Skip to main content

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

  • Brendan A. Rich (a1), Mary E. Grimley (a1), Mariana Schmajuk (a1), Karina S. Blair (a1), R. J. R. Blair (a1) and Ellen Leibenluft (a1)...

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

Corresponding author
Address correspondence and reprint requests to: Brendan A. Rich, National Institute of Mental Health, National Institutes of Health, Building 15K, Room 204, MSC 2670, Bethesda, MD 20892-2670; E-mail:
Hide All

This research was supported by the Intramural Research Program of the NIH, NIMH. We gratefully acknowledge the children and families of patients and controls without whose participation this research would not have been possible. We also thank the staff of the Section on Bipolar Spectrum Disorders at the NIMH.

Hide All
Addington J. & Addington D. (1998). Facial affect recognition and information processing in schizophrenia and bipolar disorder. Schizophrenia Research, 32, 171181.
Adolphs R. (2002). Neural systems for recognizing emotion. Currrent Opinion in Neurobiology, 12, 169177.
Adolphs R., & Tranel D. (2004). Impaired judgments of sadness but not happiness following bilateral amygdala damage. Journal of Cognitive Neuroscience, 16, 453462.
Adolphs R., Tranel D., Hamann S., Young A. W., Calder A. J., Phelps E. A., et al. (1999). Recognition of facial emotion in nine individuals with bilateral amygdala damage. Neuropsychologia, 37, 11111117.
Althoff R. R., Faraone S. V., Rettew D. C., Morley C. P., & Hudziak J. J. (2005). Family, twin, adoption, and molecular genetic studies of juvenile bipolar disorder. Bipolar Disorder, 7, 598609.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Baron-Cohen S., Ring H. A., Wheelwright S., Bullmore E. T., Brammer M. J., Simmons A., et al. (1999). Social intelligence in the normal and autistic brain: an fMRI study. European Journal Neuroscience, 11, 18911898.
Berument S. K., Rutter M., Lord C., Pickles A., & Bailey A. (1999). Autism Screening Questionnaire: Diagnostic validity. British Journal of Psychiatry, 175, 444451.
Biederman J., Faraone S. V., Chu M. P., & Wozniak J. (1999). Further evidence of a bidirectional overlap between juvenile mania and conduct disorder in children. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 468476.
Bishop D. V. (1998). Development of the Children's Communication Checklist (CCC): A method for assessing qualitative aspects of communicative impairment in children. Journal of Child Psychology and Psychiatry, 39, 879891.
Bishop D. V., & Baird G. (2001). Parent and teacher report of pragmatic aspects of communication: Use of the children's communication checklist in a clinical setting. Developmental Medicine and Child Neurology, 43, 809818.
Blair R. J., & Coles M. (2000). Expression recognition and behavioural problems in early adolescence. Cognitive Development, 15, 421434.
Blair R. J., Colledge E., Murray L., & Mitchell D. G. (2001). A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. Journal of Abnormal Child Psychology, 29, 491498.
Blair R. J., Jones L., Clark F., & Smith M. (1997). The psychopathic individual: A lack of responsiveness to distress cues? Psychophysiology, 34, 192198.
Blair R. J., Morris J. S., Frith C. D., Perrett D. I., & Dolan R. J. (1999). Dissociable neural responses to facial expressions of sadness and anger. Brain, 122, 883893.
Blumberg H. P., Fredericks C., Wang F., Kalmar J. H., Spencer L., Papademetris X., et al. (2005). Preliminary evidence for persistent abnormalities in amygdala volumes in adolescents and young adults with bipolar disorder. Bipolar Disorders, 7, 570576.
Blumberg H. P., Kaufman J., Martin A., Whiteman R., Zhang J. H., Gore J. C., et al. (2003). Amygdala and hippocampal volumes in adolescents and adults with bipolar disorder. Archives of General Psychiatry, 60, 12011208.
Blumberg H. P., Martin A., Kaufman J., Leung H. C., Skudlarski P., Lacadie C., et al. (2003). Frontostriatal abnormalities in adolescents with bipolar disorder: Preliminary observations from functional MRI. American Journal of Psychiatry, 160, 13451347.
Bozikas V. P., Tonia T., Fokas K., Karavatos A., & Kosmidis M. H. (2006). Impaired emotion processing in remitted patients with bipolar disorder. Journal of Affective Disorders, 91, 5356.
Brody L. (1985). Gender differences in emotional development: A review of theories and research. Journal of Personality, 53, 102149.
Brotman M. A., Kassem L., Reising M., Guyer A. E., Dickstein D. P., Rich B. A., et al. (2007). Parental diagnoses in youth with narrow phenotype bipolar disorder or severe mood dysregulation. American Journal of Psychiatry, 164, 12381241.
