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Autism
DOI: 10.1177/1362361306068507
2006; 10; 551 Autism
Fiona Z. Ambery, Ailsa J. Russell, Katie Perry, Robin Morris and Declan G.M. Murphy
Neuropsychological functioning in adults with Asperger syndrome
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551
Neuropsychological
functioning in adults with
Asperger syndrome
F I ONA Z . A MB E RY Institute of Psychiatry, London, UK
A I L S A J . RUS S E L L Institute of Psychiatry, London, UK
K AT I E P E R RY University of East London, UK
ROB I N MOR R I S Institute of Psychiatry, London, UK
D E C L A N G. M. MUR P HY Institute of Psychiatry,
London, UK
A B S T R AC T There is some consensus in the literature regarding the
cognitive prole of people with Asperger syndrome (AS). Findings to
date suggest that a proportion of people with AS have higher verbal
than performance IQ, a non-verbal learning disability (NVLD) and
impairments in some aspects of executive function (EF). However,
there are few published studies on adults with AS and many have
compared the AS group to an autistic control group alone. We
compared cognitive functioning in 27 AS adults without a history of
language delay and 20 normal controls who did not differ signicantly
in age, gender and IQ. People with AS had signicant impairments on
a test of visual memory and on EF tasks measuring exibility and
generativity, but not inhibition. There was no signicant difference
between verbal and performance IQ. Our results suggest that impair-
ments on tests requiring exibility of thought and generation occur at
all ages and across a range of autistic disorders including AS.
ADDRE S S Correspondence should be addressed to: DR F I ONA Z. AMBE RY, Depart-
ment of Psychological Medicine, PO Box 50, Institute of Psychiatry, De Crespigny Park,
London SE5 8AF, UK. e-mail: f.ambery@iop.kcl.ac.uk
Introduction
There have been numerous studies of neuropsychological functioning in
people with autistic spectrum disorders (ASD). These consistently report
impairments in executive functioning (Liss et al., 2001; Ozonoff et al.,
1994), with additional evidence of visuo-perceptual difculties (Klin et al.,
1995) and memory decits (Blair et al., 2002; Williams et al., 2005).
autism 2006
SAGE Publications
and The National
Autistic Society
Vol 10(6) 551564; 068507
1362-3613(200611)10:6
www.sagepublications.com
DOI: 10.1177/1362361306068507
K E Y WOR D S
Asperger
syndrome;
executive
functioning;
memory;
neuro-
psychology
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However, there has been little research focused specically on neuro-
psychological functioning in people with Asperger syndrome (AS), and in
particular adults with this condition. Such studies have examined one
aspect of cognitive functioning (Morris et al., 1999) or used an autistic
control group rather than healthy controls (Klin et al., 1995). Thus, it has
not yet been established whether the cognitive decits found in children
with AS also occur in adults and whether the specic cognitive decits
reported in studies comparing AS to HFA are also present when people with
AS are compared to healthy controls.
Studies of cognitive functioning in AS have shown: (1) similarities to
people with a non-verbal learning disability (NVLD: a term describing a
cluster of cognitive decits in non-verbal functioning such as non-verbal
problem solving and visuo-spatial functioning) (Voeller, 1986); (2) discrep-
ancies between verbal and performance IQ (PIQ) scores in favour of verbal
IQ (VIQ); and (3) impairments in executive functioning. Klin et al. (1995)
suggested that abnormalities in the development of the right hemisphere in
AS may perhaps underpin at least some of the clinical symptoms. However,
Klin et al.s study did not include healthy controls, and it is not clear whether
non-verbal function is impaired in AS compared to a healthy population.
Some studies reported that children and adolescents with AS have
signicantly higher VIQ than PIQ (Klin et al., 1995; Miller and Ozonoff,
2000), whereas others did not (Manjiviona and Prior, 1999). Tager-Flusberg
and Joseph (2003) analysed the cognitive proles of children with autistic
disorders and found that verbal/non-verbal discrepancies in either direc-
tion were more common in this group than in normal controls. However,
this study did not examine groups diagnosed as AS and HFA and it is not
therefore known whether the discrepancy is more likely to be in the VIQ
> PIQ direction in an AS group.
