Introduction 2003 2003 1981 1994 1994 2004 1986 2001 1986 1993 1980 1986 1991 1994 1995 2005 2007 2007 1999 1999 2000 2003 1998 2000 2003 2005 Face Recognition 2003 1999 2003 Identification of Facial Expression 2001 1981 1981 2005 1999 1988 2003 1998 2003 2004 Aims and Predictions of the Study 1995 We predicted that children with MCDD would differ from those with PDD-NOS on recognizing neutral faces in comparison to complex patterns. More specifically, if indeed children with MCDD are not well-placed under the PDD’s, we would expect them to be faster and more accurate on face recognition compared to children with PDD-NOS, but perform similarly on especially complex pattern recognition. Children with MCDD would show differences in the identification of facial expressions, particularly a bias toward processing fear and anger expressions, as compared to children with PDD-NOS. Any significant differences found should not be explained by differences in mental age. Methods Participants The study sample was selected from 503 children, aged 6–12 years old, who were consecutively referred to the outpatient department of child and adolescent psychiatry, between July 2002 and September 2004. Referrals were comprised of a large variety of child psychiatric disorders (externalizing disorders, internalizing disorders, PDDs). Research criteria for MCDD and PDD-NOS were rated incompletely for 12 (2.4%) children, who were excluded from further analyses. Complete MCDD and PDD-NOS criteria were rated for 491 children. Twenty-nine (5.9%) children met research criteria for a diagnosis of MCDD. Eleven children (44%) meeting MCDD research criteria also met research criteria for PDD-NOS. These children were placed in the MCDD group. The parents of four of these children refused to participate in the study. Seventy-nine children met research criteria for a diagnosis of PDD-NOS without meeting research criteria for MCDD (PDD-NOS group). These children did not meet DSM-IV criteria for autism or Asperger syndrome. Children with an IQ score of less than 70 were not administered the neuropsychological battery; two children in the MCDD group, and 13 children in the PDD-NOS group were not administered the neuropsychological tasks on this basis. A further two children meeting MCDD criteria had missing data for the face recognition (FR) task and identification of facial expressions task (IFE). Thus, the MCDD group included a total of 21 children. In addition to the children without neuropsychological data due to a low IQ, five children in the PDD-NOS group were missing data for the FR task, and four were missing data for the IFE task, resulting in a total of 61 PDD-NOS children with FR task data, and 62 children with IFE task data. Ethics Participation was voluntary, and informed consent was signed by all parents/caretakers prior to participation in the study. Children who were 12 years old also signed the consent forms themselves. The Medical Ethics Committee of the Erasmus Medical Center approved the study. MCDD and PDD-NOS Research Criteria 1 1999a 1998 Table 1 1998 1 2 (1) Impaired regulation of affective states and anxieties A 2  (1) Qualitative impairment in social interaction (a) Unusual or peculiar fears and phobias, or frequent idiosyncratic or bizarre anxiety reactions (a) Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) Recurrent panic episodes, or flooding with anxiety (b) Failure to develop peer relationships appropriate to developmental level (c) Episodes of behavioral disorganization punctuated by markedly immature, primitive, or violent behaviors (c) A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest)  (d) Lack of social and emotional reciprocity (2) Impaired social behavior (2) Qualitative impairments in communication (a) Social disinterest, detachment, avoidance, or withdrawal (a) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others (b) Markedly disturbed and/or ambivalent attachments (b) Stereotyped and repetitive use of language or idiosyncratic language (3) The presence of thought disorder (3) Restricted repetitive and stereotyped patterns of behavior, interests, and activities (a) Irrationality, magical thinking, sudden intrusions