In 1997 in this Journal we published the “Reading the Mind in the Eyes” Test, as a measure of adult “mentalising”. Whilst that test succeeded in discriminating a group of adults with Asperger syndrome (AS) or high-functioning autism (HFA) from controls, it suffered from several psychometric problems. In this paper these limitations are rectified by revising the test. The Revised Eyes Test was administered to a group of adults with AS or HFA (N = 15) and again discriminated these from a large number of normal controls (N = 239) drawn from different samples. In both the clinical and control groups the Eyes Test was inversely correlated with the Autism Spectrum Quotient (the AQ), a measure of autistic traits in adults of normal intelligence. The Revised Eyes Test has improved power to detect subtle individual differences in social sensitivity.

We review recent research on the prevalence, causes, and effects of diagnostic comorbidity among the most common groups of child and adolescent psychiatric disorders; anxiety disorders, depressive disorders, attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, and substance abuse. A meta-analysis of representative general population studies provides estimates of the strength of associations between pairs of disorders with narrower confidence intervals than have previously been available. Current evidence convincingly eliminates methodological factors as a major cause of comorbidity. We review the implications of comorbidity for understanding the development of psychopathology and for nosology.

Cross-sectional quantitative designs are often used to investigate whether peer victimization is positively related to psychosocial maladjustment. This paper presents a meta-analytic review of cross-sectional studies, published between 1978 and 1997, of the association of peer victimization with psychosocial maladjustment. Mean effect sizes were calculated for the association between peer victimization and each form of maladjustment (depression, loneliness, generalized and social anxiety, and global and social self-worth) assessed. The results suggested that victimization is most strongly related to depression, and least strongly related to anxiety. There was no evidence that victimization is more strongly related to social than to psychological forms of maladjustment. Effect sizes were stronger when the same informants were used to assess both victimization and maladjustment than when different informants were used. There were some design limitations to the studies reviewed, but all together their results provide a strong background for more complex research into the course and treatment of victims' distress.

The Development and Well-Being Assessment (DAWBA) is a novel package of questionnaires, interviews, and rating techniques designed to generate ICD-10 and DSM-IV psychiatric diagnoses on 5–16-year-olds. Nonclinical interviewers administer a structured interview to parents about psychiatric symptoms and resultant impact. When definite symptoms are identified by the structured questions, interviewers use open-ended questions and supplementary prompts to get parents to describe the problems in their own words. These descriptions are transcribed verbatim by the interviewers but are not rated by them. A similar interview is administered to 11–16-year-olds. Teachers complete a brief questionnaire covering the main conduct, emotional, and hyperactivity symptoms and any resultant impairment. The different sorts of information are brought together by a computer program that also predicts likely diagnoses. These computer-generated summary sheets and diagnoses form a convenient starting point for experienced clinical raters, who decide whether to accept or overturn the computer diagnosis (or lack of diagnosis) in the light of their review of all the data, including transcripts. In the present study, the DAWBA was administered to community (N = 491) and clinic (N = 39) samples. There was excellent discrimination between community and clinic samples in rates of diagnosed disorder. Within the community sample, subjects with and without diagnosed disorders differed markedly in external characteristics and prognosis. In the clinic sample, there was substantial agreement between DAWBA and case note diagnoses, though the DAWBA diagnosed more comorbid disorders. The use of screening questions and skip rules greatly reduced interview length by allowing many sections to be omitted with very little loss of positive information. Overall, the DAWBA successfully combined the cheapness and simplicity of respondent-based measures with the clinical persuasiveness of investigator-based diagnoses. The DAWBA has considerable potential as an epidemiological measure, and may prove to be of clinical value too.

