1. 神經精神醫學第41 卷第6 號2002
J Korean Neuropsychiatr Assoc Vo/ 41, No 6 디월 쩌口
A Neuropsychological Study of Executive Function Deficit
in Autistic Disorder
Min-Sup Shin, Ph.D.,llt Hye-Geun Park, M.A.,2> Kang-E M. Hong, M.D.ll
Objectives : This study was conducted to investigate the executive function deficit and the lack of
theory of mind in children with autístic disorder,
Methods : Forty children, aged between 11 and 15, were involved in this study : 14 autistic disor­dered,
12 non-autistic mentally retarded (psychiatric controJ), and 14 normai chil따en(norm외 controJ) .
In addition to the “ Sally-Ann" task to test theory of mind, three other neuropsychological tests were
administered individually to assess executive function in all subjects.
Results : Significant group differences were found on the executive function and the theory of
mind tests. Those deficits were more widespread in the autistic group than in the non-autistic mentally
retarded group. The autistic group was impaired on the test requiring inhibition of prepotent responses
compared to the two control groups. Both of the autistic and the non-autistic mentally retarded groups
exhlbited difficulties in predicting other's behavior based on their understanding of other’s mental
states.
Conclusions : These results show that executive function and theory of mind deficits coexist in
children with au디 stic disorder. This co-occurrence of deficits suggests the possibility that prefrontal
cortex may be the neurological region responsible for causing autistic disorder.
KEY WORDS : Executive function . 까leory of mind . Autistic disorder.
Introduction
Autistic 띠sorder is a severe lifelong developmental
disorder that has a neurobiological cause. πle condition is
접수일자 : 2002년 6 월 17 일
심사완료 : 2002년 8 월 20 일
[)서울대학교 의과대학 정신과학교실 소아정신분과
Department 01 Chlld-Adolescent Psychiatry, Seoul National
Universiη" College 01 Medicine, Seoul
2) 이화여자대학교 대학원 심리학과
Depanment 01 Psychology, Ewha Womon s University,
Seoul
tCorrespondmg author
characterized by three behavioral features : qu려itative
imp없nnents in soci외 interaction 뻐d communication,
and resσicted repe디디ve-stereotyped pattem of beha-vlor.
14)
A great de외 of research has been conducted to iden­tify
the link between cognitive deficits and the deviated
behavioral features of au디 stic disorder. One approach to
cognitive studies on autistic disorder is to investigate the
deficit of ‘간leory of mind" hypothesis.5
) A theory of
mind is the belief, or “th∞'ry"， that you hold that others
have a “ mind" capable of understanding things the same
way your mind does. Thus, the hypothesis implies that
autistic individuals have a deficit with respect to repre-
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2. senting the “ self' and other’s mental states and to expec­ting
the behavior of others. Previous studies have sup­ported
the lack of theory of mind in autistic disorder.6) In
recent y않rs ， a whole body of research has foαISed on
autism and theory of mind. These studies have postulated
how a lack of theory of mind makes autistic in며애du떠
unaware of others’ thoughts and feelings. Similarly, when
it comes to communication, a lack of theory of rnind
makes it difficult for an autistic child to know where to
start in sh뼈ng hi빠ler experiences-verbally or nonver­bally.
7) A functional neuroirnaging study using SPECT
suggested that the orbito-frontal cortex rnight be the area
involved in the ability of theory of mind.8)
Another th∞retical perspective pertaining to cognitive
irnpairment in patients with autistic disorder is related to
an executive function deticit. In conσast to the propos머
that specific social or social-cognitive abnormalities un­derlie
the symptorns of au디 stic disorder, this recent su­ggestion
is that the disorder is characterized by more
general difficulties in high-level planning and control of
behavior.9) πle observation that some aspects of autistic
behavior are sirnilar to those seen in patients with frontal
lobe lesions provided the impetus for research in this
area. According to Darnasio 뻐d Maurer,lO) ‘'They share
a similar lack of initiative, a similar concreteness in thou­ght
and language, an inability to focused attention, sh와 1-
owness of affect, and lack of empathy". πris perspective
of study has the advantage of providing an explana디on
for the resσicted， repetitive and stereotyped patterns of
behaviore.상ribited by people with au디 stic 이sorder.
“ Executive function", a condition mediated by the
frontal lobe, has been detined as the set of abilities in­volved
in maintaining an appropriate problem-solving
framewOIk.II
. 12) Included in this set of abilities are the
capacity to : disengage from the external context; inhi­bit
inappropriate responses; plan and generate sequences
of willed actions; sustain an appropriate cognitive set for
staying on-task ; monitor their own perforrnance and
make use of feedback ; flexib피ty to shift their attentional
set. η피s list of abilities is not exhaustive and there rnay
be other as야cts related to the executive control of beha­vior.
