Journal of Child Psychology and Psychiatry 53:11 (2012), pp 1157–1166 doi:10.1111/j.1469-7610.2012.02600.

Severe mood problems in adolescents

with autism spectrum disorder
Emily Simonoff, 1 Catherine R.G. Jones, 2 Andrew Pickles, 3 Francesca Happé, 4
Gillian Baird, 5 and Tony Charman6
1
Department of Child and Adolescent Psychiatry, King’s College London, Institute of Psychiatry and NIHR Biomedical
Research Centre for Mental Health, De Crespigny Park, London, UK; 2Department of Psychology, University of Essex,
Wivenhoe Park, Colchester, Essex, UK; 3Department of Biostatistics, King’s College London, Institute of Psychiatry,
London, UK; 4MRC SDGP Research Centre, King’s College London, Institute of Psychiatry, London, UK; 5Guy’s & St
Thomas’ NHS Foundation Trust, Newcomen Centre, London, UK; 6Centre for Research in Autism and Education,
Institute of Education, London, UK

Introduction: Severe mood dysregulation and problems (SMP) in otherwise typically developing youth
are recognized as an important mental health problem with a distinct set of clinical features, family
history and neurocognitive characteristics. SMP in people with autism spectrum disorders (ASDs) have
not previously been explored. Method: We studied a longitudinal, population-based cohort of
adolescents with ASD in which we collected parent-reported symptoms of SMP that included rage, low
and labile mood and depressive thoughts. Ninety-one adolescents with ASD provided data at age
16 years, of whom 79 had additional data from age 12. We studied whether SMP have similar correlates
to those seen in typically developing youth. Results: Severe mood problems were associated with
current (parent-rated) and earlier (parent- and teacher-rated) emotional problems. The number of prior
psychiatric diagnoses increased the risk of subsequent SMP. Intellectual ability and adaptive
functioning did not predict to SMP. Maternal mental health problems rated at 12 and 16 years were
associated with SMP. Autism severity as rated by parents was associated with SMP, but the relationship
did not hold for clinician ratings of autistic symptoms or diagnosis. SMP were associated with difficulty
in identifying the facial expression of surprise, but not with performance recognizing other emotions.
Relationships between SMP and tests of executive function (card sort and trail making) were not
significant after controlling for IQ. Conclusions: This is the first study of the behavioural and cognitive
correlates of severe mood problems in ASD. As in typically developing youth, SMP in adolescents
with ASD are related to other affective symptoms and maternal mental health problems. Previously
reported links to deficits in emotion recognition and cognitive flexibility were not found in the
current sample. Further research is warranted using categorical and validated measures of
SMP. Keywords: Severe mood dysregulation, mood disorders, childhood autism, autism spectrum
disorder, SNAP.

functional impairment. In support of this new diag-

Introduction
Severe mood problems (SMP) in children and ado-
lescents include high levels of irritability, often
manifested by temper tantrums, as well as low and
labile mood; together, these have been identified as
an important cause of psychosocial impairment.
Debate has raged about the aetiology of mood dys-
regulation symptoms, most specifically the extent to
which these are best conceptualized as part of the
spectrum of juvenile bipolar disorder, attention def-
icit hyperactivity disorder (ADHD) or as a separate
syndrome (Leibenluft, 2011). Leibenluft Cohen,
Gorrindo, Brook, & Pine, (2006) argue persuasively
for a new diagnostic category, severe mood dysre-
gulation (SMD), currently under consideration for
DSM-5 (www.dsm5.org). Under current proposals,
SMD would include severe and prominent mood
abnormalities, hyperarousal and increased reactivity
to negative emotional stimuli, with consequent
Conflict of interest statement: No conflicts declared.
nosis, Leibenluft and colleagues provide evidence for
distinctive presenting and longitudinal clinical fea-
tures, family history and neurocognitive profile (Lei-
benluft, 2011). They argue that, while features
aligned with irritability are included in several diag-
nostic categories, the syndrome of severe and
impairing irritability with predominant negative
mood includes features not adequately captured by
other diagnoses. Unlike classic juvenile bipolar dis-
order, manic episodes do not appear to be common
adult outcomes in SMD (Brotman et al., 2006),
whereas unipolar depression and anxiety are
(Stringaris et al., 2009). One small family study
failed to find elevated rates of bipolar disorder in
parents of children with SMD, in contrast with the
parents of children with juvenile bipolar disorder
(Brotman et al., 2007). Neurocognitive differences
exist in young people with SMD in relation to:
labelling facial emotions (Guyer et al., 2007);
response to frustration (Rich et al., 2011); and
performance on response reversal paradigms

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Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