Brotman M. A., Schmajuk M., Rich B. A., Dickstein D. P., Guyer A. E., Costello A. J., et al. (2006). Prevalence, clinical correlates, and longitudinal course of severe mood and behavioral dysregulation in children. Biological Psychiatry, 60, 991997.
Cadesky E. B., Mota V. L., & Schachar R. J. (2000). Beyond words: How do children with ADHD and/or conduct problems process nonverbal information about affect? Journal of the American Academy of Child & Adolescent Psychiatry, 39, 11601167.
Chang K., Adleman N. E., Dienes K., Simeonova D. I., Menon V., & Reiss A. (2004). Anomalous prefrontal–subcortical activation in familial pediatric bipolar disorder: A functional magnetic resonance imaging investigation. Archives of General Psychiatry, 61, 781792.
Chang K., Karchemskiy A., Barnea-Goraly N., Garrett A., Simeonova D. I., & Reiss A. (2005). Reduced amygdalar gray matter volume in familial pediatric bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 565573.
Chen B. K., Sassi R., Axelson D., Hatch J. P., Sanches M., Nicoletti M., et al. (2004). Cross-sectional study of abnormal amygdala development in adolescents and young adults with bipolar disorder. Biological Psychiatry, 56, 399405.
Cicchetti D., Ackerman B., & Izard C. (1995). Emotions and emotion regulation in developmental psychopathology. Development and Psychopathology, 7, 110.
Cicchetti D., & Curtis W. J. (2005). An event-related potential study of the processing of affective facial expressions in young children who experienced maltreatment during the first year of life. Developmental Psychopathology, 17, 641677.
Constantino J. N., Gruber C. P., Davis S., Hayes S., Passanante N., & Przybeck T. (2004). The factor structure of autistic traits. Journal of Child Psychology and Psychiatry, 45, 719726.
Constantino J. N., & Todd R. D. (2003). Autistic traits in the general population: a twin study. Archives of General Psychiatry, 60, 524530.
Corbett B., & Glidden H. (2000). Processing affective stimuli in children with attention-deficit hyperactivity disorder. Child Neuropsychology, 6, 144155.
Dalton K. M., Nacewicz B. M., Johnstone T., Schaefer H. S., Gernsbacher M. A., Goldsmith H. H., et al. (2005). Gaze fixation and the neural circuitry of face processing in autism. Nature Neuroscience, 8, 519526.
De Sonneville L. M., Verschoor C. A., Njiokiktjien C., Op het Veld V., Toorenaar N., & Vranken M. (2002). Facial identity and facial emotions: Speed, accuracy, and processing strategies in children and adults. Journal of Clinical and Experimental Neuropsychology, 24, 200213.
Delbello M. P., Zimmerman M. E., Mills N. P., Getz G. E., & Strakowski S. M. (2004). Magnetic resonance imaging analysis of amygdala and other subcortical brain regions in adolescents with bipolar disorder. Bipolar Disorders, 6, 4352.
Dickstein D. P., Milham M. P., Nugent A. C., Drevets W. C., Charney D. S., Pine D. S., et al. (2005). Frontotemporal alterations in pediatric bipolar disorder: Results of a voxel-based morphometry study. Archives of General Psychiatry, 62, 734741.
Dickstein D. P., Nelson E. E., McClure E. B., Grimley M. E., Knopf L., Brotman M. A., et al. (2007). Cognitive flexibility in phenotypes of pediatric bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 341355.
Dodge K. A., Lansford J. E., Burks V. S., Bates J. E., Pettit G. S., Fontaine R., et al. (2003). Peer rejection and social information-processing factors in the development of aggressive behavior problems in children. Child Development, 74, 374393.
Ekman P., & Friesen W. V. (1976). Pictures of facial affect. Palo Alto, CA: Consulting Psychologists Press.
Fries A. B., Ziegler T. E., Kurian J. R., Jacoris S., & Pollak S. D. (2005). Early experience in humans is associated with changes in neuropeptides critical for regulating social behavior. Proceedings of the National Academy of Sciences of the United States of America, 102, 1723717240.
Geller B., Bolhofner K., Craney J. L., Williams M., Delbello M. P., & Gundersen K. (2000). Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 15431548.
Getz G. E., Shear P. K., & Strakowski S. M. (2003). Facial affect recognition deficits in bipolar disorder. Journal of the International Neuropsychological Society, 9, 623632.
Goldstein T. R., Miklowitz D. J., & Mullen K. L. (2006). Social skills knowledge and performance among adolescents with bipolar disorder. Bipolar Disorders, 8, 350361.
Gorno-Tempini M. L., Pradelli S., Serafini M., Pagnoni G., Baraldi P., Porro C., et al. (2001). Explicit and incidental facial expression processing: An fMRI study. NeuroImage, 14, 465473.