The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioural screening questionnaire that asks about children's and teenagers' symptoms and positive attributes; the extended version also includes an impact supplement that asks if the respondent thinks the young person has a problem, and if so, enquires further about chronicity, distress, social impairment, and burden for others. Closely similar versions are completed by parents, teachers, and young people aged 11 or more. The validation study involved two groups of 5–15-year-olds: a community sample (N=467) and a psychiatric clinic sample (N=232). The two groups had markedly different distributions on the measures of perceived difficulties, impact (distress plus social impairment), and burden. Impact scores were better than symptom scores at discriminating between the community and clinic samples; discrimination based on the single “Is there a problem?” item was almost as good. The SDQ burden rating correlated well (r=.74) with a standardised interview rating of burden. For clinicians and researchers with an interest in psychiatric caseness and the determinants of service use, the impact supplement of the extended SDQ appears to provide useful additional information without taking up much more of respondents' time.

We review research evidence on the emergence and development of active “self-and-other” awareness in infancy, and examine the importance of its motives and emotions to mental health practice with children. This relates to how communication begins and develops in infancy, how it influences the individual subject's movement, perception, and learning, and how the infant's biologically grounded self-regulation of internal state and self-conscious purposefulness is sustained through active engagement with sympathetic others. Mutual self-other-consciousness is found to play the lead role in developing a child's cooperative intelligence for cultural learning and language. A variety of preconceptions have animated rival research traditions investigating infant communication and cognition. We distinguish the concept of “intersubjectivity”, and outline the history of its use in developmental research.The transforming body and brain of a human individual grows in active engagement with an environment of human factors—organic at first, then psychological or inter-mental. Adaptive, human-responsive processes are generated first by interneuronal activity within the developing brain as formation of the human embryo is regulated in a support-system of maternal tissues. Neural structures are further elaborated with the benefit of intra-uterine stimuli in the foetus, then supported in the rapidly growing forebrain and cerebellum of the young child by experience of the intuitive responses of parents and other human companions. We focus particularly on intrinsic patterns and processes in pre-natal and post-natal brain maturation that anticipate psychosocial support in infancy. The operation of an intrinsic motive formation (IMF) that developed in the core of the brain before birth is evident in the tightly integrated intermodal sensory-motor coordination of a newborn infant's orienting to stimuli and preferential learning of human signals, by the temporal coherence and intrinsic rhythms of infant behaviour, especially in communication, and neonates' extraordinary capacities for reactive and evocative imitation. The correct functioning of this integrated neural motivating system is found to be essential to the development of both the infant's purposeful consciousness and his or her ability to cooperate with other persons' actions and interests, and to learn from them.The relevance of infants' inherent intersubjectivity to major child mental health issues is highlighted by examining selected areas of clinical concern. We review recent findings on postnatal depression, prematurity, autism, ADHD, specific language impairments, and central auditory processing deficits, and comment on the efficacy of interventions that aim to support intrinsic motives for intersubjective communication when these are not developing normally.

Repetitive behaviour is widely known to be one of three core and defining features of autism (ICD-10, World Health Organisation, 1990; DSM-IV, American Psychiatric Association, 1994). Any clinician who is told that a child repetitively flaps his arms, spends hours lining up Lego bricks, will not tolerate changes in routine, and has a peculiar fascination with the many varieties of electric fan available on the market will, before hearing anything about the social functioning or communicative abilities of that child, be deeply suspicious that the child is autistic. However, the literature on repetitive behaviour in autism reveals several paradoxes and inconsistencies. First, given the significant challenge that this class of behaviour can pose, the literature devoted to the study of this behaviour in autism is relatively small in comparison with the extensive literature on other aspects of autistic symptomatology. Whilst certain classes of repetitive behaviour have been described as nonspecific to autism (e.g. Prior & Macmillan, 1973), others have been suggested to be of particular significance to the disorder (e.g. U. Frith, 1989; Kanner, 1943; Wing & Gould, 1979). Finally, although repetitive behaviour is commonly defined as behaviour with no obvious goal or function (e.g. Hutt & Hutt, 1970), much of the literature concerning repetitive behaviour in autism has sought to explore what function this behaviour serves.

The aim of this Annotation is to provide a review of what is known about repetitive behaviour in autism, its specificity to the syndrome, and the functions or mechanisms that might underlie this behaviour at the psychological level.