1158 Emily Simonoff et al.
(Dickstein, Finger, Brotman, et al., 2010), with
neural circuitry differences on fMRI from juvenile
bipolar disorder patients in the first two tasks
(Brotman et al., 2010; Rich et al., 2011).
There has recently been an appreciation that other
psychiatric problems frequently occur in people with
autism spectrum disorders (ASDs), with rates as
high as 60–70%. These co-occurring disorders
include high rates of ADHD, anxiety and ODD in
children (Joshi et al., 2010; Leyfer et al., 2006;
Simonoff et al., 2008). The emergence and timing of
different psychiatric problems in ASD has not been
explicity studied, but comparison of cross-sectional
studies of different age groups suggests that
depressive and obsessive-compulsive disorder may
be more common in older adolescents and adults
(Bakken et al., 2010; Mazefsky et al., 2010) and one
longitudinal clinical study showed that affective
disorder was amongst the most common newly
emerging psychiatric disorders in adults with autism
(Hutton, Goode, Murphy, Le Couteur, & Rutter,
2008). Affective disorders in autism have included
bipolar disorder (Bradley & Bolton, 2006; Munesue
et al., 2008), although the ascertainment methods
and sample sizes in these studies do not provide a
conclusion on whether bipolar disorder is dispro-
portionately increased in ASD.
Most of the research on co-occurring psychiatric
symptoms and disorders in people with ASD has
used standardized instruments to measure recog-
nized symptom patterns and diagnoses. The syn-
drome of SMD has not, to our knowledge, been
previously explored. There are several reasons to
consider this a useful concept to explore in people
with ASD. First, several of the symptom domains
that are increased in people with ASD, including
ADHD and affective disorder, have been associated
with SMD. Second, people with ASD have high levels
of psychosocial impairment that are greater than
would be expected based on their level of intellectual
functioning. While this has often been attributed to
the core autistic deficits, it is an empirical question
whether co-occurring psychiatric problems, such as
SMD, contribute to this psychosocial impairment.
Third, the relationship between low mood and
‘challenging’ behaviour has long been recognized in
intellectual disability, where communication is sig-
nificantly impaired (Hayes, McGuire, O’Neill, Oliver,
& Morrison, 2011). Challenging behaviour occurs in
10–20% of people with ASDs, affects the entire
intellectual ability spectrum (Emerson et al., 2001),
but its causes are less well-understood than in those
with intellectual disability without ASD. One possi-
bility is that unrecognized mood problems partially
explain high rates of challenging behaviour in ASD.
In the present study, we use data collected from
the Special Needs and Autism Project (SNAP) cohort
(Baird et al., 2006) at age 16 years to create a
measure of SMP. We test whether the psychiatric,
family and neurocognitive correlates to this scale are
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J Child Psychol Psychiatry 2012; 53(11): 1157–66
similar in our ASD sample to those seen in typically
developing populations.
Methods
Participants
The sample in the present analyses comprises
ninety-one 16-year olds with ASD from the 158
participants with ASD in the original SNAP cohort. In
addition, longitudinal data from 12 years were
available on 79 of the 91 individuals. As described
previously [see Baird et al., (2006) for details], SNAP
was drawn from a total population cohort of 56,946
children. All those with a current clinical diagnosis of
pervasive developmental disorder (PDD, N = 255) or
considered ‘at risk’ for being an undetected case by
virtue of having a statement of Special Educational
Needs (SEN; N = 1,515) were surveyed using the
Social Communication Questionnaire [SCQ (Rutter,
Bailey, & Lord, 2003)]. A diagnostic assessment of a
stratified sample at 12 years (also 255 individuals)
identified 158 young people with ASD. The follow-up
assessment at 16 years focussed on the cognitive
phenotype of ASD and therefore only those who had
estimated IQs of ‡50 at 12 years were invited to
participate (Charman et al., 2011). From the SNAP
database, 131 possible participants were identified
on the basis of IQ; of these, 19 indicated they were
not interested in participating, 11 could not be con-
tracted and 1 indicated interest, but was not in-
cluded before the end of the study leaving 100
adolescent participants, for whom 91 had data to
provide an SMP score for these analyses.
For this cohort, consensus clinical ICD-10 ASD
diagnoses at 12 years were made using the Autism
Diagnostic Interview-Revised [ADI-R (Le Couteur
et al., 1989)] and Autism Diagnostic Observation
Schedule-Generic [ADOS-G (Lord et al., 2000)] as well
as IQ, language and adaptive behaviour measures.
The 91 in the contemporaneous analyses included 83
male, 8 female; 48 met consensus criteria for child-
hood autism and 43 for another ASD. For the subset of
79 included in the longitudinal analyses, 73 were
male and 41 had a diagnosis of autism. The sample
had a mean age of 15 years 6 months (SD =5 months;
range 14 years 8 months–16 years, 9 months) with a
mean time interv al from the 12 year assessment of
4 years 0 months (SD =11 months, range 1 year
7 months–5 years 8 months).
The study was approved by the South East
Research Ethics Committee (05/MRE01/67) and
informed consent was obtained from all participants.
Measures
Questionnaires and interviews. A scale comprising
‘SMP’ was generated a priori from four items on the
parent-reported Profile of Neuropsychiatric Symp-
toms (PONS), completed at 16 years. The PONS is a

