The Wisconsin Card Sorting Test and the cognitive assessment of prefrontal executive functions: A critical update

For over four decades the Wisconsin Card Sorting Test (WCST) has been one of the most distinctive tests of prefrontal function. Clinical research and recent brain imaging have brought into question the validity and specificity of this test as a marker of frontal dysfunction. Clinical studies with neurological patients have confirmed that, in its traditional form, the WCST fails to discriminate between frontal and non-frontal lesions. In addition, functional brain imaging studies show rapid and widespread activation across frontal and non-frontal brain regions during WCST performance. These studies suggest that the concept of an anatomically pure test of prefrontal function is not only empirically unattainable, but also theoretically inaccurate. The aim of the present review is to examine the causes of these criticisms and to resolve them by incorporating new methodological and conceptual advances in order to improve the construct validity of WCST scores and their relationship to prefrontal executive functions. We conclude that these objectives can be achieved by drawing on theory-guided experimental design, and on precise spatial and temporal sampling of brain activity, and then exemplify this using an integrative model of prefrontal function [i.e., Miller, E. K. (2000). The prefrontal cortex and cognitive control. Nature Reviews Neuroscience, 1, 59–65.] combined with the formal information theoretical approach to cognitive control [Koechlin, E., & Summerfield, C. (2007). An information theoretical approach to prefrontal executive function. Trends in Cognitive Sciences, 11, 229–235.].     

The impact of frontal and non-frontal brain tumor lesions on Wisconsin Card Sorting Test performance

Several lesion and imaging studies have suggested that the Wisconsin Card Sorting Test (WCST) is a measure of executive dysfunction. However, some studies have reported that this measure has poor anatomical specificity because patients with either frontal or non-frontal focal lesions exhibit similar performance. This study examined 25 frontal, 20 non-frontal low-grade brain tumor patients, and 63 normal controls (NC) on the WCST. The frontal patients were also assigned to either a left frontal (n=10) group or a right frontal group (n=15) and compared with the non-frontal group and NC. It was hypothesized that the frontal brain tumor patients would display greater deficits on categories achieved and a higher number of perseverative errors than non-frontal brain tumor patients on the WCST. Finally, it was predicted that right frontal brain tumors would result in greater executive functioning deficits than left frontal or non-frontal brain tumors. Results indicated that the left frontal group achieved the fewest categories and committed the most perseverative errors compared to the other patient and normal control groups. In addition, the left frontal group committed significantly more perseverative errors than the right frontal group. These results suggest that the WCST is sensitive to the effects of low-grade brain tumors on executive functioning.     

贫困对个体执行功能的影响

已有研究发现,贫困会对个体的执行功能产生消极的影响,这种影响贯穿于个体婴儿期、童年期以及成年期。贫困会影响与执行功能相关的前额叶的结构（如较小的灰质体积）。贫困个体与非贫困个体对额叶区域资源的调用方式不同,贫困个体需要使用额外的补偿资源来监测和抑制对干扰物的反应。贫困会通过压力、认知剥夺以及父母养育等因素直接或间接的影响个体的执行功能。今后该领域的研究应关注贫困影响执行功能的调节变量（如自我肯定、自我调节）,建立贫困影响执行功能的综合模型（如考虑贫困经历时间等）,立足执行功能的可塑性,通过认知干预提高贫困个体的执行功能。     

Trait impulsiveness and executive function in healthy young adults

Performance-based neuropsychological tests are often used to assess planning and impulse control, but the extent to which these measures reflect trait impulsiveness or specific dimensions of trait impulsiveness is not clear. This study used the Barratt Impulsiveness Scale-11 (BIS-11; [Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt Impulsiveness Scale. Journal of Clinical Psychology, 51, 768–774.]) to examine the relationship between various dimensions of trait impulsiveness and performance on several executive function tests in healthy young adults. Total BIS-11 scores correlated with performance on measures of planning and impulse control. Higher non-planning impulsiveness scores, which indicate poorer self-control and lower cognitive complexity, correlated most strongly with performance on a maze test that measures planning and impulse control (r = .58). These results provide support for the convergent validity of pencil-and-paper maze-based measures of planning and impulse control.     

Relationships between cognitive and behavioral measures of executive function in children with brain disease.

