J Autism Dev Disord (2008) 38:1161–1165
DOI 10.1007/s10803-007-0474-1
BRIEF REPORT
Brief Report: Cognitive Flexibility and Focused Attention
in Children and Adolescents with Asperger Syndrome or
High-Functioning Autism as Measured on the Computerized
Version of the Wisconsin Card Sorting Test
Nils Kaland Æ Lars Smith Æ Erik Lykke Mortensen
Published online: 27 October 2007
Ó Springer Science+Business Media, LLC 2007
Abstract The aim of the present study was to assess mental
flexibility and set maintenance of a group of individuals with
Asperger syndrome (AS) or high-functioning autism (HFA)
(N = 13; mean age 16,4), as compared with a matched group
of typically developing children and adolescents (N = 13;
mean age 15,6) on the computerized version of the Wis-
consin Card Sorting Test (WCST). The participants in the
AS/HFA group performed less well than the controls on all
categories of the WCST, but the differences did not reach
conventional statistical significance on most categories of
the WCST. On the category failure to maintain set, however,
the AS/HFA participants performed significantly less well
than the controls, suggesting a deficit of focused attention.
Keywords Asperger syndrome

High-functioning autism
Executive function

Wisconsin Card Sorting Test
Attention problems
Introduction
Asperger syndrome (AS), termed after the Austrian phy-
sician, Hans Asperger, (1944/91), is a type of pervasive
development disorder, included in the ICD-10 (World
N. Kaland (&)
Faculty of Social Science, Lillehammer University College,
Gudbrandsdalsvegen 350, Lillehammer 2624, Norway
e-mail: nils@kaland.net
L. Smith
Institute of Psychology, University of Oslo, Oslo, Norway
E. L. Mortensen
Department of Health Psychology, Institute of Public Health,
University of Copenhagen, Copenhagen, Denmark
Health Organization (WHO) 1993) and the DSM-IV-TR
(American Psychiatric Association (APA) 2000), charac-
terized by deficits in reciprocal social interaction of the
autistic kind, subtle impairment of verbal and non-verbal
communication and the presence of idiosyncratic isolated
interests. On the basis of accumulated research evidence, it
appears that there are very few qualitative distinctions
between AS and high-functioning autism (HFA), and that
most symptoms, associated features, and biological indices
are shared or overlapping (Mcintosh and Dissanayke 2004;
Ozonoff and McMahon Griffith 2000). In the present
context, the two terms, AS and HFA, will be used
interchangeably.
There is now a considerable body of evidence showing
that a majority of individuals with an autism spectrum
disorder (ASD) are subject to a social-cognitive dysfunc-
tion (Kaland et al. 2002; Wellman et al. 2001). Another
cognitive deficit in autism spectrum disorder is executive
dysfunction (Pennington and Ozonoff 1996) ‘Executive
functions’ (EF) is an umbrella term for functions such as
mental flexibility, planning, set maintenance, working
memory, impulse control, and inhibition, as well as the
initiation and monitoring of such activities (Hill 2004).
Empirical research on the executive functions of indi-
viduals with autism spectrum disorders has been
extensively conducted with a variety of tests, and different
components of these functions have been investigated
(Hughes et al. 1994; Ozonoff et al. 1991; Ozonoff and
McEvoy 1994; Ozonoff et al. 2004; Pennington and Ozo-
noff 1996). Executive functions are presumably linked to
frontal structures of the brain and to the prefrontal cortex in
particular (Pennington and Ozonoff 1996; Ozonoff et al.
2004; Roberts et al. 1998; Stuss and Knight 2002).
The present study of cognitive flexibility and focused
attention employed the Wisconsin Card Sorting Test
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(WCST) (Heaton et al. 1993). This instrument is com-
monly regarded as ‘‘the gold standard executive function
task’’ (Ozonoff et al. 2005, p. 532). It promises to be a
highly sensitive indicator of executive functions, especially
such as mental flexibility, planning, and set maintenance.
The WCST has been used in studies of clinical groups
comprising children with autism spectrum disorders, lan-
guage impairments, dyslexia, and ADHD, and individuals
with psychiatric conditions (Liss et al. 2001; Nyden et al.
1999; Ozonoff 1997; Pennington and Ozonoff 1996; Ozo-
noff et al. 1991).
The present work was part of a more extensive inves-
tigation of cognitive functions of children and adolescents
with AS/HFA. As the less intelligent individuals with AS/
HFA who had participated in a previous study (Kaland
et al. 2002) had been excluded as participants, the aim of
the study was to assess whether the remaining 13 matched
10–20-years-old normally intelligent children and adoles-
cents with AS would perform significantly less well on the
central categories of the WCST́s computerized version as
compared with a matched group of normally developing
children and adolescents.
Method
Participants
The participants in the AS/HFA group were recruited from
Kasperskolen in Copenhagen, which is a special school for
children and adolescents with Pervasive Developmental
Disorders, and from the Centre for Autism in Copenhagen.
About 25 individuals were potential participants in the
study, but only those who were regarded as specifically
meeting the ICD-10 criteria for AS were included. The
participants in the clinical group had been independently
diagnosed in clinical settings by experienced psychologists
and child psychiatrists and had received the diagnosis of
AS. They had been assessed on ADI-R (Lord et al. 1994)
and on ADOS (Lord et al. 1989). The controls were nor-
mally developing volunteers recruited from schools in
Copenhagen.
The present report presents data on 13 pairs of matched
index and control participants. The pairs were individually
matched on WISC-III IQ (Wechsler 1998) and chrono-
logical age. As shown in Table 1, there were small and
Table 1 Descriptive statistics
Variable Asperger group (N = 13)
a
Repeated measure ANOVA Chronological ageb 16.40 (2.84)
corresponding to a matched Full scale IQ 109.00 (11.52)
pairs t-test Verbal IQ 108.92 (14.55)
b
Months transformed to Performance IQ 107.00 (8.80)
decimal
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J Autism Dev Disord (2008) 38:1161–1165
insignificant differences between the AS/HFA and control
children on age as well as the three IQs (the range of Full
Scale IQs was 94–125 and 92–122 in the AS/HFA and the
control group, respectively). Eleven of the thirteen partic-
ipants in the AS/HFA group had higher VIQ than PIQ.
Only males were included in the present study. All par-
ticipants were free of medication at the time of testing.
Analysis of questionnaires, completed by 11 of the 13
pairs of parents, revealed no significant group differences
in level of parental education (F (1,10) = 0,49, p = .50),
and in parental education plus occupational experience (F
(1,10) = 0,01, p = .93).
The WCST
The computerized version of the WCST, consisting of four
stimulus cards and 128 response cards, was employed
(Heaton et al. 1993). The test proceeds through a number
of shifts in set (sorting principles) that varies along three
dimensions (color, form and number). Successful perfor-
mance on the WCST requires the participant first to
determine the correct sorting principle on the basis of
computer feedback, and then to maintain this sorting
principle or set. Scores were based on number of trials
administered, total number of correct responses, number of
errors, number of perseverative responses, number of
perseverative errors, number of non-perseverative errors,
number of categories completed, number of trials to com-
plete the first category, conceptual level responses, failure
to maintain set, and learning to learn.
Procedure
The participants were told that this test was a little unusual
in the sense that the examiner could not tell very much
about how to do it. Four ‘‘key cards’’ were displayed at the
top of the computer screen. The participant was asked to
match each of the cards that appeared on the screen to one
of the four key cards. Four symbols on the keyboard in
front of the participant resembled the four cards at the top
of the screen. In order to match the cards, the participant
had to press the key with the symbol he thought would
match the card on the screen. Then a new card appeared
from the bottom of the screen.
Control group (N = 13) Difference F (df 1,12)a p
15.60 (3.07) 0.79 0.50 .50
109.62 (10.36) –0.62 0.18 .68
110.15 (12.25) –1.23 0.18 .68
106.92 (12.87) 0.08 0.00 .98
J Autism Dev Disord (2008) 38:1161–1165 1163

