Edinburgh Social Cognition Test (ESCoT): a new test of theory of mind and social norm understanding

Social cognitive abilities are needed to process and understand social information in order to respond appropriately in everyday social interactions. While there are a number of tests that have been developed to measure social cognition in the literature, many have important limitations such as only assessing one ability, performance being predicted by measures of intelligence and exhibiting low ecological validity. To address some of these limitations, I developed a new test called the Edinburgh Social Cognition Test (ESCoT). The ESCoT is an animated test that assesses four domains of social cognition: cognitive Theory of Mind (ToM) (What is X thinking?); affective ToM (How does X feel at the end of the animation?); interpersonal understanding of social norms (Did X behave as other people should behave?); and intrapersonal understanding of social norms (Would you have acted the same as X in the animation?). The aims of this thesis were to examine the validity of the ESCoT as a test of social cognition and to further investigate social cognitive processes in healthy and neurological populations. The ESCoT was firstly administered to a healthy population of older, middle-aged and younger adults to examine the effects of ageing on social abilities. This study found that the ESCoT was sensitive to age; poorer performances on cognitive and affective ToM and also interpersonal but not intrapersonal understanding of social norms were predicted by older age. Furthermore unlike traditional tests used in the study, performance was not predicted by measures of intelligence. Instead, the sex of participants and autistic-like traits, in addition to age were found to be important for performance. The ESCoT was then validated in a sample of adults with Autism Spectrum Disorder (ASD), and performance was compared to performance on established social cognition tests. Convergent validity was demonstrated in the study and the ESCoT was sensitive to social cognitive difficulties found in ASD. This study also showed that the ESCoT was more effective than existing tests at differentiating ASD adults and neurotypical controls. The interplay of social anxiety and empathy on ESCoT performance in addition to further exploring sex and autistic-like traits were then examined in a younger adult population. Social anxiety and empathy were not significant predictors of performance on the ESCoT. Similar to the results of the ageing study, this study found that women were better than men on affective ToM. However, unlike the ageing study, better cognitive ToM performance was predicted by older age. Better performance on interpersonal understanding of social norms and ESCoT total scores were predicted by more years of education. The subsequent chapter then examined the clinical efficacy of the ESCoT in a patient population (Alzheimer's disease, behavioural-variant Frontotemporal dementia and amnestic mild cognitive impairment). Here performance on the ESCoT was compared between the patients and neurotypical controls. It was found that patients performed poorer than neurotypical controls on ESCoT total scores, affective ToM, inter-and intrapersonal understanding of social norms. The final chapter returned to healthy ageing to more closely investigate the consequences of healthy ageing on social cognitive processes, by examining the positivity bias (preference for positive over negative stimuli) found in older adults using an attention paradigm. There was no evidence of the positivity bias in older, middle-aged and younger adults in regards to reaction time or accuracy. However, older and middle-aged adults differed in accuracy across stimuli type compared to younger adults. This thesis offers novel insights into the social cognitive abilities of various populations. The ESCoT presents a new, informative and validated test of social cognition for researchers and clinicians to use, which has many advantages over established tests of social cognition

Identifying individuals with intellectual disability who access mental health support and are at high risk for adverse clinical outcomes: cohort study

BACKGROUND: People with intellectual disability often experience aggressive challenging behaviour and mental health issues. It can be difficult to identify those who are at higher risk of adverse clinical outcomes when in clinical care. AIMS: To characterise potential subgroups in adults with intellectual disability referred to mental health services in those presenting with aggressive behaviour or common mental disorders (CMDs). METHOD: There were 836 adults (≥18 years) with intellectual disability and a record of aggressive challenging behaviour, and 205 patients with intellectual disability and CMDs, who were seen in specialist mental health services over a 5-year period. Cluster analysis was used to define patient characteristics associated with clinical outcome. RESULTS: Distinct patient groups with differentiated profiles were observed in people with intellectual disability displaying aggressive challenging behaviour, and in those presenting with CMDs. Characteristics of the aggressive behaviour group who experienced adverse outcomes included being <30 years old, being male, more mentions of aggression and agitation in their clinical record, a diagnosis of pervasive developmental disorder and prescription of psychotropic medication. Characteristics of the CMD cluster that experienced adverse clinical outcomes were being older, being a White male, having a mild intellectual disability and physical health concerns. CONCLUSIONS: People with intellectual disability who experience adverse clinical outcomes can be identified with a cluster analysis approach of common features, but differ by clinical presentation. This could be used not only to stratify this clinically heterogeneous population in terms of response to interventions, but also improve precision in the development of tailored interventions