This study addressed the clinical and construct validity of the Behavior Rating Inventory of Executive Function. (BRIEF: Gioia, Isquith, Guy, & Kenworthy, 2000), a questionnaire designed to tap behavioral aspects of executive functions in children. BRIEF profiles in early treated phenylketonuria (PKU; n=44), early treated hydrocephalus (n=45), frontal focal lesions (n=20) and controls (n=80) were examined. Clinical validity was supported through significant between-group comparisons, especially between the frontal focal lesion group and other groups. To examine construct validity, raw scores on cognitive executive function measures including the Contingency Naming Test (CNT), Rey Complex Figure (RCF), Tower of London (TOL), and Controlled Oral Word Association Test (COWAT), were correlated with BRIEF scale scores. Few significant correlations were found, indicating cognitive and behavioral measures appear to tap different constructs within the executive function domain. A dissociation was found between behavioral and cognitive impairments in the frontal as opposed to PKU and hydrocephalus groups. This is discussed in relation to underlying pathology, the cognitive measures used, and possible limitations in the BRIEF's usefulness for measuring behavioral executive dysfunction in groups only mildly affected by neurological compromise.     

Relationships Between Cognitive and Behavioral Measures of Executive Function in Children With Brain Disease

This study addressed the clinical and construct validity of the Behavior Rating Inventory of Executive Function. (BRIEF: Gioia, Isquith, Guy, & Kenworthy, 2000), a questionnaire designed to tap behavioral aspects of executive functions in children. BRIEF profiles in early treated phenylketonuria (PKU; n = 44), early treated hydrocephalus (n = 45), frontal focal lesions (n = 20) and controls (n = 80) were examined. Clinical validity was supported through significant between-group comparisons, especially between the frontal focal lesion group and other groups. To examine construct validity, raw scores on cognitive executive function measures including the Contingency Naming Test (CNT), Rey Complex Figure (RCF), Tower of London (TOL), and Controlled Oral Word Association Test (COWAT), were correlated with BRIEF scale scores. Few significant correlations were found, indicating cognitive and behavioral measures appear to tap different constructs within the executive function domain. A dissociation was found between behavioral and cognitive impairments in the frontal as opposed to PKU and hydrocephalus groups. This is discussed in relation to underlying pathology, the cognitive measures used, and possible limitations in the BRIEF's usefulness for measuring behavioral executive dysfunction in groups only mildly affected by neurological compromise.     

Executive Function and the Frontal Lobes: A Meta-Analytic Review

Currently, there is debate among scholars regarding how to operationalize and measure executive functions. These functions generally are referred to as “supervisory” cognitive processes because they involve higher level organization and execution of complex thoughts and behavior. Although conceptualizations vary regarding what mental processes actually constitute the “executive function” construct, there has been a historical linkage of these “higher-level” processes with the frontal lobes. In fact, many investigators have used the term “frontal functions” synonymously with “executive functions” despite evidence that contradicts this synonymous usage. The current review provides a critical analysis of lesion and neuroimaging studies using three popular executive function measures (Wisconsin Card Sorting Test, Phonemic Verbal Fluency, and Stroop Color Word Interference Test) in order to examine the validity of the executive function construct in terms of its relation to activation and damage to the frontal lobes. Empirical lesion data are examined via meta-analysis procedures along with formula derivatives. Results reveal mixed evidence that does not support a one-to-one relationship between executive functions and frontal lobe activity. The paper concludes with a discussion of the implications of construing the validity of these neuropsychological tests in anatomical, rather than cognitive and behavioral, terms.     

Meta-analytic evidence for a superordinate cognitive control network subserving diverse executive functions

Classic cognitive theory conceptualizes executive functions as involving multiple specific domains, including initiation, inhibition, working memory, flexibility, planning, and vigilance. Lesion and neuroimaging experiments over the past two decades have suggested that both common and unique processes contribute to executive functions during higher cognition. It has been suggested that a superordinate fronto–cingulo–parietal network supporting cognitive control may also underlie a range of distinct executive functions. To test this hypothesis in the largest sample to date, we used quantitative meta-analytic methods to analyze 193 functional neuroimaging studies of 2,832 healthy individuals, ages 18–60, in which performance on executive function measures was contrasted with an active control condition. A common pattern of activation was observed in the prefrontal, dorsal anterior cingulate, and parietal cortices across executive function domains, supporting the idea that executive functions are supported by a superordinate cognitive control network. However, domain-specific analyses showed some variation in the recruitment of anterior prefrontal cortex, anterior and midcingulate regions, and unique subcortical regions such as the basal ganglia and cerebellum. These results are consistent with the existence of a superordinate cognitive control network in the brain, involving dorsolateral prefrontal, anterior cingulate, and parietal cortices, that supports a broad range of executive functions.     