The main findings of this research were that children
and adults with autistic disorder have problerns in plann­ing
and organizingl3. 14) ; in using feedbackl5) ; in swit-ching
to a new cognitive setl3•14)16) ; and in disengaging
from perceptually salient stimuli. 13)
Researches on executive function in some child psy­chiatric
disorders have primarily been guided by what
researchers call the “ frontal metaphor" ; a derivation of
ad비t neuropsychology. πle prefrontal cortex has a more
cerrσal and pervasive role in human cognition than is
usually recognized and the role of the prefrontal cortices
has been extensively debated in the history of neuropsy­chology.
9) Regarding the localization of intelligence or
other higher functions, the role of the frontallobe became
controversial in the 19th and early 2에1 centuries. When
Goldstein claimed that the frontallobe was irnportant for
“absσact attitude", a special role for the frontallobe in
human cognition reemerged. However, Hebb presented
evidence contrary to this hypothesis by demonsσa뻐g
that prefrontal removal in tive of his patients had no
noticeable effect on the social or co맑i디ve functions of
them (quoted in Pemrington & ûzonoff) 꺼 Subsequent
to Hebb’s reports, many other studies have documented
the effects of frontal lesions on a variety of cornplex
behaviors and tasks such as set shifting, planning, work­ing
memory, and inhibition. 17.18) Although the tasks and
behaviors disrupted by frontal lesions are q띠te hetero­gen∞
us with respect to their surface characteristics, they
all require goal-directed behavior, usually in novel con­texts
with competing, but erroneous response alterna­tives.
Despite understanding the go따 of the task, patients
with frontallesions fail to accornplish it, either becau않 of
perseveration, impersistence, intrusions of task-irrelevant
behavior, or lack of initiative. It is this dysregulation of
go떠-이rected behavior that cannot be attributed to a
more basic deticit in percep디on， memory, or language
cornprehension, and occurs across tasks varying in con­tent
and surface ch따acteristics. This has led to the current
view in neuropsychology in which it has been postulated
that the frontal lobe is important for the “ executive" or
“ supervisory" aspect of task perforrnance. Thus, the his­torical
controversy over whether the frontal lobe plays a
S야cial role in higher cognition 뼈stx잉enp따tly resolved
Executive function deticit has been prφosed as a
primary impairrnent in the control and regulation of
behavior and rnay be able to explain the characteristic
presence of repetitive behavior in autistic patients. In
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3. terms of executive function deficit, the repetitive and
stereotyαxl behavior of autistic 이sorder can be explained
as a failure of behavior inhibition 때d an impaired gene­rative
ability.19) An inability to inhibit actions, thoughts,
and behavior would ensure that once an individuaI was
engaged in sorne activity, or following one line of thought,
this behavior would be pursued to an abnormally persis­tent
and rigid degree. 깨us， this explanation regards
repeti디ve behavior as the direct, naturalistic counterpart
of the tendency to perseveration. πle ability to respond
to the environrnent in a flexible and adaptive way depends,
not just on the ability to control and regulate behavior
through the inhibition of inappropriate activity, but also
on the ability to generate appropriate goals and courses
of action. If the ability to generate novel behavior and
ideas was permanentIy disabled, we rnight predict that
we would use a small set of action plans and use them
repeat뼈l Jy. Therefore, in people with au디stic 이sorder，
executive dysfunction rnay render individuals unable to
generate novel action plans, thus forcing them to repeat
the same acts over and over. In this way, because it is
difficult for autis디C 야x>ple to be spontaneous and creative
in their use of objects, toys, and their leisure time, they
are commonly found carrying out the same activity over
and over again.
It would therefore seem that the research described
above irnplies that the lack of theory of rnind and the
execu디ve function deficit in autistic disorder rnay expl­ain
the underlying cognitive irnpairment associated with
various behavioral symptoms. Research directed at those
cognitive irnp없rments 벼rectIy ∞nnected with behavioral
symptoms associated with the autistic disorder rnight pr­ovide
a new approach to understanding autistic disorder,
which can be helpful in the development of therapy
programs for autistic c뻐따-en. Therefore, in present study
we exarnined the executive function deficit and the lack
of theory of rnind in autistic children using neurop­sychologIcal
tests to assess executive function and the
“ Sally-Ann" task to test theory of rnind.
