Autism spectrum traits in children with mood and anxiety disorders

Familiality of Quantitative Autism Traits

Background:

Autistic traits exist along a continuum that extends into social functioning in the general population, and they aggregate in the family members of children with autism spectrum disorder (ASD). Quantitative measures are therefore essential when investigating the patterns of familiality of these traits. Prior studies have suggested differential inheritance patterns of autistic traits that depend on the cognitive level of the child with ASD as well as the family type.

Objective:

Our goal was to examine the family patterns of quantitative autism traits (QAT) in a group of simplex autism families of high-functioning children with ASD.

Method:

We used the Social Responsiveness Scale (SRS) to evaluate QAT in 47 ASD families and 46 control families. SRS assessments (parental/spousal evaluations) were collected for the children with ASD, their siblings, and their parents as well as for the control children and their parents.

Results:

The SRS was able to distinguish individuals with ASD from the control children and from their unaffected siblings. Significant group differences were also found when comparing the fathers of ASD families to control fathers and when comparing the brothers of individuals with ASD to control boys, with male members of ASD families having higher SRS scores. Gender differences were observed in the group of siblings of children with ASD and the group of parents of children with ASD, with males having higher scores than females. In ASD families, a positive trend between child and father QAT was found, whereas mothers’ scores were not associated with child outcomes. By contrast, in control families, mothers’ QAT correlated more strongly with child QAT.

Conclusions:

Autistic traits aggregate in the fathers and brothers of children with ASD in simplex autism families. The QAT levels of the family members should be taken into consideration when planning the rehabilitation of the child or adolescent with ASD and when designing family interventions.

Can autism spectrum disorders and social anxiety disorders be differentiated by the social responsiveness scale in children and adolescents?

Autism spectrum disorder (ASD) as well as social phobia (SP), and selective mutism (SM) are characterised by impaired social interaction. We assessed the validity of the Social Responsiveness Scale (SRS) to differentiate between ASD, and SP/SM. Raw scores were compared in 6-18 year old individuals with ASD (N = 60), SP (N = 38), SM (N = 43), and typically developed (N = 42). Sensitivity and specificity were examined. The three disorders showed overlapping SRS scores. Especially in boys with SM (ROC-AUC = .81), presence of ASD was overestimated by the SRS. A combination of three disorder specific questionnaires resulted in marginally improved diagnostic accuracy. For the clinically very relevant differential diagnosis of SP/SM, SRS results must be interpreted with caution.

Factor structure of autistic traits in children with ADHD

Attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) often co-occur. Factor analyses of ASD traits in children with and without ASD indicate the presence of social and restrictive–repetitive behaviour (RRB) factors. This study used exploratory factor analyses to determine the structure of ASD traits (assessed using the Social Communication Questionnaire) in children with ADHD. Distinct factors were observed for ‘social’ and ‘rigidity’ traits, corresponding to previous factor analyses in clinical ASD and population samples. This indicates that the split between social-communicative and RRB dimensions is unaffected by ADHD in children. Moreover, the study also finds that there is some overlap across hyperactive-impulsive symptoms and RRB traits in children with ADHD, which merits further investigation.

Habituation of exploratory behaviour in VPA rats: animal model of autism

Autism is a neurodevelopmental disorder with multifactorial aetiology, represented as impairment in social behaviour, communication and the occurrence of repetitive activities, which can be observed in the early life. The core features are frequently accompanied by other manifestations, including limited environmental exploration. The aim of the presented study, realised on an animal model of autism – VPA rats, i.e. animals prenatally affected with valproic acid on gestation day 12.5, was to investigate the habituation process of exploratory activity (manifested by a gradual decrease in the intensity of locomotor activity), which reflects the stage of the central nervous system. VPA rats were tested in open-field in three developmental periods – weaning (postnatal day 21 – PND 21), puberty (PND 42) and adulthood (PND 72). In each period of ontogenesis, the rapidity of habituation was evaluated by using the method of linear regression. Compared to controls, VPA rats showed a significant decrease in the intensity and an increase in the rapidity of exploratory activity habituation during puberty and adulthood. Our results indicate that the animal model of autism, i.e. VPA rats, showed disabilities in the development of the nervous system. These findings can help confirm not only the validity of this animal model of autism but can also help better understand neuronal changes in humans with autism.

Cochrane review: social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)

BACKGROUND

Since autism was first described, major difficulties in social interaction have been a defining feature of individuals with autism spectrum disorders (ASD). Social skills groups are a common intervention for individuals with ASD. Although a frequently recommended practice, the few studies that have addressed the efficacy of social skills groups have shown mixed results.

OBJECTIVES

To determine the effectiveness of social skills groups for improving social competence, social communication, and quality of life for people with ASD who are six to 21 years of age.

SEARCH METHODS

We searched the following databases in December 2011: CENTRAL (2011 Issue 4), MEDLINE (1948 to November Week 3, 2011), EMBASE (1980 to Week 50, 2011), PsycINFO (1887 to December Week 2, 2011), CINAHL (1937 to current), ERIC (1966 to current), Sociological Abstracts (1952 to current), OCLC WorldCat (12 December 2011), Social Science Citation Index (1970 to 16 December 2011), and the metaRegister of Controlled Trials (20 December 2011). We also searched the reference lists of published papers.

SELECTION CRITERIA

Randomized control trials (RCTs) comparing treatment (social skills groups) with a control group who were not receiving the treatment for participants aged six to 21 years with ASD. The control group could be no intervention, wait list, or treatment as usual. Outcomes sought were standardized measures of social competence, social communication, quality of life, emotion recognition, and any other specific behaviors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and appraised studies for inclusion and assessed the risk of bias in each included study. All outcome data were continuous and standardized mean difference effect sizes (ES) with small sample correction were calculated. We conducted random-effects meta-analysis where possible.

MAIN RESULTS

We included five RCTs evaluating the effects of social skills groups in 196 participants with ASD aged 6 to 21 years old. The results show there is some evidence that social skills groups improve overall social competence (ES = 0.47, 95% confidence interval (CI) 0.16 to 0.78, P = 0.003) and friendship quality (ES = 0.41, 95% CI 0.02 to 0.81, P = 0.04) for this population. No differences were found between treatment and control groups in relation to emotional recognition (ES = 0.34, 95% CI -0.20 to 0.88, P = 0.21) assessed in two studies or social communication as related to the understanding of idioms (ES = 0.05, 95% CI -0.63 to 0.72, P = 0.89), which was assessed in only one study. Two additional quality of life outcomes were evaluated, with results of single studies suggesting decreases in loneliness (ES = -0.66, 95% CI -1.15 to -0.17) but no effect on child or parental depression. No adverse events were reported. Given the nature of the intervention and the selected outcome measures, the risk of performance and detection bias are high. There is limited generalizability from the studies as they were all conducted in the US; they focused mainly on children aged 7 to 12, and the participants were all of average or above average intelligence.

