TEST REVIEW

The WCST-64: A Standardized Short-Form of theWisconsin Card Sorting Test�

Kevin W. GreveDepartment of Psychology, University of New Orleans, New Orleans, LA, USA, and

Jefferson Neurobehavioral Group, Metairie, LA, USA

ABSTRACT

The Wisconsin Cart Sorting Test (WCST) is a well-established measure of executive function. Practical and®nancial constraints have increased the need for abbreviated neuropsychological procedures. A number ofabbreviated versions of the WCST have been introduced and cogent arguments can be made for one overanother in certain situations. However, the single deck, 64-card WCST (WCST-64) is the most logical andpractical short form. Psychological Assessment Resources (PAR) has recently published a new manual withcomprehensive norms for the WCST-64. This paper reviews the new product, discusses the comparability ofthe WCST-64 and the standard version, and suggests directions for future research.

The Wisconsin Cart Sorting Test (WCST; Grant

& Berg, 1948; Heaton, 1981; Heaton et al., 1993)

is a well-established measure of executive func-

tion. The ever-increasing number of studies incor-

porating the WCST illustrates its value and

popularity. The ®rst 40 years of the WCST's

existence (1948±1988) saw its use in less than

100 published journal articles with over half of

those appearing in the 1980s alone. In contrast,

the last 12 years have witnessed the publication of

over 500 articles using the WCST. The early days

of the test were characterized by both systematic

and nonsystematic variation of almost all aspects

of the WCST (see Heaton, 1981, or Heaton et al.,

1993, for an outline of many of these variations)

with variations in administration and scoring con-

tinuing to appear even now (Stanford, Greve, &

Gerstle, 1997; Stuss et al., 2000). The WCST

methodology with which most neuropsycholo-

gists are familiar was formalized by Heaton with

the publication of the ®rst WCST manual by

Psychological Assessment Resources (PAR) in

1981. With the second edition of the manual

(Heaton et al., 1993), users were provided with

more comprehensive norms and scoring instruc-

tions which took much of the mystery out of

identifying perseverative responses. The use of

these new norms, of course, requires that the test

be administered in `̀ standard fashion''. Standard

fashion frequently means completing all 128

trials, an often painful and time-consuming

process. In a profession where the motivation of

the patient is critical to the validity of our clinical

tasks and the amount of time allotted to an

evaluation is limited by either practical or ®nan-

cial constraints, these are not idle concerns.

�The author served as a compensated beta-tester of the WCST-64 for Psychological Assessment Resources prior tobeing asked to write this review.Address correspondence to: Kevin W. Greve, Ph.D., Department of Psychology, University of New Orleans-Lakefront, New Orleans, LA 70148, USA. Tel.: +1-504/280-6185. Fax: +1-504/280-6048. E-mail: kwgps@uno.eduAccepted for publication: August 29, 2000.

The Clinical Neuropsychologist 1385-4046/01/1502-228$16.002001, Vol. 15, No. 2, pp. 228±234 # Swets & Zeitlinger

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Attempts to address these issues in the WCST

have led to the development of several abbre-

viated versions.

Nelson (1974) reported the use of a modi®ca-

tion (MCST) which involved the removal of all

ambiguous response cards (i.e., those matching

a key card on more than one dimension) from

the set of 128 cards, thus leaving a deck of 48

unambiguous cards. The smaller response deck

necessitated shorter criterion runs (6 rather than

10 consecutive correct responses) but greatly

simpli®ed the scoring of perseverative responses.

Unfortunately, Nelson also warned subjects of the

impending change of correct dimension thereby

eliminating an essential element of the WCST.

Also, rather than having a ®xed sequence of

`correct' dimensions, the ®rst dimension to which

the subject sorted was considered correct; after

completing that criterion run and being warned of

the changing of the rule, the next new dimension

to which the subject sorted became correct. The

advantage of this version is that it is easier, thus

potentially reducing frustration and ¯oor effects

(Lezak, 1995). Of course it also obviates the need

to discover the correct sorting dimension and to

recognize when the sorting dimension has chan-

ged. The use of this version in a number of

populations has been reported (many of these

studies are reviewed in Zubicaray & Ashton,

1996). In a study directly comparing the MCST

and the standard WCST, van Gorp et al. (1997)

found the two tests generally comparable but

questioned Lezak's (1995) conclusion about the

dif®culty of the task. In reviewing the literature on

the sensitivity of the MCST to frontal lobe patho-

logy, Zubicaray and Ashton (1996) concluded, `̀ it

is likely that the MCST is an altogether different

test from the standard version'' (p. 245).