Methods
1. Subjects
까πee groups of subjects between the ages of 11 and
Table 1. Comparisons of IQ, age and K-CARS belween
Outistic and MR groups
Autistic group MR group
(n=14) (n=12)
Mean(S.D) Mean(S.D) Statistics
FSIQ 54.36(13.39) 52.33(12.56) T=0.4O
VIQ 45.93( 9.91) 53.00( 9.65) T=l ‘84*
PIQ 74.64(17.60) 60.33(20.63) T=1.91*
이(-CARS 30.32( 5.83) 19.07( 1.79) t=6.90**
Sex(M: F) 12: 2 11 : 1
* . p<.05, ** . p<.Ol
Q ‘ Korean version of Chlldhood Autism Rating Scale
15 p따ticipated in this study; the autistic (n=14 ; boy=12,
girl=2) , 야le mentally retarded but non-autistic (n=12 ;
boy=ll, girl=I), and the normal 뼈l따-en (n=14 ; boy=12,
girl=2). Two clinical groups were recruited from three
sch。이 s for special children in Seoul, Korea. The child­ren
that were included in the clinical group had been
diagnosed as having autistic 띠sorder， or mental retarda­tion,
before being adrnitted to the speci외 school. The
autistic group consisted of c뻐.dren who meet DSM-IV
criteria for au디stic disorder and pervasive developmen­tal
disorder not otherwise specified (PDD NOS). πle
non-autistic mentally retarded group(MR group) was
rnatched with the au디 stic group on chronological age
(CA) and Full Scale IQ of the Korean version of We­chsler
Intelligence Scale for Children- Revised (Table 1) ‘
The mean ages of the autistic, MR, and normal groups
were 13.03 (S.D.=1.43) , 12.85 (S.D.=1.7I), and 13.01
(S.D.=1.37) y않rs， respectively. The chil따enofthe MR
group who manifested autistic-like symptoms were ex­cluded
from the study. πle normal children were recru­ited
from 뻐 elementary and a rniddle school in Seoul,
and were rnatched with the clinical groups on CA. 까le
normal children had no learning, behavioral and Înter­person떠
problems according to their teachers and parents
There was no significant difference in the mean age
among the three groups, or in the Full Scale IQ (FSIQ)
between the autistic and the non-autistic mentally retar­ded
groups. The mean K-CARS (the Korean version of
Childhood Autism Rating Scale) 20) score was signifi­cantly
higher in the au디stic group than the non-autistic
mentally retarded group.
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4. 2. Measures
ππ'ee neuropsychological tests were used. These con­sisted
of : πle Go-NoGo Test, the Trail Making Test­type
B and the Eight Boxes Test. πlese tests have been
demonstrated to assess the ability of inhibitory control,
attention shifting, and wor성ngmemory m때iated by the
frontal lobe. The “ Sally-Ann" task 띠so was administ­ered
to assess the children’s ability to understand the
mental states of others, namely, theory of mind.
1) Tests of Executive Function
(1) Go-NoGo Test
The Go-N어]0 test is the 33rd and 34th item con­tained
within the Luria-Nebraska Neuropsychological
Battery for Children (LNNB-C)?I) These items ass않S
the ability of behavioral control by the language direc­tion,
that is, the ability to plan and regulate a behavior
by the direction which require a sequential or conflicting
behavior. Given that the frontal lesion patients lose this
ability, the Go-NoGo test is suitable for diagnosing fron­tallobe
dysfunαion.12) 22)
ln former P'따t of the experirnent• the experirnenter
had a child hold her hand, as if shaking hands, then gave
the folIowing instruction : “If 1 say ‘red’, squeeze my
hand. lf 1 say ‘green’, do nothing". The expe디menter
repeated the insσuction 10 디mes， rar떠omly distributing
the nature of the instruction (5 red & 5 green) . Children
were then allowed to respond after each trial. ln latter
part, the experirnenter gave the instruction ; “If 1 knock
once, raise your right hand. If 1 knock twice, raise your
left hand". Once again, the instruction was reα:ated 10
times, with the nature of the instruction being randomly
disπibuted (5 once & 5 twice). The scoring added up to
the number of correct responses.
(2) Trail Making Test-ηpe B23)
The tr따1 making test measures visuo-motor σacking，
attention, and frontal lobe function such as conceptu외Ì­zation
and mental set shifting. It is administered in two
parts (A and B) ; we used onIy Part B. In this study, the
experirr‘enter changed the English alphabet to Korean
letters. The subjects were req비red to connect 25 encir­cled
numbers and letters in alternating order with a
pencil. Both numbers and letters were arrayed 피 random
order, with each child r여uired to alternate between the
two sets and complete the test as rapidIy, but as accurately.
as possible. ’The score was the total time req빠ed for
comple디on.