The examiner told the participants if they had placed a
card correctly or incorrectly and each correct response was
followed by a high-pitch beep, whereas a buzzer followed
an incorrect trial. Once 10 consecutive cards had been
categorized correctly, the sorting principle changed; all
sorts according to the previously correct strategy now
received a negative feedback. The participants were then
expected to use the examiner’s feedback to shift to a new
categorization principle until 128 response cards had been
completed.
Results
The results are listed in Table 2. As may be seen, the
participants in the AS group performed less well than those
in the control group on all categories, but the differences
did not reach statistical significance, except for the cate-
gory failure to maintain set (p \ .04). Table 2 also shows
that the differences were approaching conventional statis-
tical significance on conceptual level responses and
categories completed. With only 13 participants in each
group statistical power was necessarily low.
No significant differences were observed between the
AS and the control group with respect to the correlations
between background variables (age and IQ) and WCST
performance. Consequently, we calculated the mean of the
correlations in the two groups (using Fischer’s Z-trans-
formation). The mean correlations were generally low (in
most cases \ .20) and insignificant.
Discussion
The participants in the AS group performed below the level
of the control group on all measures of the WCST. How-
ever, the differences between the groups were not
statistically significant, except for the category failure to
maintain set. This pattern of group differences suggests
that intelligent individuals with AS or HFA may be less
prone than individuals with a diagnosis of autism to per-
severate on the WCST. The reported group difference on
the category conceptual level responses, which almost
reached statistical significance (p = .06), suggests than the
participants in the clinical group showed less reliable
insight into the correct sorting principle than the typically
developed control persons.
Some studies have found limited executive dysfunctions
in relatively able individuals with AS or HFA when
assessed on the WCST. Liss and coworkers (2001) found
that children with HFA showed impairments relative to
children with developmental language only on the category
perseverative errors. Hill and Bird (2006) did not find
significant differences between persons with AS and mat-
ched controls on ‘‘classical’’ tests of executive functions
such as the Modified Card Sorting Test (Nelson 1976),
whereas significant differences were demonstrated on
newer and more sensitive tests of executive functions.
Minshew et al. (1992) detected no difference between the
number of perseverative errors produced by a group of
adolescents with HFA and the number of such errors pro-
duced by normal controls. Schneider and Asarnow (1987),
whose study may be methodologically questionable, also
found few significant differences on the WCST between
children with ASD and schizophrenia and typically
developing control children.
There may be different pattern of group differences in
participants with and without mental retardation. Turner
(1995, as cited in Turner 1997) found that whereas those
with mental retardation performed significantly less well
than the controls on a set-shifting task, there were no sig-
nificant difference between the high-functioning group and
the comparison group on this task. Nydén et al. (1999)
found no specific marker of executive functions in children
with AS and attention disorder.

