995725

research-article2021
AUT0010.1177/1362361321995725AutismZhang et al.

Original Article

Autism

Recognition of affective prosody in autism 1­–16

© The Author(s) 2021
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DOI: 10.1177/1362361321995725
https://doi.org/10.1177/1362361321995725

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Minyue Zhang1 , Suyun Xu1 , Yu Chen1, Yi Lin1,

Hongwei Ding1 and Yang Zhang2

Abstract
Affective prosody recognition is an important area of research in autism spectrum conditions where difficulties in social
cognition have been frequently observed. To probe into the mixed results reported in the literature, we conducted a
systematic review with meta-analysis and examined potential factors that could explain the inconsistent results. Our
literature search included six electronic databases for studies that compared the affective prosody recognition performance
in individuals with autism spectrum condition with typically developing participants, which yielded 23 papers eligible for
quantitative synthesis. Using a random-effects model, we obtained a moderate-to-large pooled effect (Hedges’ g = −0.63) for
the overall affective prosody recognition performance of autism spectrum condition participants, which, however, reduced
substantially (to −0.26) and became non-significant after the correction for publication bias. The number of answer codes
was found to be a significant moderator for the effect estimate, whereas the number of speakers was not. Moreover, the
magnitude of the pooled effect estimate varied across emotions. The findings suggested moderate differences in affective
prosody recognition ability between autism spectrum condition and typically developing individuals, which reduced to
marginal difficulties for autism spectrum condition when the impact of publication bias was taken into account. Diversity in
the number of answer codes could have differential effects on affective prosody recognition performance in autism spectrum
condition, which varied across emotions. The present review and meta-analysis demonstrated the insufficiency of research
on affective prosody recognition in autism spectrum condition, highlighting a need for further exploration of the contributors
and underlying mechanisms for specific affective prosody recognition difficulties.

Lay abstract
Differences in understanding others’ emotions and attitudes through features in speech (e.g. intonation) have been
observed in individuals with autism spectrum conditions, which contribute greatly to their social communication
challenges. However, some studies reported that individuals with autism spectrum condition performed comparably
to typically developing individuals on affective prosody recognition. Here, we provide a comprehensive review with
statistical analysis of 23 existing studies on this topic to examine potential factors that could explain the discrepancies.
Compared with typically developing individuals, autism spectrum condition participants generally appeared to encounter
more difficulties in affective prosody recognition. But this finding was likely due to the tendency of the existing research
to overly focus on deficits in autism. The affective prosody recognition performance in individuals with autism spectrum
condition was closely related to the number of answer options offered to them. Moreover, the degree of difficulty in

1
S peech-Language-Hearing Center, School of Foreign Languages,
Shanghai Jiao Tong University, Shanghai, China
2
Department of Speech-Language-Hearing Sciences and Center for
Neurobehavioral Development, The University of Minnesota, Twin
Cities, MN, USA
Yang Zhang, Department of Speech-Language-Hearing Sciences
and Center for Neurobehavioral Development, The University of
Minnesota, Twin Cities, 115 Shevlin Hall, 164 Pillsbury Drive SE,
Minneapolis, MN 55455, USA.
Email: zhanglab@umn.edu