As this is a complex visu떠 scanning test with motor
skill, po어 visual-motor coordination, φ，fficulty of visual
scanning, I'OW m'Otivational level, and frontal I'Obe im­p없rrnent
떠1 c'Ontribute to inhibit perf'Ormance. The brain­injured
patients e상ribited α)()rer p앉formance than the
n'Orrnal group, and there was a significant correlati'On
between an electrophysiologicaI index of frontal I'Obe
functi'Oning and measures of πail making test. 24)
(3) Eight Boxes Task
The eight boxes task was an eight-box version 'Of
Diam'Ond’s ‘six boxes sc때nbl뼈’ task?5) lt was used t'O
measure w'Orking mem'Ory in the study 'Of n'Orrnal deve­I'Opment
'Of executive 미nc디on. 13) Ei양lt different col'Ored
boxes (red, yelI'Ow, green, blue, navy blue, purple, pink,
and sky blue : 6 x 6 x 4cm) were arranged on the tray
(60X 갱cm). πle c비ld obseπed the experimenter place
a piece 'Of chocolate in each of the eight different boxes.
The σay was then covered with a scarf and spun 따'Ound.
까le child was then asked to choose a box c'Ontaining
chocolate. Each time the child ch'Ose a box that conta­ined
a chocolate ; he/she C'Ould eat choc'Olate as a reward
After this frrst successful 띠외 (in which all the boxes
contained choc'Olate) , the boxes were scrambled, co­vered,
and spun ready for the next 미외. In each of the
subsequent trials, the child was reminded to choose a
box that they hadn’t yet looked in. This pro야dure was
repeated until all eight pieces 'Of chocolate had been
f'Ound, 'Or after 15 σials had been c'Onducted, whichever
occurred sooner. The number of σials required to find all
eight pieces of chocolate, and the number of errors made
in the process, were recorded.
2) Test of Theory of Mind
The “ Sally-Ann Task", the f;허 se belief task that was
used in the frrst experiment on metarepresentation외
deficit of autistic children,51 was also adrninistered. This
task is a story about false be!ief where the experimenter
tells the story by showing 5 pictures in which each scene
Ìs described2) : ‘This is Sally and 야ris is Ann (“9꺼1'0 is
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5. To바e 2. Comparisons of neuropsychological te앙s among groups
Autistic1 MR2 Normal3
(n=14) (n=12) (n=14)
Mean(S.D) Mean(S.D) Mean(S.D) F SNI(b
Go-NoGo test 16 ∞( 2.96) 18.75( 2.1 Q) 20 ∞ (0 ) 13.31** 1 <2.3
。'Trail making tes• 185.14(99.79) 296.58 (1 55.13) 86.21 (22.55) 13.20** 2 < 1 <3
。Eight-Boxes task 1O.07( 2.95) 1l .92( 3.06) 7.93( 1.38) 7.96** 1. 2 < 3
** ‘ p< .0 1. 0 . higher score means p。α performance. b : Student-Newman-Keul (p< .05)
Sallyand who is Ann?"). Sally has a ball. She puts the
ball into her basket. Sally goes out for a walk. Ann takes
the ball out of the basket and puts it into the box. Now
Sally comes back. She wants to play with her ball. Where
will Sally look for her ball?" (Belief qu얹디on) . If a child
points to the previous location of the ball, then the child
can pass the belief question by appreciating the Sally’s
now false belief. If however, a child points to the ball’s
current location, then the child fails the question by not
taking into account the Sally’s belief. These conclusions
are warranted if two control questions are answered c(•
rrectly : “Where is the ball really?" (Reality question)
“ Where was the ball in the beginning?" (Memory ques­디on).
πle control questions are crucial to ensure that the
child has both knowledge of the real current location of
the object and an accurate memory of the previous
location. Finally the rationalized question is given :
“Why did S외ly look in the basket (or box) to find her
ball?" In the belief question, the scoring is pass or fail.
In the rationalized question, the child’s answer is scored
as zero-orderGrrelevant answer) , or frrst-order(Sally
behaved as she thought) .
3. Procedures
Two clinical psychologists administered the Korean
version of Wechsler Intelligence Scale for Children-Re­vised
(KEDI-WISC) to the autistic and the non-autistic
mentally retarded groups. The Korean version of Child­ho여
Autism Ra피19 Scale(K-CARS) was also adrnini­stered
to the two clinical groups by means of interview
with their teachers. ’fhree neuropsychological tests of
executive function and the Sally-Ann task were subse­quently
administered in a predetennined order, with the
order being counter-balanced across su비ects. It took
approximately 20 minutes. At the beginning of each test,
children received a standard set of instructions and the
subsequent practice session allowed them to become
farniliar with the test instruments and response require­ments.
AlI the clinical subjects were tested individually
in the quiet room at their school. KEDI-WISC 때d K­CARS
were not administered to the normal group.
4. Data Analysis
MANOVA was used to compare three groups using
the data obtained from the neuropsychological tests.
Post-hoc comparisons (Student Newman-Keuls) were
subsequently conducted to identiη significant group di­fferen야s.