A frequent nding in cognitive studies of people with ASD is impair-
ment in aspects of executive function (EF). Included in the range of EF
impairments are: (1) signicantly more perseverative errors on the
Wisconsin Card Sorting Test (WCST: Liss et al., 2001; Prior and Hoffmann,
1990; Rumsey, 1985; Shu et al., 2001) and a computerized attentional set-
shifting test (Hughes et al., 1994; Ozonoff et al., 2000; AS impaired but not
HFA); (2) decits in planning on the Tower of Hanoi or Tower of London
tests (Hughes et al., 1994; Rumsey, 1985); (3) signicantly reduced output
on uency tests (Rumsey and Hamburger, 1988; Turner, 1999); and (4)
impairment in spatial working memory (Morris et al., 1999). By contrast,
no decits have been reported in response inhibition (Ozonoff and Jenson,
1999; Ozonoff and Strayer, 1997). Further, some studies comparing AS
and HFA have found differential patterns of impairment on EF tasks. For
example, decits on tests of response inhibition have been found in HFA
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but not AS (Rinehart et al., 2002). Other studies have found no differences
in executive functioning between AS and HFA (e.g. Manjiviona and Prior,
1999).
In summary, there is evidence that children with AS may have specic
cognitive decits. However, many of the studies have used inexact diagnos-
tic criteria and/or have not used a healthy control sample. Those studies
examining adults with AS have explored single cognitive functions (Blair
et al., 2002; Morris et al., 1999) or were prior to the DSM-IV and ICD-10
diagnostic criteria (Rumsey, 1985). To date, there appear to be no
published studies of the full neuropsychological prole of a relatively
homogeneous sample of adults with AS dened using recognized diagnos-
tic criteria (e.g. ICD-10). Hence, we examined cognitive functioning in
adults with AS. We hypothesized: (1) decits on tests of visual memory
and visual perceptual processing; (2) a verbalperformance IQ differential
in favour of VIQ; and (3) EF decits that affect tasks of set shifting and
exibility but not response inhibition.
Method
Participants
We recruited 27 adults with AS from a specialist assessment service at the
South London and Maudsley NHS Trust (see Table 1 for sample character-
istics). All participants were diagnosed by a psychiatrist (DM) and satised
the rst three ICD-10 (World Health Organization, 1992) criteria for AS,
namely: (1) qualitative abnormalities in reciprocal social interaction; (2)
restricted, repetitive and stereotyped patterns of behaviour, interests and
activities; (3) no clinically signicant general delay in spoken or receptive
language or cognitive development. The study did not use the ICD-10
criterion 4, namely, not meeting the criteria for any other pervasive
developmental disorder, because this would preclude a diagnosis of AS in
nearly all cases. In keeping with other studies (Howlin, 2003; Kim et al.,
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Table 1 Background characteristics of patient and control groups
Sex M/F Mean (SD) range
Age (years) VIQ PIQ
AS (n = 27) 22/5 37.6 (14.6) 106.1 (15.7) 103.7 (19.2)
1967 82135 75147
Controls (n = 20) 16/4 33.5 (12) 107.05 (13.1) 109.4 (18.5)
2158 93140 80140
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2000) we diagnosed people with AS who met criteria for autism but had
no signicant delay in language development. In addition, where parental
informants were available we employed the Autism Diagnostic Instrument
(ADI: Lord et al., 1994) (N = 12), and where participants were willing we
also used the Autistic Diagnostic Observation Schedule (ADOS) (N = 4).
Participants also brought documentation such as school reports to aid diag-
nosis. Any cases where there was no reliable informant regarding language
development were excluded.
All participants underwent mental state and physical examination,
routine laboratory blood tests, chromosome analysis, and structural magnetic
resonance imaging to exclude clinically detectable neuropathology.
The AS group were compared to 20 normal controls who did not differ
in age, sex, VIQ, PIQ and years of education.