This study investigated predictors of attachment security in a play context using a sample of 71 mothers and their 6-month-old infants. We sought to rethink the concept of maternal sensitivity by focusing on mothers' ability accurately to read the mental states governing infant behaviour. Five categories were devised to assess this ability, four of which were dependent on maternal responses to infant behaviours, such as object-directed activity. The fifth, mothers' Appropriate mind-related comments, assessed individual differences in mothers' proclivity to comment appropriately on their infants' mental states and processes. Higher scores in this fifth category related to a secure attachment relationship at 12 months. Maternal sensitivity and Appropriate mind-related comments were independent predictors of attachment security at 12 months, respectively accounting for 6·5% and 12·7% of its variance. We suggest that these findings are in line with current theorising on internal working models of attachment, and may help to explain security-related differences in mentalising abilities.

Developmental psychology and the study of behaviour and emotion have tended to be considered in parallel to the study of neurobiological processes. This review explores the effects of child abuse and neglect on the brain, excluding nonaccidental injury that causes gross physical trauma to the brain. It commences with a background summary of the nature, context, and some deleterious effects of omission and commission within child maltreatment. There is no post-maltreatment syndrome, outcomes varying with many factors including nature, duration, and interpersonal context of the maltreatment as well as the nature of later intervention. There then follows a section on environmental influences on brain development, demonstrating the dependence of the orderly process of neurodevelopment on the child's environment. Ontogenesis, or the development of the self through self-determination, proceeds in the context of the nature–nurture interaction. As a prelude to reviewing the neurobiology of child abuse and neglect, the next section is concerned with bridging the mind and the brain. Here, neurobiological processes, including cellular, biochemical, and neurophysiological processes, are examined alongside their behavioural, cognitive, and emotional equivalents and vice versa. Child maltreatment is a potent source of stress and the stress response is therefore discussed in some detail. Evidence is outlined for the buffering effects of a secure attachment on the stress response. The section dealing with actual effects on the brain of child abuse and neglect discusses manifestations of the stress response including dysregulation of the hypothalamic-pituitary-adrenal axis, and parasympathetic and catecholamine responses. Recent evidence about reduction in brain volume following child abuse and neglect is also outlined. Some biochemical, functional, and structural changes in the brain that are not reflections of the stress response are observed following child maltreatment. The mechanisms bringing about these changes are less clearly understood and may well be related to early and more chronic abuse and neglect affecting the process of brain development. The behavioural and emotional concomitants of their neurobiological manifestations are discussed. The importance of early intervention and attention to the chronicity of environmental adversity may indicate the need for permanent alternative caregivers, in order to preserve the development of the most vulnerable children.

The extent of developmental deficit and catch-up following adoption after severe global early privation was examined at 4 years in a sample of 111 Romanian children who came to the U.K. before the age of 2 years, and compared with respect to their functioning at the same age to a sample of 52 U.K. adopted children placed before the age of 6 months. The measures at 4 years included height, head circumference, and general cognitive level (assessed on both the McCarthy and Denver Scales). The children from Romania were severely developmentally impaired at the time of U.K. entry, with about half below the third percentile on height, on weight, on head circumference, and on developmental quotient. Many were also in a poor physical state with recurrent intestinal and respiratory infections. The catch-up in both physical growth and cognitive level appeared nearly complete at 4 years for those children who came to the U.K. before the age of 6 months, despite the fact that their background prior to U.K. entry was similar to the children who came to the U.K. when older. The developmental catch-up was also impressive, but not complete, in those placed after 6 months of age. The mean McCarthy General Cognitive Index was 92 compared with 109 for the within-U.K. adoptees. The strongest predictor of level of cognitive functioning at 4 years was the children's age at entry to the U.K. It was concluded that the remaining cognitive deficit was likely to be a consequence of gross early privation, with psychological privation probably more important than nutritional privation. A further follow-up at age 6 years will determine whether there is continuing recovery after 4 years.

