The conceptualisation of dreams by adults with intellectual disabilities: relationship with theory...

The conceptualisation of dreams by adults withintellectual disabilities: relationship with theory ofmind abilities and verbal ability

A. Dodd,1 D. J. Hare,2 & S. Hendy3

1 Pennine Care NHS Trust, Lancashire, UK2 School of Psychological Sciences, University of Manchester, Manchester, UK3 Cheshire andWirral NHS Trust, Cheshire, UK

Abstract

Background Empirical studies suggest that indi-viduals with intellectual disabilities (ID) have diffi-culties in conceptualising dreams as perceptuallyprivate, non-physical, individuated and potentiallyfictional entities. The aim of the current study wasto replicate the results found by Stenfert Kroeseet al. using a comparative sample size, and toexamine putative cognitive correlates of accuratedream conceptualisation [receptive language and 1storder theory of mind (ToM) abilities].Method Conceptualisation of dreams, real objectsand photographs was assessed with a structuredclosed-question interview schedule, together withreceptive language, and ToM abilities.Results Findings from the current study replicatedthose of previous research, finding that many adultswith ID tend to think that dreams take placearound them, can be witnessed by others, can betouched and manipulated, can be shared by othersand are about real events. The ability to accuratelyconceptualise dreams was found to increase alongwith receptive language ability, and there was a

non-significant association between ToM ability andthe ability to understand that dreams can be aboutpotentially fictional entities.Conclusions Some individuals with ID have a dif-ferent understanding of mental phenomena such asdreams, which has implications for several aspectsof care and support, particularly relating to mentalhealth and therapeutic work.

Keywords dreams, intellectual disabilities, theoryof mind

Introduction

The concept of consciousness encompasses all thatindividuals are aware of or experience (Velmans2000). This includes inner experiences such asthoughts, feelings, visual images and dreams (inter-nal experiences), but also includes experiences ofthe three-dimensional world, such as the perceptionof an object (external experiences). While there areongoing philosophical discussions about the actualnature of these experiences, the realities of theseexperiences are recognisable and understandable tothe majority of people. As usually experienced,dreaming and waking consciousness are distin-guished on the basis of whether a person can

Dr Dougal J. Hare, School of Psychological Sciences, University ofManchester, Zochonis Building Brunswick St. Manchester M13

9LP, UK (e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2007.01026.x

volume 52 part 4 pp 337–347 april 2008337

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

mailto:[email protected]

determine the experience as internal or external.This distinction involves the understanding thatcertain conscious experiences can only be experi-enced by the individual (e.g. inner experiences) andthat others can be shared (e.g. external experi-ences). Hobson (2002) proposes a framework inwhich those characteristics of dreaming that arecommon to or differ from waking consciousness canbe explored. This framework involves perception,cognition and effect. With regard to perception,dreaming is an example of an inner experiencewhere the perceptual experience is very similar tothat of perception of the external (phenomenal)world (e.g. Shepard 1984). Kerr (1993) asserts thatthe visual, auditory and other sensory qualities ofdreams have a hallucinatory quality and areassumed by the person dreaming to representreality. Hobson (op cit) proposes the ‘cardinal’ cog-nitive features of dreaming to be a loss of awarenessof self (self-reflective awareness), loss of orienta-tional stability, loss of directed thought, reductionin logical reasoning abilities, diminished realitytesting and poor memory both during and afterthe dream. Interesting, these cognitive aspects aresimilar to the cognitive impairments seen in peoplewith intellectual disabilities (ID). From a neo-Piagetian perspective, Cohen (1979) has proposedthat the dreaming mind usually follows lower levelstructures of cognitive development and generallyfunctions at the concrete operational level, but maylower to the sensorimotor level and very infre-quently may rise to the formal operational stage.This suggests that while asleep, the dreamer wouldnot possess the cognitive skills necessary to deter-mine internal, from external, experiences, andhence the dreaming mind would function, inPiagetian terms, at a realistic level (Piaget 1929,cited in Wellman & Estes 1986).

With regard to the affective component of dream-ing, internally generated emotions are sometimesregarded as a core feature, being often more intensethan those of waking experience, owing to activationof the limbic system during sleep (Hobson 2002).Therefore, dreaming is experienced as reality (at thetime it is occurring) owing to the strength of the per-ceptions and emotions that are generated, in combi-nation with the lack of logical reasoning that occursthroughout (Foulkes 1993; Hobson 2002).What isless clear is how this realistic experience affects con-

ceptualisation of dreams upon awakening, and thisappears to depend on individual skill in relation tosource monitoring (e.g. Bentall 2000).This skill islikely to depend on a number of factors, includingcognitive ability and theory of mind (ToM).