An investigation of the validity of the Edinburgh Social Cognition Test (ESCoT) in acquired brain injury (ABI)

Objectives: Social cognition is frequently impaired following an acquired brain injury (ABI) but often overlooked in clinical assessments. There are few validated and appropriate measures of social cognitive abilities for ABI patients. The current study examined the validity of the Edinburgh Social Cognition Test (ESCoT, Baksh et al., 2018) in measuring social cognition following an ABI. Methods: Forty-one patients with ABI were recruited from a rehabilitation service and completed measures of general ability, executive functions and social cognition (Faux Pas; FP, Reading the Mind in the Eyes; RME, Social Norms Questionnaire; SNQ and the ESCoT). Forty-one controls matched on age, sex and years of education also performed the RME, SNQ and ESCoT. Results: A diagnosis of ABI was significantly associated with poorer performance on all ESCoT measures and RME while adjusting for age, sex and years of education. In ABI patients, the ESCoT showed good internal consistency with its subcomponents and performance correlated with the other measures of social cognition demonstrating convergent validity. Better Trail Making Test performance predicted better ESCoT total, RME and SNQ scores. Higher TOPF IQ was associated with higher RME scores, while higher WAIS-IV working memory predicted better FP performance. Conclusions: The ESCoT is a brief, valid and internally consistent assessment tool able to detect social cognition deficits in neurological patients. Given the prevalence of social cognition deficits in ABI and the marked impact these can have on an individual’s recovery, this assessment can be a helpful addition to a comprehensive neuropsychological assessment

The relationship between social cognitive processes and behavior changes in people with amnestic Mild Cognitive Impairment or dementia using the Edinburgh Social Cognition Test (ESCoT)

Objectives: People with amnestic Mild Cognitive Impairment (aMCI) or dementia often exhibit a decline in their social abilities, but few tests of social cognition exist that are suitable for clinical use. Moreover, the relationship between changes in behaviour and impairments in social cognition is poorly understood. We examined the utility of the Edinburgh Social Cognition Test (ESCoT) in people with aMCI/dementia and explored associations between social cognition performance and behaviour changes. Methods: We administered the ESCoT and two established social cognition tests (Reading the Mind in the Eyes; RME and the Social Norms Questionnaire; SNQ) to 28 people with aMCI or dementia and 28 age and sex matched cognitively healthy controls. Behaviour change was measured using a semi-structured interview which assesses behavioural abnormalities found in frontotemporal dementia. Results: People with aMCI/dementia were impaired on the ESCoT affective ToM, ESCoT total score and the RME. Behaviour changes in the domains of apathy, loss of sympathy/empathy, perseveration, and psychotic symptoms were associated with poorer affective ToM scores. Disinhibition, loss of sympathy/empathy and hyperorality or altered food preferences were associated with cognitive ToM. All behaviours were significantly associated with poorer performance on ESCoT total score, but not the RME or SNQ.Conclusion: The ESCoT was sensitive to social cognition impairments in people with aMCI/dementia and it relates to behaviour change in aMCI/dementia unlike established tests. Different subtests of the ESCoT were related to different behaviour changes. These findings suggest that the ESCoT may be a clinically valuable tool when examining social cognition

Italian adaptation of the Edinburgh Social Cognition Test (ESCoT):A new tool for the assessment of theory of mind and social norm understanding

The relevance of social cognition assessment has been formally described in the Diagnostic and Statistical Manual of Mental Disorders-5. However, social cognition tools evaluating different socio-cognitive components for Italian-speaking populations are lacking. The Edinburgh Social Cognition Test (ESCoT) is a new social cognition measure that uses animations of everyday social interactions to assess (i) cognitive theory of mind, (ii) affective theory of mind, (iii) interpersonal social norm understanding, and (iv) intrapersonal social norm understanding. Previous studies have shown that the ESCoT is a sensitive measure of social cognition in healthy and clinical populations in the United Kingdom. This work aimed to adapt and validate the ESCoT in an Italian population of healthy adults. A translation-back-translation procedure was followed to create and refine the Italian version. Then, 94 healthy adults (47 females, mean age  35 ± 15.9) completed the ESCoT, a battery of conventional social cognition tests (Yoni; Reading the Mind in the Eyes Strange Stories, and Social Norm Questionnaire, SNQ) and measures of intelligence and executive functions. Reliability, convergent validity, and predictors of performance on the ESCoT were examined. Results demonstrated good reliability of the ESCoT and an association between the ESCoT scores and some traditional social cognition tests (Yoni cognitive subscale, SNQ). Hierarchical regression results showed that the ESCoT total score was associated with age. Also, the ESCoT subscore (intrapersonal social norm understanding) was associated with education. These findings support the ESCoT as a valid tool testing social norm understanding, a reliable measure of social cognition for an adult Italian population, and provides further evidence that the ESCoT is sensitive to age- and education-related changes in social cognition, and it is a task not affected by general cognitive functioning

