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Child Neuropsychol. 2011 ; 17(4): 391–399. doi:10.1080/09297049.2010.547462.

Impaired Consonant Trigrams Test (CTT) performance relates to

everyday working memory difficulties in children with autism
spectrum disorders
Benjamin E. Yerys1,2, Gregory L. Wallace3, Kathryn F. Jankowski1,2, Angela Bollich1,2, and
Lauren Kenworthy1,2
1Children’s Research Institute – Neuroscience, Children’s National Medical Center

2Center for Autism Spectrum Disorders – Children’s National Medical Center

3Laboratory of Brain and Cognition – National Institute of Mental Health

Abstract
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Background—Individuals with autism spectrum disorders (ASD) often struggle with complex
tasks, such as those requiring divided attention (simultaneously completing two independent tasks)
which also place high demands on working memory. Prior research shows that divided attention is
impaired in adults and children with ASD, and is related to ASD and co-morbid attention deficit/
hyperactivity disorder ADHD symptoms, but the impact on everyday functioning is unclear.
Because ADHD symptoms are associated with poor divided attention and working memory
performance in children with ASD, we also examined ADHD symptoms as moderators of divided
attention performance.
Method—We examined performance on the Consonant Trigrams Test (CTT) between high-
functioning 8–13-year-olds with ASD (n=28) and typically developing controls (n=18) matched
on age and IQ. In the ASD group, we also correlated performance with ADHD symptoms and
behavior ratings of everyday working memory.
Results—CTT performance in children with ASD was significantly worse than in matched
controls. A significant correlation between CTT performance and everyday working memory was
observed, but CTT performance was not related to co-morbid ADHD symptoms, in the ASD
group.
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Conclusion—Divided attention with high working memory demands is a relative weakness in

children with high-functioning ASD, this weakness relates to everyday functioning, and it is
independent from ADHD symptoms. That ADHD symptoms are not associated with divided
attention performance is inconsistent with one prior investigation, which likely results from using
different divided attention tasks in the two studies.

Individuals with autism spectrum disorders (ASD) often struggle with complex multi-step
tasks. These tasks can be social in nature, such as participating in a ‘to and fro’ conversation,
or they can be non-social, such as getting dressed. Many of these tasks require dividing
attention, which involves completing two independent tasks simultaneously, or holding
information about one task in working memory, while completing another task. The current

Correspondence addressed to: Ben Yerys, Center for Autism Spectrum Disorders, Children’s National Medical Center, 15245 Shady
Grove Road, Suite 350, Rockville MD, 20850, byerys@cnmc.org.
BEY, JLS, AB, and LK are affiliated with the Center for Autism Spectrum Disorders and the Center for Neuroscience at Children’s
National Medical Center and the Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The
George Washington University, both of which are located in Washington, DC, USA. GLW is affiliated with the Laboratory of Brain &
Cognition, National Institute of Mental Health, Bethesda, Maryland, USA.
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study addresses a gap in our understanding of divided attention in children with ASD, as
there have been only two pediatric studies (Kenworthy, Black, Harrison, Della Rosa, &
Wallace, 2009a; Sinzig, Bruning, Morsch, & Lehmkuhl, 2008), and a few adult studies
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examining divided attention either within a single mode (Bogte, Flamma, Van Der Meere, &
Van Engeland, 2009; García-Villamisar & Della Sala, 2002) or cross-modally (Ciesielski,
Knight, Prince, Harris, & Handmaker, 1995; Sinzig et al., 2008), though none has examined
the relation between task performance and everyday functioning.