Corresponding authors:
Hongwei Ding, Speech-Language-Hearing Center, School of Foreign
Languages, Shanghai Jiao Tong University, 800 Dongchuan Road,
Minhang District, Shanghai 200240, China.
Email: hwding@sjtu.edu.cn
2 Autism 00(0)
affective prosody recognition encountered by individuals with autism spectrum condition varied across emotions. The
findings of this systematic review highlighted the need for further research on affective prosody recognition in autism
(e.g. studies that include tonal language speakers and autism spectrum condition individuals with lower cognitive or
verbal abilities).
Keywords
affective prosody, autism spectrum conditions, emotion recognition, meta-analysis
Introduction
Autism spectrum disorder (ASD, henceforth autism spec-
trum condition (ASC)1) is characterized by differences in
social communication and interaction across multiple con-
texts, as well as excessively repetitive behaviours,
restricted interests and insistence on sameness (American
Psychiatric Association, 2013). Individuals with ASC gen-
erally experience difficulties processing and interpreting
socio-emotional cues (Todorova et al., 2019). They dem-
onstrate deviations in understanding others’ emotions and
attitudes in speech (Bormann-Kischkel et al., 1995; Golan
et al., 2007; Shriberg et al., 2001), which contributes
greatly to their social and communication challenges
(Shriberg et al., 2001). In the recognition of others’ emo-
tions, speech prosody, being an important channel of emo-
tional information via variations in pitch, intensity and
duration of sounds and words, plays an indispensable role
(Navas et al., 2004; Scherer, 2003; C. E. Williams &
Stevens, 1972). However, existing studies on ASC indi-
viduals’ ability to recognize emotions through affective
prosody have produced discrepant results. Some studies
reported significantly different performances observed in
participants with ASC on affective prosody recognition
(APR) compared with their typically developing (TD)
counterparts (Järvinen-Pasley et al., 2008; Mazefsky &
Oswald, 2007; Ozonoff et al., 1990; Peppé et al., 2007),
while others revealed similarities between the two groups
(Baker et al., 2010; Brennand et al., 2011; Chevallier et al.,
2011; Grossman et al., 2010; Kim et al., 2013). Several
factors have been suggested to explain this divergence.
While some of these factors have been confirmed in facial
emotion recognition studies with extensive replications,
the sources for the mixed results in the vocal domain
remain undetermined.
One important factor is age. Developmental changes
have been well documented in both prosodic performance
(Wells & Peppé, 2003) and emotion recognition (Leitzke
& Pollak, 2016). As multiple aspects of social cognition
are delayed in the development of individuals with ASC
(Leekam, 2016), it is possible that young children with
ASC would experience more difficulties in emotion recog-
nition relative to their TD peers. Nevertheless, this dispar-
ity may become narrower along with their cognitive
development (Fridenson-Hayo et al., 2016; Rump et al.,
2009). Researchers have also discovered that as individu-
als with ASC grow older, they tend to develop compensa-
tory mechanisms, which enable them to recognize basic
emotions better (Fridenson-Hayo et al., 2016; Globerson
et al., 2015). Therefore, the variability of results obtained
in existing research might be associated with the varied
age groups tested in different studies.
Other participant characteristics such as gender and
intelligence quotient (IQ) have been suggested as potential
influential factors as well. Prior studies have discussed
gender differences in emotion recognition abilities in both
typical development and ASC (Kothari et al., 2013;
Thompson & Voyer, 2014). Besides, Harms et al. (2010)
argued that discrepancies between verbal, non-verbal or
full-scale IQ could affect findings over differences related
to social communication problems in ASC. Results from
some studies that specifically investigated emotion recog-
nition also suggested that full-scale intelligence quotient
(FSIQ; Jones et al., 2011), verbal intelligence quotient
(VIQ; Golan et al., 2007; D. Williams & Happé, 2010),
and non-verbal intelligence quotient (NVIQ; Hillier &
Allinson, 2002) might respectively have certain associa-
tions with emotion identification performance in the ASC
population.
Methodology-related issues, especially task difficulty,
can be another potential source of inconsistency. It is
argued that studies investigating emotional prosody pro-
cessing that included one or two speakers and a very few
answer options might lack the sensitivity to detect the sub-
tle difference in prosody processing abilities of ASC indi-
viduals with above-average IQ (Rosenblau et al., 2017).
Indeed, studies using a limited number of speakers, emo-
tions or answer options (Boucher et al., 2000; Chevallier
et al., 2011; Loveland et al., 1997) have detected no differ-
ences in APR between participants with and without ASC.
Thus, the number of speakers and the number of answer
options could be considered as potential contributing fac-
tors to the mixed results.
Apart from the factors mentioned above, the role of dif-
ferent types of emotions should also be taken into consid-
eration. Compared with complex emotions (e.g. Golan
et al., 2015; Rutherford et al., 2002), the recognition of
which has demonstrated relatively conclusive difficulties
encountered by the ASC group, results of studies examin-
ing APR of basic emotions (e.g. Grossman et al., 2010;
Zhang et al.
Lyons et al., 2014; Stewart et al., 2013) show more dis-
crepancies (Fridenson-Hayo et al., 2016). Some scholars
argued that instead of having a generalized problem in
basic emotion recognition, participants with ASC might
just have difficulties in the recognition of some of the six
basic emotions (Uljarevic & Hamilton, 2013). This idea of
emotion-specific problems in ASC has been widely inves-
tigated in the visual domain (Ashwin et al., 2006; Baron-
Cohen et al., 1993; Wallace et al., 2008) but remains
underexplored in the vocal domain. As Brennand et al.
(2011) have highlighted, past findings of emotion-specific
differences in facial emotion recognition in ASC could not
necessarily be generalized to the perception of vocal emo-