doi:10.1111/j.1469-7610.2012.02600.x
62-item questionnaire that assesses the severity and
impact of 31 symptoms commonly reported in chil-
dren and young people with neurodevelopmental
disorders (Santosh, Baird, Pityaratstian, Tavare, &
Gringras, 2006). For each symptom, a brief definition
is given and the respondent is asked to endorse the
overall frequency and impact on everyday life. Each
component (frequency and impact) is each scored 0–5
(‘not at all’ to ‘all the time’/‘extremely’), with a com-
bined score ranging from 0 to 10. Four items were
included in the SMP scale, taking into consideration,
the proposed DSM-5 criteria: ‘explosive range’, ‘low
mood’, ‘depressive thoughts’ and ‘labile mood’. A
description of the PONS, the presentation of the indi-
vidual items and the means and ranges for the SNAP
ASD samples are described in the supplementary
online appendix and Supplementary Table S1. The
scale had good internal consistency with a Cronbach’s
a of .92. The raw scale was nonnormally distributed
with a mean of 7.8 (SD 8.0, range 0–36) and a square-
root transformation was applied to generate a more
normally distributed continuous measure with
skewness of 0.16 and kurtosis 2.78. A binary classi-
fication divided the top 25% of scores (13–36, N = 24)
from the rest of the distribution (0–12, N = 67). This
threshold was chosen pragmatically because (a) it was
likely to have reasonable power to detect mean dif-
ferences and (b) it is conservative compared to the
rates of ADHD (28%) and anxiety disorders (42%) re-
ported in this cohort and is therefore, a plausible
threshold to select.
The Strengths and Difficulties Questionnaire [SDQ
(Goodman, Ford, Simmons, Gatward, & Meltzer,
2000)], rated by parents at 12 and 16 years and
teachers at 12 years, was also used to measure
mental health symptoms. The SDQ is a widely used
screening instrument for child psychiatric problems
and its psychometric properties have been estab-
lished in several samples, including UK (Goodman
et al., 2000) and US studies (Bourdon, Goodman,
Rae, Simpson, & Koretz, 2005). The present analyses
use the hyperactivity, conduct and emotional sub-
scales.
At 12 years, the parent-reported Child and Ado-
lescent Psychiatric Assessment [CAPA (Angold &
Costello, 2000)] was completed on 69 of the present
sample. The CAPA is a semistructured psychiatric
interview and the following diagnostic areas were
included: all anxiety and phobic disorders (including
obsessive-compulsive disorder); major depression
and dysthymic disorder; ODD and conduct disorder
(CD); ADHD; tics/Tourette/trichotillomania; enure-
sis and encopresis. The prevalence rates and diag-
nostic correlates have been reported previously
(Simonoff et al., 2008).
Autism severity was assessed in three ways. We
used the diagnostic dichotomy of childhood autism/
other PDD. Clinicians undertaking the review of
autism diagnostic information based on the ADI-R
and ADOS-G described above scored the 12 ICD-10
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Mood problems in autism 1159
symptoms that comprise the autism spectrum dis-
order diagnoses. The Social Responsiveness Scale
[SRS (Constantino et al., 2003)] T scores were used
as a quantitative measure of autism severity, scored
at 12 years in 60 participants and at 16 years in 27,
where data were missing at 12 years.
Adaptive functioning at 12 years was measured
using the Vineland Adaptive Behaviour Scales com-
posite score (Sparrow, Balla, & Cichetti, 1984). A
quantitative measure of the shortfall, or adaptive
‘under-function’, was generated by subtracting the
Vineland score from the full-scale IQ, both measured
at 12 years and standardized to mean of 100, SD 15
and.
Maternal self-reports on the General Health
Questionnaire [GHQ-30 (Goldberg & Muller, 1988)]
when the participants were 12 and 16 years pro-
vided a measure of maternal psychiatric symptoms
with particular emphasis on mood, anxiety and so-
matic difficulties. The Parenting Stress Index [PSI
Short Form; (Abidin, 1995)] measures difficulties in
the parent-child relationship on three subscales:
disturbed child, parental distress and parent-child
dysfunctional interaction. Parental distress was
used, herein, to index the parental component of
stress, as it attempts to measure parental charac-
teristics rather than aspects of the parent-child
relationship, which may be affected by the presence
of an ASD in the child.
Neurocognitive measures. IQ was measured at
12 years with the Wechsler Intelligence Scales for
Children-Third Edition [WISC-IIIUK (Wechsler,
1992)] and at 16 years with the Wechsler Abbrevi-
ated Scales of Intelligence [WASI (Wechsler, 1999)].
Details of the neurocognitive tasks are given in the
Supplementary online appendix. All were adminis-
tered at 16 years. The emotion recognition task has
been previously described (Jones et al., 2011). In the
present analysis, we used the Ekman-Friesen test of
affect recognition (Ekman & Friesen, 1976), as this
was most similar to tasks undertaken in typically
developing youths with SMD (Brotman et al., 2008).
We measured total number of correct responses.
The Card Sort was included as a measure of cog-
nitive flexibility and response reversal (Tregay, Gil-
mour, & Charman, 2009). The task requires the
participant to correctly sort cards to one of three
alternative sets across three trials, with the correct
set varying in each trial. The key variable was the
number of sorts required to reach criterion. In the
present analyses, we included only those partici-
pants who demonstrated an understanding of the
rule in the first trial by reaching criterion before the
end. The number of sorts required in the second and
third trials was divided into four levels: top half
(scores 12–18, N = 42); third quartile (scores 19–24,
N = 22), bottom quartile (scores 25–40, N = 17) and
those who did not reach criterion by the end of both
trials (N = 8).
 14697610, 2012, 11, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02600.x by Cisug, Wiley Online Library on [11/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1160 Emily Simonoff et al. J Child Psychol Psychiatry 2012; 53(11): 1157–66