The aim of this study was to investigate whether impaired response inhibition is uniquely related to AD/HD or whether deficits in response inhibition are also evident in other psychopathological disorders. Furthermore, the suggestion was examined that anxiety disorders are associated with abnormally high levels of response inhibition. This paper presents the results of a meta-analysis of eight studies in which response inhibition was assessed with the so-called stop task in five groups of children: children with attention deficit/hyperactivity disorder (AD/HD), children with conduct disorder (CD), children with AD/HD+CD, children with anxiety disorders, and control children. A total of 456 children participated in the 8 studies. All children were in the age range 6–12 years. Consistent and robust evidence was found for a response inhibition deficit in AD/HD. However, response inhibition deficits did not distinguish children with AD/HD from children with CD, nor from children with comorbid AD/HD+CD. Contrary to predictions, anxious children did not demonstrate enhanced levels of response inhibition.

We analysed results from seven American and British studies that compared groups of mothers with and without clinically diagnosed depression, and assessed the attachment category of their infants (under 3 years) using the Strange Situation. The samples were predominantly middle-income and free of risk factors other than maternal depression. Meta-analysis using loglinear modelling and standardised residuals showed that the effect of depression on the distribution of infants' attachment was statistically heterogeneous. However, after removing one outlier study, the effect of depression was homogeneous across the remaining six studies. Infants of depressed mothers showed significantly reduced likelihood of secure (B) attachment and marginally raised likelihood of avoidant (A) and disorganised (D) attachment. The first two effects varied considerably in magnitude between studies, whereas the increase in disorganised attachment, from 17% to 28% on average, was consistent.

This paper reports the results of a randomised treatment trial of two forms of outpatient family intervention for anorexia nervosa. Forty adolescent patients with anorexia nervosa were randomly assigned to “conjoint family therapy” (CFT) or to “separated family therapy” (SFT) using a stratified design controlling for levels of critical comments using the Expressed Emotion index. The design required therapists to undertake both forms of treatment and the distinctiveness of the two therapies was ensured by separate supervisors conducting live supervision of the treatments. Measures were undertaken on admission to the study, at 3 months, at 6 months and at the end of treatment. Considerable improvement in nutritional and psychological state occurred across both treatment groups. On global measure of outcome, the two forms of therapy were associated with equivalent end of treatment results. However, for those patients with high levels of maternal criticism towards the patient, the SFT was shown to be superior to the CFT. When individual status measures were explored, there were further differences between the treatments. Symptomatic change was more marked in the SFT whereas there was considerably more psychological change in the CFT group. There were significant changes in family measures of Expressed Emotion. Critical comments between parents and patient were significantly reduced and that between parents was also diminished. Warmth between parents increased.

This paper focuses on general social functioning in two groups of young men, one with autism and one with developmental receptive language disorders, who were first assessed at the ages of 7–8 years. At that time, although matched for nonverbal IQ (mean 92–93) and expressive language, the Language group showed significantly fewer social and behavioural problems. At follow-up, when aged on average, 23 to 24 years, the Autism group continued to show significantly more impairments in terms of stereotyped behaviour patterns, social relationships, jobs, and independence. However, problems in all these areas were also common in the Language group. Many still lived with their parents, few had close friends or permanent jobs, and ratings of social interaction indicated abnormalities in a number of different areas. On a composite measure of social competence only 10% of the Language group was assessed as having severe social difficulties compared to 74% of the Autism group. Nevertheless, 65% were rated as having moderate social problems and only 25% were rated as being of near/normal social functioning. Two individuals in the Language group, but none in the Autism group, had also developed a florid paranoid psychosis in late adolescence.

As in the follow-up of cognitive and linguistic functioning (see Mawhood et al., 2000, this volume, pp. 547–559), discriminant function analysis, which had clearly distinguished between the groups as children, now showed much greater overlap between them. Regression analysis indicated that although early language ability appeared to be related to outcome in the Autism group, there was little association between any measures of childhood functioning and prognosis in the Language group. Theoretically, these findings have implications for our understanding of the nature of autism and other pervasive language disorders, and of the relationship between them. Practically, they demonstrate the very persistent problems experienced by individuals with developmental language disorders, and their need for much greater help and support than is presently available.