tions. Although some studies in the vocal domain have
found that certain affective prosody, such as angry pros-
ody, was more difficult than other emotions to be success-
fully recognized (Chiew & Kjelgaard, 2017), this difficulty
was observed across groups, which means that it was the
most difficult for both ASC and TD participants. However,
it is still unknown whether it poses more difficulty to the
ASC population.
Previous literature reviews, which are all narrative
summaries, have pointed out factors related to participants
and methodology that could possibly influence the find-
ings of emotional language processing in ASC (Lartseva
et al., 2014; McCann & Pepp, 2003; Nuske et al., 2013).
To further examine these key factors so that the existing
research findings on APR in ASC could be better explained,
a systematic investigation of the literature is needed. In
contrast with traditional narrative reviews that synthesize
information in existing studies in a qualitative way, meta-
analytic procedures provide a more rigorous quantitative
method to examine the impact of ASC diagnosis on APR
performance in terms of the magnitude and direction of the
overall effect. This is achieved by calculating individual
effect sizes for the relevant studies and aggregating them
in a systematic manner. Meta-analytic methods also permit
examination of participant- and methodology-related fac-
tors that moderate the size of the effect. An important
strength of meta-analytic techniques is that by encoding
the magnitude and direction of each relevant statistical
relationship in a collection of studies, meta-analysis avoids
the possibility of drawing misleading conclusions through
qualitative summaries or ‘vote-counting’ on statistical sig-
nificance, which could be substantially influenced by sam-
ple sizes (Lipsey & Wilson, 2001). Researchers have
employed meta-analytic methods to investigate facial
emotion recognition performance in ASC (Uljarevic &
Hamilton, 2013) as well as affective prosody processing in
certain psychiatric disorders such as schizophrenia (Lin
et al., 2018) and Parkinson’s disease (Coundouris et al.,
2019). However, to our knowledge, while systematic
reviews with meta-analysis exist for emotion recognition
in the visual domain (e.g. Uljarevic & Hamilton, 2013), no
meta-analytic study has been conducted yet focusing on
3
affective prosody processing in ASC individuals. This sys-
tematic review and meta-analysis aimed to provide quanti-
tative assessment across existing studies on APR in ASC
to (1) investigate whether the ability to recognize basic
emotions through affective prosody is different in ASC
individuals compared with TD participants, (2) identify
the potential factors that might be associated with the dis-
parate findings in this field, and (3) examine whether the
magnitude of ASC individuals’ potential difficulties in
APR varies across different emotions.
Methods
This systematic review and meta-analysis was undertaken
and reported in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement (see Supplemental Table 1; Moher
et al., 2009).
Inclusion and exclusion criteria
Types of participants. We considered studies in which par-
ticipants have been formally diagnosed by a clinical psy-
chologist or psychiatrist as meeting the criteria of
Diagnostic and Statistical Manual of Mental Disorders
(4th ed., DSM-IV), International Statistical Classification
of Diseases and Related Health Problems–Tenth Edition
(ICD-10) or other valid diagnostic procedures. Given that
comorbid disorders are common in individuals with ASC
(Goldstein & Schwebach, 2004; Tantam, 2000), concur-
rent secondary disorders that have been frequently
observed accompanying ASC, such as attention-deficit/
hyperactivity disorder (ADHD), were not part of the exclu-
sion criteria. However, studies were excluded if the par-
ticipants had comorbid affective disorders like depression
at the time of testing. Studies were also excluded if partici-
pants were examined with impaired hearing abilities or
auditory disorders.
Types of studies. The studies considered for inclusion had
to be primary empirical studies involving investigation on
APR in individuals with ASC in comparison with TD par-
ticipants. Review articles, editorials and meta-analyses
with no original data were not included. As mentioned in
section ‘Introduction’, we only considered studies examin-
ing at least one of the six basic emotions (happiness, sad-
ness, anger, fear, disgust and surprise; Ekman, 1992)
presented in the auditory modality. Complex or social
emotions (e.g. sarcasm, contempt, embarrassment, amuse-
ment and excitement) were not included due to a much
broader variety with an insufficient number of studies for
running meta-analysis on each target category of complex
emotion. Studies exclusively on emotion processing in the
visual domain were also excluded. We considered studies
using stimuli with pure prosody, that is, without semantic
4 Autism 00(0)
content, but due to the limited number of existing studies,
we also included studies using stimuli with neutral seman-
tic content. A test of moderators was conducted to ensure
that the presence of neutral semantic content would not
affect the result. The studies were required to use behav-
ioural tasks and data regarding the emotion recognition
performance had to be reported. Eye-tracking, neuroimag-
ing, electroencephalographic and physiological studies
were also included if they employed behavioural tasks that
met the inclusion criteria. For studies involving one or
more measures of affective prosody processing as an
aspect of social cognition, only pure measures of APR
were included in this review. When insufficient data were
available for the calculation of effect sizes and when we
could not obtain necessary data from the author(s), those
studies were excluded.
Outcome measures
We defined the accuracy of APR as any measure calcu-
lated from percent correct scores of each group for the rel-
evant tasks. If the results were reported as percentages of
errors, corresponding percent correct data were calculated.
Moreover, since a recent meta-analysis has suggested that
measures such as reaction time might reveal more subtle
differences in ASC individuals’ emotion recognition abil-
