European Child & Adolescent Psychiatry

10:7990 (2001) Steinkopff Verlag 2001 ORIGINAL CONTRIBUTION

C. Njiokiktjien Disordered recognition of facial identity

A. Verschoor
L. de Sonneville and emotions in three Asperger type
C. Huyser
V. Op het Veld autists
N. Toorenaar

Accepted: 18 January 2000

C. Njiokiktjien (&) A. Verschoor
L. de Sonneville V. Op het Veld
N. Toorenaar
Pediatric outpatients clinic
Free University Hospital
P.O. Box 7057
NL-1007 MB Amsterdam
The Netherlands
C. Njiokiktjien A. Verschoor C. Huyser
Triversum
Institute for child and adolescent
psychiatry
K.Boekestraat 5
1817 EZ Alkmaar, The Netherlands
j Abstract In this report we aim
to explore severe decits in facial
affect recognition in three boys all
of whom meet the criteria of
Asperger's syndrome (AS), as well
as overt prosopagnosia in one (B)
and covert prosopagnosia in the
remaining two (C and D). Subject
B, with a familially-based talent of
being highly gifted in physics and
mathematics, showed no interest
in people, a quasi complete lack of
comprehension of emotions, and
very poor emotional reactivity.
The marked neuropsychological
decits were a moderate proso-
pagnosia and severely disordered
recognition of facial emotions,
gender and age. Expressive facial
emotion, whole body psychomo-
tor expression and speech proso-
dy were quasi absent as well. In all
three boys these facial processing
decits were more or less isolated,
and general visuospatial func-
tions, attention, formal language
and scholastic performances were
normal or even highly developed
with the exception of decient
gestalt perception in B. We con-
sider the decient facial emotion
perception as an important
pathogenetic symptom for the
autistic behaviour in the three
boys. Prosopagnosia, the absent
facial and bodily expression, and
speech prosody were important
but varying co-morbid disorders.
The total clinical picture of non-
verbal disordered communication
is a complex of predominantly
bilateral and/or right hemisphere
cortical decits. Moreover, in B,
insensitivity to pain, smells, nois-
es and internal bodily feelings
suggested a more general emo-
tional anaesthesia and/or a
decient means of expression. It is
possible that a limbic component
might be involved, thus making
affective appreciation also de-
cient.
j Key words Asperger's syn-
drome autism facial emotion
right hemisphere decit
j Abbreviations AS Asperger's
syndrome; B, C, D abbreviation for
subjects described; ANT Amster-
dam Neuropsychological Test;
RH Right Hemisphere; LH Left
Hemisphere; PIQ Performance IQ;
VIQ Verbal IQ

denition of autistic behaviour the clinical core of

Introduction autism is `decient or absent social relatedness'.
When performing a study with autistic children one However, this denition neither resolves the ques-
ECAP 0204