AUTHORS' CONCLUSIONS

There is some evidence that social skills groups can improve social competence for some children and adolescents with ASD. More research is needed to draw more robust conclusions, especially with respect to improvements in quality of life.

Validity of the social responsiveness scale to differentiate between autism spectrum disorders and disruptive behaviour disorders

Autism spectrum disorder (ASD) as well as oppositional defiant (ODD) and conduct disorder (CD) is characterised by difficulties in social interaction with peers. The Social Responsiveness Scale (SRS) measures reciprocal social behaviour in children and adolescents and was originally developed as a quantitative measure of autistic traits. In the present study, we compare parent-rated SRS scores in children with ODD, CD, and ASD and examine the diagnostic validity of the SRS alone and in combination with additional questionnaires to differentiate between groups. We hypothesize that the SRS better differentiates ASD and typically developing controls (TD) than ASD and the disruptive behaviour disorders ODD and CD. The sample consists of three clinical groups: ASD without comorbid intellectual delay (N = 55), ODD/CD (N = 55), and TD (N = 55), between 6 and 18 years. The groups were matched by age, sex, and IQ. SRS scores were compared for the three groups. Sensitivity and specificity of the SRS total and sub-scores were examined by receiver operating characteristics (ROC) analyses. Logistic regression analyses were calculated for estimating the rate of correctly specified individuals. The SRS differentiated excellently between ASD and TD (ROC-AUC = 1.00), but sensitivity and specificity were considerably lower when ASD was compared with ODD/CD (ROC-AUC = 0.82). A combination of three parent-rated questionnaires resulted in an improved validity to differentiate ASD and ODD/CD. For clinical screening purposes in children suspicious of ASD and/or ODD/CD, the SRS should be used in combination with additional disorder-specific questionnaires to improve the rate of correct classification of both disorders.

Utility of teacher-report assessments of autistic severity in Japanese school children

Recent studies suggest that many children with milder autism spectrum disorder (ASD) are undiagnosed, untreated, and being educated in mainstream classes without support and that school teachers might be the best persons to identify a child's social deviance. At present, only a few screening measures using teacher ratings of ASD have been validated. The aim of this study was to examine the utility of teacher ratings on the Social Responsiveness Scale (SRS), a quantitative measure of ASD. We recruited 130 participants aged 4 to 17 years from local schools or local pediatric outpatient clinics specializing in neurodevelopmental disorders that included 70 children with ASD. We found that the teacher-report SRS can be reliably and validly applied to children as a screening tool or for other research purposes, and it also has cross-cultural comparability. Although parent-teacher agreement was satisfactory overall, a discrepancy existed for children with ASD, especially for girls with ASD. To improve sensitivity in children at higher risk, especially girls, we cannot overstate the importance of using standardized norms specific to gender, informant, and culture.

Narrowly versus broadly defined autism spectrum disorders: differences in pre- and perinatal risk factors

This study examined the differential contribution of pre- and perinatal risks in narrowly versus broadly defined autism spectrum disorder (ASD) and across core symptom domains, IQ and co-morbid problems. Children with a DSM-IV diagnosis of autistic disorder (AD) (n = 121) or pervasive developmental disorder not otherwise specified (PDD-NOS) (n = 75) were compared to a typical control sample (n = 311). Diagnoses were based on extensive assessments between 12 and 49 months of age (M = 33.3, SD = 6.4) and re-evaluated at 43-98 months (M = 68.1, SD = 10.7) in 70% of the cases. Compared with controls, cases with ASD were more likely to be firstborn and show a suboptimal condition after birth. Case mothers reported more infections and more stress during pregnancy. Although the ASD subgroups showed mostly overlapping risks, cases with PDD-NOS differed from those with AD by higher exposure to smoking during pregnancy (SDP) and by a negative association of smoking with IQ, regardless of confounders. SDP appears to contribute more to broadly defined (PDD-NOS) than to narrowly defined ASD (AD). Findings suggest differences in etiological contributors between ASD phenotypes.

Maladaptive cognitive appraisals in children with high-functioning autism: associations with fear, anxiety and theory of mind

Despite the well-documented success of cognitive restructuring techniques in the treatment of anxiety disorders, there is still little clarity on which cognitions underpin fear and anxiety in children with high-functioning autism spectrum disorder. This study examined whether certain cognitive appraisals, known to be associated with fear and anxiety in typically developing groups, may help explain these emotions in children with high-functioning autism spectrum disorder. It also investigated relations between these cognitive appraisals and theory of mind. Appraisals, fear and anxiety were assessed using a vignette approach in 22 children with high-functioning autism spectrum disorders and 22 typically developing children. The two groups differed significantly on all four appraisal types. Anxiety was negatively correlated with future expectancy and positively with problem-focused coping potential in the high-functioning autism spectrum disorder group but was not correlated with appraisals in the typically developing group. The two appraisals associated with fear were emotion-focused coping potential (in the high-functioning autism spectrum disorder group only) and self-accountability (in the typically developing group only). Linear regression analysis found that appraisals of emotion-focused coping potential, problem-focused coping potential and future expectancy were significant predictors of theory-of-mind ability in the high-functioning autism spectrum disorders group. These findings indicate that specific, problematic patterns of appraisal may characterise children with high-functioning autism spectrum disorders.

Autism spectrum traits in children with anxiety disorders

The aim of this study was to examine ASD traits in children with clinical anxiety in early development, as well as current manifestations. Parents of 42 children with an anxiety disorder (but no known diagnosis of ASD) and 42 typically developing children were interviewed using the Autism Diagnostic Interview (ADI-R). They also completed questionnaires that assessed child anxiety (SCARED-71) and children’s ASD symptoms. Results revealed that children with anxiety disorders had higher scores than typically developing children, for both ASD traits in early development as well as current ASD symptoms. A specific association was found between symptoms of Social Anxiety Disorder and ASD traits early in life. Findings are considered in terms of clinical implications, and limitations are discussed.