ity (Uljarevic & Hamilton, 2013), we also coded reaction
time data to corroborate the results obtained via analysis
on the accuracy data.
Quality assessment
We assessed the quality of the studies using the standard
quality assessment (SQA) criteria for evaluating primary
research papers from various fields for quantitative studies
(Kmet et al., 2004). The checklist contains 14 items. Given
that item 5 (If interventional and random allocation was pos-
sible, is it described?), item 6 (If interventional and blinding
of investigators to intervention was possible, is it reported?)
and item 7 (If interventional and blinding of subjects to inter-
vention was possible, is it reported?) refer to the use of inter-
ventions and are therefore not applicable for the studies
reviewed here, these three items were not evaluated. Two
reviewers independently rated each of the included studies.
Moderator variables
In light of the findings in the literature, the following mod-
erators were considered: age, IQ (including FSIQ, VIQ
and NVIQ), gender distribution of the individuals, stimu-
lus type (stimuli with pure prosody (SPP) or stimuli with
neutral semantic content (SNSC)), task difficulty (includ-
ing the number of speakers and the number of answer
options), region (Europe, the United States, Asia or
Australia), year of publication and study quality. Moderator
analyses were conducted to (1) examine whether factors,
especially stimulus type, region, year of publication and
study quality, contributed to the between-study heteroge-
neity and (2) to assess the relationship between the APR
performance of autistic people and the potential influential
factors such as age, IQ, gender and task difficulty.
Search strategy
We conducted a computerized search through major elec-
tronic databases (Web of Science, MEDLINE, ERIC,
PsycINFO, PsycARTICLES, and Psychology and
Behavioral Sciences Collection) for studies published until
February 2020, using the combination of the following key-
words: (‘emotional prosody’ OR ‘affective prosody’) AND
(autism OR ASD OR Asperger). In addition, we manually
examined reference lists of the included studies and relevant
review articles for additional potential studies.
Study selection and data extraction
Our search process identified 341 potentially eligible arti-
cles (Figure 1). We then removed duplicate articles and
screened the titles and abstracts against the inclusion and
exclusion criteria, which yielded 43 articles for full-text
reviews. Two reviewers (M.Z. and S.X.) examined the full
text of these studies and identified 18 eligible articles.
Another eight articles were discovered from the reference
lists of the included studies and relevant review articles.
Any inconsistently screened articles (i.e. included by one
reviewer, but excluded by the other) were re-evaluated,
and a consensus was achieved on all disagreements
through discussion. The resulting 26 studies were included
for qualitative analysis, of which three studies were
excluded from the quantitative synthesis (meta-analysis)
because of insufficient data for effect size calculation on
both overall and individual emotions, but are listed in
Appendix 1 of supplemental material.
Data were extracted from each included study in terms
of the following key elements: (1) characteristics for iden-
tification (e.g. first author and publication year), (2) par-
ticipant information (e.g. sample size, age range, gender
ratio, IQ and diagnostic criteria), (3) task characteristics
(e.g. study type, task paradigm and stimulus type), and (4)
major results (e.g. mean value and standard deviation for
the ASC group and the TD group, t-test value and p-value).
When studies reported separate data concerning the accu-
racy of recognizing each individual emotion, we recorded
the data to enable an analysis of emotion-specific perfor-
mance on APR.
Statistical analysis
Meta-analyses were performed using R (version 3.5.1).
Effect sizes were calculated as standardized mean differ-
ences with Hedges’ g, of which the magnitude was inter-
preted as follows: 0.2 for small, 0.5 for medium and 0.8 for
Zhang et al.
Figure 1. Flow diagram for the different phases of the systematic review and meta-analysis.
large (Cohen, 1988). While Hedges’ g offers the same inter-
pretation as Cohen’s d, it includes a correction for small sam-
ple sizes (Hedges, 1981). Since the included studies varied in
study populations, effect size estimates were modelled using
a random-effects model (DerSimonian–Laird estimate),
which estimates the mean of a distribution of effect sizes. A
priori power analysis indicated that there were sufficient
studies included in the meta-analysis to detect moderate to
large effects, with the statistical power above 90%.
We assessed between-study heterogeneity and the impact
of heterogeneity using the Cochran’s Q statistic and the I2
statistic (Higgins & Thompson, 2002). A significant result
on the Q-test indicates that the observed effect sizes are
widely dispersed, and I2, as the ratio of true heterogeneity to
the total variation in observed effects, reflects what propor-
tion of the observed dispersion is real and whether it would
make sense to speculate about reasons for the variance
(Borenstein et al., 2009). The I2 values of 25%, 50% and
75% were considered to imply low, moderate and high
degrees of heterogeneity (Higgins et al., 2003).
Outliers were identified based on the criteria that the
study’s confidence interval (CI) did not overlap with the
5
CI of the pooled effect (Harrer et al., 2019). Sensitivity
analyses were carried out after the removal of probable
outliers that may distort the effect size estimate and its pre-
cision. We also conducted influential analyses based on the
Leave-One-Out method to ensure that no single study
unduly influenced the effect size estimate (Lam et al.,
2016; Passos et al., 2015). This method tests if the pooled
effect size is highly influenced by one single study by
removing one study at a time from the data set and running
the meta-analysis without the removed study. This Leave-
One-Out method is considered better-suited for assessing
if the influence may distort the pooled effect rather than an
approach to yielding a more valid estimate of the overall
effect (Passos et al., 2015).
We assessed publication bias by first inspecting funnel