on normal thought process, bizarre ideas, neologism, repetition of nonsense words (a) Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements) (b) Perplexity and easy confusability. overvalued ideas, including fantasies of omni-potence, paranoid preoccupations, overengagement with fantasy figures, referential ideation B. Does not meet criteria for autistic disorder or for other specific pervasive developmental disorder 1 2 An interrater reliability study was conducted for 30 randomly selected children (27%). Two clinicians independently rated all MCDD and PDD-NOS research criteria. Agreement between the raters on the presence or absence of a PDD-NOS diagnosis was good (κ = .62). Agreement for MCDD diagnosis could not be calculated, as MCDD did not occur once in this subsample. Materials Procedure Children were assessed on two occasions, separated by a week. Testing was conducted in a quiet room in the outpatient department of the hospital. On the first occasion, the full Weschsler Intelligence Scale for Children (WISC-R) was administered, taking on average, 2 h per child. The social-cognitive tasks were administered on the second visit the following week as part of a larger neuropsychological battery taking approximately one and a half hours. Children were always tested in the morning to minimize the effects of fatigue and to maximize concentration. Intelligence: Weschsler Intelligence Scale for Children (WISC-R) 1999b 1995 Baseline Speed (BS) Amsterdam Neuropsychological Tasks 1999 Face Recognition ANT 2.1 1999 2003 2002 1 Fig. 1 a b  Pattern Recognition ANT 2.1 1 Identification of Facial Expressions ANT 2.1 2 Fig. 2 Examples of different expressions in the Identification of Facial Expressions (IFE) task. Children are presented with four different tasks (each corresponding to one of four target emotions: happy, sad, anger, and fear). For each task, children are required to focus on a particular emotion, and to judge whether the face displays a specific target emotion. The target consists of an adult face expressing one of four emotions. When the face matches the emotion a ‘yes’ response is required, when the face does not match the emotion, a ‘no’ response is required. A total of 40 trials per emotion condition were presented, with half of those trials requiring a ‘yes’ response (target), and half requiring a ‘no’ response (nontarget). RT and accuracy (i.e. proportion correct) for target and non-target conditions were calculated  Statistical Analysis 1997 F p 2 1992 If any significant group differences were found, we repeated the analyses while covarying for the effects of mental age (MA) to exclude the possibility that the differences could be explained by variations in general intelligence. Results Group Characteristics F p F p F p F p F p 2 F p F p Table 2 Frequencies, Means (SD) for the MCDD and PDD-NOS groups for age, sex, and IQ  N N N Mean (SD) Chronological age (years) 9.22 (1.82)  9.89 (1.49)  9.87 (1.47)  n 54/8 18/3 10/3 Mental age (years) 8.83 (2.10)  9.35 (1.60)  9.43 (1.77) IQ: WISC-R Verbal IQ 95.54 (14.26)  97.33 (17.75)  98.77 (21.31) Performance IQ 97.57 (16.64)  94.52 (12.55)  94.46 (10.15) Total IQ 95.97 (14.39)  95.24 (14.17)  96.00 (14.52) Face Recognition (FR) Compared with Pattern Recognition (PR) 3 Table 3 Means (SD) for face recognition, pattern recognition, and identification of facial expressions tasks Task variables PDD-NOS MCDD-all Pure MCDD RT (ms): Mean (SD) Proportion accurate: Mean (SD) Face recognition (FR) N N N Targets 2155.29 (625.54) 1862.71 (469.08) 1853.12 (468.23) 0.76 (0.17) 0.83 (0.17) 0.86 (0.11) Non-targets 2751.15 (730.77) 2599.61 (697.01) 2701.30 (742.33) 0.84 (0.12) 0.84 (0.14) 0.82 (0.15) Pattern recognition (PR) N N N Easy PR: Targets 1826.3 (519.12) 1689.90 (509.77) 1785.92 (544.13) 0.96 (0.07) 0.97 (0.05) 0.98 (0.02) Easy PR: Non-targets 1449.47 (470.34) 1332.83 (356.20) 1364.01 (392.80) 0.85 (0.23) 0.89 (0.17) 0.87 (0.20) Complex PR: Targets 2627.03 (723.78) 2536.89 (763.48) 2656.76 (886.98) 0.83 (0.23) 0.80 (0.26) 0.78 (0.29) Complex PR: Non-targets 3318.54 (984.58) 3084.97 (845.74) 3129.71 (1016.1) 0.76 (0.20) 0.84 (0.13) 0.83 (0.14) Identification of Facial Expressions (IFE) N N N Happy: Targets 1001.03 (358.12) 977.91 (347.91) 1103.95 (380.76) 0.92 (0.09) 0.95 (0.04) 0.95 (0.05) Happy: Non-targets 1322.07 (482.98) 1145.38 (352.43) 1231.97 (394.17) 0.95 (0.06) 0.94 (0.06) 0.95 (0.06) Sad: Targets 1345.73 (419.14) 1217.74 (414.07) 1311.15 (467.99) 0.69 (0.25) 0.77 (0.21) 0.81 (0.15) Sad: Non-targets 1691.06 (657.64) 1482.22 (412.78) 1569.99 (382.69) 0.78 (0.19) 0.86 (0.13) 0.86 (0.14) Anger: Targets 1221.14 (513.73) 1115.36 (275.29) 1172.91 (296.49) 0.73 (0.20) 0.75 (0.21) 0.79 (0.19) Anger: Non-targets 1538.94 (614.53) 1417.10 (361.06) 1535.36 (347.95) 0.89 (0.15) 0.89 (0.13) 0.87 (0.15) Fear: Targets 1351.81 (573.98) 1301.85 (491.01) 1327.11 (586.66) 0.79 (0.18) 0.78 (0.24) 0.80 (0.26) Fear: Non-targets 1476.66 (519.16) 1321.81 (300.87) 1377.08 (355.14) 0.82 (0.20) 0.87 (0.14) 0.87 (0.15) To test our hypothesis, two types of repeated measures analyses were conducted, each on our measures of accuracy and speed of processing separately. In the first type we compared the easy condition of the PR task with the performance of the FR task, in the second type we compared the complex condition of the PR with the FR task. Each analysis included two within-subjects variables: (1) “task” (FR versus PR) and (2) “response type” (target versus non-target). The between-subjects variable was group. Significant group by task interactions would indicate that the groups differ in their manner of processing neutral faces as compared to abstract patterns. easy F p p 2    F p p 2    3 p p 2    p p 2    p p 2  p p 2  F p p 2    Fig. 3 Accuracy of PDD-NOS versus MCDD children for face recognition (FR) and complex pattern recognition (PR). This figure is based on raw (untransformed) error rates, without covarying for MA. Error bars represent standard error of the mean  Our first hypothesis was therefore partially supported: children with PDD-NOS were less accurate than children with MCDD in recognizing that a neutral face was present in the response set, but this effect was not seen when they were asked to note whether an abstract pattern was present amongst similar ones (i.e. complex condition). There was, however, no group difference in task dependent RTs. Identification of Facial Expressions (IFE) Task 3 p p p p Reanalyses Including ‘Pure’ MCDD Versus PDD-NOS Children n n F p p 2    p p 2    Discussion 1995 2007 2003 2004 Face Recognition 2003 1 2007 Identification of Facial Expressions 2003 2003 2004 2003 2007 Strengths and Limitations 1995 2005 1993 2004 2007 2005 2007 Conclusion Despite the existence of thought disorder in children with MCDD, the symptom level differences between PDD-NOS and MCDD children, and the biological/psychophysiological differences between MCDD children and other comparison groups, we found little evidence that children with MCDD are clearly distinguishable from those with PDD-NOS on the identification of facial expressions. Surprisingly, the high rates of anxieties and fears clinically characteristic of children with MCDD did not translate to any significant effects on our emotion-processing task. Further work is needed to probe whether more subtle emotion-processing differences exist. Such studies should focus on examining children’s processing of emotional stimuli within a context more relevant to ‘real-life’ as well as detailed evaluation of children’s emotion regulation ability. The only significant difference to emerge was that children with MCDD not meeting the criteria for a PDD diagnosis demonstrated fewer errors and a faster processing of unfamiliar neutral faces compared to children with PDD-NOS who processed faces more similarly to how they processed complex patterns. This suggests a disadvantage in face processing being related to the autistic characteristics of the PDD-NOS. Based on these findings, it is recommended that the impact of autistic features (amount and severity) are carefully considered when evaluating a child with MCDD symptoms since such features may yield relevant information about the child’s social cognitive abilities. Ideally, future work should include prospective designs which follow up children with MCDD who do and do not demonstrate autistic characteristics.