Socio-emotional processing and functioning of youth at high risk for bipolar disorder

BACKGROUND

The goal of this study was to investigate differences in socio-emotional processing and functioning in children and adolescents at high risk for bipolar disorder (BD) and healthy control participants.

METHODS

Children and adolescents with a parent with bipolar disorder, who had mood dysregulation but not fully syndromal BD (high risk, HR, n=24), were compared to participants with no personal or family history of psychopathology (healthy control, HC, n=27) across several neuropsychological domains. Social reciprocity was measured by the Social Responsiveness Scale, theory of mind was measured by use of the NEPSY, and affect recognition was measured by the NEPSY and the Diagnostic Test of Nonverbal Accuracy 2 (DANVA).

RESULTS

The HR group demonstrated significant impairment in social reciprocity, including impairments in social awareness, social cognition, social communication, social motivation, and autistic mannerisms. There were no significant group differences in performance on theory of mind or affect recognition tasks.

LIMITATIONS

Lack of impairment in tasks associated with theory of mind or affect recognition indicate that social functioning difficulties are not likely due to impairments in these areas, or that the measures employed were not sufficiently sensitive to detect group differences.

CONCLUSIONS

Youth at high risk for BD demonstrated impairments in numerous social domains, which may be due to innate differences in brain development governing socio-emotional functioning or may be due to disruptions in normal development caused by mood regulation difficulties.

Assessing autistic traits in a Taiwan preschool population: cross-cultural validation of the Social Responsiveness Scale (SRS)

The cross-cultural validity of the Mandarin-adaptation of the social responsiveness scale (SRS) was examined in a sample of N = 307 participants in Taiwan, 140 typically developing and 167 with clinically-diagnosed developmental disorders. This scale is an autism assessment tool that provides a quantitative rather than categorical measure of social impairment in the general population. SRS total and subscale scores distinguished significantly between autism spectrum disorder and other developmental disorders (p < 0.01). Total SRS scores and sensitivity and specificity of the scale for diagnosing developmental disorders in the Taiwan study were similar to those observed in Western studies. These findings support the cross-cultural validity of the SRS scale for detecting autistic traits and for distinguishing between autism and other neuropsychiatric conditions.

Differentiating high-functioning autism and social phobia

Both high-functioning autism (HFA) and social phobia (SP) involve profound social interaction deficits. Although these disorders share some similar symptoms, they are conceptualized as distinct. Because both HFA and SP are defined behaviorally, the degree of overlap between the two disorders may result in misinterpretation of symptoms. However, the deficits in each disorder differ, particularly in areas of social interaction, emotion recognition and expression, and communication. This paper reviews the literature that informs our current understanding of the behavioral overlaps and differences in HFA and SP. The review also addresses the implications of our current knowledge of these two disorders for differential diagnosis, treatment, and future research. Interdisciplinary, developmentally-oriented research may help extend current approaches to HFA and SP.

Differential diagnosis of bipolar disorder in children and adolescents

Issues complicating the differential diagnosis of bipolar disorder in young people are discussed. They include: a) the subtype of bipolar disorder being considered; b) the person's age and stage of development; c) whether one views bipolar disorder more conservatively, requiring clear episodes that mark a distinct change from premorbid levels of function, or more liberally, focusing for instance on severe irritability/explosive outbursts as the mood change; d) who is reporting manic symptoms, and whether symptoms are past and must be recalled or current and more likely to be observed; e) impact of family history. The diagnosis of mania/bipolar I disorder may not become clear for a number of years. This is an impairing disorder, but so are the conditions from which it must be distinguished. Family history may increase the odds that certain symptoms/behaviors are manifestations of bipolar disorder but it does not make the diagnosis. Until there are biomarkers that can confirm the diagnosis, and treatments unique to the condition, it is wise to make a diagnosis of bipolar disorder in children and adolescents provisionally and keep an open mind to the likelihood that revisions may be necessary.

Disentangling the associations between autistic-like and internalizing traits: a community based twin study

Internalizing difficulties are prevalent in children with autism spectrum disorders (ASD), yet little is known about the underlying cause of this comorbidity. It is also unclear which types of autistic-like and internalizing difficulties are most strongly associated. The current study investigated the phenotypic and etiological associations between specific autistic-like traits and internalizing traits within a population-based sample. Parent-reported data were analyzed from 7,311 twin pairs at age 7 to 8 years. Structural equation modeling revealed distinguishable patterns of overlap between the three autistic-like traits (social difficulties, communication problems and repetitive/restricted behaviors) and four subtypes of internalizing traits (social anxiety, fears, generalized anxiety, negative affect). Although all phenotypic associations were modest (rph = 0.00-0.36), autistic-like communication impairments and repetitive/restricted behaviors correlated most strongly with generalized anxiety and negative affect both phenotypically and genetically. Conversely, autistic-like social difficulties showed little overlap with internalizing behaviors. Disentangling these associations and their etiological underpinnings may help contribute to the conceptualization and diagnosis of 'comorbidity' within ASD and internalizing disorders.

Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)

BACKGROUND

Since autism was first described, major difficulties in social interaction have been a defining feature of individuals with autism spectrum disorders (ASD). Social skills groups are a common intervention for individuals with ASD. Although a frequently recommended practice, the few studies that have addressed the efficacy of social skills groups have shown mixed results.

OBJECTIVES

To determine the effectiveness of social skills groups for improving social competence, social communication, and quality of life for people with ASD who are six to 21 years of age.

SEARCH METHODS

We searched the following databases in December 2011: CENTRAL (2011 Issue 4), MEDLINE (1948 to November Week 3, 2011), EMBASE (1980 to Week 50, 2011), PsycINFO (1887 to December Week 2, 2011), CINAHL (1937 to current), ERIC (1966 to current), Sociological Abstracts (1952 to current), OCLC WorldCat (12 December 2011), Social Science Citation Index (1970 to 16 December 2011), and the metaRegister of Controlled Trials (20 December 2011). We also searched the reference lists of published papers.

SELECTION CRITERIA

Randomized control trials (RCTs) comparing treatment (social skills groups) with a control group who were not receiving the treatment for participants aged six to 21 years with ASD. The control group could be no intervention, wait list, or treatment as usual. Outcomes sought were standardized measures of social competence, social communication, quality of life, emotion recognition, and any other specific behaviors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and appraised studies for inclusion and assessed the risk of bias in each included study. All outcome data were continuous and standardized mean difference effect sizes (ES) with small sample correction were calculated. We conducted random-effects meta-analysis where possible.