Chi-square tests were performed to assess the
벼fference between group scores for the “ Sally-Ann task"
Results
1. Executive Function
The means and standard deviations for each group on
executive function tests are presented in Table 2. 깨e
multivariate analysis of variance for the tlrree neuropsy­chological
tests showed significant differences among
tlrree groups.
On the Go-N어Jo test, the autistic group exhibited a
significantly lower performance(p<.Ol) than the MR
and the normal groups. No significant difference was
apparent between the MR and the normal groups. These
results indicate that autistic children have difficulty in
inhibitory control and shifting cognitive sets. on the trail
making test-type B, the MR group exhibited the lowest
perfom퍼nce among tlrree groups (p<.Ol), with the au­디S디c
group’s performance being slower than that of the
normal group on this test (p<.05). on the eight boxes
task, the MR and autistic groups e상피bited significantly
lower performances than the normal group (p<.O 1), and
there was no significant difference between the MR and
the autistic groups.
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6. 1al벼e3.Compari∞ns of Sally-Ann task among groups
Autistic group
(n=14)
MRgroup
(n=12)
Normal group
(n=14)
Belief question
Correct respanse (ratio)
Inc。πect response(ratio)
5 (36%)
9 (64%)
6 (50%)
6 (50%)
14 (1α뼈)
o ( 0%)
Rationalized question Zero-order 14 11 12
Flrst-order 0 2
X 2: 13.49, df=2, p< .01
2. Theory of Mind
πle perfonnance of each group on the belief and
rationalization question in the Sally-Ann task is depicted
in Table 3. With the exception of four autistic chil따en，
외 1 subjects were able to answer the control questions
correctly. A significant difference (p<.Ol) was app'와ent
between groups in the belief question. All of the norrnal
chil따en answered correctly, but only 5 autistic chil따en
(36%) and 6 MR children (50%) answered correctly.
There was no group difference between the au디stic and
the MR groups. Both of clinical groups e앙ribited lower
perfonnances than the norrnal group. In the rationalized
question, there were a few children who gave an answer
based on Sally’s false belief(frrst-order) in all groups.
Autistic children who answer correctly in the belief
ques디on could not infer Sally’s menta1 state (She thinks
a ball is in the basket) , but gave a descriptive explana­디on(
S외ly put a ball in the baskeÙ. Most of the MR
children answered in a sinrilar way. For example, “The
ball isn’t in the basket", or “Her friend put the ball in the
box", even if they could expect Sally’s behavior corr­ectly.
Only one MR child responded, “ Sally didn’tknow
the ball had been moved". All the norrnal children ex­pected
Sally’s behavior correctly, but in the rationalized
question, only two children could infer her behavior
fromherf;매se belief.
Discussion
In this study, the executive function deficit and the
theory of mind impairment in au디stic children were in­vestigated.
’The au디S디c children e.상ribited si맹ificantly
lower perfom퍼nce than the norrnal and the MR chil따en
on the Go-NoGo test. The perfonnance of MR c비l따en
did not differ significantly from that of norrnal children.
πlese results mean that executive function deficit that
was measured using the Go-N어]0 test is specific to
autistic children and it is not due to their menta1 retar­dation.
on the Go-NoGo test, the autistic children could
understand the instruction, but could not give correct
answers. πley merely raised their hands alternatively
without regard to stimulus they heard, suggesting that
they have a difficulty in controlling and inhibiting their
behavior. Luria12
) explained this 암nd of difficulty as “a
phenomenon that planned behavior is replaced with the
stereoty야영 one". In the latter p따t of the Go-NoGo test,
some autistic children inritated experimenter-giving inst­ructions
before they were required to respond to the
stimulus. This behavior would suggest that they couldn’t
I띠ribit their behavior at seeing the perceptu외ly salient
stim버us ， so responded to it automatically. This kind of
behavior seemed to obsσuct them from giving the correct
response. Taken together, these results demonstrate that
autis디c children have an executive function deficit.
In order to succeed in the σail making test-type B, the
subject requires the capacity for visual scanning, com­bined
with alterna디on of attention. on the σ없1 making
test-type B, the autistic children exhibited significantly
lower perfonnance than the norrnal. However, the MR
children had more difficulties in 꺼su떠 scanning than the
autistic c비l따en. Considering the deviant cognitive char­acteristics
of autistic children, this result could be under­stood.
Given that children with autistic 띠sorder have
one or more resσicted interests in inanin1ate and non­social
stimuli like letters and numbers, restricted
patterns of interest have been included in the diagnostic
criteria for autistic disorders. 1
) As the σail making test­type
B consists of numbers and letters that au다stic
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7. children tend to be up to the eyes in, they might perform
better than the MR children. Therefore, the higher
performance of autis디c children on the σ없1 rna잉ng test­B
could be inteψreted as ret1ecting their stereotyped
behavior pattem dealing with letters and nurnbers as
opposed to a genuine ability for mental shifting and
altemating their attention.
ln the eight boxes test, both of the autistic and the MR
children did not perform as well as the norrnal children.