老年执行功能的认知可塑性和神经可塑性

执行衰退假说认为执行功能的特异性衰退是引起认知年老化的主要原因, 近年来越来越多的研究表明, 老年人的执行功能及其相关脑区(主要为前额叶)存在可塑性, 通过训练执行功能的衰退可得到缓解, 且相关脑区的激活水平、脑容量或神经递质都可发生改变; 部分研究还发现执行功能训练对其它认知能力有一定的迁移效应。这些发现对于认知年老化理论的继续探索和认知干预研究的实践应用都具有重要意义。     

Gestational age and gender influence on executive control and its related neural structures in preterm-born children at 6 years of age

Within preterm-born children, being born male and at a lower gestational age (GA) have both been associated with a heightened risk for developmental difficulties. However, in this population little is known about the combined effect and the influence of these risk factors on cortical structures and executive control. In the present study, 58 preterm-born children (GA ranging from 24.0 to 35.1 weeks) were administered the computerized Child Attention Network Task at 6 years of age. Brain magnetic resonance imaging was performed and analyzed using Voxel-Based Morphometry (VBM) in all children. At a behavioral level, boys born <28 weeks of GA had significantly less executive control than preterm-born girls <28 weeks (p = .001) and preterm-born boys ≥28 (p = .003). The reduced executive control in preterm-born boys <28 weeks gestation was related to lower cortical densities in the inferior frontal gyrus (IFG) and dorsolateral prefrontal cortex (DLPFC). The current study links the higher incidence of reduced executive control in preterm-born boys to a higher degree of prematurity (low GA) and identifies brain structural abnormalities in the prefrontal cortex related to these deficits. The implications of these results are discussed.     

The neural basis of updating: Distinguishing substitution processes from other concurrent processes

Sörqvist, P. & Sætrevik, B. (2010). The neural basis of updating: Distinguishing substitution processes from other concurrent processes. Scandinavian Journal of Psychology, 51, 357–362. Most previous studies of updating processes have not been able to contrast processes of substituting items in memory with other concurrent processes. In the present investigation, we used a new task called “number updating” and an fMRI protocol to contrast the activation of trials that require item substitution (adding a new item to the working memory representation and suppressing an old item) with trials that involve no substitution (discarding the new item). Trials that require item substitution activated the dorsolateral prefrontal cortex, the posterior medial frontal cortex and the parietal lobes, areas typically seen activated for working memory tasks in general. Trials that do not require substitution activated the anterior medial frontal cortex. Studies examining executive functions have associated this area with cognitive conflict, and may represent suppression of the substitution processes.     

Relationships between executive function,working memory,and decision-making on the Iowa Gambling Task: Evidence from ventromedial patients,dorsolateral patients,and normal subjects

The results of previous studies are inconsistent in regard to the relationship between the Iowa Gambling Task (IGT), working-memory (WM), and executive tasks, and whether these cognitive processes could be considered as mechanisms underlying a decision-making deficit. Moreover, the relationship between the IGT and executive measures is examined based on a limited number of executive tasks, within different populations showing diffuse damage. In addition, there are fewer studies carried out within control participants, with those studies also being inconclusive. It is also suggested that the association of the IGT performance with executive tasks depends on whether the IGT was running under ambiguity or under risk. In this work, all of these issues are studied. Results showed that both patients with ventromedial (VMPFC, N = 10) and dorsolateral (DLPFC, N = 10) prefrontal cortex lesions are significantly impaired on almost all executive tasks, WM tasks, and the IGT. Furthermore, when the IGT is run under risk, there are significant correlations between executive measures and the IGT for the DLPFC patients and the control participants (N = 34) but not the VMPFC patients. No correlation was found between WM tasks and the IGT for both frontal subgroups and control participants. These findings suggested that the mechanisms underlying the IGT deficit differ according to the lesion locations.     

经颅直流电刺激对健康人群反应抑制的影响

反应抑制是指抑制不恰当的或不符合当前需要的行为的能力, 研究表明反应抑制主要与额下回、背外侧前额叶和前辅助运动区的功能有关。经颅直流电刺激(tDCS)是一种非侵入式脑刺激技术, 近年来对健康人群使用tDCS刺激相应脑区从而影响反应抑制功能的研究日益增多, 但主要研究结果不一致。阐明tDCS影响反应抑制具体的神经机制、减少tDCS研究的异质性、探索更有效的tDCS刺激方式和确定tDCS效果的年龄依赖性差异已成为目前亟待解决的问题。     