plots for asymmetry and then evaluating them with
Egger’s test (Egger et al., 1997). If Egger’s regression
test indicates publication bias (p < 0.1), we applied the
trim-and-fill method to redress funnel plot asymmetry
(Duval & Tweedie, 2000). The adjusted pooled effect
size and 95% CI were reported after the addition of
potential missing studies.
6 Autism 00(0)
We conducted meta-regression analyses using a mixed-
effects model in an attempt to examine sources of hetero-
geneity and the degree of their contribution to the observed
dispersion of effect sizes between studies. All the modera-
tors were included in the meta-regression analyses pro-
vided that information was available for a sufficient
number of studies (⩾4; Velikonja et al., 2019). The signifi-
cance of the test of moderators means that the relationship
between the moderator and the estimated effect is stronger
than we would expect by chance (Borenstein et al., 2009).
The regression coefficients, the Qmodel (QM) statistics, and
the p-values were reported in the meta-regression analy-
ses, and R2, the proportion of variance explained by the
moderator, was calculated to quantify the magnitude of the
relationship of the significant moderator to the estimated
effect (Borenstein et al., 2009; Lai et al., 2019).
Results
Description of included studies
The search of electronic databases identified 341 studies.
Twenty-three papers published from 2000 to 2019 were
eligible for inclusion in the quantitative synthesis (see
Figure 1 for the description of selection process). The
included studies provided a combined sample of 770 par-
ticipants with ASC (mean (standard deviation (SD)) age
of samples across studies, 15.54 (8.78) years) and 864 TD
participants (mean (SD) age of samples across studies,
15.69 (10.38) years).
Supplemental Table 2 presents the general characteristics
of the studies included in our quantitative analysis. Three
studies (Heikkinen et al., 2010; Jones et al., 2011; Kujala
et al., 2005) were excluded from the meta-analysis for the
overall performance of individuals with ASC on APR due to
no reporting of data on the overall accuracy. Most of the 23
studies were conducted in Europe (14 (60.9%)) followed by
the United States (5 (21.7%)), and the rest four studies were
conducted in Australia (1), China (Taiwan) (1), Japan (1) and
Korea (1), respectively. English (12) was the language used in
over half of the included studies, followed by Finnish (3),
Dutch (2), Hebrew (2), German (2), Greek (1), Japanese (1),
Korean (1) and Mandarin Chinese (1). One study (Fridenson-
Hayo et al., 2016) carried out cross-cultural investigations in
three different languages: English, German and Hebrew. It is
worth noting that studies in non-tonal languages (languages
that do not use syllable-level pitch variations (or lexical tones)
to distinguish words, e.g. English, German, Dutch, Finnish,
Hebrew and Korean) significantly outnumbered those in
tonal languages (languages where the meaning of words is
affected by the lexical tone, e.g. Mandarin Chinese), and
many more studies were conducted in stress-timed languages
(languages where syllables are stressed at regular intervals
and unstressed syllables are shortened to fit this rhythm, e.g.
English, German and Dutch) than syllable-timed languages
(languages whose syllables take approximately equal amounts
of time to pronounce, irrespective of the stress placed on
them, e.g. Finnish, Korean and Mandarin Chinese). The sam-
ple sizes varied greatly, ranging from eight participants
(Kujala et al., 2005) to 140 participants (including TD partici-
pants; Oerlemans et al., 2013), with 18 studies (78.3%) using
samples between 10 and 30 participants. All of the included
studies employed identification tasks and most of them
required participants to give responses by selecting one emo-
tional label among several possible options. Verbal SNSC and
stimuli that kept the affective prosody information without
semantic content (SPP) were employed in the 23 studies, with
one study also including meaning-prosody congruent and
incongruent stimuli (J. E. Wang & Tsao, 2015).
The results of the quality assessment of the included
studies are provided in Supplemental Table 3. The inter-
rater correlation coefficient (using the Spearman’s correla-
tion; Gwet, 2014) between the two reviewers was 0.84.
Disagreements were resolved by follow-up discussion to
reach consensus. The overall SQA score of all the papers
was medium/high (Todorova et al., 2019; M = 0.81;
SD = 0.05, minimum–maximum (0.73–0.91)).
Overall performance of individuals with ASC on
APR
Supplemental Table 3 summarizes the results concerning
the overall accuracy of participants with ASC on APR
compared with that of TD participants in each included
study. The standardized mean effect size was medium to
large and significant (Hedges’ g = −0.63, 95% CI −0.86
to −0.39, p < 0.001; Figure 2). The heterogeneity
between studies was significant (Q(27) = 117.04,
p < 0.001), indicating significant variability in effect
sizes among the included studies. This was corroborated
by the rather high level of true heterogeneity between
the included studies (I2 = 76.93%) independent of the
amount of heterogeneity (approximately 20%) account-
able by sampling error. The examination of the studies’
CIs identified six outliers. After the removal of these
outliers, the standardized mean effect size remained
nearly medium and significant (Hedges’ g = −0.44, 95%
CI −0.60 to −0.29, p < 0.001). Influential analyses
showed no significant change in results, with effect sizes
ranging from −0.66 (95% CI −0.89 to −0.43) to −0.56
(95% CI −0.78 to −0.34), suggesting that no study
unduly influenced the results (Supplemental Figure 1).
For publication bias, visual inspection of the funnel plot
detected asymmetry. The result of Egger’s test was sig-
nificant (p = 0.03), confirming significant publication
bias. In the trim-and-fill analysis, nine studies were
imputed (Supplemental Figure 2), resulting in an
adjusted smaller and non-significant point estimate
(Hedges’ g = −0.26, 95% CI −0.54 to 0.01, p = 0.06). The
results of the included studies that reported the reaction
time of participants on APR are presented in Supplemental
Table 4. The pooled effect size was large and significant
Zhang et al. 7