To date, there has been limited research into theinner experience of individuals with ID, eventhough the understanding and discussing of abstractconcepts, self-reporting and understanding emo-tions and internal states and the relationshipsbetween external events, thoughts and emotions arecentral effective clinical work with this population(Stenfert Kroese et al. 1998). For example, the mis-interpretation of self-reports of people with ID mayresult in a mistaken diagnosis of psychosis (Slade &Bentall 1988). It is also important to consider howthis would affect therapeutic input, both from apsychoanalytical perspective using dreams withpeople with ID, which some studies have suggestedcan be used positively (e.g. Morris 1994), and alsothe use of cognitive behavioural intervention. Theresearch that is available suggests that individualswith ID have difficulties understanding a number ofareas of conscious inner experience, e.g. in under-standing emotions (e.g. Reed 1997), reportingthoughts (Dagnan & Chadwick 1997) and under-standing dreams (Stenfert Kroese et al. 1998;Edwards 1999). The research regarding emotionsand thoughts suggested that these areas of con-scious experience could be remembered, referred toand reflected upon by some individuals with ID.However, there were some individuals for whomthis was harder. The studies do not shed any lighton how these thoughts are experienced [e.g. Hurl-burt’s (1990, 1993) work with non-ID individuals],or whether individuals with ID view them as inter-nal, private cognitive events (the culturally norma-tive conceptualisation of a thought).

Previous research on dreams in people with ID(e.g. Stenfert Kroese et al. 1998; Edwards 1999)indicated that individuals with ID had difficultiesconceptualising dreams as perceptually private,non-physical, individuated and potentially fictionalentities. Using a modified version of Woolley &Wellman’s (1992) methodology, both studiesindicated substantial confusion regarding thenon-physical, perceptually private nature andindividuated nature of dreams. Many participantsbelieved that two people sleeping in the same room

338Journal of Intellectual Disability Research volume 52 part 4 april 2008

A. Dodd et al. • Dream conceptualisation in people with ID


would share the same dream, and a substantial pro-portion of participants did not believe that it waspossible to dream about (or think about) fictionalentities. Edwards (1999) also compared individualswith a diagnosis of ID and ‘schizophrenia’ andadults with a diagnosis of ‘schizophrenia’ only (SO),although small numbers limit the conclusions thatcan be drawn, but it was noted that some of the SOgroup did not have a clear conceptualisation ofdreams, with particular difficulties with the percep-tually public and non-physical nature. A minority ofparticipants in this group were also confused aboutthe ability to dream and think about the possibilityof fictional events. Edwards (1999) speculated thatthe difficulties of the SO group may have been par-tially due to ToM deficits (cf. Frith & Corcoran1996). Both studies lend credence to Beail’s (1989)observation that some individuals with ID cannotdistinguish between fantasy, dreams and reality.

Hobson (2002) discusses how an individual’ssense of psychological reality is set by the strengthsof their percepts and feelings as well as by theirthoughts about them. Internally generated percep-tions and emotions are cardinal features of dreams.The intensity of these features during dreaming canbe explained by the selective activation of the partsof the brain that generate emotions and perceptionsin sleep and similarities between visual images,when dreaming and normal visual perception aremarked (Shepard 1984). Thus, people with impairedcognitive functioning may have particular difficultiesin differentiating such internal experiences fromexternal reality. As dreams are phenomenologicallysimilar to external events, differentiation requiresthe ability to recognise the self-generated nature ofdreams, i.e. objectivity is required (Piaget 1927).ToM ability, namely, the ability to think about one’sown and other’s mental states (Leslie 1987), wouldappear to be a prerequisite for this process. Thiswould fit with Edwards’ (1999) findings.

The aim of the present study was to investigatewhether ToM ability was associated with accurateconceptualisation of dreams in adults with ID. Theassociations of verbal comprehension (a measure ofcognitive ability) and level of ID with dream con-ceptualisation were also explored. The main hypoth-eses examined were that people with ID would: (1)produce a significantly greater percentage of correctresponses in total to questions relating to real

objects and objects seen in photographs as com-pared with objects in dreams; (2) produce responsessuggesting that dreams are entities that are sharedwith others; (3) give a significantly higher percent-age of correct responses to questions relating to theability to dream about or think about real asopposed to fictional objects; (4) give more correctanswers about the nature of dreams if they demon-strated 1st order ToM ability; and (5) give morecorrect answers about the nature of dreams if theypossessed higher receptive language abilities.

Method

Design

A within-group design was used to assess whetheradults with ID could successfully conceptualiseobjects in dreams as perceptually private, non-physical, potentially fictional entities that are indi-vidual to the dreamer. The ability to successfullyconceptualise real (physical) objects and objects inphotographs was also assessed and compared. Thestudy was designed to be accessible and non-threatening to participants with ID.