has to clarify what one's position is regarding the tion whether autism is based on one single or on
essence of autism. In our opinion, a sound clinical several partial decits, nor answers what the
80 European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001
pathophysiologic mechanism(s) is (are). Being in-
terested in the neuropsychological background of
abnormal contact, we asked ourselves whether there
are agnosias pertaining to various aspects of the
non-verbal or body language. Langdell (28) pointed
to facial identity recognition problems and Hob-
son's initial studies showed that autistic children
are impaired in the ability to link appropriately
drawn and photographed faces with videotaped
emotional gestures and voices (23), to link drawn
gestures with faces on video (24) and also faces
with voices (26). Weeks and Hobson (53) clearly
stated that autistic children tend to be insensitive
to other people's facial expression of emotions.
Tantam et al. (47) subsequently conrmed that
autists have difculties in distinguishing between
facial expressions and in naming them. Macdonald
et al. (30) also stressed the disturbed expression of
emotions in autists and Yirmiya et al. (56) drew
attention to the at/neutral or ambiguous facial
expression.
Anamnestic data and observation of three high
functioning boys (B, C and D), diagnosed as Asperger
autists according to DSM-IV criteria (3), suggested a
severe lack of comprehension of emotions in other
people. This led us to perform an extensive examin-
ation, including a set of computerised tests developed
to evaluate speed and accuracy of processing facial
emotion information.
Asperger's syndrome (AS) is known as a develop-
mental disorder in the autism spectrum. The syn-
drome is not only accepted as a mild subtype of
autism (20, 45, 46, 54), but there is an argument to
retain the name Asperger's syndrome because AS is a
clinical entity with specic characteristics, among
others a better prognosis and a higher prevalence rate
than autism with more severe verbal components
(17, 34). We take the position that AS is a subtype of
autism in high functioning people. The clinical
symptoms of AS include abnormal social relatedness
and a restricted range of behaviours and interests, and
exclude marked formal spoken language disorders
and other signicant cognitive decits and neuropsy-
chiatric disorders. Throughout the literature there are
small differences depending on whether one looks at
the work of individual authors (17, 45, 46), or at
diagnostic criteria in DSM-IV (3) or ICD-10 (55). For
example clumsiness is included in ICD-10, but
excluded in DSM-IV.
The boys B, C and D have, in this order, symptoms
with a decreasing clinical severity. B will be described
extensively because he showed added symptoms
which are interesting for the discussion on the
processing of emotions; the two other boys with
essentially the same facial processing decits are
presented in brief.
Assessment methods
j Clinical examinations
History, psychiatric examination (by child psychia-
trist CH) and neurological examination and clinical
neuropsychological screening (by pediatric neurolo-
gist CN).
j Neuropsychological examination
(by neuropsychologists CAV and NT)
Sensory Integration and Praxis tests (B)
Dutch version of the WISC-R (boys B, C, D), WISC
III (B)
Woodcock Johnson test of cognitive ability (B)
Kaufman ABC; Gestalt closure and Spatial Locali-
sation (C, D)
Peabody Picture Vocabulary Test (B)
TVK Dutch language Test for Children; Active and
passive vocabulary (C, D)
Beery VMI (B, C, D)
j Recognition of smells
Ten common substances in containers have to be
identied by matching them to a written list of 15
substance names. The substances are known to the
subject.
j Photo screening tasks
1) Discrimination of gender and age. The subject has
to successively identify pictures of boys, girls, men
and women that have been printed on a card in
random order,
2) Identication of the basic emotions `happiness',
`sadness', `anger', and `fear' from a card with
pictures of adult men and women displaying the
four emotions. The subject has to successively
point out the respective emotions.
j Computerised tasks selected from the Amsterdam
Neuropsychological Tasks battery [ANT, de Sonneville,
1999 (15, 16)]
1. The rst four tasks are `control' tasks: they provide
a reference with regard to the performance in the
facial emotion tasks, on the following levels
respectively:
 Baseline Speed: to measure simple reaction time
(detection of stimulus presence).
 Sustained Attention (attention capacity): in this
task, 50 series of 12 dot patterns are presented in
 C. Njiokiktjien et al.
Disordered recognition of facial emotions
continuous succession. Subjects have to discrim-
inate between patterns with three, four and ve
dots. Evaluation parameters are tempo, tempo
uctuation and accuracy.
 Feature Identication: to evaluate speed and
accuracy of processing abstract visuospatial
patterns (non-facial information). The subject
has to detect a specic conguration of red and
white blocks (target) which may, or may not, be
present in a signal which always consists of four
patterns. The constituting patterns may look
very similar to the target, which makes target
detection hard, or may look very dissimilar to
the target, which makes target detection easy.
 Face Recognition: to investigate speed and
accuracy of recognising a neutral face. Each
signal is preceded by a probe (the to be identied
face), and consists of a random set of four faces
of the same age and gender that are selected from
a stimulus set of digitised photographs of 20
different people (boys, girls, men, women). The
subject has to detect the probe which may, or
may not, be present in the signal.
2. Identication of Facial Expressions: to investigate
speed and accuracy of processing facial expres-
sions (emotions). The signal consists of one
(digitised) photograph of a face which may show
any of the following expressions: happiness, sad-
ness, anger, fear, disgust, surprise, shame, con-
tempt. The stimulus set consists of pictures of four
different people (two men, two women) who all
show these expressions. The task consists of four
parts in which the target expression (the to be
identied emotion) is happiness, sadness, anger,
fear, respectively.
3. Matching of Facial Expressions: in contrast with the
identication task, the subject needs not identify a
certain facial expression but is asked to judge
whether two faces show the same or a different
expression. The signal consists of a pair of pictures,
always of different people, from the same stimulus
set as is used in the identication task.
Case description of B
j Reason for referral
B, a boy aged 10 years 6 months, was referred for
social contact problems which were so severe that he
had been removed from his school (see social
behaviour in History). In addition, B, a right-hander,
had mild hand motor problems and as a much
younger child had been clumsy with gross body
movements. One year before referral B had tempo-
rarily slight tic symptoms.
81
j Family
Both parents have an academic background and live
separately. The brother of the father, as well as an
older brother of B, attended university before the age
of 16 to study physics and chemistry. Neither of them
were autistic.
j Perinatal history and early development
B is a second child. Pregnancy was accompanied by
hyperemesis and medication for unspecied non-
gynaecological infections. He was prematurely born
at 31 weeks in breech position, birthweight 1765 g, and
nursed for 2 weeks in an incubator with no complica-
tions other than polycythemia. B was very hypotonic
with a head lag. Sitting independently as well as walking
occurred only after 15 to 17 months. Eye contact
was established very early. The behaviour problems
became obvious from the age of 4 years onwards.
j Speech and language
Normal milestones. The family is bilingual (Hebrew
and Dutch). B speaks three languages: Hebrew,
English which he learnt from his father's side before
the age of 3 years 6 months and in an international
school, and Dutch since the age of 3 years 6 months.
He understands jokes, although he sometimes takes
things literally. Verbalisation is slow, especially `on
command' and in subjects outside his domain of
interests. B speaks without prosodic intonation and
one never hears any excitement expressed although
sometimes irritation.
j Scholastic performances
Reading was acquired ``by himself'' before the age of
6 years in three languages. Spelling is average,
handwriting is slow but neat. At the age of 10 years
his mathematical abilities and understanding of
subjects in mathematics and physics were at an
advanced college level. His interests, narrow though
not bizarre, are rooted in his high giftedness.
j Facial behaviour
Eye contact is normal at home only. Facial expression
is very impassive and he does not show affect, only
occasionally happiness. He does not react to the facial
emotions of others. A smile is identied ``because the
edges of the mouth go upwards''. B often fails to
recognise people who are familiar to him.
82 European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001

j Social behaviour further abnormalities in posture and motor behaviour.

B does adapt to changes and requirements from others
such as the school teacher but only if these are
acceptable to him through logical understanding. This
often leads to refusal. B needs a long time to adapt to
strangers. He does not initiate the making of contact
and instead waits for others to make an approach.
Once a relationship is established, it is frequently
temporary and often breaks down. He appears to lack
assertion and never displays fear or anger. With one
friend B talks a lot about his interests which are
physics, mathematics and computers. B does not like
phone calls. Impulsiveness, hyperactivity, distractibil-
ity, sensation seeking, tactile defensiveness and affec-
tive instability are all absent.
According to anamnestic data, B's emotions and
feelings could be classied according to their degree of
presence and intensity (Table 1). The emotions which
are present tend to be positive ones while negative
emotions are absent. Absent means that they are never
or rarely expressed by B himself and/or that he
never shows recognition of these emotions in others.
At rst contact he was willing to co-operate but seemed
almost unaware of the social interaction. He did not
initiate or respond to formal greetings, and personal
questions and eye contact were often avoided. During
the testing period there was little sense of rapport
building with the examiners, and any contact that was
made seemed to vanish at the end of the session. He
did not recognise the neurologist whom he had met
6 weeks previously. He often had the tendency to
control the conversation, to set it on his own terms and
to focus on areas of personal interest, these being
physics and computers. Interest and involvement in
the tests was dominated by these strong preferences.
In performing tasks, in which he could excel, B was
very eager, swift and concentrated, and showed pride
in his good results. When confronted with a task
which he could not readily solve, he was often
obstructive. He would reside in silence and simply
not respond, being very reluctant to try and guess. In
these subject areas, thinking seemed slow and rigid.
j Psychiatric examination

Assessment results in B
j Clinical examinations: appearance and behaviour
(an impression shared by all examiners)
B is a pleasant-looking, slender boy who is restless and
ill at ease. He has a rather impassive facial and body
expression and speaks slowly with a squeaky tone and
strange prosody. The content of his speech is formal
and pedantic. Apart from an `open mouth' tendency
and an inexpressive whole body behaviour there are no
B did not want to play and he asked the reason for
every part of the examination. Conversation and
personal wishes were restricted to his interests.
Thinking appeared to be rigid and concrete, and he
spoke of having complete control over his fantasy life.
In conclusion, B has a severe pervasive disorder of the
Asperger type (DSM-IV, axis I), with an island of
extreme well functioning. In social and emotional
development he is lagging far behind. He has no other
psychiatric symptoms, syndromes or disorders. Fur-
ther DSM-IV classication: axis II: no diagnosis; axis