MAIN RESULTS

We included five RCTs evaluating the effects of social skills groups in 196 participants with ASD aged 6 to 21 years old. The results show there is some evidence that social skills groups improve overall social competence (ES = 0.47, 95% confidence interval (CI) 0.16 to 0.78, P = 0.003) and friendship quality (ES = 0.41, 95% CI 0.02 to 0.81, P = 0.04) for this population. No differences were found between treatment and control groups in relation to emotional recognition (ES = 0.34, 95% CI -0.20 to 0.88, P = 0.21) assessed in two studies or social communication as related to the understanding of idioms (ES = 0.05, 95% CI -0.63 to 0.72, P = 0.89), which was assessed in only one study. Two additional quality of life outcomes were evaluated, with results of single studies suggesting decreases in loneliness (ES = -0.66, 95% CI -1.15 to -0.17) but no effect on child or parental depression. No adverse events were reported.Given the nature of the intervention and the selected outcome measures, the risk of performance and detection bias are high. There is limited generalizability from the studies as they were all conducted in the US; they focused mainly on children aged 7 to 12, and the participants were all of average or above average intelligence.

AUTHORS' CONCLUSIONS

There is some evidence that social skills groups can improve social competence for some children and adolescents with ASD. More research is needed to draw more robust conclusions, especially with respect to improvements in quality of life.

Reward circuitry dysfunction in psychiatric and neurodevelopmental disorders and genetic syndromes: animal models and clinical findings

This review summarizes evidence of dysregulated reward circuitry function in a range of neurodevelopmental and psychiatric disorders and genetic syndromes. First, the contribution of identifying a core mechanistic process across disparate disorders to disease classification is discussed, followed by a review of the neurobiology of reward circuitry. We next consider preclinical animal models and clinical evidence of reward-pathway dysfunction in a range of disorders, including psychiatric disorders (i.e., substance-use disorders, affective disorders, eating disorders, and obsessive compulsive disorders), neurodevelopmental disorders (i.e., schizophrenia, attention-deficit/hyperactivity disorder, autism spectrum disorders, Tourette's syndrome, conduct disorder/oppositional defiant disorder), and genetic syndromes (i.e., Fragile X syndrome, Prader-Willi syndrome, Williams syndrome, Angelman syndrome, and Rett syndrome). We also provide brief overviews of effective psychopharmacologic agents that have an effect on the dopamine system in these disorders. This review concludes with methodological considerations for future research designed to more clearly probe reward-circuitry dysfunction, with the ultimate goal of improved intervention strategies.

ASD, a psychiatric disorder, or both? Psychiatric diagnoses in adolescents with high-functioning ASD

Varied presentations of emotion dysregulation in autism complicate diagnostic decision making and may lead to inaccurate psychiatric diagnoses or delayed autism diagnosis for high-functioning children. This pilot study aimed to determine the concordance between prior psychiatric diagnoses and the results of an autism-specific psychiatric interview in adolescents with high-functioning autism. Participants included 35 predominantly Caucasian and male verbal 10- to 17-year-olds with a confirmed autism spectrum disorder and without intellectual disability. The average age of autism spectrum diagnosis was 11 years old. Lifetime psychiatric diagnoses were established via the Autism Comorbidity Interview, developed to identify comorbid conditions within the context of autism. Autism Comorbidity Interview results were compared to parent report of prior community psychiatric diagnoses. Approximately 60% of prior psychiatric diagnoses were not supported on the Autism Comorbidity Interview; the lowest diagnostic concordance was for prior bipolar disorder and obsessive-compulsive disorder diagnoses. Although 51% of children met Autism Comorbidity Interview criteria for at least one psychiatric disorder, rates of prior diagnoses were much higher, with 77% having at least one prior psychiatric diagnosis and 60% having two or more. Although many participants met criteria for comorbid psychiatric disorders, the majority of previous psychiatric diagnoses were not supported when autism-related manifestations were systematically taken into account. These findings require replication and may not generalize to lower functioning and earlier diagnosed children with autism spectrum disorder. Results emphasize the importance of increasing awareness of the manifestations of high-functioning autism in order to improve accuracy of diagnosis and appropriateness of interventions.

Characteristics and anxiety symptom presentation associated with autism spectrum traits in youth with anxiety disorders

There is limited information about the nature of anxiety among youth with symptoms of autism spectrum disorder (ASD). The present study examined (a) differences in the clinical characteristics of anxious youth with and without symptoms of ASD and (b) the symptoms of anxiety that best distinguish between these groups. Results indicated that anxious youth with elevated ASD symptoms had significantly more diagnoses (e.g., specific phobias), and were more likely to meet diagnostic criteria for social phobia (and list social concerns among their top fears) than youth without elevated ASD symptoms. At the symptom level, severity of interpersonal worry based on parent report and severity of fear of medical (doctor/dentist) visits based on youth report best differentiated ASD status. The findings inform diagnostic evaluations, case conceptualization, and treatment planning for youth with anxiety disorders and ASD symptoms.

Affective prosody labeling in youths with bipolar disorder or severe mood dysregulation

BACKGROUND

Accurate identification of nonverbal emotional cues is essential to successful social interactions, yet most research is limited to emotional face expression labeling. Little research focuses on the processing of emotional prosody, or tone of verbal speech, in clinical populations.

METHODS

Using the Diagnostic Analysis of Nonverbal Accuracy, the current study examined whether youths with pediatric-onset bipolar disorder (BD) and/or those with chronic and severe irritability (i.e. the severe mood dysregulation phenotype) are impaired in their ability to identify the emotional prosody of a spoken sentence with neutral content.

RESULTS

Youths with severe mood dysregulation (n = 67) performed more poorly than healthy comparison children (n = 57), even when the sample was limited to unmedicated patients. Medicated BD youths (n = 52) exhibited impairment relative to healthy comparison children. No interactions between group and emotion were observed, suggesting that emotional prosody labeling problems may represent a general deficit in chronically irritable youths and in medicated youths with BD.

CONCLUSION

In concert with previously documented facial emotion labeling deficits, difficulties ascertaining the correct emotional tone of a spoken sentence may contribute to emotion dysregulation in chronically irritable children, and possibly also in youths with BD.