Participants

Using power = 0.8, it was calculated that an effectsize of 0.20 could be detected if 52 participants wererecruited, this effect size being identified with refer-ence to previous studies of similar design (StenfertKroese et al. 1998). Participants were adults withmild to moderate ID who attended day services.Potential participants were able to volunteer afterreceiving information about the study. Participantswere excluded if they had insufficient verbal compre-hension to be able to understand interview questions(as determined by a British Picture Vocabulary ScaleII (BPVS-II) age-equivalent score <4 years), visualimpairment or history of head injury. In total, 62

individuals met initial inclusion criteria for the study.Ethical approval was obtained through the NationalHealth Service (NHS) Local Research EthicsCommittee.

Measures

Dream Interview Schedule (Stenfert Kroese et al.1998) – this was developed to examine dream




conceptualisation in adults with mild to moderateID, being adapted from a paradigm developed toinvestigate children’s developing conceptualisationof dreams (Woolley & Wellman 1992) andcomprised:1 Open questions; and

• ‘Do you have dreams?’ (prompted by ‘tell me abit about your dreams’ or ‘can you give me anexample?’)• ‘What is a dream?’ (prompted by ‘When dothey happen?’ ‘Where do they happen?’ ‘How dothey happen?’)• ‘What do dreams make you feel like?’(prompted by ‘happy, sad, scared, upset’ etc.)

2 Closed questions.Forty-four closed questions are based on the verbalpresentation of eight short stories. The questionsassessed conceptualisation of physical objects,objects in photographs and objects in dreamsaccording to four dimensions:

• Perceptually public (i.e. could be seen by morethan one person) vs. perceptually private (i.e.could only be seen by one person);• Physical (i.e. object was physically present,something you could touch) vs. non-physical (i.e.object was not physically present, could not betouched);• Shared (i.e. whether two people could have thedream experience at the same time) vs. individu-ated (i.e. only one person could have the dreamexperience at that time); and• Potentially fictional vs. real.

Modified version of the Sally-Ann Task (Wimmer &Perner 1983) – the Sally-Ann task is a simpleversion of a false belief task devised by Wimmer &Perner (1983) to explore 1st order ToM abilities(Premack & Woodruff 1978), having been used suc-cessfully with people with ID and/or autistic spec-trum disorders (ASD) (e.g. Baron-Cohen et al.1985; Leslie & Frith 1988; Perner et al. 1989). Thecurrent study used the same framework, but inorder to make the test more age-appropriate, thedolls were changed to men, the basket to a box, thebox to cupboards, and the marble to chocolate. Thestory was presented to participants both verballyand visually. The verbal description was as follows:‘In the story there are two men, one called Markand one called Ben. Mark has a box and Ben has acupboard. Mark has some chocolate. Mark places

his chocolate in his box and then goes out. While heis out, Ben moves Mark’s chocolate from the boxand places it in his own cupboard. Ben then goesout. Mark comes back in’. The test question asked,‘Where will Mark look for his chocolate?’ There wasalso a memory question asking ‘where was thechocolate in the beginning?’ and a reality questionasking ‘where is the chocolate really?’ The latter twoquestions provide important information regardingthe possible reasons for test failure. For example:• If a participant answered all questions correctly(test, memory and reality), then they were deemedto have passed the test and could be assumed topossess 1st order ToM ability.• If a participant answered the test question incor-rectly, but the reality and memory questions cor-rectly, then they were deemed to have failed the testand could be assumed to lack 1st ToM ability.• If a participant answered either the reality ormemory question incorrectly, regardless of theirresponse to the test question, their results could beassumed to be unreliable, suggesting incomprehen-sion of the test.British Picture Vocabulary Scale II (Dunn et al.1997) – the BPVS-II is a standardised, wide-rangetest of vocabulary (hearing) for standard English,with good reliability and validity (Dunn et al. 1997).

Learning Disability Casemix Scale (Pendaries1997) – this is a questionnaire completed by family,staff or carers to determine the severity of an indi-vidual’s ID (mild, moderate or severe) and chal-lenging behaviour (none, mild or severe).

Additional information on psychiatric diagnosisand medication was gathered from participants andstaff.

Procedure

Participants were seen at the day service on thedays they normally attended. A private room wasused for the interviews, which were arranged at par-ticipants’ convenience. Each participant’s under-standing of the study had been assessed at theinitial meeting to determine whether they wouldconsider taking part and was at least 1 week beforethe actual research session. Understanding of thestudy was reassessed and consent obtained. Back-ground information was initially obtained fromparticipants, and their consent for requesting any




missing information from staff was obtained. TheBPVS-II was administered, followed by the dreaminterview schedule and the Sally-Ann test. Theinterview generally took between 45 and 60 min,with breaks as required. The Casemix scale wascompleted by day-service staff. Data analysis uti-lised spss for Windows version 11.5.

