstances and social situations requiring the elaboration and integration of complex levels of representational abstraction in order to explain and prevent certain mental states or social behaviors. These findings confirm the social-cognitive difficulties in ASD and are consistent with previous studies (Baldimtsi et al. 2020; Baron-Cohen 1989; Carlsson et al. 2018; Fadda et al. 2024; Kimhi et al. 2024; Tsang et al. 2016; Young and Brewer 2020) that have demonstrated that children with ASD have impaired mentalizing abilities, particularly with this type of mental reasoning (2nd-order or advanced mentalizing). Indeed, these social-cognitive skills are strongly associated with abstract cognitive and/or metacognition abilities, which have also been shown to be lacking in ASD (Grainger et al. 2016). However, some studies (Bauminger and Kasari 1999; Begeer et al. 2016; Glenwright et al. 2021; Hoogenhout and Malcolm-Smith 2014; Schneider et al. 2013) have reported that the majority of individuals with ASD successfully pass mentalizing assessment tasks (both simple and complex) from either first or second order and their performance on these is comparable to their peers with TD at the normative mental or chronological age. In addition, the children with ASD in our study exceeded the normal age for acquiring and developing these abilities, being at school age (around 7 or 8 years; Miller 2009). At this level, it seems that they really do suffer from difficulties in cognitive inference abilities, even though they are in late childhood (even adolescence; Fadda et al. 2024; Mazza et al. 2014), compared with their physical attribution abilities, which appear normal (Poulin-Dubois et al. 2021; Williams 2010). Another objective of this study was to evaluate the associations between participants’ age (ranging from 7 to 13 years) and their cognitive mentalizing abilities. The data analyzed revealed that age did not predict cognitive mentalizing performance in children with or without ASD. Unlike the latter, it constitutes a predictive and positive factor for affective mentalizing skills (e.g., Charki and Ettouzani 2024). These findings are in line with those of Schaller and Rauh (2017), who revealed that the cognitive aspects of mentalizing in subjects with ASD do not vary as a function of age. Some recent studies (e.g., Hoogenhout and Malcolm-Smith 2014; Rosello et al. 2020) have demonstrated that mentalizing aspects in ASD take on specific, heterogeneous profiles and follow a different developmental trajectory compared with neurotypical children. Accordingly, the age factor contributes progressively to the improvement of mentalizing skills (e.g., basic or advanced) in individuals with ASD, particularly during childhood and adolescence (Hoogenhout and Malcolm-Smith 2014; Pino et al. 2017). However, these social-cognitive abilities are developed in children with ASD (with the exception of low-functioning ASD) late, compared to neurotypical children (Hoogenhout and Malcolm-Smith 2014). In this respect, the autistic individuals targeted in these earlier studies and others (Bauminger and Kasari 1999; Begeer et al. 2016; Glenwright et al. 2021; Schneider et al. 2013) are clinically diagnosed as having Asperger syndrome or ASD-Hf (see DSM-4), characterized by high intellectual performance (over 80 IQ) and relatively normal language skills (Noterdaeme et al. 2010; Riccioni et al. 2021). These abilities, in fact, positively affect the development of mentalizing in general (Bigelow et al. 2021; Csulak et al. 2022; Ebert 2020; Polónyiová et al. 2024), and individual differences in particular refer to the general factor of intelligence (Coyle et al. 2018). Indeed, these individuals use these language and cognitive abilities as compensatory strategies to accomplish the mentalizing tasks (Frith et al. 1994; Tager-Flusberg 2007), but when they find themselves in real social situations (e.g., that of deception) they clearly fail (Frith et al. 1994; Happé 1995; Philpott et al. 2013), as well as showing unsynchronized, often bizarre responses in everyday social interactions (Bowler 1992). This is because the latter require flexible and rapid processes (Philpott et al. 2013), whereas individuals with ASD process information (e.g., social) more slowly and laboriously, and in many cases this processing appears atypical (e.g., Chan and Leung 2022) and leads to an abnormal elaboration of social judgments (Adolphs et al. 2001). In general terms, mentalizing and social cognition abilities play a very important role in communication skills (verbal and non-verbal) and interpersonal relations (Happè and Conway 2016; Mao et al. 2023), but their impairments (in basic, advanced ToM, or social attribution) can give rise to real social problems (Chiu et al. 2023; Crisci et al. 2024; Peterson et al. 2016; Vandewouw et al. 2021). In this context, our results confirm that the majority of children with ASD exhibit significant difficulties in cognitive mentalizing (e.g., complex reasoning), even at later stages of childhood development. Mentalizing abnormalities are found to be strongly associated with impaired communication and social interaction in individuals with ASD (Chiu et al. 2023; Mao et al. 2023; Rosello et al. 2020). Our results reinforce the hypothesis that ToM impairments explain some of the autistic symptoms of individuals with ASD (e.g., Baron-Cohen et al. 1985; Baron-Cohen 1989), and suggest that future research should develop intervention programs based on cognitive mentalizing training aimed at improving the metacognition and social communication skills of subjects with ASD.
Conclusions
The current study examined the cognitive aspects of mentalizing in children with ASD and neurotypical children. Our findings confirmed some of our hypotheses. On the one hand, they found that children with ASD perform poorly in second-order cognitive mentalizing, and moderately in first-order cognitive mentalizing, compared with neurotypical children. In this case, the ASD children in our study showed an inability to understand complex false-belief tasks proposed in second-order, compared with those in first-order cognitive mentalizing. This indicates that they lack cognitive inference skills, particularly high-level cognitive mentalizing. Indeed, the latter require very high levels of abstraction and meta-representation during the process of their realization (e.g., 2nd-order ToM, or advanced mentalizing), and children with ASD are unable to perform them. At the developmental level, mentalizing abilities (2nd-order) are typically acquired in children by school age. For children with ASD, however, they appear impaired even in late childhood. These impairments in cognitive mentalizing are a real challenge for children with ASD on a daily basis. On the other hand, the results show that the age factor of children with or without ASD was not related to their cognitive mentalizing aspects, whether 1st- or 2nd-order.
Disclosures
This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.
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