Aggressive challenging behaviour in adults with intellectual disability: an electronic register-based cohort study of clinical outcome and service use

Background: Aggressive challenging behavior in people with intellectual disability is a frequent reason for referral to secondary care services and is associated with direct harm, social exclusion, and criminal sanctions. Understanding the factors underlying aggressive challenging behavior and predictors of adverse clinical outcome is important in providing services and developing effective interventions. Methods: This was a retrospective total-population cohort study using electronic records linked with Hospital Episode Statistics data. Participants were adults with intellectual disability accessing secondary services at a large mental healthcare provider in London, United Kingdom, between 2014 and 2018. An adverse outcome was defined as at least one of the following: admission to a mental health hospital, Mental Health Act assessment, contact with a psychiatric crisis team or attendance at an emergency department. Results: There were 1,515 patient episodes related to 1,225 individuals, of which 1,019 episodes were reported as displaying aggressive challenging behavior. Increased episode length, being younger, psychotropic medication use, pervasive developmental disorder (PDD), more mentions of mood instability, agitation, and irritability, more contact with mental health professionals, and more mentions of social and/or home care package in-episode were all associated with increased odds of medium-high levels of aggression. Risk factors for an adverse clinical outcome in those who exhibited aggression included increased episode length, personality disorder, common mental disorder (CMD), more mentions of agitation in-episode, and contact with mental health professionals. PDD predicted better outcome. Conclusions: Routinely collected data confirm aggressive challenging behavior as a common concern in adults with intellectual disability who are referred for specialist support and highlight factors likely to signal an adverse outcome. Treatment targets may include optimizing management of CMDs and agitation

Social cognition in adults with autism spectrum disorders: Validation of the Edinburgh Social Cognition Test (ESCoT).

Objective: Many existing tests of social cognition are not appropriate for clinical use, due to their length, complexity or uncertainty in what they are assessing. The Edinburgh Social Cognition Test (ESCoT) is a new test of social cognition that assesses affective and cognitive Theory of Mind as well as inter- and intrapersonal understanding of social norms using animated interactions.Method: To support the development of the ESCoT as a clinical tool, we derived cut-off scores from a neurotypical population (n = 236) and sought to validate the ESCoT in a sample of Autism Spectrum Disorder (ASD; n = 19) adults and neurotypical controls (NC; n = 38) matched on age and education. The ESCoT was administered alongside established tests and questionnaire measures of ASD, empathy, systemizing traits and intelligence.Results: Performance on the subtests of the ESCoT and ESCoT total scores correlated with performance on traditional tests, demonstrating convergent validity. ASD adults performed poorer on all measures of social cognition. Unlike the ESCoT, performance on the established tests was predicted by verbal comprehension abilities. Using a ROC curve analysis, we showed that the ESCoT was more effective than existing tests at differentiating ASD adults from NC. Furthermore, a total of 42.11% of ASD adults were impaired on the ESCoT compared to 0% of NC adults.Conclusions: Overall these results demonstrate that the ESCoT is a useful test for clinical assessment and can aid in the detection of potential difficulties in ToM and social norm understanding

Markers of early changes in cognition across cohorts of adults with Down syndrome at risk of Alzheimer's disease.

Introduction: Down syndrome (DS), a genetic variant of early onset Alzheimer's disease (AD), lacks a suitable outcome measure for prevention trials targeting pre-dementia stages. Methods: We used cognitive test data collected in several longitudinal aging studies internationally from 312 participants with DS without dementia to identify composites that were sensitive to change over time. We then conducted additional analyses to provide support for the utility of the composites. The composites were presented to an expert panel to determine the most optimal cognitive battery based on predetermined criteria. Results: There were common cognitive domains across site composites, which were sensitive to early decline. The final composite consisted of memory, language/executive functioning, selective attention, orientation, and praxis tests. Discussion: We have identified a composite that is sensitive to early decline and thus may have utility as an outcome measure in trials to prevent or delay symptoms of AD in DS