Figure 2. Forest plot with effect sizes (Hedges’ g) and confidence intervals for the included studies (the outcome measure being
accuracy). Gray squares depict individual effect sizes of APR in ASC compared to TD, with sizes indicating the relative weight of
each study’s effect size estimate to the analysis. Black diamond reflects the overall summary effect across studies.

Figure 3. Forest plot with effect sizes (Hedges’ g) and confidence intervals for the included studies (the outcome measure being
reaction time).

(Hedges’ g = −1.35, 95% CI −2.64 to −0.07, p < 0.05;
Figure 3). Due to the limited number (<10) of studies
that have reported the reaction time data, Egger’s test
was not performed.
Moderators
Meta-regressions revealed that of the included moderators,
the number of answer options alone significantly explained
the heterogeneity between studies (QM(1) = 9.40, R2 = 18.21%,
p = 0.002). This suggested that studies employing tasks with
more answer options were significantly associated with larger
effect sizes (Supplemental Figure 3). The other moderators
did not account for the between-study heterogeneity
(Supplemental Table 5). Effect size differences were not sig-
nificantly associated with mean age (QM(1) = 3.25, p = 0.07),
FSIQ (QM(1) = 0.31, p = 0.58), VIQ (QM(1) = 0.27, p = 0.60),
NVIQ (QM(1) = 0.01, p = 0.95), percentage of men
(QM(1) = 0.71, p = 0.40), stimulus type (QM(1) = 1.25, p = 0.74),
number of speakers (QM(1) = 0.49, p = 0.49), study quality
(QM(1) = 0.44, p = 0.51), region (QM(3) = 0.95, p = 0.81) or year
of publication (QM(1) = 0.01, p = 0.95).
8 Autism 00(0)
Individual emotion perception accuracy in ASC
participants compared to TD participants
When performance was examined separately for each
emotion, a set of random-effects meta-analyses discovered
that compared to TD participants, individuals with ASC
demonstrated significantly lower accuracy in recognizing
happiness (Hedges’ g = −0.49, 95% CI −0.79 to −0.20,
p = 0.001), but not in sadness (Hedges’ g = 0.04, 95% CI
−0.55 to 0.64, p = 0.88), anger (Hedges’ g = −0.28, 95% CI
−0.78 to 0.22, p = 0.27), fear (Hedges’ g = 0.15, 95% CI
−0.57 to 0.87, p = 0.68) or surprise (Hedges’ g = −0.76,
95% CI −1.63 to 0.12, p = 0.09) (Figure 4). As emotion-
specific data on recognizing disgust were obtained for only
one study (see Supplemental Table 6), a meta-analysis for
this emotion could not be performed.
Discussion
The present meta-analysis investigated whether individu-
als with ASC displayed any difference in APR and
explored potential factors that could contribute to the var-
iable and often mixed results on this issue. The results
showed that (1) findings from previous studies aggre-
gated, individuals with ASC show lower overall accuracy
and need longer reaction time in recognizing emotions
through affective prosody, but there is likely an impact of
publication bias; (2) ASC individuals’ difficulties in APR
compared with their TD counterparts may vary across
emotions; and (3) the number of answer options can have
a certain impact on ASC individuals’ APR performance.
The findings of this study highlight several future direc-
tions for later research on APR in ASC.
Overall APR in individuals with ASC
We examined 20 studies testing 651 participants with ASC
and found evidence of a moderate-to-large negative effect
size (−0.63), which indicates that there are indeed certain
differences in ASC individuals’ overall accuracy in recog-
nizing emotions through affective prosody. This finding is
consistent with the results obtained by Lartseva and her
colleagues (2014), who concluded that participants with
ASC show certain difficulties in affective prosody percep-
tion. However, the effect estimate of the meta-analysis was
substantially reduced (to −0.26) after the correction for
publication bias, with the 95% CI after the correction span-
ning zero and the p-value increasing to slightly above 0.05.
This suggests that there existed a crucial impact of publica-
tion bias. As highlighted by Uljarevic and Hamilton (2013),
the issue of publication bias is likely to be important in
autism-emotion research. It tends to be harder for non-sig-
nificant results to be published than significant results
(Dickersin, 1990), so it is possible that studies with non-
significant findings (or even better performance in partici-
pants with ASC) have been denied an opportunity of public
viewing. Interestingly, despite the impact of publication
bias, the already published studies probing APR in ASC
still produced very mixed results. This might lead to the
conjecture that the real picture of ASC individuals’ perfor-
mance on APR could be different from what has been found
through the aggregation of findings from previous studies.
Verification of this hypothesis requires more research in
this field in the future where non-significant or null results
could be reported and published in full.
The results of the meta-analysis based on the reaction
time data available from the included studies suggest that
individuals with autism tend to need more time in perceiv-
ing and recognizing emotions through affective prosody.
Together with the results from the analysis of accuracy
data, this finding suggests that ASC individuals can
achieve a level of accuracy comparable to that of their TD
counterparts, but they may need significantly more time to
process the prosodic information in order to make the cor-
rect judgement. This is consistent with the findings of pre-
vious literature that compared with accuracy, measures
such as reaction time might be able to reveal more subtle
differences in ASC individuals’ emotion recognition abil-
ity (Uljarevic & Hamilton, 2013). Therefore, we advocate
that future research in this field should record and report
reaction time data in addition to accuracy measures.
Influential factors of APR in ASC
Despite the possible difficulties of individuals with ASC in
recognizing emotions from affective prosody, a high level
of between-study heterogeneity indicates that factors other
than an ASC diagnosis per se may have an impact on the
participants’ performance on APR. This is supported by
the results of meta-regression analyses, which served to
reveal the relationship between the moderator variables
and the effect estimate.
Methodology-related factors. In our analysis, two methodol-
ogy-related factors were taken into consideration: task dif-
ficulty and stimulus type. For task difficulty, we examined
whether the number of answer options and the number of
speakers would affect the participants’ performance, while
for stimulus type, we mainly focused on whether the pres-
ence of semantic information was a contributor to the het-
erogeneity of results.
The results of moderator analyses indicated that the
number of answer options was a significant cause for the
heterogeneity across studies. In the studies we examined,
the number of answer options ranged from two to six.
Fifteen comparisons provided participants with four
answer options while six used less than four answer
options and another six used more than four answer
options. The comparison using only two answer options
barely found any distinction between the two groups,
whereas the comparisons using as many as six answer
options all generated medium-to-large effect sizes. Thus,
Zhang et al. 9