Trail Making was included as a measure of atten-
tional switching and response reversal. The task was
comprised of three separate trials (Reitan & Wolfson,
1985). The participant was asked to ‘join the dots’ in
numerical order, then, in a second trial, in alpha-
betic order, followed by a third trial switching be-
tween numbers and letters. The difference score
between the time taken on the first and the third trial
comprised a measure of switching ability. The mean
difference score was 57.8 (SD 40.7, range 10.5–
229.1). As the data were highly skewed, a square-
root transformed score was used in the present
analyses.
Statistical analysis
Data reduction and statistical analysis were
undertaken in Stata version 11 (StataCorp, 2009).
Linear regression was used to examine the contin-
uous outcome of the transformed SMP score and
logistic regression for the binary variable of high
versus low SMP scores. Ordinal logistic regression
was used for the Card Sort, where a 4-level scale
was generated, and for the analyses using the total
number of psychiatric diagnoses on the CAPA.
Multivariate regression, analogous to multiple
analysis of variance, was employed to analyse the
emotion recognition profile to allow for tests of an
overall effect and those specific to an emotion.
Ordinal logistic regression was also used for ordinal
outcomes, such as number of diagnoses. For sets of
ordinal items, such as SDQ items, specificity of
association was tested using similar models esti-
mated in gllamm (www.gllamm.org) using a gener-
alized estimating equations approach with an
Independent Working Model. The models allowed
separate threshold parameters for each item and
estimated a common and an item-specific effect in
the manner of testing for differential item function-
ing. Significance of effects was determined from
Wald tests using the robust form of the parameter
covariance matrix.
Results
Participant characteristics, according to high/low
SMP are shown in Table 1.
Emotional and behavioural characteristics
associated with SMP
Examining the contemporaneous relationships be-
tween the three parent-rated mental health problems
domains of the SDQ (Table 2) revealed that hyper-
activity, conduct and emotional problems all were
associated with SMP in bivariate analyses, but that

Table 1 Sample characteristics according to severe mood dysregulation and problems (SMP) classification [M (SD)]

High SMP (N = 24) Low SMPa (N = 67)

Raw PONS scores on individual items

Explosive rage 4.9 (2.4) 1.2 (1.4)
Low mood 4.8 (2.3) 1.2 (1.4)
Labile mood 4.8 (2.8) 0.8 (1.6)
Depressive thoughts 4.6 (2.8) 0.6 (1.2)
Other characteristics at 16 years
Full-scale IQ 80.0 (16.6) 85.8 (17.5)
SDQc Hyperactivity 6.6 (2.6) 5.7 (2.4)
SDQc Conduct problems 2.6 (1.1) 1.5 (1.6)
SDQc Emotional problems 5.3 (2.1) 2.9 (2.3)
Maternal GHQ score 8.0 (8.5) 4.1 (6.3)
Other characteristics at 12 years
Adaptive behaviour 50.6 (12.3) 52.1 (14.4)
Diagnosed childhood autism N (%) 13 (54) 35 (52)
ICD-10 symptom severity 8.4 (2.4) 8.0 (2.5)
SRSb 101.3 (25.9) 90.3 (22.4)
SDQc Hyperactivity (parent) 7.4 (2.8) 7.5 (2.5)
SDQc Conduct problems (parent) 3.5 (1.9) 2.9 (2.1)
SDQ3 Emotional problems (parent) 6.3 (2.5) 3.8 (2.4)
CAPA Any emotional problem N (%) 11 (57.9) 13 (26.0)
CAPA Oppositional defiant/conduct disorder N (%) 8 (42.1) 9 (18.0)
CAPA ADHD N (%) 8 (42.1) 9 (16.0)
Maternal GHQ score 7.3 (7.3) 4.9 (6.5)
Neurocognitive measures at 16
Ekman faces total score 41.8 (8.2) 42.8 (7.7)
Card sort errors to criterion 24.5 (8.3) 21.8 (8.7)
Trail making difference score 69.1 (48.8) 61.9 (43.7)

ADHD, attention deficit hyperactivity disorder; CAPA, Child and Adolescent Psychiatric Assessment; GHQ, General Health
Questionnaire; SDQ, Strengths and Difficulties Questionnaire; SRS, Social Responsiveness Scale.
a
High SMP refers to those scoring in the top quartile, whereas low SMP is the rest of the distribution.
b
Measured at 12 years in 60, at 16 years in 27.
c
Parent-reported measures at 12 and 16 years.