Bilingualism alters children's frontal lobe functioning for attentional control

Bilingualism is a typical linguistic experience, yet relatively little is known about its impact on children's cognitive and brain development. Theories of bilingualism suggest that early dual‐language acquisition can improve children's cognitive abilities, specifically those relying on frontal lobe functioning. While behavioral findings present much conflicting evidence, little is known about its effects on children's frontal lobe development. Using functional near‐infrared spectroscopy (fNIRS), the findings suggest that Spanish–English bilingual children (n = 13, ages 7–13) had greater activation in left prefrontal cortex during a non‐verbal attentional control task relative to age‐matched English monolinguals. In contrast, monolinguals (n = 14) showed greater right prefrontal activation than bilinguals. The present findings suggest that early bilingualism yields significant changes to the functional organization of children's prefrontal cortex for attentional control and carry implications for understanding how early life experiences impact cognition and brain development.     

Gender-moderated dorsolateral prefrontal reductions in 22q11.2 Deletion Syndrome: implications for risk for schizophrenia.

To investigate the impact of the microdeletion on morphology of the prefrontal cortex in 22q11.2 Deletion Syndrome (22q11.2 DS), high-resolution, anatomic magnetic resonance imaging was performed on 19 children and adolescents with 22q11.2 DS (11 females, 8 males) and 18 unaffected controls (10 females, 8 males). Tissue volumes of the dorsolateral, dorsomedial, orbitolateral, and orbitomedial prefrontal cortex were measured. Tasks of executive function and working memory were administered to investigate the association between anatomy and function. Whole brain volume and frontal lobe tissue volume were preserved in girls but reduced in boys with 22q11.2 DS relative to age-matched controls. Dorsolateral prefrontal cortex (DLPFC) volumes were reduced in participants with 22q11.2 DS, although the gender-by-diagnosis effect found for frontal lobe was not as robust for DLPFC. DLPFC volumes were associated with performance on tasks of planning and emotional facial recognition. Longitudinal studies are needed to clarify whether gender differences in frontal lobe and DLPFC persist with development, and whether the volumes of the DLPFC are associated with eventual deterioration in adaptive/psychosocial function that may presage the onset of schizophrenia, for which individuals with 22q11.2 DS are at a disproportionately high risk.     

Gender-Moderated Dorsolateral Prefrontal Reductions in 22q11.2 Deletion Syndrome: Implications for Risk for Schizophrenia

To investigate the impact of the microdeletion on morphology of the prefrontal cortex in 22q11.2 Deletion Syndrome (22q11.2 DS), high-resolution, anatomic magnetic resonance imaging was performed on 19 children and adolescents with 22q11.2 DS (11 females, 8 males) and 18 unaffected controls (10 females, 8 males). Tissue volumes of the dorsolateral, dorsomedial, orbitolateral, and orbitomedial prefrontal cortex were measured. Tasks of executive function and working memory were administered to investigate the association between anatomy and function. Whole brain volume and frontal lobe tissue volume were preserved in girls but reduced in boys with 22q11.2 DS relative to age-matched controls. Dorsolateral prefrontal cortex (DLPFC) volumes were reduced in participants with 22q11.2 DS, although the gender-by-diagnosis effect found for frontal lobe was not as robust for DLPFC. DLPFC volumes were associated with performance on tasks of planning and emotional facial recognition. Longitudinal studies are needed to clarify whether gender differences in frontal lobe and DLPFC persist with development, and whether the volumes of the DLPFC are associated with eventual deterioration in adaptive/psychosocial function that may presage the onset of schizophrenia, for which individuals with 22q11.2 DS are at a disproportionately high risk.     

Parallel associative processing in the dorsal striatum: segregation of stimulus-response and cognitive control subregions

Although evidence suggests that the dorsal striatum contributes to multiple learning and memory functions, there nevertheless remains considerable disagreement on the specific associative roles of different neuroanatomical subregions. We review evidence indicating that the dorsolateral striatum (DLS) is a substrate for stimulus–response habit formation – incremental strengthening of simple S–R bonds – via input from sensorimotor neocortex while the dorsomedial striatum (DMS) contributes to behavioral flexibility – the cognitive control of behavior – via prefrontal and limbic circuits engaged in relational and spatial information processing. The parallel circuits through dorsal striatum interact with incentive/affective motivational processing in the ventral striatum and portions of the prefrontal cortex leading to overt responding under specific testing conditions. Converging evidence obtained through a detailed task analysis and neurobehavioral assessment is beginning to illuminate striatal subregional interactions and relations to the rest of the mammalian brain.     