Table 1 Presence and intensity of emotions and feelings in B

1. Present emotions, but without nuance

 Happiness, love, satisfaction; likes cuddling before sleep;
 Interest, self-confidence, pride;
 Humour, mostly verbal. B does not like slapstick humour. He understands sarcasm and can pretend it, but without prosody;
 Interest in the difference between beautiful and ugly and a taste for clothes, surroundings and music.
B knows how to play the violin and the piano, but does not like it. He prefers the computer;
 Irritation, boredom, anger.
2. Absent emotions or feelings
 Hope, expectation, compassion, patience;
 Amazement, astonishment;
 Excitement, fear, panic;
 Sadness, loneliness, depressed feelings, despair;
 Shame, stress, self-consciousness;
 Hate;
 Fear of concrete events; curiosity, frustration and deception are barely felt and rarely displayed.
3. Absent or weak body sensations
 Pain, hunger, nausea, absence of well-being during illnesses. B probably does not experience these sensations adequately, and/or does
not react to them with any emotion. He once said: ``Apparently I bumped my head, because I can feel a lump with my hand'';
 No reaction to loud noises;
 Unable to recognise smell; deviant taste and eating habits, preference for carbohydrates.
 C. Njiokiktjien et al.
Disordered recognition of facial emotions
III: anosmic e.c.i.; axis IV: problems with the social
environment, school problems, one-parent family.
j Neurological examination/basic neuromotor
functions
Head circumference 53 cm. Slight lordosis, at feet
and hypotonia, including the oral area; asymmetrical
and symmetrical tonic neck reex were still present;
standing balance on one leg was difcult on the right
side. Irregular hand motor movements while per-
forming pronation/supination and open/close hands
according to Touwen's manual (48). Bimanual alter-
nate movements and axial movements were also
poorly executed.
j Sensory awareness, perception and gnosis
 Acoustic. Anamnestic data showing a general
hyposensitivity were conrmed; B did not react to
loud and bothering noises.
 Smell. B was anosmic, he could not recognise one of
ten common substances and could only indicate the
existence and intensity of a smell. When asked for
his appraisal he referred to his quick withdrawal
from the vinegar container saying ``my reaction
must have meant that I did not like it''.
 Somatosensory perception. Kinaesthesia and tactile
perception were normal but signicantly less
adequate on the right side. Right-left orientation
was normal. From his history it was known that his
reactions to pain were slow or absent.
 Visual and auditory perception. B had an above
average score in a test of gure-ground perception,
and an average score in a visual matching task.
However, he had very low scores in visual and
auditory closure tasks. Although these closure tasks
were administered in English and word retrieval
difculties could have inuenced the performance,
the extremely low level was taken to indicate a
decient gestalt perception.
j Praxis
B is a right-hander. Gnosopraxis was poor in two
different tests for imitation of postures. Representation
Information 6 Picture Completion
Similarities 12 Codes
Arithmetic 19 Picture Arrangement
Vocabulary 9 Block Design
Comprehension 6 Object Assembly
Digit Span 17 Mazes
Symbol Search
83
of object use was very hesitant. This task is used as an
assessment of ideomotor praxis; the subject has to
show how to use, for example, a toothbrush. Sometimes
B was unable to respond at all. Bilateral integration and
co-ordination were normal. Basic eye-hand co-ordina-
tion scores in a line following task were below average
for the right hand, and average for the left hand.
Graphic praxis in copying gures was good, the VMI
score was well above age level. Drawing a person from
memory was very difcult, B needed an example. Hand-
writing was neat but slow, the pencil grip was tense.
j Speech and language
Speech was slow and mildly inarticulate. Prosody was
nearly absent, sometimes even bizarre. During narra-
tion he was dysuent with word-nding difculties,
sound, word, and phrase repetitions as well as sound
additions and prolongations in Dutch and English.
Dysuency was especially apparent when B had to
describe social situations and events. He was, howev-
er, more uent when the subjects were physics or
computers. On the Peabody PV Test in English, his
passive vocabulary was below average and his ex-
pressive vocabulary was well below his age level.
Syntactic structures in his spontaneous speech were
age-appropriate. Tests on these abilities were not
performed in Dutch and Hebrew.
j Intelligence
At 8 years 8 months, the formal IQ scores in the Dutch
WISC-R were at an average level. However, these
scores were not representative of B's capacities as his
rigidity and selective co-operation made it impossible
for the examiner to arrive at a valid interpretation. The
subtest prole was very erratic, standard scores
varying between 5 and 19. Nine months later the
American WISC-III was administered. Rapport and
co-operation were better, but the results were more or
less the same. After having taken into account that B is
not a native English speaker, together with a possible
learning effect from using the same test after a short
time interval, the examiner judged the results to
accurately reect current functioning.
B's performance showed the following results:
10 IQ Factor scores
14 Full scale: 115 Verbal Comprehension 90
6 Verbal: 110 Perceptual Organisation 110
17 Perform 120 Freedom from Distraction 145
15 Processing Speed 125
19
14
84 European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001