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doi:10.1111/j.1469-7610.2012.02600.x Mood problems in autism 1161

Table 2 Personal characteristics under various scales associated with severe mood problems [95 per cent confidence intervals]

Unadjusted Adjusted

B (95% CIs) p b (95% CIs) p

Emotional and behavioural problems at 16 (parent-rated)

SDQ Hyperactivity .15 (.03, .28) .02 .03 ().08, .14) .56
SDQ Conduct problems .37 (.19, .56) <.001 .27 (.11, .44) <.01
SDQ Emotional problems .35 (.22, .45) <.001 .30 (.19, .41) <.001
Emotional and behavioural problems at 12 (parent-rated)
SDQ Hyperactivity .000 ().13, .13) .98
SDQ Conduct problems .14 ().03, .30) .10
SDQ Emotional problems .25 (.13, .36) <.001
Emotional and behavioural problems at 12 (teacher-rated)
SDQ Hyperactivity ).02 ().19, .13) .75
SDQ Conduct problems .11 ().08, .30) .27
SDQ Emotional problems .29 (.16, .42) <.001
Other personal characteristics
Full-scale IQ (current) ).01 ().03, .00) .13
Adaptive functioning (12 years) ).02 ().04, .01) .17
IQ-adaptive functioning discrepancy (12 years) .00 ().02, .02) .99
Social Responsiveness Scale (SRS) Autism severity .02 (.01, .03) <.01
ICD-10 total autism symptom score .10 ().04, .23) .15
Maternal distress
Maternal GHQ, 16 years .07 (.02, .11) <.01
Maternal GHQ, 12 years .08 (.03, .13) .01

GHQ, General Health Questionnaire; SDQ, Strengths and Difficulties Questionnaire.

only conduct and emotional problems remained
significant in multivariate regression. The conduct
problems scale includes amongst its five items ‘often
has temper tantrums or hot tempers’, which is clo-
sely related to the SMP concept; we hypothesized this
item might underpin the association of SMP with
conduct problems. Fitting an ordinal response model
to the five SDQ conduct items showed a significant
association with SMP (common proportional odds
ratio (OR) 1.43, 95% CIs 1.23, 1.66; p < .001).
However, the inclusion of an additional effect specific
to tempers reduced the common partial OR to 1.18
(95% CIs 1.00, 1.40; p = .055), whereas the specific
effect item was itself large and significant
(OR = 2.09, 95% CIs 1.38, 3.16; p < .001). This
provides concurrent validity for the concept of SMP
as defined in the current study. Furthermore, al-
though the emotional subscale of the SDQ includes
items on anxiety as well as mood, this can also be
considered an index of concurrent validity. To ad-
dress the issue of whether the association with the
SDQ emotional scale was simply due to overlapping
item content, we repeated the regression with a
truncated version of the SMP scale that included
only explosive rage and labile mood. The results re-
mained highly significant (b = .19, p < .001), indi-
cating the relationship is due to co-occurrence of
common mood and anxiety symptoms and those
specifically related to severe mood dysregulation.
In examining the prediction of SMP at 16 years
from mental health symptoms at 12 years, bivari-
ate analyses showed the same pattern for parent
and teacher ratings at 12 years; only SDQ emo-
tional symptoms were significantly associated
(Table 2); however, these effects were of moderate
size, with correlations for parent and teacher
emotional scores at 12 and SMP of 0.44 and 0.18,
respectively. These associations remained signifi-
cant using the truncated SMP scale of explosive
rage and labile mood (b = .16, p = .002; b = .20,
p = .001 for parent and teacher SDQ emotional
scale respectively), indicating that common emo-
tional symptoms predict to the less emotional
components of SMD. Finally, in the subsample of
69, we used CAPA diagnoses at 12 years to predict
the category of high (top quartile) SMP score.
Having any CAPA emotional or behavioural disor-
der at 12 years substantially increased the odds of
being in the top quartile for SMP (OR = 9.6,
95%CIs 2.43, 37.00, p < .001), as did a diagnosis
in each of the three domains: ADHD (OR = 3.82,
95%CIs 1.17, 12.47, p = .03.,); ODD/CD (OR =
3.32, 95%CIs 1.04, 10.59, p = .04); and any emo-
tional (anxiety/depressive/phobic) disorder (OR =
3.92, 95%CIs 1.29, 11.86, p = .02). There were
strong associations among the CAPA diagnoses and
a multivariable analysis including all three CAPA
domains as predictors of the high SMP category
failed to distinguish an independent domain pre-
dicting SMP 4 years later. However, ordinal logistic
regression indicated a significant trend in the
association between the number of the 12 possible
CAPA disorders and being in the high SMP group
(p value from ordinal logistic regression = .006). In
relation to the high SMP category, rates were as
follows: for no CAPA disorder, 3%, 95% CIs 0–19%;
one CAPA disorder, 32%, 95% CIs 9–55%; ‡2 dis-
orders 44%, 95% CIs 23–65%. The finding repli-
cated when the CAPA diagnoses were collapsed to
the three domains described above (ordinal logistic