Variations of Nelson's approach which pre-

serve the essential character of the WCST

administration procedure while using only the

unambiguous cards have also been reported

(Bondi, Kazniak, Bayles, & Vance, 1993;

Greve & Smith, 1991; Hart, Kwentus, Wade, &

Taylor, 1988; Jenkins & Parsons, 1978; Ramage,

Bayles, Helm-Estabrooks, & Cruz, 1999). Greve,

Bianchini, Hartley, and Adams (1999) argued that

this type of modi®cation might be more useful

with older or more severely impaired patients in

rehabilitation settings than standard versions of

the WCST because it might be less prone to ¯oor

effects. While this modi®cation compared favor-

ably with the standard WCST in a small sample of

neurologically intact older adults (Greve & Smith,

1991), the question remains whether it also is `an

altogether different test'.

A more intuitive approach to WCST short-

form development is the use of one deck of

response cards instead of two (the WCST-64),

thus immediately cutting the test in half. This

procedure retains all the features of the standard

WCST except length. Unlike the MCST, the use

of the WCST-64 is relatively recent, ®rst reported

by Haaland, Vranes, Goodwin, and Garry (1987)

in a study of normal aging. In direct comparisons

Heaton and Thompson (1992), Axelrod, Henry,

and Woodard (1992), Sillanpaa et al. (1993), and

Smith-Seemiller, Franzen, and Bowers (1997)

found the WCST-64 to be generally comparable

to the standard version. Axelrod, Jiron, and Henry

(1993) and Paolo, Axelrod, TroÈster, Blackwell,

and Koller (1996) found the WCST-64 sensitive

to the effects of normal aging and pathological

aging (Alzheimer's and Parkinson's disease),

respectively. While there appears to be justi®ca-

tion for believing that the two versions are

comparable and have similar sensitivity to the

effects of neuropathology, Axelrod, Abraham,

and Paolo (1996) cautioned against simply

converting WCST-64 scores to percentages and

then using the standard norms.

Unlike the MCST and the WCST-64, which

have been used repeatedly in published research,

two other variations of the WCST, the WCST-3

(Robinson, Kester, Saykin, Kaplan, & Gur, 1991)

and the Milwaukee Card Sorting Test (Osmon &

Suchy, 1996) have been reported once each. The

WCST-3 is identical to the standard WCST but is

terminated when three, rather than six, catego-

ries, have been successfully achieved. While this

version may be shorter in theory, in practice it

likely will not be since many patients often have

dif®culty achieving even a single category.

Further, it was found inferior to the WCST-64 in

terms of classi®cation accuracy and in under-

estimating performance on the standard WCST

(Robinson et al., 1991). The Milwaukee Card

Sorting Test is a 64-card version administered

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with the standard instructions designed to quan-

tify the `̀ separate, elemental executive abilities

needed for card sorting performance'' (p. 541;

Osmon & Suchy, 1996). This version requires the

subjects to verbalize how they are sorting each

card. A factor analysis resulted in three factors

similar in interpretation to those usually reported

for the WCST but included a number of idi-

osyncratic scores which make direct comparison

dif®cult.

The prevalence of WCST short-forms in the

research literature illustrates the demand for an

abbreviated version. The need in clinical settings

may be even greater given the multitude of

practical factors affecting clinical test selection.

The WCST-64 is the most logical downward

extension of the WCST, the one for which quality

norms are most readily available, and the one to

which the existing WCST literature is most likely

to generalize. Thus, PAR has now introduced a

comprehensive WCST-64 package.

PAR'S WCST-64 PACKAGE

The WCST-64 package has ®ve elements which

can be purchased together, in various combina-

tions, or individually. These include: (1) a single

deck of 64 response cards and four stimulus cards;

(2) record sheets; (3) scoring software; (4) admin-

istration software; and (5) a professional manual

with comprehensive norms. Needless to say, the

cards themselves differ in no way from the cards

already in use. The record sheets are modeled

after the revised forms used with the standard

version. Speci®cally, the ®rst of three pages has

spaces for general identifying information, refer-

ral information, current medications, behavioral

observation information, and a description of the

testing situation. Devoting space on the record for

most of this information is unnecessary since

most of those data will be collected elsewhere and

need not be listed again. Realistically, it is an

inef®cient use of time to do so and there is ample

room on the response record form (page 2) to

record necessary identifying information and

behavioral observations. Page 3 is the familiar

`scoring area' modi®ed for 64 trials. There is

nothing but a copyright notice on the back. In

short, the WCST-64 score sheet is unnecessarily

long and wasteful; what is really needed would

easily ®t on the front and back of a single letter-

size page.