πle autistic children were unable to memorize the colors
of the boxes, while the norrnal children usually remem­bered
the colors of the boxes in which they had already
removed the chocolate, or the number of boxes that still
contained chocolates. These results suggest that the au­디stic
and the MR children have poor working memories,
and are unable to irnplement memory sσategies effec디­vely.
πle autistic and the MR groups were found to have
difficulty in representing other's beliefs and pr<잉ict their
behavior. On the Sally-Ann task, in which nOffi1a1 4-
y않r-old children have been demonsσated to give the
correct response, only 36% of the autistic children and
50% of the MR children answered correctly. πús su­ggests
that both the MR and the autistic children have a
deficit when attributing other’s mental state. These results
are contradictory to previous reports in which it was
stated that theory of mind deficit is specific to the au­tistic
disorder. However, given that the autistic group
exhibited fewer correct and more incorrect responses
than the MR group on the Sally-Ann task, combined
with the fact that the difference was not statistically
significant, 미띠ler study using a larger number of clinical
subjects is needed to ascertain whether theory of mind
deficit is specific to the autistic disorder or not.
πle Executive dysfunction 때d lack of theory of mind
have been discussed as a prim따y cognitive impairment
underlying the autistic 이sorder. Recent studies claimed
that a single cognitive deficit could not account for the
various autistic syrnptoms and that an attempt to explain
the failure on theory of mind task by tlIe executive func­tion
irnpairment was no longer me없피Igful. 26-27) However,
tlIe present study demonstrates tlIat autistic children had
more difficulties on tlIe tests of executive function 뻐d
tlIeory of mind tlIan tlIe MR chil따.en. These fmding
irnply that executive function deficit as well as tlIe lack
of tlIeory of mind rnay be tlIe prirnary cognitive deficits
responsible for tlIe diverse behavioral syrnptoms ch따ac­teristic
of tlIe au디 stic disorder. Given tlIat previous rese­따chers
have proposed tlIat those two cognitive abilities
are mediated by the sarne brain 따ea，28) the finding that
executive function inIpairment and tlIeory of mind deficit
co-exist in autistic c삐1φen seems to be persuasive. It
could explain tlIe various autis디.c symptoms better 암lan
any single theory. A 미nction려 MRl study inψlicated
the involvement of the orbitofrontal cortex when perfor­ming
a test in which words pertaining to mental state
had to be recalled29
) as well as a PET study that inIpli­cated
the left cenσal frontal cortex when perfomúng a
r않soning test based on thoughfO
) botlI suggest that tlIe
possible brain 따ea responsible for regulating the th∞ry
of mind ability, as well as executive function, might be
the frontal lobe. Executive function irnpairment has
been well documented as a primary syrnptom in frontal
lesion pa디ents. πle diverse syrnptoms of autistic 며sorder
could be fully explained by the executive dysfunction
and theory of mind deficit, tlIat is, tlIe social and
l없19uage impairments by a theory of mind deficit and
tlIe stereotyped-repetitive beha꺼or by an executive func­tlon
lmp없rment.
The significance of present study is that it exarnin어
tlIe restricted and stereotyped-repetitive behaviors of
autistic 며sorder in teffi1S of executive function deficit
using the neuropsychological tests for frontallobe func­tioning.
As the autistic syrnptoms like repetitive-stereo­typed
pattem of behavior, resσicted interest, and rigidity
have obtained relatively less attention than the social
and communication deficits,31) a study of executive
function in autistic children is indispensable when trying
to understand those behavioral symptoms and to deve­lop
intervention prograrns for tlIem. Considering tlIe
longitudinal research that the cognitive t1exibility is
closely related to tlIe development of social ability,32)
renewed emphasis should accompany the realization
tlIat executive function is an important factor of autis디C
symptoms and should receive more attention tlIan ever
before.
πle present study rnay have significant clinical im­plications
insofar as tlIe σ'eatlnent of autistic 띠sorder in
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8. C아lcemed. As executive function en∞mpasses the ability
for p1anning and organi깅ng， mental flexibility and self­regula디on，
it is σuci외 to adapt effectively to the daily
life and school ac디vity. Nevertheless, the treatment of
executive imp따nnent in autistic children has not been
emphasized?3) Autistic chil따-en with executive imp'머f­ment
have many difficulties in finishing schoolwork on
time, and their off-task behavior interferes with their
scho이 activi디es. Even thou뱅 some children with au­tistic
disorder are not mentally retarded, their inflexi­bility
and rigid sσategies in problem solving prevent
them from displaying their intellectual ability and cause
many problems in their school and everyday lives. 깐lUS，
the intervention approach for facilitating and exercising
executive function may be helpful for school-aged au­tistic
children. For ex따때le， extemal structuring, such as
planning the school activity in advance, providing the
cl않f instructions and methods with which to do home­work,
making the object of tasks obvious, and giving
prompt feedback for perfonnance, could aid children
with executive function deficit like autistic 마sorder.