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1162 Emily Simonoff et al. J Child Psychol Psychiatry 2012; 53(11): 1157–66

Table 3 Multivariate regression of association between severe mood problems and emotion recognition

Emotion Overall
testa

Happiness Sadness Rear Anger Surprise Disgust

B (95% CIs) p B (95% CIs) p B (95% CIs) p B (95% CIs) p B (95% CIs) p B (95% CIs) p F(6) p

).09 ().21, 020) .11 ).01 ().31, .29) .96 ).15 ().54, .24) .45 .05 ().22, .32) .75 ).45 ().77, ).13) <.01 18 ().22, .58) .37 3.00 .01
a
Bonferroni-corrected test of overall significance.

regression p < .001); the rate of high SMP category Table 4 Severe mood problems score according to Card sort
for one disorder domain 44%, 95% CIs 19–70%; ‡2 trials to criterion
disorder domains 50%, 95% CIs 22–78%. SMPa

Mean score 95% CIs

Other participant characteristics
Full-scale IQ, whether measured at 16 (Table 2) or
12 years (b = .01, 95%CIs ).02, .01, p = .42) was not
associated with SMP. Similarly, neither adaptive
functioning at 12 years nor the difference between
cognitive ability and adaptive functioning was sig-
nificantly associated with SMP.
Autism symptoms on the parent-reported SRS
were strongly and positively related to SMP. In con-
trast, the relationship was not replicated when using
either the clinician-rated ICD-10 symptom score or
the diagnostic classification of childhood autism/
other PDD. For the latter, the mean transformed
SMP scores were 2.38 (childhood autism) versus
2.32 (other PDD), t = 0.20, p = .84).
Maternal mental health
Using maternal GHQ scores, we found a significant
relationship between SMP and high scores at both
ages. The latter relationship remained significant
when the other contemporaneously assessed
parental variables of educational and socioeconomic
status and contextual factors of family-based and
neighbourhood deprivation were included as cova-
riates (b = .08, 95% CIs .02, .14, p = .01). To address
the possibility that maternal mental health was
indexing distress in relation to having a challenging
child with ASD, rather than a characteristic of the
mothers, we undertook a further regression in which
we included as independent variables both the
maternal GHQ score and the parental distress sub-
scale from the Parenting Stress Index, both mea-
sures at 12 years. The GHQ retained a similar level
of prediction (b = .08, p = .002) as seen in the
bivariate analysis (Table 2) while the index of
parental distress was nonsignificant (b = .02,
p = .43).
Neurocognitive performance associated with SMP
Association with all emotions was tested using
multivariate regression, which revealed a significant
overall association between poorer emotion recogni-
Card-sort trials to criterion
Top 50% 2.03 1.58, 2.47
51–75% 2.57 1.68, 3.25
76%+ 2.84 1.68, 3.25
Did not meet criterion 3.09 2.23, 3.96
SMP, severe mood problems.
a
Square root transformed score.
tion and SMP (F(6,86) = 3.00, p = .010), which post
hoc tests identified as being due to a specific asso-
ciation with surprise (Bonferroni corrected p = .04)
(Table 3). Covarying for full-scale IQ and including
only those 72 participants with IQ ‡70 showed sim-
ilar overall significant findings, but the Bonferroni-
adjusted significance level is associated with sur-
prise fell to 0.11 and 0.37 respectively. Results on
the Card Sort using ordinal logistic regression, in
which the three response categories were predicted
by SMP, showed that SMP was associated with more
errors or decreased cognitive flexibility (OR = 1.35,
95%CIs 1.04, 1.73, p = .02) (Table 4). However, the
Card Sort trials to criterion were strongly associated
with IQ (ordinal logistic regression OR = 0.91, 95%
CIs 0.88, 0.94, p < .001), and when this was added
as a covariate, the relationship between Card Sort
trials and SMP became nonsignificant (OR = 1.24,
95% CIs 0.94, 1.63, p = .13). A sensitivity analysis
limiting the participants to those with IQ ‡70
(N = 72) replicated the nonsignificant finding
(p = .13).
In the Trail Making, there was no significant rela-
tionship between transformed time difference score
and SMP (b = .17, 95% CIs ).17, .51, p = .33). IQ was
also strongly related to Trail Making (b = .07, 95%
CIs ).10, ).04, p < .001), but its addition, as a co-
variate did not alter the pattern of results (p = .63),
nor did the exclusion of participants with IQ <70
(p = .64).
Discussion and conclusions
This is the first examination of the mental health
and neurocognitive correlates of SMP in adolescents