The scoring / administration software (WCST-

64: CV; Heaton & PAR Staff, 2000) is identical to

the program recently released for the standard

version (WCST: CV3; Heaton & PAR Staff,

1999) except that it accepts/administers only 64

trials and contains the norms for the WCST-64. It

also comes with its own set of paper scoring forms

which contain the same information page and

response area on which one marks the stimulus

card matched rather than the matching dimen-

sions (the WCST-64: CV can accept either type of

response). As with the original version, this

software is very easy to use, allows scoring and

storing of multiple administrations per individual,

and has some useful ¯exibility in terms of the

style of presentation. Unfortunately, this version

is completely independent of the WCST: CV3

software, so if you intend to score / administer and

norm both standard and 64-card protocols with

the computer, you must have both sets of software.

This is an expensive problem that apparently will

not be remedied in the near future. On the plus

side, one can buy just the scoring software which

at US$ 225 is about half the price of the total

software package. A technical problem relevant to

all the WCST software is that one must be able to

simultaneously run a CD ROM drive and ¯oppy

disk drive to load the application. This makes it

nearly impossible to load on most laptop

computers.

Norms for the WCST-64 are easily produced

since no new data need be collected. One need

only rescore for the ®rst 64 cards the protocols for

the original normative groups and this is precisely

what has been done. The WCST-64 generates 10

familiar scores: Total Number Correct (TC), Total

Number of Errors (TE), Perseverative Responses

(PR), Perseverative Errors (PE), Nonperseverative

Errors (NPE), Conceptual Level Responses

(CLR), Number of Categories Completed (CC),

Trials to Complete First Category (T1C), Failure

to Maintain Set (FMS), and Learning to Learn

(LL). As with the standard version, no norms are

provided for TC. For TE, PR, PE, NPE, and CLR

age- and education-corrected standard scores,

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t-scores, and percentile rankings are provided for

adults. Similar scores are provided based upon the

United States Census age-matched adult sample.

For children and adolescents under 20, only age-

corrected norms are provided. Percentile ranks

only, based on the same samples, are provided for

CC, T1C, and LL. Note that there are no percent

scores since all subjects always complete the

same number of trials. That all subjects receive

the same number of trials is a signi®cant strength

of the WCST-64; having two different termination

criteria for the standard version is a signi®cant

methodological ¯aw that cannot really be over-

come with percent scores and which is unlikely to

be corrected for practical reasons. Many research-

ers are using all 128 cards (Stanford, Greve, &

Gerstle, 1997; Stuss et al., 2000) and there is

evidence that the factor structure in that version is

more consistent than with the standard version

(Greve et al., 1999). No norms are provided for

FMS because FMS was `̀ rare in all samples and

did not discriminate between the normal and

clinical groups'' (p. 24, Kongs, Thompson,

Iverson, & Heaton, 2000). One must hope that

FMS, despite its presence in almost all factor

analytic solutions including those for the WCST-

64 (see below), is not a clinically relevant

variable; that question remains open.

The new manual is an excellent addition to the

WCST literature. Structured almost identically to

the 1993 manual, it contains seven chapters and

®ve appendices and runs to 242 pages (the 1993

manual is 230 pages long). The Introduction

(Chapter 1) is a brief overview of the WCST

including a discussion of short-forms. The reader

should not expect anything approaching a com-

prehensive comparative review of this topic; in

fact, the review is disappointingly cursory.

Chapters 2 (Test Materials and Use) and 3

(Administration and Scoring) are little different

in the two manuals with modi®cation necessary

for the WCST-64 and some slight changes in

scoring instructions that seem to re¯ect improve-

ments suggested by experience over the past 7

years of use. Chapter 4 presents the methods used

to norm the WCST-64 while Chapter 5 discusses

interpretive issues. One addition in this latter

chapter is a discussion of the interpretation of

multiple scores. The gist of this section is to

remind users of the high inter-correlations among

many WCST scores and caution them against

necessarily considering those scores independent

sources of information. This section also notes

that a ®nding of at least one score in the impaired

range is a fairly common occurrence even in the

normal population. Three sample cases are

provided. Chapter 6 discusses reliability and

validity. Much of the reliability data are new,

speci®c to the WCST-64. The data on scoring

accuracy and reliability are based on published

research with the standard WCST but are directly

applicable to the WCST-64. This chapter also

contains an updated discussion of validity studies.

Many reported validity studies naturally involve

the standard WCST because there have been few

direct studies of the WCST-64. The authors

cautiously assume that if the two versions of the

WCST are comparable then research done with

the standard version will be generalizable to the

WCST-64. There is reason to believe that the two

are quite comparable and these data are also

presented in the manual (Chapter 7). Both

manuals have ®ve appendices including the two

sets of normative tables (for the United States

Census age-matched adult sample and for the

demographically corrected normative data) and

base-rate data for the normative and clinical

samples. Dropped from the current manual are the

two appendices presenting administration and

scoring variations of the WCST. The ®nal

appendix, a completely new addition, provides

cumulative percentile ranks for the normative

sample by age for selected scores (TE, PR, PE,

NPE, and CLR). Despite their importance, the

base-rate tables are a little hard to follow and their

use in interpretation is not described in the

detailed case illustrations of Chapter 5.