Gross A. L., & Ballif B. (1991). Children's understanding of emotion from facial expression and situations: A review. Developmental Review, 11, 368398.
Guyer A. E., McClure E. B., Adler A., Brotman M. A., Rich B. A., Pine D. S., et al. (2007). Specificity of facial expression labeling deficits in childhood psychopathology. Journal of Clinical Psychology and Psychiatry, 48, 863871.
Harmer C. J., Grayson L., & Goodwin G. M. (2002). Enhanced recognition of disgust in bipolar illness. Biological Psychiatry, 51, 298304.
Harrigan J. (1984). The effects of task order on children's identification of facial expressions. Motivation and Emotion, 8, 157169.
Kaufman J., Birmaher B., Brent D., Rao U., Flynn C., Moreci P., et al. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 980988.
Kaur S., Sassi R. B., Axelson D., Nicoletti M., Brambilla P., Monkul E. S., et al. (2005). Cingulate cortex anatomical abnormalities in children and adolescents with bipolar disorder. American Journal of Psychiatry, 162, 16371643.
Keller M. B., Lavori P. W., Friedman B., Nielsen E., Endicott J., McDonald-Scott P. et al. (1987). The Longitudinal Interval Follow-up Evaluation. A comprehensive method for assessing outcome in prospective longitudinal studies. Archives of General Psychiatry, 44, 540548.
Killgore W. D., & Yurgelun-Todd D. A. (2004). Activation of the amygdala and anterior cingulate during nonconscious processing of sad versus happy faces. NeuroImage, 21, 12151223.
Klinnert M. D., Emde R. N., Butterfield P., & Campos J. J. (1987). Social referencing: The infant's use of emtoional signals from a friendly adult with mother present. Annual Progress in Child Psychiatry and Child Development, 22, 427432.
Kowatch R. A., Youngstrom E. A., Danielyan A., & Findling R. L. (2005). Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disorders, 7, 483496.
Leibenluft E., Charney D. S., Towbin K. E., Bhangoo R. K., & Pine D. S. (2003). Defining clinical phenotypes of juvenile mania. American Journal of Psychiatry, 160, 430437.
Leibenluft E., Rich B. A., Vinton D. T., Nelson E. E., Fromm S. J., Berghorst L. H., et al. (2007). Neural circuitry engaged during unsuccessful motor inhibition in pediatric bipolar disorder. American Journal of Psychiatry, 164, 5260.
Lembke A. & Ketter T. A. (2002). Impaired recognition of facial emotion in mania. American Journal of Psychiatry, 159, 302304.
Lennox B. R., Jacob R., Calder A. J., Lupson V., & Bullmore E. T. (2004). Behavioural and neurocognitive responses to sad facial affect are attenuated in patients with mania. Psychological Medicine, 34, 795802.
Lenti C., Giacobbe A., & Pegna C. (2000). Recognition of emotional facial expressions in depressed children and adolescents. Perceptual and Motor Skills, 91, 227236.
Lewinsohn P. M., Seeley J. R., & Klein D. N. (2003). Bipolar disorders during adolescence. Acta Psychiatrica Scandinavica Supplementum, 4750.
March J. S., Parker J. D., Sullivan K., Stallings P., & Conners C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 554565.
Markham R. & Adams K. (1992). The effect of type of task on childrens' identification of facial expressions. Journal of Nonverbal Behavior, 16, 2139.
Marshall P. J., & Fox N. A. (2004). A comparison of the electroencephalogram between institutionalized and community children in Romania. Journal of Cognitive Neuroscience, 16, 13271338.
McClure E. B. (2000). A meta-analytic review of sex differences in facial expression processing and their development in infants, children, and adolescents. Psychological Bulletin, 126, 424453.
McClure E. B., Treland J. E., Snow J., Schmajuk M., Dickstein D. P., Towbin K. E., et al. (2005). Deficits in social cognition and response flexibility in pediatric bipolar disorder. American Journal of Psychiatry, 162, 16441651.
Morris J. S., Frith C. D., Perrett D. I., Rowland D., Young A. W., Calder A. J., et al. (1996). A differential neural response in the human amygdala to fearful and happy facial expressions. Nature, 383, 812815.
Parker S. W., & Nelson C. A. (2005). The impact of early institutional rearing on the ability to discriminate facial expressions of emotion: An event-related potential study. Child Development, 76, 5472.
Penn D. L., Mueser K. T., Spaulding W., Hope D. A., & Reed D. (1995). Information processing and social competence in chronic schizophrenia. Schizophrenia Bulletin, 21, 269281.
Phillips M. L., Bullmore E. T., Howard R., Woodruff P. W., Wright I. C., Williams S. C., et al. (1998). Investigation of facial recognition memory and happy and sad facial expression perception: An fMRI study. Psychiatry Research, 83, 127138.