Table 2 Results on the WCST for the AS group and in the control group
Category AS group (N = 13) Means (SD) Control group (N = 13) Means (SD) Difference F p

Trials administered 107.15 (20.14) 96.69 (18.07) 10.46 1.67 .22

Total number of correct responses 82.62 (12.09) 75.46 (9.15) 7.15 2.20 .16
Total numbers of errors 24.54 (11.39) 21.23 (11.40) 3.31 0.64 .44
Perseverative responses 12.31 (5.89) 10.77 (4.40) 1.54 0.76 .40
Perseverative errors 11.46 (5.21) 10.31 (4.37) 1.15 0.49 .50
Non-perseverative errors 13.08 (6.84) 10.92 (7.43) 2.15 0.68 .43
Conceptual level responses 76.69 (10.74) 69.08 (7.30) 7.62 4.16 .06
Number of categories completed 5.15 (1.28) 5.92 (0.28) –0.77 4.14 .06
Number of trials to complete 1. category 17.15 (8.24) 14.46 (5.29) 2.69 0.85 .37
Failure to maintain set 2.46 (2.30) 0.69 (0.85) 1.77 5.41 \.04
Learning to learn 3.17 (3.44) 2.30 (1.68) 0.87 0.48 .50

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In the present study the participants in the AS group
seemed to recognize the sorting principle, but did not
manage to keep the strategy of sorting in mind during the
whole test session. The category failure to maintain set
appeared to be the one that demonstrated the AS persons’
impairment on the WCST most persuasively. This finding,
however, contrasts with other studies showing that persons
with the diagnosis of high-functioning autism and AS are
impaired on several categories of the WCST (Ozonoff et
al. 1991; Shu et al. 2001).
Did the AS participants in the present study have
problems with attention, making them unable to control
their impulses, thus missing the sorting principle during
the WCST test session? There may be seeds of evidence
for this assumption. On the WISC-III’s subtest digit
span, which is a measure of focused attention, the AS
participants performed significantly less well than the
controls (p = .0276), and this was also the case for the
subtest symbols (p = .0151, which is a measure of sus-
tained attention. These findings are in accordance with
those of Garretson et al. (1990) and Nyden et al. (1999),
who found that children and adolescents with high-
functioning autism or AS showed attention problems
when assessed on diverse measures of executive
functions.
Individuals with ASD do not seem to perform poorly on
the WCST across the board. It is also important to recog-
nize that there can be considerable within-group
heterogeneity (Liss et al. 2001), as was the case in the
present study. Moreover, detailed WCST studies by per-
sons with focal frontal lobe lesions have revealed varying
performance profiles according to the site of the lesion
(Ozonoff et al. 2004; Stuss et al. 2000).
Studies that include participants from across the autism
spectrum are needed in answering basic questions about the
universality of executive function impairments in this
spectrum and also the external validity of subtypes, for
example Asperger syndrome (Ozonoff et al. 2004). Ozo-
noff (1997) suggested that executive functions should be
understood in a multidimensional perspective. There is still
uncertainty about which executive and non-executive
functions the WCST measures; while generally considered
to be a test of cognitive flexibility, a variety of other
cognitive operations appear to be required for successful
performance. Administration of a more extensive and
sensitive battery of executive function measures for indi-
viduals with ASD may permit identification of a unique
executive profile, with disorder-specific patterns of
strengths and weaknesses. Such executive ‘‘fingerprints’’
(Ozonoff and Jensen 1999, p. 175) may be a useful guide in
the attempt to identify profiles in AS/HFA and other
aberrant conditions.
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J Autism Dev Disord (2008) 38:1161–1165
Acknowledgments Colleagues and mentors contributed to the work
presented in this paper with ideas and discussions. Special thanks are
given to Kirsten Callesen, Dorte Gottlieb and Annette Moller Nielsen
for their enthusiastic and indefatigable effort in testing the children
and adolescents. The kind involvement of the participants and their
families is thankfully acknowledged. This work was supported by
grants from the Norwegian Council for Research (to the first author).
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