All subjects had a VIQ above 80, were medication/drug free, and had
grossly intact language. We excluded people with: (1) developmental
language delay, including dyslexia; (2) comorbid diagnoses of psychosis,
attention decit hyperactivity disorder, personality disorder and/or substance
misuse; (3) physical or neurological impairments affecting brain function
(e.g. epilepsy); and (4) genetic disorders such as fragile X syndrome.
Neuropsychological testing
We administered tests of: (1) overall intellectual functioning (Canavan
et al., 1986); (2) memory (recall and recognition in both verbal and visual
modalities); (3) EF (including tests of response inhibition, generativity and
mental exibility); (4) language; and (5) visuo-spatial perception.
General intellectual ability Canavan et al.s (1986) short-form version
of the Wechsler Adult Intelligence ScaleRevised (WAISR: Wechsler, 1986)
was used, which comprises ve subtests: vocabulary, comprehension, simi-
larities, block design and object assembly. This provides prorated verbal,
performance and full-scale IQ scores. Age-scaled scores for each subtest
were also calculated.
Memory tests The Doors and People Test of Verbal and Visual Recall and
Recognition (Baddeley et al., 1994) was used. The battery divides into four
separate sections yielding composite scores for verbal and visual memory,
recall and recognition and forgetting.
In addition, tests of prose recall and verbal associate learning were
administered using the Wechsler Memory ScaleRevised (Wechsler, 1987)
logical memory and verbal paired associates tests.
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Executive function
1 Stroop Colour-Word Reading Test (Trenerry et al., 1989). This version requires
reading colour words followed by incongruent colour naming. The
measure was the number of colours named in 120 seconds.
2 Wisconsin Card Sorting Test (WCST: Heaton et al., 1993). The study used
the 128-card version with six set shifts across three sorting categories
(colour, shape and number). The measures used were: (1) persevera-
tive responses, (2) perseverative errors, (3) non-perseverative errors,
(4) number of categories achieved and (5) failure to maintain set.
3 Controlled Oral Word Association Test (COWAT: Benton and Hamsher, 1989).
The study used the letters F, A and S.
Language comprehension The British Picture Vocabulary ScaleRevised
(Dunn et al., 1997) was used. This requires pointing to one out of four
pictures, given a single word. The total number of correct responses was
used for the analysis.
Visual perception Two tests were administered from the Visual Object
and Space Perception Test (VOSP: Warrington and James, 1991), measur-
ing visuo-spatial (cube analysis) and visual perception (object decision).
Procedure
All tests were administered by trained psychologists (FA and KP) follow-
ing standard instructions from the test manuals. Testing time was up to 2
1
2
hours and participants completed the tests in the same order on one
occasion. Three controls and four AS subjects were unable to complete the
Stroop due to colour-blindness.
Statistical analysis
Analysis was completed using the Statistical Package for Social Sciences for
Windows version 11. Groups were compared using an independent sample
t-test (two-tailed), with statistical signicance dened as p < 0.05. To
explore the prole of impairment the AS scores were transformed into
Z-scores, based on the control data.
Results
1 Intellectual functioning. There were no signicant differences between the
two groups on measures of overall intellectual functioning (VIQ,
t(d.f. 45) = 0.225, n.s.; PIQ, t(d.f. 45) = 1.02, n.s.; see Table 1) or on
any of the WAISR subtests. The VIQPIQ discrepancy scores were
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calculated by subtracting the PIQ score from the VIQ score. Thus, a
positive score indicates that VIQ is higher than PIQ. There was no differ-
ence in the mean discrepancy score (control mean, 1.8 (22.7); AS
mean, 2.37 (17.21); t(d.f. 45) = 0.717, n.s.). In the AS group the
scores ranged from 33 to +30. The scores showed a relatively normal
distribution, with 17 subjects having positive scores and 10 subjects
having negative scores. Sixteen (59%) AS subjects had discrepancy
scores that were greater than 12 points, as compared to 25 percent in
the normal population (Grossman, 1983), with 10 showing VIQ > PIQ
and six showing PIQ > VIQ.