Figure 4. Individual and pooled effect sizes (Hedges’ g and 95% CIs) for each emotion.
10
aligned with Rosenblau et al.’s (2017) arguments, the sen-
sitivity to detect subtle differences in APR of individuals
with ASC increases when participants are presented with
more answer options. Similar findings have also been
observed by Grossman et al. (2010), who affirmed that
within the confines of relatively simplistic tasks using less
than four answer options, adolescents with ASC are not
significantly different from their TD peers in the accuracy
of affective prosody interpretation. This is not unexpected
since as previous literature has highlighted, test items with
a relatively large number of answer options reduced the
probability of chance success and were thus more difficult
(Swanson et al., 2006) and discriminated better among
high- and low-performing participants (Rutgers et al.,
2018). Meta-analyses on emotional prosody processing in
other psychiatric disorders also discovered that the number
of emotions would influence task complexity. The inclu-
sion of more emotions is likely to increase cognitive
demands, which may lead to the result of more difficulties
in affect perception (Hoekert et al., 2007). Unlike the criti-
cal impact that the number of answer options could have,
no significant effect was found for the number of speakers.
However, caution is needed for the interpretation of this
null finding because for tests of moderators that involve a
small number of eligible studies, the finding that a mod-
erator is not significantly related to effect size variation
does not mean that there is no relationship between the
moderator and effect size variation (Hedges & Pigott,
2004). The non-significant result could be attributed to the
fact that very few of the existing studies had the stimulus
design of using multiple speakers. Of the 20 studies we
examined, over half (11) used one or two speakers to pre-
sent stimuli and only two studies used more than ten
speakers. This is understandable because as Hearnshaw
et al. (2019) have pointed out, many researchers might not
have the time or resources to record stimuli from multiple
speakers. Thus, establishing validated databases of vocal
emotional stimuli presented by a wide range of speakers
would be beneficial to researchers in this area.
In regard to the stimulus type, there was no significance
detected, either. As stated in section ‘Methods’, due to the
limited number of existing studies using SPP, we also included
studies using SNSC. The result of meta-regression suggested
that the stimulus type of the studies included was not associ-
ated with the heterogeneity across studies. It is, therefore, rea-
sonable to pool together studies using SPP and those using
SNSC. Caution is needed as the result of the meta-regression
here only indicated that the presence of neutral semantic
information did not contribute to the variability in findings. It
should not be interpreted as a sign of no interaction between
emotional prosody and emotion-laden semantic content. As
this review focuses on the ability of ASC participants to rec-
ognize basic emotions through affective prosody, the effect of
meaning-prosody (in)congruency on emotion recognition is
another topic that is not under investigation here.
Autism 00(0)
Participant-related factors. In addition to factors related to
tasks, the heterogeneity of participants was also consid-
ered as a possible explanation for the variability of results.
We examined the relationship between the effect estimate
and the participants’ age, gender, FSIQ, VIQ and NVIQ.
Contrary to our expectation, only age was found to have a
trending association (p = 0.07) with effect size variation.
The studies included covered a wide age range (from pre-
teens to adolescents and adults), but the results did not
reveal a significant effect of age on APR performance.
Similar results have been obtained in the previous meta-
analysis on facial emotion recognition, which concluded
that there were no substantial changes in emotion recogni-
tion performance with age (Uljarevic & Hamilton, 2013).
However, it might be too hasty to reach such a conclusion
solely based on the non-significant results. Although the
meta-regression analyses assessing age and gender all
included more than 25 effect sizes and were thus less likely
to be at risk of being underpowered (Baker et al., 2009),
caution is needed for the interpretation of these seemingly
null findings. As highlighted by Borenstein et al. (2009),
tests of moderators are generally not of very high power if
there are a small number of eligible studies, and one should
never use a non-significant finding to conclude that a
covariate is not related to effect size. It is possible that the
number of the existing eligible studies was not large
enough for the relationship between age and APR perfor-
mance to be detected and thus only managed to reflect a
trending association. In addition, this non-significant result
does not indicate that individuals with ASC cannot improve
their APR performance as they grow older, but rather that
despite the possible improvements, the difference still
exists between the two groups. This finding also accords
with the arguments by Rosenblau et al. (2017) and Lart-
seva et al. (2014) that the problems of individuals with
ASC in social perception and emotional language process-
ing persist from early childhood throughout adulthood.
Apart from the age, the gender ratio of the participant
groups was investigated as a potential moderator as well.
Prior research has suggested that gender difference could be
the source of variability in some of the results related to per-
formance in the ASC population (Van der Hallen et al.,
2015). However, in accordance with other meta-analyses in
the domain of social cognition in ASC (Todorova et al.,
2019), we did not find any significant effect of gender in
APR performance in ASC. This null finding may not neces-
sarily indicate the non-existence of gender difference;
rather, it could result from the dearth of research with gen-
der-balanced samples of autistic people. The number of
males in the studies included in this meta-analysis (N = 535)
far outweighed the number of females (N = 100), with only
two studies recruiting evenly balanced samples of both gen-
ders. It is possible that the analysis of the association
between gender and effect size has been confounded by this
difference in the grouped sample sizes of the two genders.
Zhang et al.
Similarly, none of the FSIQ, the VIQ and the NVIQ
scores of the ASC groups revealed a significant effect on
their overall recognition accuracy, either. However, we
need to point out that this absence of an IQ effect has to be
interpreted with caution. It should not be viewed as direct
evidence of no relationship between IQ scores and APR in
ASC. One reason is that some of the studies included in the
meta-analysis either did not report IQ data or only pro-
vided broad IQ ranges of their samples, which could have
resulted in low power to detect any relationship between
IQ scores and APR performance. Another important rea-
son is that even in those studies that have reported ade-
quate data, the mean FSIQ, VIQ and NVIQ scores of the
ASC groups were matched to those of the TD groups –
with averages nearly all centring around 100. Thus, it is
plausible that the proportion of heterogeneity that may be
explained from the perspective of IQ scores might not
have been captured in the analysis based on existing stud-
ies. Since most of the current literature is on individuals
with ASC whose IQ scores were at or above average (also
referred to as high-functioning autism by some research-
ers; see Alvares et al. (2020) for empirical support to aban-
don the terms of high- and low-functioning autism), this
nuance would not be grasped unless further research is
conducted with ASC participants with lower IQ.
Emotion-specific performance on APR in ASC
compared to TD
We analysed recognition of individual emotions through
affective prosody in the studies that provided sufficient
data for effect calculation. Most of the studies included
investigated the recognition of happiness, sadness and
anger, but much fewer studies covered fear, surprise and
disgust, especially the last two emotions, which less than
one-third of the included studies took into consideration.
The results showed that among the five emotions exam-
ined, the recognition of surprise demonstrated the biggest
magnitude of the overall effect (in favour of TD partici-
pants), and that ASC participants showed significantly dif-
ferent performance in the recognition of happiness but not
in that of sadness, anger and fear. The recognition of sur-
prise displayed a marginal difficulty, with the CI just span-
ning zero and the p-value slightly above 0.05. Prior
research has suggested that of the six basic emotions, only
the recognition of surprise requires an assessment of cog-
nitive mental state (Baron-Cohen et al., 1993) and that
identifying this emotion may rely on more complex social
understanding (Adolphs, 2006). Thus, it is reasonable to
believe that the difficulty, if any, in the recognition of sur-
prise should be most evident among the six basic emo-
tions, as has been argued by previous studies (Baron-Cohen