In general, the subtest and factor score prole were

again extremely erratic. The low scores in the verbal
subtests Information and Comprehension, seemed,
apart from verbal uency problems, to reect his
problems in social knowledge and pragmatic reason-
ing. This was again seen in his performance in the
Picture Arrangement subtest and to a lesser degree in
both the Vocabulary and Picture Completion tests. In
the subtest Similarities these problems could be
surpassed by good abstract logic reasoning and
although arithmetic was tested in the verbal realm,
B showed an excellent ability. The high scores in the
performance subtests Block Design and Object As-
sembly showed his extremely well-developed visual
analysis, synthesis and non-verbal abstract reasoning
skills.
Fig. 1 Task performance of B in z-scores as a function of task and signal type
(10 yrs 6 mo) As regards baseline speed, separate bars have been plotted to
j Memory indicate B's reaction time and his fluctuation in speed. For the sustained
attention task, 3 bars indicate B's tempo, fluctuation in tempo, and mean
Short-term memory for non-verbal auditory sequences accuracy respectively. For the remaining tasks, per type of signal the pairs of
(Stambak's rhythm reproduction) was normal. Mem- bars indicate the speed and accuracy of responses. Z-score values lower than
)4 have been printed in the graph
ory for verbal sequences (digits, words and sentences)
was very accurate. Associative learning with a social
connotation, like in Memory for Names from the WJR- good basic speed, tempo and accuracy in sustained
COG, was again very poor. Long term memory, as can attention and visuo-spatial analysis.
be determined from, for example, the level of factual
knowledge on the WISC subtest Information, seemed
to be strongly inuenced by B's preferences. He was j Processing of neutral facial information (age,
unable to name the different seasons or tell the word gender, prosopognosis) (Fig. 1)
used for a young cow, but he could explain how to make
uid out of a gas and could describe the causes of an In the picture screening task B could only discrim-
eclipse of the sun. inate between gender and age with great difculty.
The recognition of females and adults proved more
difcult for him than the recognition of males and
j Planning and cognitive flexibility children. RT scores in the ANT facial recognition task
were far below average and accuracy was below
Planning skills were excellent on the WISC subtest average especially with non-targets: B scored many
Mazes test. Performance on simple go-no-go tasks false alarms, i.e. erroneously deciding that the probe
was normal. Further formal testing in this area could face was present in the signal.
not be done due to circumstances. There was a
denite element of overfocused attention and thought
rigidity could be observed in the difcult social area. j Processing of emotional facial information (Fig. 1)
However, a high performance in maths and physics
would also normally involve a exibility in problem At the rst attempt to administer the picture screen-
solving. ing task, B did not respond at all. At the second
attempt, some weeks later, he could identify the
pictures of the happy faces fairly quickly, commenting
j Attention and processing of non-facial that he could distinguish them by the mouth. Only
information (Fig. 1) with extreme reluctance and after extensive descrip-
tion of the `key features' of an angry face was he able
Baseline speed and stability, as well as tempo, to identify one of the two pictures of an angry
uctuation in tempo and accuracy in sustained expression. When asked to make an angry face
attention were in the above average or high average himself he said he was unable to imagine his own
range. The same was true for his performance in the anger. Furthermore, he could not be persuaded to
Feature Identication task. In summary, B showed identify the other expressions of fear and sadness. In
 C. Njiokiktjien et al.
Disordered recognition of facial emotions
the ANT task `identication of emotion' with happy as
the target emotion, he was only able to make positive
identications with appropriate speed and accuracy
(deciding that the face looks happy when the signal
indeed shows a happy face). Negative identication
(rejection of signals exhibiting non-happy faces) were
reasonably accurate but extremely slow. Speed of
processing when the identication of `angry' expres-
sions was required was very slow but accurate. Again,
the target emotions of `fear' and `sadness' could not
be administered because he refused to respond.
Finally, when asked to match facial emotions, B's
performance showed a below-average overall score in
processing similar emotion pairs and in processing
dissimilar emotion pairs. Both overall scores were
favourably inuenced by his reasonable level of
processing pairs containing at least one happy face.
Signalling pairs of angry faces was accurate but slow,
identifying pairs of sad faces was practically impos-
sible, and identication of frightened faces was
inaccurate and extremely slow.
In summary, B has no major neurological signs,
but basic neuromotor functions are immature and
there is hypotonia. There is a dyspraxia and B has
ideomotor praxis representation problems. Further-
more, he exhibits acoustic hyposensitivity, anosmia
and visual and auditory Gestalt perception decien-
cies. Kallman's syndrome was excluded. Speech and
language reveal dysprosody and dysuency, especially
within the social realm but this was not formally
assessed in his rst (Hebrew) and second language
(Dutch). The IQ prole is extremely erratic: visuospa-
tial analysis, abstract logical reasoning, planning and
short term memory without social connotations are
all good to excellent. B's performance was very
decient in a number of facial perception tests,
neutral as well as emotional, and this cannot be
explained by decient general information processing
speed, sustained attention or visuospatial analysis.
There is a strong indication that B tries to use his
good visuospatial analysis and formal cognitive
reasoning skills in the perception and interpretation
of the facial gestalts with the personal features and
emotional information. By selecting one salient part
of an expression, e.g. the open mouth and visible teeth
in the happy face, he could succeed in identifying this
expression. All other facial emotions are far too
complex and diverse in their expressions, as are the
neutral facial characteristics, to be correctly perceived
by analysis.
Case description of C and D
Two boys, C and D aged 6 years 7 months and 8 years
3 months respectively were referred for behaviour
85
problems and particularly marked problems in social
contact. They relate poorly to other people in general,
seldom play with age mates and appear particularly
unaware and unresponsive to their own emotions.
They have exclusive interests in non-social areas such
as space ships and computers, and are characterised
as inexible, unimaginative and pedantic. Regarding
non-verbal behaviour, eye contact is poor and facial
expression is impassive. They have trouble interpret-
ing body language and prosody in others. In both
boys formal speech and language development is
normal and scholastic learning presents no problems.
In both families the parents are divorced and there
are social contact disorders in rst degree relatives on
the father's side.
Boy C had a normal perinatal history; he is,
however, clumsy, has vocal and motor tics and can
further be described as restless, impulsive and
oppositional with strong reactive aggression. He was
unable to function socially at a regular school. A
previous psychiatric examination referred to his
behaviour as an oppositional deant disorder, which
was later interpreted as an AS type autistic disorder.
Boy D was born ve weeks preterm but without
further complications. Apart from two febrile con-
vulsions he has had no medical problems. He has
normal motor skills and still attends a regular