One pediatric study on a clinic-referred, high-functioning ASD sample found that the ability
to divide auditory attention was associated with reduced ASD symptoms (Kenworthy et al.,
2009a). In particular, a significant negative correlation was reported between performance
on an auditory divided attention task from the Tests of Everyday Attention for Children
(Score! DT subtest) and ASD symptoms (social and communication domains from autism
diagnostic measures). The Score! DT task requires a child to divide attention between
counting beeps and listening to a newscast for a specific animal name. As such, it confounds
language, versus more pure auditory processing requirements (i.e., identifying animal names
versus counting beeps), with divided attention/working memory demands. Furthermore, this
investigation did not address a recent concern that comorbid attention deficit/hyperactivity
disorder (ADHD) symptoms moderate cognition in ASD (Corbett, Constantine, Hendren,
Rocke, & Ozonoff, 2009; Sinzig et al., 2008; Yerys et al., 2009). Thus, new studies of
cognition, particularly those related to executive control, need to control for the effects of
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ADHD symptoms. The other pediatric study examined divided attention in school-aged
children with ADHD, children with ASD and clinically significant ADHD symptoms (ASD
+ADHD), children with ASD but non-clinically significant ADHD symptoms (ASD−), and
typically developing controls (Sinzig et al., 2008). Children were required to respond
whenever a square was presented on a computer screen and when a high- or low-beep tone
was repeated. The ADHD and ASD+ADHD groups provided fewer correct responses to the
tone and shape identification tasks compared to controls. Furthermore, the ASD+ADHD
group made more omissions (targets that did not receive a response) than the ASD− group.
Taken together, these two pediatric studies suggest that there are divided attention
impairments among children with ASD relative to typically developing children, and that
ADHD symptoms may be the primary contributor to impaired performance.

Investigations of basic cognitive processes have demonstrated that working memory

capacity plays a role in divided attention performance (Kane & Engle, 2000). Verbal
working memory is most relevant for these auditory divided attention tasks, because they
likely invoke verbal mediation for successful performance. A recent literature review of
verbal working memory in ASD found that children and adults with ASD perform similarly
to matched control groups on most n-back, digit-, letter- and word-span tasks (Kenworthy,
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Yerys, Anthony, & Wallace, 2008); however, we have found that the presence of ADHD
symptoms moderates verbal working memory performance in ASD, such that greater
working memory deficits are associated with greater ADHD symptom severity (Yerys et al.,
2009). In a much more limited literature, there is also evidence that divided attention
impairments may correlate with co-morbid ADHD symptoms in children with ASD (Sinzig
et al., 2008). Additionally, ADHD symptoms have a significant relationship with real world
behaviors that require working memory and divided attention in ADHD (Gioia, Isquith,
Kenworthy, & Barton, 2002; Mahone et al., 2002) and in ASD (Matsushima et al., 2008;
Yerys et al., 2009). The relationship between performance measures of divided attention
with strong working memory demands and everyday working memory/divided attention has
not been examined in ASD.

A ‘classic’ divided attention task is the Brown-Peterson technique (L. R. Peterson & M. J.
Peterson, 1959), also known as the Consonant Trigrams Test (CTT), which requires

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individuals to listen to a sequence of three letters and then a number (e.g., “LBQ 88”). The
individual must retain the letters in working memory while simultaneously subtracting three
from the number (e.g., “88 85 82) during a delay, and then recite the letter sequence. The
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CTT clearly requires splitting attention between two concurrent tasks. It also relies on
working memory, as individuals are required to maintain information (three letters) in the
face of interfering stimuli that require mental manipulation (counting backwards). It has
adequate sensitivity for detecting subtle impairments, as demonstrated in an investigation of
individuals with good recovery from closed head injuries (Stuss et al., 1985). One avenue
that has not been explored previously is whether CTT performance relates to real world
behaviors for clinical groups, particularly behaviors that rely heavily upon working memory
and divided attention.