et al., 1993; Golan et al., 2006). We suspect that the tenta-
tive evidence for more difficulty in the recognition of sur-
prise in this study could be attributed to the small sample
11
size due to the limited number of studies that provided data
concerning ASC participants’ recognition of this emotion.
The difficulty of individuals with ASC in the recognition
of happiness through affective prosody is significant accord-
ing to the results of the meta-analysis. This finding corre-
sponds with the results of some neural studies in this field.
In a functional magnetic resonance imaging (fMRI) study
on affective prosody perception, Gebauer et al. (2014) found
differences in the processing of happy prosody in partici-
pants with ASC and indicated that emotion recognition for
affective prosody, particularly happy prosody, was more
attentionally demanding for the ASC group compared to the
TD group. Given that a vast majority of individuals with
ASC display attentional problems (Burack, 1994; Sturm
et al., 2004), such as allocating insufficient attentional
resources for the processing of external environmental stim-
uli (Schauder et al., 2015), it is possible that attentional
problems have contributed to their increasing difficulty in
recognizing happiness through affective prosody.
Limitations of the present study
Our meta-analysis findings should be considered within
the context of certain limitations. First, given the substan-
tial differences between basic and complex emotions and
the relatively high heterogeneity in the types of complex
emotions examined in existing studies, more complex,
social emotions were not included in the present meta-
analysis. Basic emotions are universally acknowledged by
different studies as consisting of these six categories of
emotions: happiness, sadness, anger, fear, disgust and sur-
prise, while studies on complex emotion recognition tend
to include a diverse variety of complex emotions (e.g.
embarrassed (Hillier & Allinson, 2002) and enthusiastic
and grouchy (Brooks & Ploog, 2013)). Some researchers
defined 12 complex emotions (i.e. interested, bored,
excited, worried, disappointed, frustrated, proud, ashamed,
kind, unfriendly, joking and hurt; Fridenson-Hayo et al.,
2016), and others used a taxonomy of 22 complex emo-
tions including smug, awkward and concerned (Golan
et al., 2006). While basic emotions are suggested to be
cross-culturally expressed and recognized (Ekman, 1993),
complex emotions are considered more culture-dependent
(Griffiths, 2008; Izard, 2007). In addition, studies on basic
emotion recognition in autistic people have yielded mixed
results, whereas those on complex emotion recognition
have shown more conclusive difficulties in ASC
(Fridenson-Hayo et al., 2016; Golan et al., 2015).
Therefore, it is advisable to run a separate meta-analysis
on the topic of APR for complex emotions when a suffi-
cient number of studies are available.
Second, due to the limited amount of research in this
field, the number of studies included in our meta-analyses,
especially those for emotion-specific performance, was
relatively small. Although theoretically speaking, as few
12
as two empirical studies suffice for a meta-analysis (Pigott,
2012; Valentine et al., 2010), results based on a greater
number of studies would be more convincing with ade-
quate statistical power. Thus, while our findings regarding
the emotion-specific APR performance need to be inter-
preted with caution, they also provide a powerful argu-
ment for conducting more primary studies in the future
that explore emotion-specific performance on APR in
ASC.
Future directions
The findings of this study serve to inspire future research
on APR in ASC to move forward in several directions.
First, given that the majority of existing studies focused on
ASC individuals with average or above-average IQ, more
research is required exploring APR performance in the
ASC population at the lower end of the IQ distribution,
which demands more novel and elaborate approaches in
experimental design. Previous studies have demonstrated
success in attempting to employ the video-game paradigm
to train ASC individuals in facial emotion recognition
(Almeida et al., 2019; Kim et al., 2015; Serret et al., 2014)
or to investigate ASC children’s patterns of attention to
prosodic information during complex emotion discrimina-
tion (Brooks & Ploog, 2013), but few have been conducted
yet to examine the ability of ASC individuals with below-
average IQ to identify basic emotions through affective
prosody. Thus, we suggest implementing the gamified
approach in future research to shed light on the APR per-
formance of this underexplored population. Second, more
research conducted in tonal languages (e.g. Mandarin
Chinese) is needed to examine the cross-linguistic differ-
ences in affective prosody processing in ASC individuals.
Most of the existing studies in this field were conducted in
non-tonal languages, and although there has been research
investigating the influence of cross-cultural factors, few
have examined the cross-linguistic influence in affective
prosody processing in ASC. Verbal communication pro-
cessing may vary not only across speakers and cultures but
also across languages (Lin et al., 2018). Recent studies on
ASC individuals who are tonal language speakers revealed
interesting language-specific issues with respect to lexical
tone processing and durational cue processing independent
of general auditory processing capacity of pitch and dura-
tion coding (Huang et al., 2018; X. Wang et al., 2017).
Given the existence of distinctive acoustic features of
emotional intonation in a tonal language such as Chinese
(Li et al., 2011; T. Wang et al., 2014, 2018), it remains to
be examined whether emotional processing would also
demonstrate language-specific effects in individuals with
ASC. Therefore, we call for more studies with the global
linguistic diversity perspective to include ASC individuals
with tonal language experience and more cross-linguistic
investigation of affective prosody processing in the ASC
Autism 00(0)
population. Another key direction for future research is to
utilize neurophysiological and neuroimaging techniques to
explore affective prosody processing in individuals with
ASC. Research applying brain imaging (both anatomical
and functional imaging) techniques can identify the neural
processes that underlie the seemingly conflicting behav-
ioural results and may contribute to the clarification of cer-
tain phenotypic heterogeneity (Eigsti et al., 2012).
Moreover, our review analysis indicated a critical impact
of publication bias in the domain of APR in ASC. Hence,
we strongly encourage researchers in this field to report
their results in full, even when the effects are not signifi-
cant. In addition, we recommend further research on APR
in ASC to examine a more uniform range of complex emo-
tions, so that future meta-analyses on APR in ASC could
possibly include these more complex, social emotions and
investigate emotion recognition through affective prosody
in ASC in a more context- and culture-dependent domain.
Conclusion
This study is the first systematic review with meta-analysis
to investigate APR performance in individuals with ASC,
covering studies published over the past two decades that
examined basic emotion recognition through affective pros-
ody in the ASC population compared with TD individuals.
Results suggest a moderate reduction in ASC individuals’
overall ability to recognize basic emotions through affective
prosody. When the crucial impact of publication bias is
taken into consideration, individuals with ASC may display
only marginal difficulties in APR for basic emotions. In
addition, the results demonstrate that diversity in the num-
ber of answer options could have a certain impact on APR
performance in ASC. Furthermore, the ASC groups’ diffi-
culties in APR compared with their TD counterparts may
vary across emotions. Further research employing neurobi-
ological techniques is needed to better understand the nature
of these difficulties. As previous research predominantly
features non-tonal language users, future efforts can benefit
from including tonal language speakers and individuals
with below-average IQ to gain new insights into affective
prosody processing in ASC individuals with different lan-
guage backgrounds and cognitive abilities.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship and/or publication of this article:
This work was supported by grants from the major project of
National Social Science Foundation of China (18ZDA293), who
had no other role in the article.
Zhang et al.
ORCID iDs
Minyue Zhang https://orcid.org/0000-0002-4428-2500
Suyun Xu https://orcid.org/0000-0002-2838-5294
Hongwei Ding https://orcid.org/0000-0001-8684-0788
Yang Zhang https://orcid.org/0000-0001-6777-3487
Supplemental material
Supplemental material for this article is available online.
Note
1. These autistic symptoms generally reflect a form of behav-
ioural differences from neurotypicals more than a set of
deficits or disorders. Accordingly, the term ‘autism spec-
trum condition’ (ASC) is adopted as a preferred alternative
to ASD in this review.
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