Although the present study demonstrates the clinical
implications underlying an 뻐derstan띠ng of the deviant
behavioral symptoms and social deficit of au디S디c child­ren
and their σ'eatment， it has several limitations. Since
the autistic children that participated in this study had
mentally retarded IQs, the typical neuropsychological
tests for executive function, like the Wisconsin Card
Sorting Test and the Tower of Hanoi, could not be admi­nistered.
Furthennore, only non-verbal tests requiring
less verb허 ability were used. In addition, the sample size
of clinical group was relatively small. To generalize our
result and obtain a definite answer to the question, the
findings of present study that executive function irrψ허f­ment
and theory of mind deficit co웅xist in autistic ch­ildren
need to be replicated using additional neuropsy­ch이ogical
tests that measure frontal lobe functioning
with a larger clinical group that includes subjects with
high functioning autistic disorder.
References
I) Amcrican Psychiatric Association(I994) Diagnostic
and statistica1 manu머 of mental disorders. 4th ed, Wa-shington
DC, American Psychiatric Press
2) Frith U(1989) : Autism : Explaining the enigma. Ox­ford,
Basil Blackwell
3) M뼈lbov GB, Adams LW, K1inger W (1997) : Autism :
Understanding the disorder. New York, Plenum Press.
4) Sigman M(1995) : Behaviora1 research in childhood
autism. In : Frontiers of developmental psychopatho­logy.
Ed by Lenzenweger M and Haugaard J, New York
SpringerNeriag, pp 190-206
5) Baron-Cohcn S, Lcsic AM, Frith U(1985) : Does the
autistic child have a “ theory of mind"? Cognition 21 :
37-46
6) B와'On- Cohcn S, T:앵cr-에usbcr영 H, Cohcn D(1993)
Understanding others minds : Perspectives from autism.
Oxford, Oxford University Press
7) Sicgcl B (1996) : πle worid of the autistic child. Ox­ford,
Oxford University Press
8) Baron-Cohcn S, Ring H, Moriatrγ J, Shmitz P, Costa
D, Ell P (1994) : Recognition of mental state teffilS :
A clinica1 study of autism and a functiona1 neuroimag­ing
study of normai adu1ts. Br J Psychiatry 165 : 640-649
9) Pcnnington BF, Ownoff S(1996) : Executive function
and developmental psychopatho10gy. J Chi1d Psychol
psychia따 37 : 51-87
IO)D없n잃io AR, Maurcr RG (1978) : A neurological mo­del
for childho얘 autism. Arch Neurol35 : 777-786
11) Lczak MD (1 995) : Neuropsychologica1 싫sessment. 3rd
ed, Oxford, Oxfird University Press
12) Luria AR (1973) : πle working brain : lntroduction to
neuropsycho10gy. New York, Basic B∞ks
13) Hughcs C, Russell J, Robbins TW(1994) : E꺼dence
for executive dysfunction in autism. Neuropsycho1ogia
32 : 477-492.
14) Ownoff S, Pennington BF, Rogcrs S (1991) Exe-cutive
function deficits in high-functioning autistic ch­ildren
: Reiationship to the아y of mind. J Child Psycho1
Psyc비atry 32 : 1081-1106
15) Prior MR, Hoffmann W(1990) Neuropsych이ogica1
testing of autistic children through an exploration with
frontallobe tests. J Autism Dev Disord 20 : 581-590
16) Rumsey JM, Hamburger SD (1988) Neuropsychol-ogica1
fmdings in high-functioning men with infantile
autism, residua1 state. J Clin Exp Neuropsychol 10
201-221
17) Fuster JM (I 989) πle prefrontal cortex : Anatomy,
physiology and neuropsychology of the frontal lobe.
2nd ed, New York, Raven
- 1066-

9. 18) Kolb B & Wìsbaw IQ (l990) : Fundamentalsofhuman
neuropsychology. New York, WH Freemont and Com-pany
19) Tumer M (J 997) : Towards an executive dysfunction
account of repetinve behavior in autism. In : Autism as
an executive disorder, Ed by Russell J, Oxford, Oxfird
University Press, pp57-IOO
20) 8hin M8, Kim YH (1998) : A study of standardization
for the Korean version of Childho여 Autism Rating
Scale. Korean J Clin Psychol 17 : 1-16
21) Golden CJ (l987) Luria-Nebraska Neuropsycholo-gical
Battery : Children’s Revision. Los Angeles, We­stem
Psychological Service
22) tc Gall D Truelle JL, Jo않ph PP (J990) : Gestural
disturbances following frontal lobe lesions. J Clin Exp
Neuropsychol 12 : 405
23) Reitan RM, Wolfson D (t 985) : The Halsted-Reitan
Neuropsychological Test Battery. Tuscan, Neuropsycho­logical
Press
24) ScgaIOitz, 8J. Unsal A, Dywan J (J992) : CNV evi­dence
for the distinctiveness of frontal and posterior
neural processes in a traurnatic brain-mjured population.
