Outcome Measure Wisconsin Card Sorting Test (WCST)
Sensitivity to Yes
Change
Population Adult
Domain Neuropsychological Impairment
Type of Measure Objective test
ICF-Code/s b1
Description The Wisconsin Card Sorting Test (WCST; Heaton et al. 1993) is a
neuropsychological test of "set-shifting", i.e. the ability to display flexibility
in the face of changing schedules of reinforcement.
Initially, a number of stimulus cards are presented to the participant. The
participant is told to match the cards, but not how to match; however, he
or she is told whether a particular match is right or wrong.
Clinically, the test is widely used by neuropsychologists, clinical
psychologists, neurologists and psychiatrists in patients with acquired
brain injury, neurodegenerative disease, or mental illness such as
schizophrenia. It has been considered a measure of executive function
because of its reported sensitivity to frontal lobe dysfunction. As such, the
WCST allows the clinician to assess the following "frontal" lobe functions:
strategic planning, organized searching, utilizing environmental feedback
to shift cognitive sets, directing behavior toward achieving a goal, and
modulating impulsive responding. The test can be administered to those
from 6.5 years to 89 years of age.
Although successful completion of the test relies upon a number of intact
cognitive functions including attention, working memory, and visual
processing, it is loosely termed a "frontal lobe" test on the basis that
patients with any sort of frontal lobe lesion generally do poorly at the test.
The test takes approximately 12–20 minutes to carry out and generates a
number of psychometric scores, including numbers, percentages, and
percentiles of: categories achieved, trials, errors, and perseverative errors.
Properties See Heaton (1993) and Strauss (2006).
Inter-rater reliability: (Axelrod, 1992) Good in both experienced users (r =
.93) and novices (r = .88). The manual (Heaton, Chelune, Talley, Kay &
Curtiss, 1993) also indicates good inter-rater reliability for
nonperseverative reponses (r = .88) and perseverative responses (r = .93).
Test-retest reliability: ?
Practice effects: In one study (Ferland, Ramsay, Engeland & O’Hara, 1998),
normal controls only modestly improved their performance on repeat
testing. In contrast, using a reliability of change (RC) index, TBI survivors
demonstrated clinically meaningful gains in performance.
Construct validity: (Greve, Love & Sherwin et al. 2002) In TBI-patients, a 3-
factor solution with 99.1% of the total variance has been demonstrated
(cognitive flexibility; problem solving; response maintenance).
Concurrent validity: (review: Nyhus & Barcelo, 2009) 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. The WCST scores may not be considered as either valid or
specific markers of prefrontal executive function.
There are, however, studies that do indicate that the WCST differentiates
TBIs from controls (e.g., Axelrod, Goldman, Tompkins & Jiron, 1994)
The shorter WCST-64 does not discriminate TBIs from controls (Merrick,
Donders & Wiersum, 2003)
Advantages • Good normative data available.
• Is one of the most distinctive tests of prefrontal function.
Disadvantages • Is an expensive test to purchase (scoring program kit = $820;
introductory kit = $375).
• Can be lengthy to administer (usually 20-30 mins but perhaps
longer in TBI).
• Is a difficult test to administer if done manually.
• Difficult to score if manually administered.
• Construct and anatomical validity has been criticised.
• Potentially confusing for clients.
Additional
Information
Reviewers Skye McDonald
References
Axelrod, B. N., Goldman, R. S., Tompkins, L. M., & Jiron, C. C. (1994). Poor differential performance
on the Wisconsin Card Sorting Test in schizophrenia, mood disorder, and traumatic brain
injury. Cognitive and Behavioral Neurology, 7(1), 20-24.
Axelrod, B. N., Goldman, R. S., & Woodard, J. L. (1992). Interrater reliability in scoring the Wisconsin
card sorting test. The Clinical Neuropsychologist, 6(2), 143-155.
Ferland, M. B., Ramsay, J., Engeland, C., & O'Hara, P. (1998). Comparison of the performance of
normal individuals and survivors of traumatic brain injury on repeat administrations of the
Wisconsin Card Sorting Test. Journal of Clinical and Experimental Neuropsychology, 20(4),
473-482.
Greve, K. W., Love, J. M., Sherwin, E., Mathias, C. W., Ramzinski, P., & Levy, J. (2002). Wisconsin Card
Sorting Test in chronic severe traumatic brain injury: Factor structure and performance
subgroups. Brain Injury, 16(1), 29-40.
Heaton, R., Chelune, G., Talley, J., Kay, G., & Curtiss, G. Wisconsin Card Sorting Test Manual—Revised
and Expanded 1993. Lutz, FL: Psychological Assessment Resources Inc.
Heaton, R. K. (1993). Wisconsin card sorting test: Computer version 2. Odessa: Psychological
Assessment Resources.
Merrick, E. E., Donders, J., & Wiersum, M. (2003). Validity of the WCST-64 after traumatic brain
injury. The Clinical Neuropsychologist, 17(2), 153-158.
Nyhus, E., & Barceló, F. (2009). The Wisconsin Card Sorting Test and the cognitive assessment of
prefrontal executive functions: A critical update. Brain and Cognition, 71(3), 437-451.
Strauss, E. H. (2006). A compendium of neuropsychological tests: Administration, norms, and
commentary: Oxford University Press.