DISCUSSION

As with the standard WCST, the PAR group have

done an excellent job in their technical presenta-

tion of the WCST-64. Of course, an important

consideration in determining the ultimate value of

the WCST-64 is whether the short version is

comparable to the standard version. Comparabil-

ity is not an absolute necessity as the normative

REVIEW OF A STANDARDIZED SHORT-FORM OF THE WCST-64 231

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and related data for the WCST-64 allow it to stand

alone as a neuropsychological procedure. How-

ever, if the two tests are comparable, then past

research on the standard WCST could more safely

be applied to the WCST-64. In this regard, there

are convincing data to support the comparability

assumption in an overall sense. Some of the

earlier comparison studies have been discussed

above; these tend to support the comparability of

the two versions. Comparisons of the two versions

undertaken speci®cally for the new manual, using

the normative and patient data sets, also support

comparability. Some statistically signi®cant dif-

ferences between PR standard scores for the two

versions were reported but examination of the

sample means indicates that these differences are

generally statistically trivial given the large

sample sizes.

The factor structure and construct validity of

the WCST have been the subject of considerable

research throughout the 1990s (Goldman et al.,

1996; Greve, Love, et al., 1999; Greve, Bianchini,

et al., 1999; Greve, Brooks, Crouch, Williams, &

Rice, 1997; Greve, Ingram, & Bianchini, 1998;

Koren et al., 1998; Paolo, TroÈster, Axelrod, &

Koller, 1995; Sullivan et al., 1993; Wiegner &

Donders, 1999). These studies have reported a

relatively consistent three-factor structure across

a number of different populations though the

exact number and organization of the factors is

dependent on variable and sample selection (see

Greve et al., 1998, for a review of many of the

recent studies). The scores which load most highly

on Factor I re¯ect aspects of executive function,

particularly response in¯exibility (PE, PR, TE)

and, secondarily, disrupted problem solving (per-

cent CLR, CC, TC). The composition of Factor II

(high loading for NPE; moderate loadings for

percent CLR, CC, TC) seems to re¯ect an inef-

fective hypothesis-testing strategy in the absence

of perseveration. Factor II is often absent in high

functioning persons (see for example, Greve et al.,

1997, and Wiegner & Donders, 1999). Factor III

is comprised of scores which seem to measure the

ability to maintain correct responding once the

correct dimension is discovered (high FMS and

commensurately fewer CC).

The manual reports factor analyses of the

WCST-64 in ®ve different subsamples (adult

normative, adult clinical, child normative, child

lesion, child diagnostic) which revealed the same

three-factor structure. These authors interpreted

their factors as re¯ecting a perseveration compo-

nent, a concept-formation component, and a

Failure to Maintain Set component. The analysis

of the Adult Clinical group resulted in a fourth

marginal factor represented only by CLR. This

factor had an Eigenvalue of only .71, which is

well below the usual 1.0 minimum, but accounted

for over 10% of the observed variance. Overall

this solution accounted for 99% of the variance.

The similarity of the factor structure of the

WCST-64 to those solutions for the standard

WCST reported for various populations supports

the notion that the abbreviated version is com-

parably sensitive to the cognitive processes

underlying performance in the standard test.

However, factor analyses of the standard WCST

in the normative and clinical samples have not

been reported. A direct comparison of the factor

structures for the two WCST versions in the same

subjects would have provided stronger evidence

of their comparability.

It is hard to argue that there is not a need for a

briefer version of the WCST in many clinical

contexts. A number of abbreviated versions have

been introduced and cogent arguments can be

made for one over another in certain situations.

Nevertheless, if we as clinicians wish to have a

short-form with quality norms that can also take

advantage of over 50 years of research on the

WCST then the most pragmatic approach is to use

the WCST-64. The PAR group have done an

admirable job in developing the norms for this

version and making a solid case for the compar-

ability of the two versions. The weaknesses of

PAR's WCST-64 are not directly related to the

psychometric features of the test but may be more

an issue with software development and market-

ing; these weaknesses have little or no direct

impact on the clinical utility of the WCST-64. In

terms of direct use of the WCST-64, one should

be cautious about using the WCST-64 to the

exclusion of the standard WCST in research.

Additional research is needed to further establish

the nature and strength of the relationships

between the two versions in a variety of patient

populations and to identify cases in which com-

232 KEVIN W. GREVE

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parability might be weak and one version might

be superior to the other. Expansion of the WCST-

64 research base can be done by piggy-backing

analysis of the WCST-64 onto studies utilizing the

standard WCST. This approach may not be feasi-

ble for all WCST studies but every effort should

be made to include WCST-64 data when possible,

especially in any research directly examining the

psychometric properties of the WCST.

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