school.
After psychiatric, neurological and neuropsycho-
logical examination both boys were diagnosed as high
functioning with AS. Dyspraxia, tics and compulsive
behaviour are a comorbidity in boy C only. There
were no prominent neurological signs, only some
minor neuromotor dysfunctions in boy C.
Both boys are right-handed. Formal intelligence is
well above average but performance IQ is signicantly
lower than verbal IQ. Nonetheless most test results,
including those pertaining to visual memory for non-
facial information and visual gestalt perception, fall
within normal limits.
The computerised reaction time tests (Figs. 2 and
3) show baseline speed, tempo and accuracy in
sustained attention and visuospatial analysis tasks to
be fundamentally normal. On the other hand, results
in many aspects of the face and facial expression
identication tasks are clearly below average. In the
face recognition task, both boys display slow and
inaccurate non target responses (target face absent)
reecting an insufcient internal representation or
active memory for faces. In the identication of facial
expression task boy C is predominantly slow, but he
can identify what the face depicts, while boy D is
extremely inaccurate as well as being slow. In the
matching of facial expressions both boys are slow and
inaccurate, boy C having particular trouble deciding
whether the faces show the same expression, and boy
86
Fig. 2 Task performance of C in z-scores as a function of task and signal type
(8 yrs 3 mo). For legends see Fig. 1
Fig. 3 Task performance of D in z-scores as a function of task and signal type
(6 yrs 7 mo). For legends see Fig. 1
D tending to erroneously decide that different
expressions are the same.
In conclusion, both boys show a marked receptive
facial emotion processing dysfunction alongside in-
adequate face identication skills, but there is no
overt prosopagnosia.
Discussion
j Emotion processing deficits in the subjects
under study are present in several modalities
Although the literature often focuses only on the face,
anamnestic data as well as assessment suggest an
inadequate comprehension and a decient expression
European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001
of emotions in the face, the voice and the body, the
most marked symptom being a facial recognition
decit.
1. Facial contact: all three boys have an impassive
facial expression. We could detect a quasi-absent
understanding of negative facial emotions in B,
which was less marked in C and D. Moreover there
was a signicantly decient judgement of facial age
and gender, less marked in C and D. Prosopagnosia
was clinically present in B, in C and D in a covert
way only (see also Ref. 9). This symptom might be
partly due to an obvious lack of interest in other
people, thus resulting in no imprinting. All three
boys avoided eye contact, and gaze avoidance was
even displayed towards the computer screen during
the tests with faces. Faces, regardless of the form of
presentation, appear to perplex them. Among the
various face processing decits in the subjects
under study, the emotional expression and percep-
tion seem most marked (7).
2. B has a dysprosody, and his voice is monotonous,
in C and D this is less obvious. A receptive
dysprosody was present in the three boys in
anamnestic data. The testing of receptive dyspro-
sody remains beyond this discussion.
3. B has very inexpressive body movements and he
shows no affect with his body. It could not be
assessed whether he was able to judge expressive
body movements in other people. In C and D this
expressive symptom was less marked.
One may consider the facial affect recognition de-
ciency in the three boys as a common core symptom
and the other face processing dysfunctions (facial
identity, gender and age processing) as important co-
morbid conditions, not necessarily occurring in AS,
respectively autism. It is well known that these three
functions are separately represented in the brain
(1, 2, 18, 49, 35), obeying the double dissociation rule
in patients. The same is true for body language, speech
prosody and object recognition. One may even state
that, although expression suffers from abnormal
reception, expressive and receptive functions are
separated. This is true for formal spoken language,
for prosody and probably for the processing of various
aspects of facial information as well.
j Emotion processing deficits in the subjects
under study suggest a partial right hemisphere (RH)
or bilateral dysfunction
One may rst question whether the dysfunctions within
the three domains have one pathogenetic locus or
neural circuit and why they cluster. As children engage
in emotion recognition tasks there are hemispheric
 C. Njiokiktjien et al.
Disordered recognition of facial emotions
electrophysiological differences, depending on what
the child is expecting from the task (12). Although they
are doubly dissociated, it is generally assumed that
facial, body and emotional voice perception are mainly
controlled by the RH (8, 39, 40). However, left hemi-
sphere (LH) participation, especially connected to
verbal labelling (44), is not excluded (29, 35). It is also
the case that some people adhere to the `valence
hypothesis', i.e. the idea that the LH harbours more
positive emotions, the RH more negative emotions
(31). However, a number of studies (8, 29, 35) do not
support this hypothesis. In general, it has been rightly
argued that emotion perception decits are predomi-
nantly due to developmental RH dysfunction (32).
One may also approach the question from the angle
of well-known RH syndromes. Rourke's (41) so-called
non-verbal learning disabilities (NLD) syndrome,
associated with RH dysfunction, often includes marked
social interaction problems. Many clinical features,
encompassed in the NLD syndrome, are also found in
what has been described by others as the developmental
learning disabilities of the RH or RH decit syndrome,
including abnormal interpretation and expression of
affect (a.o. 50, 51). Klin et al. (27), arguing that AS and
the NLD syndrome converge, found the performance
IQ (PIQ) to be lower than the verbal IQ (VIQ) in their
AS group, which does not mean, however, that all
children with low PIQ have AS. Irregular cognitive
proles with a low PIQ can point to less optimal RH
function. However, many children with RH symptoms
and relatively low PIQs are not diagnosed as being
autists. In a sample of 45 children with low PIQ and
higher VIQ and a discrepancy of at least 25 points we
have only diagnosed eight mildly autistic children (33).
Moreover, a low PIQ does not gure in the ICD-10
criteria for AS, neither is a low PIQ a sine qua non for
the NLD syndrome (41). Our patients C and D had a
lower PIQ than VIQ. Although B had a lower VIQ than
PIQ, he has been described by the psychologists as
verbally intelligent with excellent attention and nu-
merical abilities. He had low vocabulary, information
and comprehension scores on the WISC for three
reasons: trilinguism, no interest in social aspects, and
near-mutistic behaviour as soon as questions con-
cerned social areas. When questioned about his
inability to name the seasons in English, he answered
logically: ``I do not need to know them because in
Hebrew the language spoken at home you can name
them by season 1, 2, 3 and 4.'' This answer also shows
B's `logico-affective state' (see further), which may
impoverish his formal VIQ.
The combination of the above-mentioned dysfunc-
tions regarding emotions in the face, body and
voice might have an aetiological background in B,
namely diffuse perinatal damage, sparing other RH
functions and most LH language functions.
87
B also had right-sided sensory and motor distur-
bances, presumably on the basis of LH dysfunction by
perinatal damage. It is not excluded that this LH
damage also contributes to B's autistic features.
Perinatal insults in AS are mentioned by Gillberg
(19) as a frequently occurring aetiological factor. In B,