The effect of communication deficits on anxiety symptoms in infants and toddlers with autism spectrum disorders

Autism spectrum disorders (ASDs) are life-long developmental disorders characterized by impairments in the development of reciprocal social and communication skills, abnormal language development, and a restricted repertoire of behaviors and interests. While it has been known for some time that children with ASD can evince elevated rates of anxiety symptoms, little research has been conducted on whether deficits in communication skills affect the range of anxiety symptoms in infants and toddlers with ASD. This study represents a first attempt to determine whether deficits in communication skills have an effect on the expression of anxiety in infants and toddlers with autistic disorder and pervasive developmental disorder-not otherwise specified. Seven hundred thirty-five infants were evaluated with respect to the nature and extent of anxiety symptoms and developmental functioning. Both receptive and expressive communication skills appeared to play a significant role in the manifestation of anxiety symptoms.

The Need for a Broader Approach to Emotion Regulation Research in Autism

Maladaptive emotional reactions are common among individuals diagnosed with an autism spectrum disorder (ASD) and often impair functioning. Most research on emotional processes in ASD has focused on the recognition of emotion in others. This article argues for a broader approach to affective research in ASD, one that includes investigations into emotional reactivity and regulation. For example, research has typically looked at perseveration in ASD from a cognitive or perceptual perspective, yet perseveration also appears to have emotional aspects. This article discusses examples of emotion regulation research in other populations to illustrate how this approach could inform understanding of perseveration in ASD, particularly related to affective interference with cognitive control. More broadly, it highlights the potential contributions of emotion regulation research in ASD in relation to improving treatment specificity, increasing understanding of individual differences and diagnostic conceptualizations, and, potentially, contributing to a deeper understanding the neurobehavioral underpinnings of ASD.

Exploring language profiles for children with ADHD and children with asperger syndrome

OBJECTIVE

The aims of the present study was to investigate communication impairments in a Norwegian sample of children with ADHD and children with Asperger syndrome (AS) and to explore whether children with ADHD can be differentiated from children with AS in terms of their language profiles on the Norwegian adaptation of the Children's Communication Checklist Second Edition (CCC-2).

METHOD

The CCC-2 was completed by the parents, and altogether, 77 children aged between 6 and 15 years participated in the study.

RESULTS

Communication impairments were as common in a group of children with ADHD as in a group of children with AS. Although a similar pattern appeared on most CCC-2 scales, children with ADHD and children with AS could be distinguished from each other in terms of their language profiles on the subscales assessing stereotyped language and nonverbal communication.

CONCLUSION

Language abilities should be taken into account when standard assessments of ADHD and AS are performed and before therapies are initiated.

Repetitive self-grooming behavior in the BTBR mouse model of autism is blocked by the mGluR5 antagonist MPEP

Autism is a neurodevelopmental disorder characterized by abnormal reciprocal social interactions, communication deficits, and repetitive behaviors with restricted interests. BTBR T+tf/J (BTBR) is an inbred mouse strain that shows robust behavioral phenotypes with analogies to all three of the diagnostic symptoms of autism, including well-replicated deficits in reciprocal social interactions and social approach, unusual patterns of ultrasonic vocalization, and high levels of repetitive self-grooming. These phenotypes offer straightforward behavioral assays for translational investigations of pharmacological compounds. Two suggested treatments for autism were evaluated in the BTBR mouse model. Methyl-6-phenylethynyl-pyridine (MPEP), an antagonist of the mGluR5 metabotropic glutamate receptor, blocks aberrant phenotypes in the Fmr1 mouse model of Fragile X, a comorbid neurodevelopmental disorder with autistic features. Risperidone has been approved by the United States Food and Drug Administration for the treatment of irritability, tantrums, and self-injurious behavior in autistic individuals. We evaluated the actions of MPEP and risperidone on two BTBR phenotypes, low sociability and high repetitive self-grooming. Open field activity served as an independent control for non-social exploratory activity and motor functions. C57BL/6J (B6), an inbred strain with high sociability and low self-grooming, served as the strain control. MPEP significantly reduced repetitive self-grooming in BTBR, at doses that had no sedating effects on open field activity. Risperidone reduced repetitive self-grooming in BTBR, but only at doses that induced sedation in both strains. No overall improvements in sociability were detected in BTBR after treatment with either MPEP or risperidone. Our findings suggest that antagonists of mGluR5 receptors may have selective therapeutic efficacy in treating repetitive behaviors in autism.

Sex-specific therapeutic strategies based on neuroactive steroids: In search for innovative tools for neuroprotection

Different pathologies of the central and peripheral nervous system show sex differences in their incidence, symptomatology and/or neurodegenerative outcome. These include Parkinson's disease, Alzheimer's disease, Huntington's disease, multiple sclerosis, traumatic brain injury, stroke, autism, schizophrenia, depression, anxiety disorders, eating disorders and peripheral neuropathy. These sex differences reveal the need for sex-specific neuroprotective strategies. This review article and other manuscripts published in this issue of Hormones and Behavior analyze possible sex-specific therapeutic strategies based on neuroactive steroids. In particular in our introductory article, the possibility that sex differences in the levels or in the action of neuroactive steroids may represent causative factors for sex differences in the incidence or manifestation of pathologies of the nervous system is considered.

Decreased GABAA receptors and benzodiazepine binding sites in the anterior cingulate cortex in autism

The anterior cingulate cortex (ACC; BA 24) via its extensive limbic and high order association cortical connectivity to prefrontal cortex is a key part of an important circuitry participating in executive function, affect, and socio-emotional behavior. Multiple lines of evidence, including genetic and imaging studies, suggest that the ACC and gamma-amino-butyric acid (GABA) system may be affected in autism. The benzodiazepine binding site on the GABA(A) receptor complex is an important target for pharmacotherapy and has important clinical implications. The present multiple-concentration ligand-binding study utilized (3)H-muscimol and (3)H-flunitrazepam to determine the number (B(max)), binding affinity (K(d)), and distribution of GABA(A) receptors and benzodiazepine binding sites, respectively, in the ACC in adult autistic and control cases. Compared to controls, the autistic group had significant decreases in the mean density of GABA(A) receptors in the supragranular (46.8%) and infragranular (20.2%) layers of the ACC and in the density of benzodiazepine binding sites in the supragranular (28.9%) and infragranular (16.4%) lamina [corrected]. These findings suggest that in the autistic group this downregulation of both benzodiazepine sites and GABA(A) receptors in the ACC may be the result of increased GABA innervation and/or release disturbing the delicate excitation/inhibition balance of principal neurons as well as their output to key limbic cortical targets. Such disturbances likely underlie the core alterations in socio-emotional behaviors in autism.