Participants

Sixty-two people with ID who fulfilled initial inclu-sion criteria were invited to participate in the study,with data from nine participants being subsequentlyexcluded from the analysis as they did not obtain areliability score of 75% across the closed-questionsection of the dream interview schedule (cf. Sten-fert Kroese et al. 1998). Data from another partici-pant were excluded as they had answered ‘yes’ toevery question (cf. Woolley & Wellman 1992). Meanage of the final 52 participants was 34 years 5

months (SD = 9.2) and mean age-equivalent recep-tive language level was 8 years 9 months (SD = 3.3).There were 22 male and 30 female participants, two

of whom were of black British origin, the rest beingwhite British. The Learning Disability CasemixScale indicated that majority of participants (96%)had a mild ID, but the BPVS-II suggested a morevaried range of ability, at least in terms of receptivelanguage ability. The majority of participants(n = 40) had an ID of non-specified aetiology, ninehad Down’s syndrome, two ASD and one fragile Xsyndrome. The Casemix Scale indicated no chal-lenging behaviour in the majority of participants(n = 45), with seven showing mild challengingbehaviour.

Results

The data were found to be non-normally distrib-uted, indicating the use of non-parametric analysis.

Hypothesis 1

Figure 1 illustrates the observed response pattern ofparticipants in the present study, and this can be

0

10

20

30

40

50

60

70

80

90

100

Can you act on it?Can others see it?Can you see it?

Question asked

Per

cen

tag

e o

f 'y

es' r

esp

on

ses

Object

Dream

Photograph

Figure 1 Observed response pattern for participants regarding the perceptually private/public and physical/non-physical properties of realobjects, objects in photographs and objects in dreams.




contrasted with the ‘correct’ pattern of responses(i.e. objects can be seen by self and others in thereal world and acted upon, photographs can beseen but not acted upon and dreams can be neitherseen nor acted upon in the real world). A Friedmantwo-way anova was carried out on the combinedresponses from the dimensions concerning realobjects, objects in photographs and objects indreams. This demonstrated a significant differencebetween the total percentage of correct responsesacross the three groups when all dimensions werecombined (c2 = 68.405, p < 0.001). The differenceswere unlikely to be due to sampling error. Plannedpair-wise comparisons using the Wilcoxon signed-ranks test revealed significant differences betweenall three groups, the greatest significant differencesbeing found between percentage of correctresponses for real objects vs. objects in dreams(z = -5.658, p < 0.001) and objects in photographsvs. objects in dreams (z = -5.613, p < 0.001). Overallfewer questions were answered correctly regardingobjects in dreams.

Participants’ understanding of the perceptuallyprivate and non-physical nature of dreams (asassessed by the questions ‘can others see it?’ and‘can you act on it?’) demonstrated the mostdeviation from the correct pattern of understanding.

Separate Friedman two-way anovas were carriedout on the data concerning the perceptually publicvs. private properties and the physical vs. non-physical properties of real objects, objects in photo-graphs and objects in dreams. A significantdifference was found regarding the percentage ofcorrect responses on the perceptually public vs.private dimension across the three groups(c2 = 51.209, p < 0.001). The differences in the per-centage of correct responses for real objects com-pared with objects in dreams were significant(z = -4.545, p < 0.001), with significantly fewerquestions answered correctly regarding objects indreams, and a similar difference was observedfor the percentage of correct responses forobjects in photographs compared withobjects in dreams (z = -4.910, p < 0.001), withsignificantly fewer correct responses relating todreams.

Friedman analysis also indicated significant dif-ferences in the percentage of correct responsesacross the three groups of objects on the physical

vs. non-physical dimension (c2 = 35.830, p < 0.001)and the percentage of correct responses for realobjects compared with objects in dreams(z = -4.682, p < 0.001), with fewer questionsanswered correctly regarding objects in dreams. Sig-nificant differences were found in the percentage ofcorrect responses regarding real objects comparedwith objects in photographs (z = -3.610, p < 0.001),with fewer correct responses about objects inphotographs, and the percentage of correctanswers regarding objects in photographsand objects in dreams (z = -2.577, p < 0.01),with fewer correct response relating to objects indreams.

Hypothesis 2

About 29% of answers reflected a shared notion ofdreams, with a further 27% indicative of a privatenotion of dreams. The majority of answers, approxi-mately 42%, reflected an inconsistent conceptualisa-tion of the individuated vs. shared properties ofdreams.