Phillips M. L., Young A. W., Senior C., Brammer M., Andrew C., Calder A. J., et al. (1997). A specific neural substrate for perceiving facial expressions of disgust. Nature, 389, 495498.
Pogge D. L., Wayland-Smith D., Zaccario M., Borgaro S., Stokes J., & Harvey P. D. (2001). Diagnosis of manic episodes in adolescent inpatients: Structured diagnostic procedures compared to clinical chart diagnoses. Psychiatry Research, 101, 4754.
Pollak S. D., Cicchetti D., Hornung K., & Reed A. (2000). Recognizing emotion in faces: Developmental effects of child abuse and neglect. Developmental Psychology, 36, 679688.
Pollak S. D., & Kistler D. J. (2002). Early experience is associated with the development of categorical representations for facial expressions of emotion. Proceedings of the National Academy of Sciences of the United States of America, 99, 90729076.
Pollak S. D., Klorman R., Thatcher J. E., & Cicchetti D. (2001). P3b reflects maltreated children's reactions to facial displays of emotion. Psychophysiology, 38, 267274.
Pollak S. D., & Tolley-Schell S. A. (2003). Selective attention to facial emotion in physically abused children. Journal of Abnormal Psychology, 112, 323338.
Poznanski E. O., Grossman J. A., Buchsbaum Y., Banegas M., Freeman L., & Gibbons R. (1984). Preliminary studies of the reliability and validity of the Children's Depression Rating Scale. Journal of the American Academy of Child Psychiatry, 23, 191197.
Rich B. A., Schmajuk M., Perez-Edgar K. E., Fox N. A., Pine D. S., & Leibenluft E. (2007). Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. American Journal of Psychiatry, 164, 309317.
Rich B. A., Vinton D., Roberson-Nay R., Hommer R., Berghorst L., McClure E., et al. (2006). Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder. Proceedings of the National Academy of Sciences of the United States of America, 103, 89008905.
Rucklidge J. J. (2006). Psychosocial functioning of adolescents with and without paediatric bipolar disorder. Journal of Affective Disorders, 91, 181188.
Shaffer D., Gould M. S., Brasic J., Ambrosini P., Fisher P., Bird H., et al. (1983). A Children's Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 12281231.
Sprengelmeyer R., Rausch M., Eysel U. T., & Przuntek H. (1998). Neural structures associated with recognition of facial expressions of basic emotions. Proceedings in Biological Sciences/ The Royal Society, 265, 19271931.
Stevens D., Charman T., & Blair R. J. (2001). Recognition of emotion in facial expressions and vocal tones in children with psychopathic tendencies. The Journal of Genetic Psychology, 162, 201211.
Taylor M. J., Batty M., & Itier R. J. (2004). The faces of development: A review of early face processing over childhood. Journal of Cognitive Neuroscience, 16, 14261442.
Towbin K. E., Pradella A., Gorrindo T., Pine D. S., & Leibenluft E. (2005). Autism spectrum traits in children with mood and anxiety disorders. Journal of Child and Adolescent Psychopharmacology, 15, 452464.
Wechsler D. (1999). Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: Psychological Corporation.
Whalen P. J., Rauch S. L., Etcoff N. L., McInerney S. C., Lee M. B., & Jenike M. A. (1998). Masked presentations of emotional facial expressions modulate amygdala activity without explicit knowledge. Journal of Neuroscience, 18, 411418.
Wilke M., Kowatch R. A., Delbello M. P., Mills N. P., & Holland S. K. (2004). Voxel-based morphometry in adolescents with bipolar disorder: First results. Psychiatry Research, 131, 5769.
Wilkinson D. & Halligan P. (2004). The relevance of behavioural measures for functional-imaging studies of cognition. Nature Reviews. Neuroscience, 5, 6773.
Yang T. T., Menon V., Eliez S., Blasey C., White C. D., Reid A. J., et al. (2002). Amygdalar activation associated with positive and negative facial expressions. NeuroReport, 13, 17371741.
Young R. C., Biggs J. T., Ziegler V. E., & Meyer D. A. (1978). A rating scale for mania: Reliability, validity and sensitivity. Britsh Journal of Psychiatry, 133, 429435.
Yurgelun-Todd D. A., Gruber S. A., Kanayama G., Killgore W. D., Baird A. A., & Young A. D. (2000). fMRI during affect discrimination in bipolar affective disorder. Bipolar Disorders, 2, 237248.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Development and Psychopathology
  • ISSN: 0954-5794
  • EISSN: 1469-2198
  • URL: /core/journals/development-and-psychopathology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 2
Total number of PDF views: 69 *
Loading metrics...

Abstract views

Total abstract views: 318 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd November 2017. This data will be updated every 24 hours.