 2012 The Authors. Journal of Child Psychology and Psychiatry  2012 Association for Child and Adolescent Mental Health.

doi:10.1111/j.1469-7610.2012.02600.x
with ASDs. The strongest mental health correlates
are with emotional symptoms both in contempora-
neous and predictive analyses. We considered the
possibility that the SMP scale could be dominated
by mood symptoms and therefore be not more than
a proxy for emotional symptoms. However, all four
symptoms contribute similar to the high SMP group
and the scale has high internal consistency. Fur-
thermore, the specific link to the ‘tempers’ item of
the conduct scale adds additional support for the
SMP construct in our sample. In addition, the
association with the teacher emotional score at
12 years excludes the possibility of a parental rater
bias. This finding is consistent with the literature in
typically developing children showing that the lon-
gitudinal course of SMP involves affective problems
primarily (Brotman et al., 2006; Stringaris et al.,
2009).
The relationship between SMP and ADHD has
been previously identified, with a suggestion that
emotional lability may be prominent in people with
ADHD (Sobanski et al., 2010). Our findings in ASD
do not provide a clear answer. SDQ ADHD symp-
toms were neither predictive nor independently
correlated with SMP. On the other hand, the pres-
ence of any psychiatric disorder at age 12 was
highly predictive of being in the top quartile for SMP
at 16 (OR>9) and the prediction was equally strong
for disorders in each of the three domains of emo-
tional, oppositional/conduct and ADHD. Previously,
we showed that, in this sample, more than 80% of
those with ADHD also had an emotional and/or
oppositional/CD (Simonoff et al., 2008), and this
may be consistent with the SMP concept. However,
it is interesting that a high SMP score at 16 is
predicted not only by the presence of any disorder,
but also by the number of individual diagnoses,
further highlighting that there may be a number of
different psychiatric correlates to SMP in people
with ASD.
We found that autism severity, as measured on
the parent-reported SRS was strongly associated
with SMP, whereas the clinician-rated symptom
score generated at 12 years was not. The SRS con-
tains many more items with a wider range of scores
than the other measures. The possibility of corre-
lated measurement error in parents’ responses to
the SRS and SMP scale cannot be excluded without
another data source. Whatever the explanation for
the discrepancy between parent- and clinician- re-
ported autism severity scores and SMP, the finding
that SMP are not associated with childhood autism
versus another PDD is important for service provi-
sion. As autism is generally considered more severe
than Asperger syndrome or atypical autism/ ASDs,
there is a temptation for clinicians to assume that
all aspects of psychosocial functioning will be less
impaired in the latter group. Our previous findings
highlight that this diagnostic dichotomy does
not predict the rate of co-occurring psychiatric
 2012 The Authors. Journal of Child Psychology and Psychiatry  2012 Association for Child and Adolescent Mental Health.
14697610, 2012, 11, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02600.x by Cisug, Wiley Online Library on [11/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mood problems in autism 1163
disorders (Simonoff et al., 2008) or the stability of
psychiatric symptoms over time (Simonoff et al.,
2012).
Neither full-scale IQ nor adaptive functioning was
associated with SMP. This is consistent with previ-
ous findings regarding co-occurring psychiatric dis-
orders in SNAP (Simonoff et al., 2008) but it should
be noted that other studies report a relationship
between lower IQ and psychiatric problems in ASD
(Totsika, Hastings, Emerson, Lancaster, & Berridge,
2011). Our prediction of an association between
adaptive under-function and SMP was also not
substantiated, excluding this as one reason for the
IQ-adaptive functioning discrepancy.
We replicate the finding in otherwise typically
developing children with SMD that parents are at
increased risk of affective disorder (Brotman et al.,
2007) and show that this is independent of the
possible confounders of family background, neigh-
bourhood deprivation and parental distress associ-
ated with having a challenging child with ASD.
Families of individuals with ASDs have higher rates
of affective disorder, both major depression and
bipolar disorder, and the nature of this association is
not fully understood (Bolton, Pickles, Murphy, &
Rutter, 1998; Ingersoll, Meyer, & Becker, 2011).
However, this relationship does not appear to be
solely a consequence of stress induced by raising a
child with ASD as some cases of affective disorder in
parents commenced prior to the child’s birth and
other instances of affective disorder occurred in
second degree, and other relatives not directly in-
volved in the care of the autistic child. The current
analyses suggest a specific relationship between
maternal affective symptoms and SMP in offspring
within the ASD group that warrants additional
exploration with more detailed psychiatric mea-
sures, as the GHQ is a nonspecific measure of psy-
chiatric symptoms.
We find very little support for the same neuro-
cognitive correlates of SMD in our ASD sample as
are reported in typically developing youth, i.e.
poorer performance on emotion recognition (Guyer
et al., 2007) and response reversal tasks (Dickstein
et al., 2007; Dickstein, Finger, Skup, et al., 2010).
Previous analyses of the emotion recognition tasks
in SNAP demonstrated that participants with ASD
were not generally deficient in emotion recognition
compared to controls of the same intellectual abil-
ity, but rather had specific difficulties correctly
identifying the emotion of surprise (Jones et al.,
2011). We report an association of SMP to the same
emotion, but not for a wider range of emotions, as
described in typically developing populations with
SMD.
The Card Sort task used in this study is a measure
of cognitive flexibility; in fact, the ID/ED task used
by (Dickstein et al., 2007) in youth with SMD is de-
scribed as being based on the Wisconsin Card Sort.
We found a significant relationship between SMP
 14697610, 2012, 11, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02600.x by Cisug, Wiley Online Library on [11/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1164 Emily Simonoff et al. J Child Psychol Psychiatry 2012; 53(11): 1157–66