Hypothesis 3

Figure 2 illustrates the observed response patternfor participants in the present study, and visualinspection indicated that participants’ understand-ing of thoughts and dreams as containing realcontent is close to the ‘correct’ pattern (i.e. thatwhich is real exists, can be seen, thought about anddreamt, whereas that which is fictional neither existsnor can it be seen, but it can be thought anddreamt about), but understanding of thoughts anddreams as containing fictional content reflectsgreater discrepancy. The observed response patternsuggested that participants were generally confidentthat real objects can be seen, while fictional objectscannot be seen and do not exist. There were signifi-cant difference between the percentages of correctresponses for fictional and real objects (fewer ques-tions answered correctly regarding fictional objects)(z = -4.420, p < 0.001), percentage of correctresponses for ability to think about real orfictional objects. (z = -5.052, p < 0.001) and per-centage of correct answers regarding the ability todream about real or fictional objects (z = -3.873,p < 0.001).




Hypothesis 4

With regard to 1st order ToM ability, 25 partici-pants successfully passed the false belief test, and 16

failed the test, suggesting impaired 1st order ToM,and 11 failed the test owing to incomprehension.The data from the core questionnaire were reanaly-sed omitting the results of the latter 11 participantsin order to clarify whether the dream understandingdifficulties would be as great if their responses wereremoved (i.e. in case their responses on the corequestionnaire were an artefact of their comprehen-sion difficulties). This indicated no differences ineither the direction or significance of the results forthe analyses for hypotheses 1 and 3. For this reason,these 11 have remained in the overall data set.

While more participants who passed the 1st orderToM test produced more correct answers(median = 78.57%) compared with participants whofailed (median = 64.29%) and those who did notunderstand (median = 28.57%), this was not signifi-

cant (c2 = 4.239, p = 0.120). Kruskal-Wallis analyseswere performed on the data concerning the percep-tually public/private, physically/non-physical,individuated/shared and real/fictional nature ofobjects in dreams. There was no group differenceregarding the individuated/shared nature of objectsin dreams, but group differences were found regard-ing the perceptually private/public nature of objectsin dreams (c2 = 6.982, p = 0.030). However, pair-wise comparisons demonstrated that the significantdifference was between those who passed the 1storder ToM test and those who did not understandthe test (p = 0.012). Hence, participants who failedthe ToM test owing to incomprehension answeredfewer questions correctly regarding the perceptuallyprivate nature of dreams. The number of questionsanswered correctly regarding the perceptuallyprivate nature of dreams was not significantly differ-ent in those who demonstrated 1st order ToM andthose who did not (p = 0.869).

0

10

20

30

40

50

60

70

80

90

100

Have you ever seen? Does it exist? Can you think about? Can you dream about?

Question asked

Per

cent

age

of 'y

es' r

espo

nses

Fictional

Real

Figure 2 Response pattern illustrating observed pattern of responses regarding the understanding of thoughts and dreams as mentalevents that can include both real and fictional content.




A similar pattern was observed with regard to thephysical/non-physical nature of dreams, in that sig-nificant group differences (c2 = 6.900, p = 0.032)were observed, but pair-wise analysis indicated thatthe significant difference was between those whodemonstrated 1st order ToM and those who failedthe reality or memory question (p = 0.008). Thedifference in the percentage of correct answersbetween those who demonstrated 1st order ToMand those who ‘failed’ 1st order ToM, was not sig-nificant (p = 0.237). There were group differencesrelating to the percentage of correct responsesregarding the ability to dream about fictionalobjects (c2 = 10.428, p = 0.005), this being in thepredicted direction. Pair-wise comparisons indicatedthat the significant difference was between thosewho demonstrated 1st order ToM and those whofailed the reality or memory question group(p = 0.007). There was also a difference approachingsignificance between those demonstrating 1st orderToM and those who did not (p = 0.023). However,this suggests that participants who failed the 1storder ToM test owing to incomprehension againgave significantly fewer correct questions regardingdreaming about fictional objects, rather than thosewho lacked ToM.

Hypothesis 5

There was a moderate correlation between receptivelanguage ability and total percentage of correctresponses regarding dreams (r = 0.467, p < 0.001), asignificance value of p < 0.017 being utilised as aBonferonni corrections to correct for multiple com-parisons (Field 2000). Similar associations werefound between receptive language ability and per-centage of correct answers, regarding the perceptu-ally private nature of dreams (r = 0.457, p = 0.001),the non-physical nature of dreams (r = 0.547,p < 0.001) and the possibility of dreaming aboutfictional objects (r = 0.396, p = 0.004). No othersignificant correlations were observed.