because of refusal, we could not perform brain neuro-
imaging and EEG to nd out more about the
pathogenesis. In C and D there is familial occurrence
of contact disorders. In these boys, with a less severe
clinical picture, there is no other sign of perinatal
brain damage. This, therefore, suggests that the
aetiological dimension might be the reason for a
different clinical picture.
j The significance of receptive and expressive
facial processing abnormalities in autists
Our study revealed the presence of facial processing
abnormalities, for the rst time, in reaction time tasks,
which enhances the sensitivity of deviant ndings. Such
abnormalities were rst proposed by Langdell (28),
then by Weeks and Hobson (53) and Tantam et al. (47)
specically in AS, whereas Macdonald et al. (30) and
Yirmiya et al. (56) stressed abnormal facial expressions
(see introduction). In one study the presence of specic
decits in the perception of faces per se was denied,
because autists have no obvious problem in assembling
puzzles of photographs of human faces (52). This could
be explained by the piece by piece approach and inner
language reasoning of autists. Another study (11)
suggested a general perceptual decit, not specic to
faces or emotions. Hobson's ndings (see also an
overview by Hobson, 25) were found to be inconclusive
in other studies and Ozonoff et al. (34) have rightly
suggested that multiple primary decits underly autis-
tic behaviour. Thus, as Davies et al. (11) state, group
averages mask substantial individual variation. Weak
statistical effects might also be explained as a large
overlap in distributions (6). Our results demonstrate
that some autists are able to perform in the receptive
domain while others are less able to perform. If one
takes these neuropsychological facts into account, one
may propose that autism is concurrent with an
underlying spectrum of neuropsychological decits of
varying severity. Whether one regards the limitations
of the face, the whole body or the prosody to be
responsible for the decient social engagement, is more
or less arbitrary. However, the effects of face and voice
deciencies commence from birth onwards, whereas
the consequences of body language deciencies are
manifest later. We suspect, however, that abnormal
receptive processing of face, voice and body language
may have an additive effect on the construction of the
affective world of a child. It is well known from other
88 European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001
developmental disorders, for example the dysphasias,
that receptive disorders have a deleterious inuence on
language function and a worse prognosis. B is an
example of a boy with severe receptive and expressive
emotion function disturbances. The overall clinical
picture is less severe in C and D.
The literature might lead one to question whether
deviant perceptual facial processing is the underlying
key factor, whether this dysfunction is always based
on the same mechanism and whether this is the only
pathogenetic factor underlying the decient social
relatedness in autism. We suggest that the underlying
abnormal processing of affect may be crucial in
explaining the social behaviour of some autistic
children. We would not propose, however, that this
is the only pathogenetic mechanism or that this
mechanism always has an identical structure.
j Co-morbid symptoms
A range of stimuli other than facial, bodily and vocal
provoked an abnormal reaction in B. His insensitivity
to pain, smells, noises and internal bodily feelings
suggest a more general emotional anaesthesia. Hypo-
emotionality of visually observed events has been
interpreted as a visual-limbic disconnection (5). Facial,
bodily and voiced emotional signals as well as pain,
smells etc. might have a common neural target in the
limbic system (Papez' circuit) where these signals
already cortically recognised provoke an emotional
resonance in order to be memorised and transferred to
the hypothalamic regions for autonomic expression,
and via the thalamus to the prefrontal cortex for
expression. In children with autistic regression, limbic
pathology (notably of the amygdala) has been shown
(13). Facial fear perception involves the amygdala
without lateralisation in a fMRI study (4, 37) and facial
disgust activates the anterior insular cortex (37), which
is also involved in responses to offensive tastes (36). A
study by Borod et al. (8) supports not only the RH
hypothesis for identication of emotion across multi-
ple channels, but also the existence of a single
processor across these channels. This might be the
superior temporal gyrus (37). B's problems in express-
ing feelings in general, not only socially driven feelings,
might be due to the inadequate working of a common
neural limbic and/or prefrontal circuit. This does,
alternatively, not exclude a possible thalamic dysfunc-
tion.
Motor clumsiness has been forwarded as an
integral symptom in AS (19, 55). When one refers to
this term at the elementary manual level, present in B
and C, we consider it as aspecic co-morbidity. Some
people use the term `clumsiness' to describe dyspr-
axia, again an aspecic co-morbid condition in B, who
had a normal visuospatial function. `Clumsiness'
might also infer poor overall body language. The
`clumsy' imitation of postures by B and C, due to
dyspraxia, might indicate a special difculty experi-
enced by autists in understanding other people's
perspectives (43). Dyspraxia and hypotonia are not
specic markers in autists if one looks at the results of
a large study by Rapin and collaborators (38). In B
and C drawing and pretending ideomotor acts on
request were poor (clumsily and hesitantly executed),
as was imaginative play at pre-school age (in B, C and
D). This might reect a poor visual imagery function.
In the WISC-R `Comprehension' difculties (prag-
matic reasoning) might also be due to imagination
problems (21). Visual mental imagery is a function of
the visual association cortex and asymmetrically
lateralised to the left (14), whereas there is no
hemispheric lateralisation when mental rotation is
involved (10). An alternative explanatory concept for
defective visual imagery might be poor `conservation'
(57).
Overfocused attention and mental set rigidity (in B,
C and D), observed during psychological evaluation,
might both be due to executive dysfunction, possibly
a RH symptom.
In B, his absence of self-consciousness and lack of
insight of his own desires and emotions can be seen as
reliable anamnestic data and might point to some
kind of neglect or anosognosia, a RH symptom.
Hermelin and O'Connor (22) have proposed the
notion of a ``logico-affective state'' in high functioning
autists when part of the emotional problems are
overcome by using cognitive or intellectual strategies.
This might be the case in B and C. While interpreting
faces or situations they often employed reasoning or
they used gestural or environmental cues. It is as if B
used his mathematical talents when taking decisions
and he only seemed motivated by logical insights.
Gestalt perception was decient (in B), but visuo-
spatial and gure-back-ground perceptual functions
were normal or even highly developed (in B, C and D).
While interpreting faces B often looked at facial
details, a `piecemeal' approach, using no holistic
strategy. This has also been noted by Weeks and
Hobson (53). This simultanagnosia a RH symptom
was also present when interpreting non-facial
objects. B's and C's relatively high performance in
block design suggest a propensity for the use of
details instead of the normal Gestalt processing of
patterns. This occurs in many children with mild
autism and AS, and has been called `low central
coherence' (42). The high `digit span' in B (above
average in C and D) as well as `block design'
performance are explained in the same way (21).
High `block design' performances are not explained
by high visuospatial insight (21, 42).
 C. Njiokiktjien et al. 89
Disordered recognition of facial emotions