Neural correlates of metaphor processing: The roles of figurativeness,familiarity and difficulty

There is currently much interest in investigating the neural substrates of metaphor processing. In particular, it has been suggested that the right hemisphere plays a special role in the comprehension of figurative (non-literal) language, and in particular metaphors. However, some studies find no evidence of right hemisphere involvement in metaphor comprehension (e.g. [Lee, S. S., & Dapretto, M. (2006). Metaphorical vs. literal word meanings: fMRI evidence against a selective role of the right hemisphere. NeuroImage, 29, 536–544; Rapp, A. M., Leube, D. T., Erb, M., Grodd, W., & Kircher, T. T. J. (2004). Neural correlates of metaphor processing. Cognitive Brain Research, 20, 395–402]). We suggest that lateralization differences between literal and metaphorical language may be due to factors such as differences in familiarity ([Schmidt, G. L., DeBuse, C. J., & Seger, C. A. (2007). Right hemisphere metaphor processing? Characterizing the lateralization of semantic processes. Brain and Language, 100, 127–141]), or difficulty ([Bookheimer, S. (2002). Functional MRI of language: New approaches to understanding the cortical organization of semantic processing. Annual Review of Neuroscience, 25, 151–188; Rapp, A. M., Leube, D. T., Erb, M., Grodd, W., & Kircher, T. T. J. (2004). Neural correlates of metaphor processing. Cognitive Brain Research, 20, 395–402]) in addition to figurativeness. The purpose of this study was to separate the effects of figurativeness, familiarity, and difficulty on the recruitment of neural systems involved in language, in particular right hemisphere mechanisms. This was achieved by comparing neural activation using functional magnetic resonance imaging (fMRI) between four conditions: literal sentences, familiar and easy to understand metaphors, unfamiliar and easy to understand metaphors, and unfamiliar and difficult to understand metaphors. Metaphors recruited the right insula, left temporal pole and right inferior frontal gyrus in comparison with literal sentences. Familiar metaphors recruited the right middle frontal gyrus when contrasted with unfamiliar metaphors. Easy metaphors showed higher activation in the left middle frontal gyrus as compared to difficult metaphors, while difficult metaphors showed selective activation in the left inferior frontal gyrus as compared to easy metaphors. We conclude that the right hemisphere is involved in metaphor processing and that the factors of figurativeness, familiarity and difficulty are important in determining neural recruitment of semantic processing.     

Frontal theta activation associated with error detection in toddlers: influence of familial socioeconomic status

Error detection is one of the functions of the executive attention network, a brain system involved in executive control that includes the anterior cingulate cortex and other prefrontal regions. Despite the key role of this function in a wide range of life outcomes, very limited research has examined the early development of the network and whether its functional efficacy is related to environmental factors. Electrophysiological studies with adults have shown oscillatory activity in theta (4–7 Hz) range arising from medial frontal cortex that follows the detection of self‐committed or observed errors. In the current study, we designed a novel experimental procedure that involved a familiarization phase with simple three‐pieces puzzles followed by an experimental phase in which toddlers observed the puzzles being formed either correctly or incorrectly. Observation of incorrect configurations produced increased potentials in midline channels and greater power theta activity for both toddlers (n = 56) and adults (n = 14). In addition, socioeconomic status of the family in general, and parental education in particular, contributed to individual differences in the amplitude of the error‐related signal and associated theta power in toddlers, indicating that children raised in lower SES families show poorer activation of the executive attention network. These data demonstrate the influence of environmental factors at the earliest stages of development of the executive attention network. Importantly, the results show that error‐detection EEG signals can be used as neural markers of the initial development of executive attention, which can be of great help for the early detection of risk for developmental disorders involving deficits in this function.     

Age,executive function,and social decision making: a dorsolateral prefrontal theory of cognitive aging

Current neuropsychological models propose that some age-related cognitive changes are due to frontal-lobe deterioration. However, these models have not considered the possible subdivision of the frontal lobes into the dorsolateral and ventromedial regions. This study assessed the age effects on 3 tasks of executive function and working memory, tasks dependent on dorsolateral prefrontal dysfunction; and 3 tasks of emotion and social decision making, tasks dependent on ventromedial prefrontal dysfunction. Age-related differences in performance were found on all tasks dependent on dorsolateral prefrontal dysfunction. In contrast, age-related differences were not found on the majority of the tasks dependent on ventromedial prefrontal dysfunction. The results support a specific dorsolateral prefrontal theory of cognitive changes with age, rather than a global decline in frontal-lobe function.