Discussion

The hypothesis that a greater percentage of correctresponses would be produced regarding real objectsand objects in photographs as compared with

objects in dreams, was supported by the data.Moreover, the mean of 41.76% of responses toquestions regarding dreams being incorrect wascomparable with previous research that reportedbetween 38% and 40% (Stenfert Kroese et al. 1998;Edwards 1999), although the present study alsoincluded the individuated nature of dreams in thisanalysis, which was not examined statistically inprevious studies. A significantly greater percentageof correct responses was found in the case of realobjects and objects in photographs as comparedwith objects in dreams, and this held across boththe perceptually public/private and physical/non-physical dimensions. This suggests that many par-ticipants believed that dreams were entities thatcould be seen by other people by going into theirbedrooms, that dreams were physically present andthat the objects in dreams could be touched andmanipulated.

The second hypothesis related to the sharednature of dreams was not supported by the data.However, 42% of responses reflected an inconsis-tent conceptualisation of the individuated vs. sharedproperties of dreams, indicating that some partici-pants were unclear about whether dreams wereshared with others or whether they were private.This highlights the potential for confusion regardingwhether other individuals would have access to, oralready know about their dreams, if they had beensleeping in the same room. The results were againbroadly comparable with previous research (StenfertKroese et al. 1998; Edwards 1999).

The third hypothesis regarding correct responsesto questions relating to real as compared with fic-tional objects was supported by the data. Althoughno comparable statistical findings have been previ-ously reported, visual inspection of the observedpattern of responses across the four questions overall three studies demonstrated a similar pattern ofresponding, and suggested that participants wereprone to believing that what they dreamt aboutreflected reality, as dreams had to be about realentities. Interestingly, the finding regarding theinability to think fictional thoughts (median 0%)could be taken as indicating that participantsbelieved that all thoughts must be about real things.

The hypothesis relating to correct understandingof dreams and 1st order ToM ability was notsupported by the data, but the direction of the




results fits with developmental models, e.g. Well-man’s (1994), which propose that the first compo-nent of ToM ability is the ability to distinguishbetween the phenomenal real (physical) world andthe noumenal mental (inner) world. Although theassociation between 1st order ToM ability and rec-ognition of the fictional nature of dreams was non-significant, in part owing to the small sample sizeand the use of a more stringent level of significance,this might be a potentially promising area for futureresearch.

Receptive language ability was found to be sig-nificantly associated with accurate dream conceptu-alisation, specifically with regard to the perceptuallyprivate, non-physical and potentially fictional natureof dreams. Specifically, age-equivalent scores on theBPVS-II correlated with percentages of correctanswers regarding dreams, with the exception of theindividuated nature of dreams. These findings werebroadly comparable with those of Edwards (1999).

The study had several limitations, particularly theself-selected nature of the sample as people withlimited understanding or experience, of dreams, maynot have seen the point in taking part. Interestingly,when the study was explained to people with ASD,none of these potential participants could identifyany dream experiences, and most declined to partici-pate, despite assurances that this did not precludethem from participation. It was also noted that themajority of incorrect responses relating to dreamswere due to acquiescence (Sigelman et al. 1981).Themajority of correct responses regarding dreamsrequired a ‘no’ answer (i.e. questions relating to theperceptually private, non-physical and individuatednature of dreams), as did the question regarding thenon-physical nature of photographs, which elicited ahigh percentage of incorrect answers. However, inagreement with Stenfert Kroese et al. (1998), thiswas not the case across the whole interview sched-ule. For example, the questions regarding the abilityto think and dream about fictional entities allrequired ‘yes’ answers to be correct and participantsgave a large proportion of ‘no’ answers to these ques-tions (cf. Stenfert Kroese et al. 1998; Edwards 1999),in which case the social desirability of agreeing withthe researcher might have been overridden by notwanting to admit to thoughts or dreams consideredunusual or bizarre (Edwards 1999).The presentstudy may also have been underpowered, as addi-

tional variables were employed compared with Sten-fert Kroese et al.’s study, which was used as thereference for the power calculation.

Implications of current findings for researchand practice

These findings indicate that many adults with mildto moderate ID may believe that their dreams takeplace around them, that other people can witnessand share these dreams, which in turn can betouched and manipulated, and that dreams are gen-erally about real events. This suggests a realisticmisconception of dreams, namely, the attribution ofphysical properties to the dream (Piaget 1929, citedin Wellman & Estes 1986), which may have implica-tions for the ability of adults with ID to distinguishother internal phenomena (such as thoughts) fromexternal events. As some people without ID withdiagnoses of schizophrenia also report realisticdream conceptions (Edwards 1999), it is possiblethat such dream conceptualisation could beexplained in both populations by impaired sourcemonitoring (Johnson & Magaro 1987; Johnson et al.1993). The non-significant association between 1storder ToM ability and conceptualising dreams aspotentially fictional entities may be indicative of justsuch a process, given the links between ToM abilityand imagination (Scott & Baron-Cohen 1996) andintrospection (Hurlburt et al. 1994). Implicationsfor clinical practice may follow from the possible‘different’ experience of some adults with IDregarding dreams (and other mental phenomena),given that difference theorists posit that such cogni-tive differences result in qualitatively different waysof making sense of the world (Barrett & Jones1996). In particular, clinical involvement wouldneed to ensure that the understanding or experienceof dreams, or perhaps any mental event, was notassumed to be the same (or to be communicated inthe same way) for individuals with ID. Participantsin the present study reported examples of apparentmisunderstandings, e.g. a participant diagnosedwith schizophrenia reporting his grandmotherspeaking to him at night and although it was notclear whether this experience had led to the schizo-phrenia diagnosis, the participant now described theexperience as a hallucination. The possibility of amisunderstood dream experience did not appear to