Conclusion absent social relatedness and might also be related to

B, and in a less severe degree C and D are AS type
autistic boys with severe receptive and expressive
emotional function disturbances in three areas of
non-verbal social contact: face, body and voice. We
consider the absence of emotion perception as a
crucial pathogenetic factor for the autistic behaviour
and this clinical picture seems to be rooted in a RH or
bilateral decit. The poor age and gender identica-
tion and the partial prosopagnosia are facial process-
ing disorders that are not necessarily present in all
autists with facial emotion perception problems.
Mental rigidity, poor visual mental imagery and
imagery of other people's perspective as well as
pragmatic language aspects contribute to absent
social relatedness as well, while the dysphasic symp-
toms as well as most motor symptoms are aspecic
co-morbidity. Ritualism and bizarre or narrow inter-
ests are possibly more a consequence than a cause of
other problems in autists.
In our opinion, facial, body and voice recognition,
processed at different cortical levels, might converge
towards an underlying common locus in the limbic
system for affective appreciation. A more general
emotional anaesthesia and/or expression disturbance
beyond the social domain is thus a possibility. The
perceptual (cortical and possibly thalamic) and/or
appreciation dysfunctions (limbic) have a deleterious
additive impact on emerging emotion concepts. This
does not exclude rather isolated expressive, not
receptive, dysfunctions in other autists, explaining
the variance of ndings in larger groups of autists.
The aetiological background in B might be perinatal
damage, sparing other RH functions and major
language functions, while genetic factors play a role
in C and D.
j Acknowledgements This research project has been supported by
grant 28-2915 of Zorgonderzoek Nederland (Praeventiefonds).