Comorbidity in Pediatric Bipolar Disorder

The growing literature shows the pervasiveness and importance of comorbidity in youth with bipolar disorder (BPD). For instance, up to 90% of youth with BPD have been described to manifest comorbidity with attention-deficit hyperactivity disorder. Multiple anxiety, substance use, and disruptive behavior disorders are the other most commonly reported comorbidities with BPD. Moreover, important recent data highlight the importance of obsessive-compulsive and pervasive developmental illness in the context of BPD. Data suggest that not only special developmental relationships are operant in the context of comorbidity but also that the presence of comorbid disorders with BPD results in a more severe clinical condition. Moreover, the presence of comorbidity has therapeutic implications for the treatment response for both BPD and the associated comorbid disorder. Future longitudinal studies to address the relationship and the impact of comorbid disorders on course and therapeutic response over time are required in youth with BPD.

Clinical management of adolescents with autism

Autism spectrum disorder is a spectrum of neurodevelopmental disorders that includes autistic disorder and pervasive developmental disorder-not otherwise specified. This article provides the reader with an overview of the major psychosocial issues related to adolescents with autism. This discussion is followed by an interjection of medications that may be useful in maximizing the functioning of adolescents with autism.

Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation

Children with narrow phenotype bipolar disorder (NP-BD; i.e., history of at least one hypomanic or manic episode with euphoric mood) are deficient when labeling face emotions. It is unknown if this deficit is specific to particular emotions, or if it extends to children with severe mood dysregulation (SMD; i.e., chronic irritability and hyperarousal without episodes of mania). Thirty-nine NP-BD, 31 SMD, and 36 control subjects completed the emotional expression multimorph task, which presents gradations of facial emotions from 100% neutrality to 100% emotional expression (happiness, surprise, fear, sadness, anger, and disgust). Groups were compared in terms of intensity of emotion required before identification occurred and accuracy. Both NP-BD and SMD youth required significantly more morphs than controls to label correctly disgusted, surprised, fearful, and happy faces. Impaired face labeling correlated with deficient social reciprocity skills in NP-BD youth and dysfunctional family relationships in SMD youth. Compared to controls, patients with NP-BD or SMD require significantly more intense facial emotion before they are able to label the emotion correctly. These deficits are associated with psychosocial impairments. Understanding the neural circuitry associated with face-labeling deficits has the potential to clarify the pathophysiology of these disorders.

Mirror neuron system based therapy for emotional disorders

Mirror neuron system (MNS) represents one of the most important discoveries in the area of neuropsychology of past decades. More than 500 papers have been published in this area (PubMed), and the major functions of MNS include action understanding, imitation, empathy, all of which are critical for an individual to be social. Recent studies suggested that MNS can modulate emotion states possibly through the empathy mechanism. Here we propose that MNS-based therapies provide a non-invasive approach in treatments to emotional disorders that were observed in autism patients, post-stroke patients with depression as well as other mood dysregulation conditions.

Gender-specific behavioral and immunological alterations in an animal model of autism induced by prenatal exposure to valproic acid

Autism is a severe behavioral disorder characterized by pervasive impairments in social interactions, deficits in verbal and non-verbal communication, and stereotyped behaviors, with a four times higher incidence in boys than in girls. The core symptoms are frequently accompanied by a spectrum of neurobehavioral and immunological derangements, including: aberrant sensitivity to sensory stimulation, anxiety, and decreased cellular immune capacity. Recently, a new potential rodent model of autism induced by prenatal exposure to valproic acid (VPA rats) has been proposed. In order to determine if gender has an influence on alterations observed in VPA rats, male and female rats have been evaluated in a battery of behavioral, immunological, and endocrinological tests. A plethora of aberrations has been found in male VPA rats: lower sensitivity to pain, increased repetitive/stereotypic-like activity, higher anxiety, decreased level of social interaction, increased basal level of corticosterone, decreased weight of the thymus, decreased splenocytes proliferative response to concanavaline A, lower IFN-gamma/IL-10 ratio, and increased production of NO by peritoneal macrophages. Female VPA rats exhibited only increased repetitive/stereotypic-like activity and decreased IFN-gamma/IL-10 ratio. Sexual dimorphism characteristics for measured parameters have been observed in both groups of animals, except social interaction in VPA rats. Our results confirm existence of similarities between the observed pattern of aberrations in VPA rats and features of disturbed behavior and immune function in autistic patients, and suggest that they are gender-specific, which is intriguing in light of disproportion in boys to girls ratio in autism.

Language profiles in ASD, SLI, and ADHD

Developmental disorders might differ in their language profiles when using parent reports. The first study indicated that school aged children with ASD have similar language profiles as children with ADHD. Both groups had relatively more difficulties with pragmatics than with structural language aspects. The second study indicated that both preschoolers with ASD and those with SLI show the opposite pattern, thus having relatively more difficulties with structural language aspects than with pragmatics. Finally, an increase in the presence of ADHD characteristics of impulsivity in these preschoolers is associated with an increase in language difficulties, while there is no such relation with inattention. It seems useful to evaluate the communication abilities of children regularly in the course of development and take ADHD characteristics into account. Finally recommendations on clinical use of the Children's Communication Checklist-2 (CCC-2, Bishop 2003) are discussed.

Autism spectrum disorder scale scores in pediatric mood and anxiety disorders

OBJECTIVE

To compare scores on autism spectrum disorder (ASD) symptom scales in healthy youths and youths with mood or anxiety disorders.

METHOD

A total of 352 youths were recruited (107 healthy participants, 88 with an anxiety disorder, 32 with major depressive disorder, 62 with bipolar disorder, and 63 with a mood disorder characterized by severe nonepisodic irritability). Participants received structured psychiatric interviews and parent ratings on at least one of three ASD symptom scales: Children's Communication Checklist, Social Communication Questionnaire, and Social Responsiveness Scale.

RESULTS

Relative to healthy youths, youths with mood or anxiety disorders exhibited higher scores on each ASD symptom scale. ASD symptom scale scores also showed an association with impairment severity and attention-deficit/hyperactivity disorder. Among patients with mood disorders but not those with anxiety disorders, consistent, statistically significant associations between diagnosis and ASD symptom scale scores remained even after controlling for potential confounders.