have been discussed with him. This demonstratesthe inherent difficulties in attempting to diagnose‘breaks’ in reality testing in people with difficultiesin communicating or conceptualising their view ofreality (Weisblatt 1994), with the potential for mis-diagnosis of psychiatric disorders.

Although there are reports of the therapeutic useof dream reports in psychotherapy with people ID(Bradshaw 1991; Morris 1994), the current findingsindicate that a cautious approach when workingwith dream reports is warranted. With regard to theuse of cognitive-behavioural techniques (cf. StenfertKroese et al. 1997), the finding that a large propor-tion of people with ID report the impossibility ofthinking about fictional entities has implications forevaluating the evidence for thoughts, as they maybelieve that by definition their thoughts are true(i.e. they are real and it is not possible to thinkabout things that are not real). Also, if the resultswere conservatively interpreted as being due to anunwillingness to admit to bizarre or unusualthoughts, then this might also hold in therapeuticsituations and impede the elicitation of, e.g. nega-tive automatic thoughts or images.

Future research would benefit from further ques-tioning to explore the limits of participants’ under-standing (e.g. Laurendeau & Pinard 1963; Woolley& Wellman 1992) to provide more detailed informa-tion, particularly regarding the degree of realismbeing suggested by participants. There were severalproblems with the somewhat complex questioninginvolved in the present study and effort would berequired in future studies to ensure that moredetailed questioning did not result in distress orchanges in participants’ responses owing to socialdesirability. Although a more exploratory open-ended questioning with subsequent qualitativeanalysis might be feasible with participants withmild ID, this might exclude people with a greaterseverity of ID from taking part in the research.

References

Baron-Cohen S., Leslie A. M. & Frith U. (1985) Does theautistic child have a ‘theory of mind’? Cognition 21,37–46.

Barrett H. & Jones D. (1996) The inner life of childrenwith moderate learning disabilities. In: The Inner Life ofChildren with Special Needs (ed. V. P. Varma), pp. 45–62.Whurr Publishers, London.

Beail N. (1989) Understanding emotions. In: MutualRespect (ed. D. Brandon), pp. 23–45. Good Impressions,Surbiton.

Bentall R. P. (2000) Hallucinatory experiences. In: Variet-ies of Anomalous Experience: Examining the Scientific Evi-dence (eds E. Cardena, S. Jay Lynn & S. Krippner),pp. 85–120. American Psychological Association, Wash-ington, DC.

Bradshaw S. (1991) Successful cognitive manipulation of astereotypic nightmare in a 40 year old male withDown’s syndrome. Behavioural Psychotherapy 19, 281–3.

Cohen D. B. (1979) Sleep and Dreaming. Origins, Natureand Functions. Pergamon Press, Oxford.

Dagnan D. & Chadwick P. (1997) Cognitive-behaviourtherapy for people with learning disabilities: assessmentand intervention. In: Cognitive Behaviour Therapy forPeople with Learning Disabilities (eds B. Stenfert Kroese,D. Dagnan & K. Loumidis), pp. 110–23. Routledge,London.

Dunn L. M., Dunn L. M., Whetton C. & Burley J. (1997)The British PictureVocabulary Scale, 2nd edn. NFERNelson, Windsor.

Edwards J. (1999) The conceptualisation of dreams in peoplewith intellectual disabilities and schizophrenia. UnpublishedDoctoral Thesis. University of Birmingham, Birming-ham.

Field A. (2000) Discovering Statistics Using SPSS forWindows. Sage, London.

Foulkes D. (1993) Children’s dreaming. In: Dreaming asCognition (eds C. Cavallero & D. Foulkes), pp. 114–32.Harvester Wheatsheaf, Hemel Hempstead.

Frith C. D. & Corcoran R. (1996) Exploring ‘theory ofmind’ in people with schizophrenia. Psychological Medi-cine 26, 521–30.

Hobson A. J. (2002) Dreaming: An Introduction to theScience of Sleep. Oxford University Press, New York.

Hurlburt R. T. (1990) Sampling Normal and SchizophrenicInner Experience. Plenum Press, New York.