The literacy skills of 56 school leavers from the Bishop and Edmundson (1987) cohort of preschoolers with specific language impairment (SLI) were assessed at 15 years. The SLI group performed worse on tests of reading, spelling, and reading comprehension than age-matched controls and the literacy outcomes were particularly poor for those with Performance IQ less than 100. The rate of specific reading retardation in the SLI group had increased between the ages of 8½ and 15 years and there had been a substantial drop in reading accuracy, relative to age. However, over 35% had reading skills within the normal range and those who had had isolated impairments of expressive phonology had a particularly good outcome. Our findings highlight the limitations of discrepancy definitions of dyslexia that do not take account of the changing demands of reading over time. We argue that children's phonological difficulties place them at risk of literacy failure at the outset of reading and that later, impairments of other language skills compromise development to adult levels of fluency.

More able individuals with autism and Asperger syndrome (AS) have been shown to pass relatively high level theory of mind (ToM) tasks without displaying commensurate levels of social adaptation in naturalistic settings. This paper presents a social cognitive procedure—the Social Attribution Task (SAT)—that reduces factors thought to facilitate ToM task performance without facilitating real-life social functioning. Sixty participants with autism (N = 20), AS (N = 20), and normally developing adolescents and adults (N = 20) with normative IQs were asked to provide narratives describing Heider and Simmel's (1944) silent cartoon animation in which geometric shapes enact a social plot. These narratives were coded in terms of the participants' abilities to attribute social meaning to the geometric cartoon. The SAT provides reliable and quantified scores on seven indices of social cognition. Results revealed marked deficits in both clinical groups across all indices. These deficits were not related to verbal IQ or level of metalinguistic skills. Individuals with autism and AS identified about a quarter of the social elements in the story, a third of their attributions were irrelevant to the social plot, and they used pertinent ToM terms very infrequently. They were also unable to derive psychologically based personality features from the shapes' movements. When provided with more explicit verbal information on the nature of the cartoon, individuals with AS improved their performance slightly more than those with autism, but not significantly so.

This study examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2–4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more—and 67% at least two—comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behaviour problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions.

The reading and oral language scores of 110 children with a specific reading disability (SRD) and 102 children with a specific language impairment (SLI) indicated that approximately 53% of children with an SRD and children with an SLI could be equally classified as having an SRD or an SLI, 55% of children with an SRD have impaired oral language, and 51% of children with an SLI have a reading disability. Finding that a large percentage of children can be equally classified as SRD or SLI has repercussions for the criteria used to define an SRD, for conceptualising subgroups of learning disability, and for estimates of the incidence of SRD. Further, it highlights the need for future studies to assess both the reading and oral language abilities of SRD and SLI participants to determine how specifically impaired and homogeneous samples really are.

Six per cent of child in a sample of 111 children who were adopted into U.K. families from Romania, and who were systematically assessed at the ages of 4 and 6 years, showed autistic-like patterns of behaviour. A further 6% showed milder (usually isolated) autistic features. Such autistic characteristics were not found in a similarly studied sample of 52 children adopted in the first 6 months of life within the U.K. The children from Romania with autistic patterns showed clinical features closely similar to “ordinary” autism at 4 years but they differed with respect to the improvement seen by age 6 years, to an equal sex ratio, and to a normal head circumference. The children from Romania with autistic features tended to differ from the other Romanian adoptees with respect to a greater degree of cognitive impairment and a longer duration of severe psychological privation.

Fifty children aged 7–14 years with a principal diagnosis of social phobia were randomly assigned to either child-focused cognitive-behaviour therapy (CBT), CBT plus parent involvement, or a wait list control (WLC). The integrated CBT program involved intensive social skills training combined with graded exposure and cognitive challenging. At post-treatment, significantly fewer children in the treatment conditions retained a clinical diagnosis of social phobia compared to the WLC condition. In comparison to the WLC, children in both CBT interventions showed significantly greater reductions in children's social and general anxiety and a significant increase in parental ratings of child social skills performance. At 12-month follow-up, both treatment groups retained their improvement. There was a trend towards superior results when parents were involved in treatment, but this effect was not statistically significant.