References
1. Adolphs R, Damasio H, Tranel D,
Damasio AR (1996) Cortical systems
for the recognition of emotion in facial
expressions. Journal of Neurosciences
16:76787687
2. Ahern GL, Schomer DL, Kleeeld J,
Blume H, Cosgrove G Rees, Weintraub
S, Mesulam MM (1991) Right hemi-
sphere advantage for evaluating emo-
tional facial expressions. Cortex
27:193202
3. American Psychiatric Association
(1994). DSM IV Diagnostic and Statis-
tical Manual of Mental Disorders. 4th
edn. APA, Washington DC
4. Baird AA, Gruber SA, Fein DA et al.
(1999) Functional magnetic resonance
imaging of facial affect recognition in
children and adolescents. Journal of the
American Academy of Child and Ado-
lescent Psychiatry 38:195199
5. Bauer RM (1982) Visual hypoemotion-
ality as a symptom of visual limbic
disconnection in man. Archives of
Neurology 39:702708
6. Bishop DVM (1989) Autism, Asperger's
syndrome and semantic-pragmatic dis-
order: where are the boundaries? Brit-
ish Journal of Disorders of
Communication 24:107121
7. Bormann-Kischkel C, Vilsmeier M,
Baude B (1995) The development of
emotional concepts in autism. Journal
of Child Psychology and Psychiatry
36:12431259
8. Borod JC, Cicero BA, Obler LK, Welko-
witz J, Erhan HM, Santschi C, Grunwald
IS, Agosti RM, Whalen JR (1998) Right
hemisphere emotional perception
evidence across multiple channels.
Neuropsychology 12:446458
9. Boucher J, Lewis V (1992) Unfamiliar
face recognition in relatively able au-
tistic children. Journal of Child Psy-
chology and Psychiatry 33:843859
10. Cohen MS, Kosslyn SM, Breiter HC,
DiGirolamo GJ, Thompson WL, Ander-
son AK, Bookheimer SY, Rosen BR,
Belliveau JW (1996) Changes in cortical
activity during mental rotation. A map-
ping study using functional MRI. Brain
119:89100
11. Davies S, Bishop D, Manstead ASR,
Tantam D (1994) Face perception in
children with autism and Asperger's
syndrome. Journal of Child Psychology
and Psychiatry 35:10331057
12. De Haan M, Nelson CA, Gunnar MR,
Tout KA (1998) Hemispheric differenc-
es in brain activity related to the
recognition of emotional expressions
by ve-year-old children. Developmen-
tal Neuropsychology 14:495518
13. Deonna T, Ziegler A-L, Moura-Serra J,
Innocenti G (1993) Autistic regression
in relation to limbic pathology and
epilepsy: report of two cases. Develop-
mental Medicine and Child Neurology
35:158176
14. D'Esposito M, Detre JA, Aguirre GK,
Stallcup M, Alsop DC, Tippet LJ, Farah
MJ (1997) A functional MRI study of
mental image generation. Neuropsych-
ologia 35:725730
15. De Sonneville LMJ, Njiokiktjien C, Op
het Veld V, Toornenaar N, Verschoor
CA. Speed and accuracy of facial infor-
mation processing in primary school
children 1999. Submitted
16. De Sonneville LMJ (1999) Amsterdam
neuropsychological tasks: a computer-
aided assessment program. In: den
Brinker BPLM, Beek PJ, Brand AN,
Maarse SJ, Mulder LJM (eds) Cognitive
Ergonomics, Clinical Assessment and
Computer-Assisted Learning: Comput-
ers in Psychology, Vol. 6: Swets &
Zeitlinger, Lisse, pp 187203
17. Ehlers S, Gillberg C (1993) The epi-
demiology of Asperger syndrome. A
total population study. Journal of Child
Psychology and Psychiatry 34:1327
1350
18. Etcoff NL (1984) Selective attention to
facial identity and facial emotion. Neu-
ropsychologia 22:281295
19. Gillberg C (1989) Asperger syndrome in
23 Swedish children. Developmental
Medicine and Child Neurology 31:520
531
20. Green J (1990) Is Asperger's a syn-
drome? Developmental Medicine and
Child Neurology 32:743747
21. Happe FG (1994) Wechsler IQ pro-
le and theory of mind in autism:
a research note. Journal of Child
Psychology and Psychiatry 35:1461
1471
22. Hermelin B, O'Connor N (1985) The
logoco-affective disorder in autism. In:
Schopler E, Mesobov GB (eds) Com-
90
munication Problems in Autism. New
York: Plenum pp. 283310
23. Hobson RP (1986a) The autistic child's
appraisal of expressions of emotion.
Journal of Child Psychology and Psy-
chiatry 27:321342
24. Hobson RP (1986b) The autistic child's
appraisal of expressions of emotion: a
further study. Journal of Child Psychol-
ogy and Psychiatry 27:671680
25. Hobson RP (1991) Methodological is-
sues for experiments on autistic indi-
viduals' perception and understanding
of emotion. Journal of Child Psycholo-
gy and Psychiatry 32:11351158
26. Hobson RP, Ouston J, Lee A (1988)
Emotion recognition in autism: coordi-
nating faces and voices. Psychological
Medicine 18:911923
27. Klin A, Volkmar FR, Sparrow SS,
Cicchetti DV, Rourke BP (1995) Valid-
ity and neuropsychological character-
ization of Asperger syndrome:
convergence with nonverbal learning
disabilities syndrome. Journal of Child
Psychology and Psychiatry 36:1127
1140
28. Langdell T (1978) Recognition of faces:
an approach to the study of autism.
Journal of Child Psychology and Psy-
chiatry 19:255268
29. Lane RD, Reiman EM, Ahern GL,
Schwartz GE, Davidson RJ (1997) Neu-
roanatomical correlates of happiness,
sadness and disgust. American Journal
of Psychiatry 154:926933
30. Macdonald H, Rutter M, Howlin P, Rios
P, Le Conteur A, Evered C, Folstein S
(1989) Recognition and expression of
emotional cues by autistic and normal
adults. Journal of Child Psychology and
Psychiatry 30:865877
31. Mandal MK, Tandon SC, Asthana HS
(1991) Right brain damage impairs
recognition of negative emotions. Cor-
tex 27:247253
32. McKelvey JR, Lambert R, Mottron L,
Shevell MI (1995) Right-hemisphere
dysfunction in Asperger's syndrome.
Journal of Child Neurology 10:310314
33. Njiokiktjien C, Verschoor CA (1998)
Attention and the right hemisphere.
Journal of Human Physiology 24:1622
34. Ozonoff S, Pennington BF, Rogers SJ
(1991) Asperger's syndrome: evidence
of an empirical distinction from high-
European Child & Adolescent Psychiatry, Vol. 10, No. 1 (2001)
Steinkopff Verlag 2001
functioning autism. Journal of Child
Psychology and Psychiatry 32:1107
1122
35. Phillips ML, Bullmore ET, Howard R,
Woodruff PWR, Wright IC, Williams
SCR, Simmons A, Andrew C, Brammer
M, David AS (1998) Investigation of
facial recognition memory and happy
and sad facial expression perception: an
fMRI study. Psychiatry Research: Neu-
roimaging Section 83: 127138
36. Phillips ML, Young AW, Senior C,
Brammer M, Andrew C, Calder AJ,
Bullmore ET, Perrett DI, Rowland D,
Williams SCR, Gray JA, David AS
(1997) A specic neural substrate for
perceiving facial expressions of disgust.
Nature 389:495498
37. Phillips ML, Young AW, Scott SK,
Calder AJ, Andrew C, Giampietro V,
Williams SCR, Bullmore ET, Brammer
M, Gray JA (1998) Neural responses to
facial and vocal expressions of fear and
disgust. Proc Royal Soc London
Series B: Biol Sci 265:18091817
38. Rapin I (1996) Neurological examina-
tion In: Rapin I (ed) Preschool Children
with Inadequate Communication. Clin-
ics in Developmental Medicine No. 139
Mac Keith Press, London, pp 98122
39. Ross ED (1981) The aprosodias: func-
tional anatomic organization of the
affective components of language in
the right hemisphere. Archives of Neu-
rology 38:561569
40. Ross ED, Mesulam M-M (1979) Dom-
inant language functions of the right
hemisphere? Prosody and emotional
gesturing. Archives of Neurology
36:144148
41. Rourke BP (1995) Syndrome of Non-
verbal Learning Disabilities: Neurode-
velopmental Manifestations. Guilford
Press, New York
42. Shah A, Frith U (1993) Why do autistic
individuals show superior performance
on the block design task? Journal of
Child Psychology and Psychiatry
34:13511364
43. Smith IM, Bryson SE (1998) Gesture
imitation in autism I: nonsymbolic
postures and sequences. Cognitive Neu-
ropsychology 15:747770
44. Stone VE, Nisenson L, Eliassen JC,
Gazzaniga MS (1996) Left hemisphere
representations of emotional facial ex-
pressions. Neuropsychologia 34:2329
45. Szatmari P, Bremner R, Nagi L (1989)
Asperger's syndrome: a review of clin-
ical features. Canadian Journal of Psy-
chiatry 34:554560
46. Tantam D (1988) Asperger's syndrome.
Annotation. Journal of Child Psycholo-
gy and Psychiatry 29:245255
47. Tantam D, Monaghan L, Nicholson H,
Stirling J (1989) Autistic children's
ability to interpret faces: a research
note. Journal of Child Psychology and
Psychiatry 30:624630
48. Touwen BCL (1979) Examination of the
Child with Minor Neurological Dys-
function. Clin Dev Med No. 71, SIMP,
Heinemann, London: Lippincott, Phil-
adelphia
49. Tranel D, Damasio AR, Damasio H
(1988) Intact recognition of facial ex-
pression, gender, and age in patients
with impaired recognition of face iden-
tity. Neurology 38:690696
50. Voeller KKS (1986) Right-hemisphere
decit syndrome in children. American
Journal of Psychiatry 143:10041009
51. Voeller KKS, Hanson JA, Wendt RN
(1988) Facial affect recognition in chil-
dren: a comparison of the performance
of children with right and left hemi-
sphere lesions. Neurology 38:17441748
52. Volkmar FR, Sparrow SS, Rende RD,
Cohen DJ (1989) Facial perception in
autism. Journal of Child Psychology
and Psychiatry 30:591598
53. Weeks SJ, Hobson RP (1987) The
salience of facial expression for autistic
children. Journal of Child Psychology
and Psychiatry 28:137152
54. Wing L (1981) Asperger's syndrome: a
clinical account. Psychological Medi-
cine 11:115129
55. World Health Organization (1990) In-
ternational Classication of Diseases,
10th revision. May 1990 draft for eld
trials, WHO Geneva (unpublished)
56. Yirmiya N, Kasari C, Sigman M, Mundy
P (1989) Facial expressions of affect in
autistic, mentally retarded and normal
children. Journal of Child Psychology
and Psychiatry 30:725735
57. Yirmiya N, Sigman MD, Kasari C,
Mundy P (1992) Empathy and cogni-
tion in high-functioning children with
autism. Child Development 63:150160