2 Memory. The AS group were not impaired on the Doors and People
Verbal Memory Index (see Table 2). Also, there were no decits on the
WMSR story recall test or paired associate learning tests. However, the
AS group were impaired on the Doors and People Visual Memory Index
(t(45) = 2.0, p < 0.05).
3 Executive functioning. There was no signicant group difference on the
Stroop test interference score (see Table 2). However, on the WCST
people with AS made more perseverative errors than controls (t(45) =
2.06, p < 0.05). The controls made more conceptual-level responses
than the AS group (t(45) = 1.99, p < 0.05). The AS group produced
fewer words on the verbal uency test (t(45) = 2.05, p < 0.05). To
determine whether the impairment might relate to language ability
more generally, the verbal uency measure was correlated with the
BPVS score. There was no correlation in either group. Furthermore, the
signicant uency result remained signicant after covarying for BPVS
score.
4 Language comprehension. There were no signicant group differences on the
BPVS test of single-word comprehension than controls (see Table 2).
5 Visual perception. People with AS were not signicantly impaired on either
the object decision test or the cube analysis test (see Table 2).
Z-scores were calculated for the AS group (see Figure 1). The controls are
represented as the line at zero. The mean AS scores for visual memory, BPVS
and perseverative errors on the WCST are all greater than one standard devi-
ation below the controls.
Discussion
We investigated whether the cognitive decits reported in children with
AS are also found in adults, and whether these decits exist when the AS
group was compared to healthy controls rather than an autistic group. We
specically examined three hypotheses relating to previous ndings,
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namely: (1) that people with AS show cognitive decits similar to those
of an NVLD; (2) that people with AS tend to have a higher VIQ than PIQ;
and (3) that they have decits in executive functioning relating to cogni-
tive exibility but not to inhibition. Our ndings supported only one of
our initial hypotheses, that is, individuals with AS displayed executive
function decits on tasks of set shifting, word generation and exibility
but not on a test of response inhibition.
The lack of specic impairment in visual perceptual functioning is not
consistent with the hypothesis that neuropsychological decits in AS are
similar to those of an NVLD. However, the AS group were impaired on
tests of visual memory. Previous studies of visual memory in ASD have
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Table 2 Group means and differences on neuropsychological tests
Test AS Control t p
(n = 27) (n = 20)
Mean (SD) Mean (SD)
Doors and People
Visual memory 8.8 (3.9) 10.6 (2.6) 2.008 0.05*
Verbal memory 9.9 (3.9) 9.8 (3.9) 0.073 0.94
Recognition memory 9.3 (4.1) 9.8 (4.5) 0.388 0.70
Recall memory 9.3 (3.9) 10.7 (2.8) 1.342 0.19
Verbal forgetting 10.3 (2.8) 10.8 (1.9) 0.764 0.45
Visual forgetting 10.9 (0.5) 10.4 (1.7) 1.169 0.26
Wechsler Memory ScaleRevised
Logical memory 22.7 (9.3) 23.1 (3.9) 0.183 0.86
Verbal paired associates 17.7 (5.3) 19.0 (4.1) 0.828 0.41
Wisconsin Card Sorting Test
Number of categories 4.8 (1.6) 5.4 (1.3) 1.238 0.22
Perseverative errors 17.5 (20.1) 9.0 (6.4) 2.064 0.05*
Non-perseverative errors 11.8 (12.8) 10.9 (12.3) 0.236 0.814
Conceptual-level responses 55.1 (14.1) 62.7 (12.0) 1.995 0.05*
Verbal Fluency:
total words produced 38.5 (11.8) 45.3 (10.0) 2.054 0.05*
Stroop Interference 96.2 (14.5) 101.7 (15.3) 1.148 0.258
BPVS 146.5 (13.7) 152.6 (7.5) 1.889 0.07
VOSP
Object decision 17.3 (3.2) 18.6 (1.6) 1.613 0.12
Cube analysis 9.5 (1.1) 9.7 (1.3) 0.505 0.616
* Denotes signicance at the 0.05 level (two-tailed).