and cognitive rigidity, as measured by increased
trials to criterion after having learned one rule.
However, this relationship disappeared when IQ was
accounted for. The IQ range in SNAP is wide
(50–119), making it particularly important to con-
sider its role in the performance of all neurocognitive
tasks. Trail Making, also tapping cognitive flexibility,
showed no association with SMPs in our ASD sam-
ple. Thus, we failed to replicate the neurocognitive
findings from typically developing samples. Our
findings on neurocognitive tasks raise the possibility
that different brain mechanisms are involved in SMP
in people with ASD.
This study has a number of strengths. The sample is
population–based and carefully characterized with
respect to both their autism and general cognitive
features. The longitudinal nature of the sample allows
us to examine predictors of SMP as well as correlates.
Most importantly, the sample remains unusual in
having been assessed with respect to a wide range of
both behavioural characteristics and neurocognitive
tasks. It is this feature that allowed us to explore the
relationship of SMPs to neurocognitive performance
in ASD. We have been conservative in our analytic
approach, limiting these to the tasks (emotion recog-
nition, cognitive flexibility) associated with SMD in
typically developing children.
The limitations to this study are also important to
note. The study was not originally designed to assess
SMD and the bespoke measure used herein, while
carefully constructed, is not presently standardized
or validated. Therefore, our findings must be inter-
preted with caution. Furthermore, although the
concept of SMD is an evolving one, this measure may
imperfectly characterize the current definition, as it
does not explicitly include an item on irritability
(because this was not included in the PONS). Due to
the moderate sample size of SNAP and the lack of an
identified cut-off for the SMP score, most of the
present analyses use the continuous measure in
contrast with the findings reported in non-ASD
samples, which study ‘clinical’ groups.
Despite these limitations, the results are interest-
ing and important in showing that SMP in adoles-
cents with ASD represent a coherent and primarily
emotional construct. This is the first exploration of
SMD in autism and the findings indicate that SMD is
a psychometrically coherent concept in which psy-
chiatric and family correlates are similar with those
seen in typically developing children, but where the
neurocognitive basis may be different. It will be
important to test more definitively in larger samples
that allow clinically meaningful subgroups whether
these problems have similar or distinct origins. As
SMD could be a target for intervention in ASD, future
studies should also clarify its prevalence in ASD, its
relationship to other measures of ‘challenging
behaviour’ and the additional impairment that it
causes, as well as investigating both the biological/
cognitive and environmental risk factors and corre-
lates for SMD.
Supporting information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1 The Profile of Neuropsychiatric Symp-
toms (PONS)
Appendix S2 Details of neurocognitive tasks
Table S1 Characteristics of individual PONS items for
full ASD sample
Please note: Wiley-Blackwell are not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than
missing material) should be directed to the corre-
sponding author for the article.
Acknowledgements
We thank Ellen Leibenluft for her advice on the item
selection for the SMP scale and Paramala Santosh for
permission to reprint the relevant items from the PONS.
Correspondence
Emily Simonoff, Department of Child and Adolescent
Psychiatry, King’s College London, Institute of Psychi-
atry and NIHR Biomedical Research Centre for Mental
Health, De Crespigny Park, London SE58AF, UK;
Email: emily.simonoff@kcl.ac.uk

Key points
• Severe mood problems in young people are now considered a separate entity that predicts to subsequent
depressive disorder and has distinct neurocognitve and brain imaging correlates.
• A new diagnostic category of severe mood dysregulation is proposed for DSM-5.
• Young people with autism spectrum disorder (ASD) have high rates of psychiatric comorbidities, but the role
of severe mood problems has not previously been studied.
• In adolescents with ASD, we found links to emotional and behavioural problems and family history similar to
those reported in otherwise typically developing youth, but did not see the same associations with the
neurocognitive deficits in emotion recognition and response reversal.
• Severe mood problems may have different underlying causes in ASD and this requires further investigation.

 2012 The Authors. Journal of Child Psychology and Psychiatry  2012 Association for Child and Adolescent Mental Health.

doi:10.1111/j.1469-7610.2012.02600.x
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Accepted for publication: 5 July 2012
Published online: 22 August 2012