Hurlburt R. T. (1993) Sampling Inner Experience inDisturbed Affect. Plenum Press, New York.

Hurlburt R. T., Happé F. & Frith U. (1994) Sampling theform of inner experience in three adults with Aspergersyndrome. Psychological Medicine 24, 385–95.

Johnson M. H. & Magaro P. A. (1987) Effects of moodand severity on memory processes in depression andmania. Psychological Bulletin 101, 28–40.

Johnson M. H., Hashtroudi S. & Lindsay D. S. (1993)Source monitoring. Psychological Bulletin 114, 3–28.

Kerr N. (1993) Mental imagery, dreams and perception.In: Dreaming as Cognition (eds C. Cavallero & D.Foulkes), pp. 18–37. Harvester Wheatsheaf, HemelHempstead.

Laurendeau M. & Pinard A. (1963) Causal Thinking in theChild. International University Press, Oxford.




Leslie A. M. (1987) Pretense and representation: theorigins of ‘theory of mind’. Psychological Review 94,412–26.

Leslie A. M. & Frith U. (1988) Autistic children’s under-standing of seeing, knowing and believing. BritishJournal of Developmental Psychology 6, 315–24.

Morris S. (1994) You will only hear half of it and youwon’t believe it: counselling with a woman with mildlearning disability. In: Treating Survivors of SatanistAbuse (ed. V. Sinason), pp. 302–26. Routledge,London.

Pendaries C. (1997) Pilot study on the development of thelearning disability healthcare resource groups. BritishJournal of Learning Disabilities 25, 122–6.

Perner J., Frith U., Leslie A. M. & Leekam S. R. (1989)Exploration of the autistic child’s theory of mind:knowledge, belief and communication. Child Develop-ment 60, 689–700.

Piaget J. (1927) La causalité chez l’enfant. British Journalof Psychology 18, 276–301.

Piaget J. (1929) The Child’s Conception of theWorld. Rout-ledge and Kegan Paul, London.

Premack D. & Woodruff G. (1978) Does the chimpanzeehave a theory of mind? Behavioural and Brain Sciences 4,515–26.

Reed J. (1997) Understanding and assessing depression inpeople with learning disabilities: a cognitive-behaviouralapproach. In: Cognitive Behaviour Therapy for People withLearning Disabilities (eds B. Stenfert Kroese, D. Dagnan& K. Loumidis), pp. 53–66. Routledge, London.

Scott F. J. & Baron-Cohen S. (1996) Imaging real andunreal things: evidence of dissociation in autism. Journalof Cognitive Neuroscience 8, 371–82.

Shepard R. N. (1984) Ecological constraints on internalrepresentation: resonant kinematics of perceiving, imag-ining, thinking and dreaming. Psychological Review 91,417–47.

Sigelman C. K., Budd E. C., Spanhel C. L. & SchoenrockC. J. (1981) When in doubt say yes: acquiescence ininterviews with mentally retarded persons. Mental Retar-dation 19, 53–8.

Slade P. & Bentall R. P. (1988) Sensory Deception – A Sci-entific Analysis of Hallucination. Croom Helm, London.

Stenfert Kroese B., Dagnan D. & Loumidis K. (eds)(1997) Cognitive Behaviour Therapy for People with Learn-ing Disabilities. Routledge, London.

Stenfert Kroese B., Cushway D. & Hubbard C. (1998)The conceptualisation of dreams by people with intel-lectual disabilities. Journal of Applied Research in Intellec-tual Disabilities 11, 146–55.

Velmans M. (2000) Understanding Consciousness.Routledge, London.

Weisblatt S. A. (1994) Diagnosis of psychiatric disorders inpersons with mental retardation. In: Mental Health inMental Retardation: Recent Advances and Practices (ed.N. Bouras), pp. 93–101. Cambridge University Press,Cambridge.

Wellman H. M. (1994) Early understanding of mind: thenormal case. In: Understanding Other Minds: Perspectivesfrom Autism (eds S. Baron-Cohen, H. Tager-Flusberg &D. J. Cohen), pp. 10–39. Oxford University Press,Oxford.

Wellman H. M. & Estes D. (1986) Early understanding ofmental entities: a re-examination of childhood realism.Child Development 57, 910–23.

Wimmer H. & Perner J. (1983) Beliefs about beliefs: rep-resentation and the constraining function of wrongbeliefs in young children’s understanding of deception.Cognition 13, 103–28.

Woolley J. D. & Wellman H. M. (1992) Children’s con-ceptualisation of dreams. Cognitive Development 7,365–80.

Accepted 7 November 2007




The conceptualisation of dreams by adults with intellectual disabilities: relationship with theory...

Documents

Transcript of The conceptualisation of dreams by adults with intellectual disabilities: relationship with theory...