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consistently reported decits in relation to recognition memory for faces
(Boucher and Lewis, 1992). Additionally, Ameli et al. (1988) found
impairments in recognition memory for abstract shapes, while Blair et al.
(2002) reported intact recognition memory for leaves and buildings, but
impairments for cats, horses and motorbikes. Blair et al. (2002) suggest
the latter impairment relates to objects that have agency. However, the
stimuli in the visual memory tests from the Doors and People memory
battery do not have agency and this theory cannot therefore account for
the results found in this study. Alternatively, poor visual memory could be
explained as being due to loss of central coherence, hypothesized by Frith
and Happ (1994) as a core cognitive decit in ASD, and dened as a lack
of ability to draw together information so as to derive coherent and mean-
ingful ideas. Loss of central coherence could result in too much attention
being paid to details of the pictures while the sense of the whole is lost,
thus producing recognition and recall errors.
In our study the AS group did not show a signicant verbalperform-
ance IQ discrepancy. Hence our results are not consistent with studies that
have found higher VIQ than PIQ in children with AS (Klin et al., 1995;
Ozonoff et al., 2000); but they were consistent with others (Manjiviona
and Prior, 1999; Miller and Ozonoff, 2000) who also found no VIQPIQ
discrepancy. However, the AS group were more likely to have a signicant
VIQPIQ discrepancy than a normal population (59% as opposed to 25%)
but this could be in either direction (i.e. VIQ > PIQ or PIQ > VIQ). Tager-
Flusberg and Joseph (2003) also found that people with autistic disorder
AUT I S M 10(6)
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Figure 1 Z-score prole for Asperger group across neuropsychological tests
* p < .01
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were more likely to have greater discrepancy scores than controls and found
that the direction of the discrepancy was related to symptom severity and
brain volume. Thus, future studies are required to examine the issue of
VIQPIQ discrepancies in more detail and their relationship to anatomy
and symptomatology.
It has been found previously that differences between AS and HFA in
language abilities decrease with age (Ozonoff et al., 2000; Szatmari et al.,
1995) and this has been interpreted by Howlin (2003) as suggesting that
the linguistic difculties of AS become more apparent with age. It is
possible that while VIQ and single-word comprehension was intact in our
sample, more extensive investigation of language function would have
revealed specic impairments. For example, Minshew et al. (1995) found
that individuals with autistic disorder were able to perform adequately on
tests of basic language but had decits on more complex language tasks
requiring comprehension and interpretation.
Our results support other reports of EF decits in people with ASD (Liss
et al., 2001; Rumsey, 1985). Previous research using the WCST in people
with ASD reported a similar pattern of results to those in our study, with
increased perseverative errors as compared to controls (Liss et al., 2001;
Minshew et al., 1992; Rumsey and Hamburger, 1990) and a reduced
percentage of conceptual-level responses. Studies using the WCST have
demonstrated that poor performance on the task occurs in young children,
adolescents and adults with autistic disorders (McEvoy et al., 1993), and
that the nding is cross-cultural (Shu et al., 2001). Our results show that
increased perseverative errors on the WCST are also found in adults with
AS. The nding of reduced conceptual-level responses indicates that the AS
group demonstrated less overall understanding of the task than the control
group.
Studies of letter uency in ASD have been inconsistent; some reported
impaired performance in people with autistic disorder as compared to age-
and ability-matched controls (Rumsey and Hamburger, 1988; Turner,
1999), whereas others found no verbal uency decit (Boucher et al.,
2005; Manjiviona and Prior, 1999). In our sample of adults with AS we
found clear evidence of a verbal uency decit. By contrast, the adults with
AS did not show any decits on the Stroop test of inhibition. This result
supports others (Ozonoff and Strayer, 1997; Russell et al., 1999) who also
found no decits on the Stroop test in children with autistic disorder.
Further, Ozonoff and Strayer (1997) found that children with autism are
not impaired on tests of negative priming or on the StopSignal paradigm,
both of which involve inhibition.