CONCLUSIONS

Patients with mood disorders exhibit higher scores on ASD symptom scales than healthy youths or youths with anxiety disorders. These data should alert clinicians to the importance of assessing ASD symptoms to identify social reciprocity and communication deficits as possible treatment targets in pediatric mood and anxiety disorders.

Social anxiety in high-functioning children and adolescents with Autism and Asperger syndrome

We examined social anxiety and internalizing symptoms using the Social Phobia and Anxiety Inventory for Children (SPAI-C), the Social Anxiety Scale for Children -Revised (SASC-R), and the Child Behavior Checklist (CBCL) in a sample of fifty-four high-functioning subjects with autism or Asperger syndrome (HFA/AS) (M = 11.2 +/- 1.7 years) and 305 community subjects (M = 12.2 +/- 2.2 years). Children and adolescents completed the SPAI-C and SASC-R, and their parents completed the CBCL Internalizing scale. Adolescents with HFA/AS scored higher than the community sample on all measures. Behavioural avoidance and evaluative social anxiety increased by age within the HFA/AS group, whereas behavioural avoidance decreased by age in control participants. Data support that HFA/AS in adolescents may be associated with clinically relevant social anxiety symptoms.

Abnormal fear conditioning and amygdala processing in an animal model of autism

A core feature of autism spectrum disorders is the impairment in social interactions. Among other brain regions, a deficit in amygdala processing has been suggested to underlie this impairment, but whether the amygdala is processing fear abnormally in autism, is yet not clear. We used the valproic acid (VPA) rat model of autism to (a) screen for autism-like symptoms in rats, (b) test for alterations in amygdala-dependent fear processing, and (c) evaluate neuronal reactivity and synaptic plasticity in the lateral amygdala by means of in vitro single-cell electrophysiological recordings. VPA-treated animals displayed several symptoms common to autism, among them impaired social interactions and increased repetitive behaviors. Furthermore, VPA-treated rats were more anxious and exhibited abnormally high and longer lasting fear memories, which were overgeneralized and harder to extinguish. On the cellular level, the amygdala was hyperreactive to electrical stimulation and displayed boosted synaptic plasticity as well as a deficit in inhibition. We show for the first time enhanced, overgeneralized and resistant conditioned fear memories in an animal model of autism. Such hyperfear could be caused by the hyperreactivity and hyperplasticity found in the lateral amygdala, which may in turn be due to a deficit in the inhibitory system of the amygdala. We hypothesize an 'aversive world' syndrome that could, even if not a primary cause of the disorder itself, underlie some core symptoms in autism, such as impairments in social interactions and resistance to rehabilitation.

Autism spectrum disorders: concurrent clinical disorders

Individuals with autism spectrum disorder are heterogeneous in clinical presentation, concurrent disorders, and developmental outcomes. This study characterized the clinical co-occurrences and potential subgroups in 160 children with autism spectrum disorders who presented to The Autism Center between 1999 and 2003. Medical and psychiatric co-occurrences included sleep disorders, epilepsy, food intolerance, gastrointestinal dysfunction, mood disorder, and aggressive and self-injurious behaviors. Sleep disorders were associated with gastrointestinal dysfunction (P < .05) and mood disorders (P < .01). Food intolerance was associated with gastrointestinal dysfunction (P = .001). Subjects with mood disorder tended to develop aggressive or self-injurious behaviors (P < .05). Developmental regression was not associated with increased co-occurrence of medical or psychiatric disorders. Medical co-occurrence did not present as a risk factor for psychiatric co-occurrence, and vice versa. These results showed a high prevalence of multiple medical and psychiatric co-occurrences. There may be common pathophysiologic mechanisms resulting in clinical subgroups of autism spectrum disorders. Recognition of the co-occurrence of concurrent disorders may provide insight into the therapeutic strategy.

Anterior cingulate volume in pediatric bipolar disorder and autism

BACKGROUND

An increasing number of studies indicate the anterior cingulate gyrus (ACG) may play a role in the attention deficits associated with pediatric bipolar disorder (BD). Age, medications, and intelligence quotient (IQ) may affect ACG volume; few studies have controlled for these effects.

METHODS

We recruited 16 children with BD and 24 children with autism spectrum disorder (ASD); 15 children with no psychiatric diagnosis (NP) were also included. All participants were evaluated with the K-SADS and a DSM-IV Autism/Asperger's Checklist; the ADI-R was also administered to ASD participants shortly after the study began. The participants completed a brain MRI scan on a 1.5Tesla Signa GE scanner. We segmented the ACG and compared left and right ACG volumes between groups. The influence of medications on the ACG volume was assessed while controlling for the effects of age and IQ.

RESULTS

The left ACG volume was significantly smaller in the BD group compared to the NP (p=0.004) and ASD (p=0.006) groups. No significant differences were found in the right ACG volume. These differences do not appear to be attributable to medication use or IQ.

CONCLUSIONS

Pediatric BD patients have a smaller left ACG volume compared to NP children and children diagnosed with ASD. This replication and extension of previous studies suggest that the ACG volume abnormality may be a biomarker for BD.

Efficacy of three screening instruments in the identification of autistic-spectrum disorders

BACKGROUND

Screening instruments for autistic-spectrum disorders have not been compared in the same sample.

AIMS

To compare the Social Communication Questionnaire (SCQ), the Social Responsiveness Scale (SRS) and the Children's Communication Checklist (CCC).

METHOD

Screen and diagnostic assessments on 119 children between 9 and 13 years of age with special educational needs with and without autistic-spectrum disorders were weighted to estimate screen characteristics for a realistic target population.

RESULTS

The SCQ performed best (area under receiver operating characteristic curve (AUC)=0.90; sensitivity 0.86; specificity 0.78). The SRS had a lower AUC (0.77) with high sensitivity (0.78) and moderate specificity (0.67). The CCC had a high sensitivity but lower specificity (AUC=0.79; sensitivity 0.93; specificity 0.46). The AUC of the SRS and CCC was lower for children with IQ < 70. Behaviour problems reduced specificity for all three instruments.

CONCLUSIONS

The SCQ, SRS and CCC showed strong to moderate ability to identify autistic-spectrum disorder in this at-risk sample of school-age children with special educational needs.