J Clin Exp Neuropsychol14 : 545-565
25) Diamond A, Prevor MB, Callender G, Druin DP
(J 997) : Prefrontal cortex cognitive deficits in children
treated early and continuously for PKU. Monographs of
the Society for Research in Child Development Serial
No. 252, Vol. 62, No. 4
26) Bishop DVM (J993) : Annotation : Autism, executive
functions and th∞ry of mind : A neuropsychological
perspective. J Child Psychol Psyc비atry 34 : 279-293
34)
27) Happe FGE, Frith u(l996) : ηle neuropsychology of
autism. Brain 119 : 1377-1400
28) Baron-Cohen 8, Swettham J (J997) : Theory of mind
in autism : Its reIationship to executive function 뻐d
central coherence. In : Handbook of Autism and Per­vasive
Developmental Disorders, Ed by Cohen DJ, Vo­lkmar
FR, New York, Wiley & Sons, pp880-893
29) Baron-Cohen 8, Ring H, Moriaη J, Schmitz B, Co­sta
D, 메I P (J994) : Recognition of mental state ter­ms
: Clinical findings in children with autism and a
functional neuroÎnlaging study of nomtal adults. Br J
Psyc비atry 165 : 64ι649
30) Fleteher PC, Happ F, Frith U. Baker SC, Dolan RJ,
Fraeku‘찌파‘ RSJ, Frith CD (J995) : Other minds in the
brain : A functional Înlaging study of ‘난leory of mind"
in story comprehension. Cognition 57 : 109-128
31) Happe FGE(l994b) : Annotation : Current psycholo­gical
theories of autism : πle ‘암loery of mind" account
and rival theories. J Child Psychol Psychiatry 35 :
215-299
32) Berger HJC, Van 8paendonek KPM, Horstink M찌IJM ，
Buytenhuijs EL, Lammers PWJM, Cool AR (J993)
Cogniti ve shifting as a predictor of proc강ss in social
understanding in high functioning adolescents with au­tism
: A pros야ctive study. J Autism Dev Disord 23 :
341-359
33) Ozonoff 8 (J998) Assessment and remediation of
executive dysfunction in autism and Asperger syndrome.
In : Asperger syndrome or high-functioning autism, Ed
by Sζhopler E, Mesibov GB, Kunce U , New York :
Plenum Press, pp263-289
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10. 언구륙쩍:
J Korean Neuropsychiatr Assoc Vo141, No 6, November; 2002
자폐 장애의 실행 기능 결함에 대한 신경심리학적 연구
서울대학교 의과대학 정신과학교실 소아정신분과
신민섭·박혜근·홍강의
본 연구에서는 자폐 장애 아동들의 보이는 실행기능 결함과 마음 이론의 결여에 대해 신경심리학적으
로 규명해보고자 하였다.
방 법:
11 세에서 15세 연령 범위의 자폐 장애 아동 14명(남아 12, 여아 2) , 정신 지체 아동 12명(남아 11,
여아 1), 그리고 정상 아동 14명(남아 12, 여아 2) , 총 40명의 아동이 본 연구에 참여하였다. 모든 아동
들에게 마음 이론을 평가하는 “셀리-앤” 과제와 실행 기능을 평가하는 세가지 신경심리검사를 개별적으
로 실시한 후， MANOVA와 Chi-Square 분석을 실시하여 집단간 차이를 알아보았다.
멸 과:
실행 기능 검사와 마음 이론 과제에서 세 집단간에 유의미한 차이가 었었다. 자폐장애 아동 집단이 정
신지체 아동 집단보다 이러한 검사상에서 더 광범위한 결함을 보였으며， 자폐 장애 얘들이 정신지체나
정상 아동들보다 반응을 억제하는데 더 어려움이 있었다. 자폐 ~배와 정신지체 아동 집단 모두 타인의
마음을 이해히여 행동을 예측하는데 어려움이 있었다.
멸 론:
본 연구 결과들은 설행 기능과 마음 이론의 결함이 자폐 장애 아동틀에게서 공존한다는 것을 보여주었
다. 이러한 결과는 전전두엽이 자폐장애의 원언론과 관련되어 있을 가능성을 시사해주었다.
흉심 단억 : 실행 기능· 마음 이론· 자폐 장애.
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