The universality of executive dysfunction has been debated in relation
to autism and, in this context, it has been suggested that for this to be case
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all patients would have to demonstrate this decit, which has not been
shown (Hill, 2004). In this study, the impairment was specic to set
shifting and generativity, but not to inhibition. In autism, impairments in
inhibition have been found to be a differentiating feature when compared
to other disorders including ADHD (Pennington and Ozonoff, 1996;
Seargent et al., 2002). Further, Boucher et al. (2005) found no decits in
their HFA group on spatial executive tasks such as the Zoo Map. Thus, the
proles may be dependent on the measures used and this highlights the
need to explore the prole of EF impairment in adults with AS in more
detail by using a large battery of tests.
A possible explanation for the EF decits found relates to the biologi-
cal determinants of this function which in turn are thought to involve the
prefrontal cortex. Other authors have drawn attention to the similarities in
symptoms between people with frontal lobe lesions and those with ASD,
for example, lack of initiative, lack of empathy and concreteness of thought
(Damasio and Maurer, 1978). In ASD, metabolic, structural and functional
abnormalities have been reported in the frontal lobes (Boddeart and
Zilbovicius, 2002; Carper and Courchesne, 2000; McAlonan et al., 2005).
However, Boucher et al. (2005) did not nd any correlations between
structural differences in the prefrontal cortex and clinical or neuropsycho-
logical measures. It is also possible that EF decits are caused by impair-
ments in connections between the components of the system, for example,
the prefrontal-striatal loops that support executive control mechanisms.
Signicant differences in grey matter volume of frontal-striatal circuitry,
and in white matter tracts connecting anterior and posterior (visual) brain
regions (McAlonan et al., 2005) have also been reported. It is possible that
the dissociations between performance on EF tests (relating to intact inhi-
bition but impaired generativity and mental exibility) reect differential
abnormalities in selected areas of frontal-striatal circuitry.
The present study used a large number of statistical tests and as such
there is a risk of false positive results. The acceptance of a 0.05 level of
statistical signicance in this study is not conservative and many of the
impairments reported would no longer be signicant at a 0.01 level. Taking
this into account, the areas of cognitive decit in the AS group were not
particularly severe. For example, only 11 of the 27 AS subjects performed
so poorly on the WCST that their scores reached clinical signicance. Thus,
from a clinical/diagnostic perspective, less than half of the AS group seen
would have been reported to have executive decits. Further, on the Doors
memory test, only nine of the 27 people with AS scored below the 5th
percentile and only six AS subjects were below average on the shapes test.
The subtlety of these decits may be partially explained by the fact that
most of the people were outpatients and had been able to pass a number
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of academic qualications. However, these subtle and selective decits do
appear to affect everyday functioning. That is, while some people with AS
achieved high scores on IQ tests their academic achievements were less
than would be predicted. For example, subject 3 had an IQ score in the very
superior range, yet is struggling to nish higher education. In addition, even
those who managed to reach high academic standards have not been able
to hold down jobs for signicant periods and many are unemployed. For
example, subject 16 had an IQ score of 120/124 and passed a science
degree but is now working as a shelf stacker in a supermarket. It is likely
that their poor social skills contribute signicantly to explaining these
ndings, but subtle cognitive decits could also account for the dislocation
of IQ scores, educational achievement and career progress.
In summary, we have given a preliminary assessment of overall
neuropsychological functioning in adults with AS. This group of people
provided a unique opportunity to investigate the cognitive decits associ-
ated with ASD without the confounding factor of signicant language delay
or learning disability. We found no evidence to support the hypothesis that
people with AS have an IQ differential in favour of VIQ, or that they have
neuropsychological decits that resemble those of an NVLD. However,
similar to other studies in people with an autistic disorder, we found that
adults with AS have decits in some aspects of EF but not others. It is
possible that within people with AS, the dissociations between decits and
preservation of some executive functions may relate to biological factors in
frontal-striatal circuitry. Future studies are required of the biological basis
of the cognitive variability in people with AS.
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