The intense world syndrome--an alternative hypothesis for autism

Autism is a devastating neurodevelopmental disorder with a polygenetic predisposition that seems to be triggered by multiple environmental factors during embryonic and/or early postnatal life. While significant advances have been made in identifying the neuronal structures and cells affected, a unifying theory that could explain the manifold autistic symptoms has still not emerged. Based on recent synaptic, cellular, molecular, microcircuit, and behavioral results obtained with the valproic acid (VPA) rat model of autism, we propose here a unifying hypothesis where the core pathology of the autistic brain is hyper-reactivity and hyper-plasticity of local neuronal circuits. Such excessive neuronal processing in circumscribed circuits is suggested to lead to hyper-perception, hyper-attention, and hyper-memory, which may lie at the heart of most autistic symptoms. In this view, the autistic spectrum are disorders of hyper-functionality, which turns debilitating, as opposed to disorders of hypo-functionality, as is often assumed. We discuss how excessive neuronal processing may render the world painfully intense when the neocortex is affected and even aversive when the amygdala is affected, leading to social and environmental withdrawal. Excessive neuronal learning is also hypothesized to rapidly lock down the individual into a small repertoire of secure behavioral routines that are obsessively repeated. We further discuss the key autistic neuropathologies and several of the main theories of autism and re-interpret them in the light of the hypothesized Intense World Syndrome.

Validation of the social communication questionnaire in a population cohort of children with autism spectrum disorders

OBJECTIVE

To examine the properties of the Social Communication Questionnaire (SCQ) in a population cohort of children with autism spectrum disorders (ASDs) and in the general population.

METHOD

SCQ data were collected from three samples: the Special Needs and Autism Project (SNAP) cohort of 9- to 10-year-old children with special educational needs with and without ASD and two similar but separate age groups of children from the general population (n = 411 and n= 247). Diagnostic assessments were completed on a stratified subsample (n = 255) of the special educational needs group. A sample-weighting procedure enabled us to estimate characteristics of the SCQ in the total ASD population. Diagnostic status of cases in the general population samples were extracted from child health records.

RESULTS

The SCQ showed strong discrimination between ASD and non-ASD cases (sensitivity 0.88, specificity 0.72) and between autism and nonautism cases (sensitivity 0.90, specificity 0.86). Findings were not affected by child IQ or parental education. In the general population samples between 4% and 5% of children scored above the ASD cutoff including 1.5% who scored above the autism cutoff. Although many of these high-scoring children had an ASD diagnosis, almost all(approximately 90%) of them had a diagnosed neurodevelopmental disorder.

CONCLUSIONS

This study confirms the utility of the SCQ as a first-level screen for ASD in at-risk samples of school-age children.

Specificity of facial expression labeling deficits in childhood psychopathology

BACKGROUND

We examined whether face-emotion labeling deficits are illness-specific or an epiphenomenon of generalized impairment in pediatric psychiatric disorders involving mood and behavioral dysregulation.

METHOD

Two hundred fifty-two youths (7-18 years old) completed child and adult facial expression recognition subtests from the Diagnostic Analysis of Nonverbal Accuracy (DANVA) instrument. Forty-two participants had bipolar disorder (BD), 39 had severe mood dysregulation (SMD; i.e., chronic irritability, hyperarousal without manic episodes), 44 had anxiety and/or major depressive disorders (ANX/MDD), 35 had attention-deficit/hyperactivity and/or conduct disorder (ADHD/CD), and 92 were controls. Dependent measures were number of errors labeling happy, angry, sad, or fearful emotions.

RESULTS

BD and SMD patients made more errors than ANX/MDD, ADHD/CD, or controls when labeling adult or child emotional expressions. BD and SMD patients did not differ in their emotion-labeling deficits.

CONCLUSIONS

Face-emotion labeling deficits differentiate BD and SMD patients from patients with ANX/MDD or ADHD/CD and controls. The extent to which such deficits cause vs. result from emotional dysregulation requires further study.

Prenatal exposure to valproic acid disturbs the enkephalinergic system functioning, basal hedonic tone, and emotional responses in an animal model of autism

RATIONALE

It has been suggested that behavioral aberrations observed in autism could be the result of dysfunction of the neuroregulatory role performed by the endogenous opioid peptides. Many of those aberrations have been recently modeled in rats exposed to valproic acid (VPA) on the 12th day of gestation (VPA rats).

OBJECTIVES

The aim of the present study was to elucidate functioning of the enkephalinergic system, one of the endogenous opioid peptide systems strongly involved in emotional responses, in VPA rats using both biochemical and behavioral methods.

MATERIALS AND METHODS

In situ hybridization was used to measure proenkephalin mRNA expression in adult VPA rats' central nucleus of the amygdala, the dorsal striatum, and the nucleus accumbens. Additional groups of animals were examined in a conditioned place aversion to naloxone, the elevated plus maze, and object recognition tests to assess their basal hedonic tone, anxiety, learning and memory, respectively.

RESULTS

Prenatal exposure to VPA decreased proenkephalin mRNA expression in the dorsal striatum and the nucleus accumbens but not in the central nucleus of the amygdala. It also increased anxiety and attenuated conditioned place aversion to naloxone but had no impact on learning and memory.

CONCLUSIONS

The present results suggest that prenatal exposure to VPA may lead to the decreased activity of the striatal enkephalinergic system and in consequence to increased anxiety and disregulated basal hedonic tone observed in VPA rats. Presented results are discussed in light of interactions between enkephalinergic, GABAergic, and dopaminergic systems in the striatum and mesolimbic areas of the brain.

Phenomenology and diagnosis of bipolar disorder in children, adolescents, and adults: complexities and developmental issues

This review addresses the phenomenology of mania/bipolar disorder from a developmental psychopathology perspective and uses cases with longitudinal information to illustrate major points. Beginning with a summary of the phenomenology of bipolar illness as it occurs in adults, the authors identify diagnostic complexities unique to children and adolescents. These include the challenges of characterizing elation and grandiosity; differentiating mania from comorbid symptoms, rages, sequelae of maltreatment, and typical developmental phenomena; and the unique manifestations of psychosis. We conclude with the observation that a significant difference between early and later onset bipolar disorder is that, in the former, there appears to be a global delay or arrest in the development of appropriate affect regulation; whereas in adult-onset bipolar illness, emotion dysregulation generally presents as an intermittent phenomenon. At this juncture, the study of childhood bipolar illness would benefit from a developmental psychopathology perspective to move beyond the level of cross-sectional symptom description to begin to study individuals over time, focusing on developmental, environmental, genetic, and neurobiological influences on manifest behavior.