The current study’s purpose is to investigate: (a) divided attention (and working memory)
with limited language demands in high-functioning children with ASD and age-, IQ-, gender
ratio, and socioeconomic status matched typically developing (TYP) controls; (b) the
relationship between a divided attention task with strong working memory demands and
everyday working memory in high-functioning children with ASD; and (c) the impact of
comorbid ADHD symptoms on divided attention and everyday working memory behaviors
in high-functioning children with ASD. In the current study, we use a child-friendly version
of the CTT, which requires children to count backward by one instead of three (Paniak,
Miller, Murphy, Andrews, & Flynn, 1997), and we collect informant ratings of everyday
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working memory behaviors and ADHD symptoms to explore whether the proposed working
memory components of CTT are ecologically valid and/or are moderated by ADHD
symptoms. We predicted that: (a) the ASD group would score lower than matched controls
on the CTT, due to its divided attention demands; (b) better CTT performance would relate
to fewer reported working memory impairments in everyday settings, as the CTT is
hypothesized to draw upon both divided attention and working memory abilities; (c) poorer
CTT performance would correlate with ADHD symptoms.

Method
Twenty-eight children with high-functioning ASD and 18 TYP children participated in the
study. Children were recruited through the local community via advertisements and a
hospital’s outpatient clinic specializing in ASD and neuropsychological assessment.
Children with ASD received a clinical diagnosis (Autism n=11, Asperger’s Syndrome n=12,
Pervasive Developmental Disorder-Not Otherwise Specified [PDD-NOS] n=5) based on
DSM-IV-TR criteria (American Psychiatric Association, 2000). They also met the criteria
for ‘broad ASD’ based on scores from the ADI or ADI-R (Le Couteur et al., 1989; Lord,
Rutter, & Le Couteur, 1994) and/or the ADOS (Lord et al., 2000) following criteria
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established by the NICHD/NIDCD Collaborative Programs for Excellence in Autism

(Lainhart et al., 2006); Twenty-three children received both the ADI/ADI-R and the ADOS
while five received one of the two measures. Children with ASD were screened through a
parent phone interview and excluded if they had any history of comorbid genetic,
psychiatric, or neurological disorders (e.g., Fragile X syndrome, Tourette’s syndrome, etc.),
with the exception of significant ADHD symptoms, which were quantified with the parent
version of the ADHD Rating Scale-IV: Home Verson (DuPaul, Power, Anastopoulos, &
Reid, 1998). The American Psychiatric Association does not currently allow ADHD to be
diagnosed in conjunction with ASD (American Psychiatric Association, 2000). Anti-
psychotic or anti-epileptic medication usage was grounds for exclusion; stimulant
medications were withheld at least 24 hours prior to testing (n=5). TYP children were
screened and excluded if they or a first-degree relative had developmental, language,
learning, neurological, or psychiatric disorders or psychiatric medication usage, or if the
child had a known genetic disorder. This resulted in the exclusion of two participants

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(original n=20). All participants were required to have a Full Scale IQ≥80, as measured by a
Wechsler Intelligence scale (Wechsler Intelligence Scale for Children–3rd Edition,
Wechsler Intelligence Scale for Children–4th Edition, or Wechsler Abbreviated Scale of
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Intelligence; Wechsler, 1991, 1999, 2003). Groups did not differ in terms of age, IQ, gender
ratio, race/ethnicity, or socioeconomic status based on the Four-Factor index (Hollingshead,
1975), but did significantly differ in everyday working memory ratings and ADHD
symptoms (see Table 1).

Children completed CTT (Paniak et al., 1997), while parents completed the ADHD Rating
Scale-Parent Edition (DuPaul et al., 1998), and the Behavior Rating Inventory of Executive
Function-Parent Form (BRIEF; (Gioia, Isquith, Guy, & Kenworthy, 2000). This CTT is a
pediatric version of the Brown-Peterson technique (L. R. Peterson & M. J. Peterson, 1959)
and is normed on a sample of over 700 8–15-year-olds. In a series of trials, children are
presented with three consonant letters followed by a number. They must count backwards
from that number during a variable delay (0, 3, 9, or 18 seconds), after which they are asked
to state the letters. The primary metric of performance for each trial is the correct number of
letters recalled. Standard scores can be derived for each delay interval and the total score.
The total score was chosen as the dependent variable due to its good reliability; the normed
data were near ceiling in the lowest delay conditions, which created widely distributed
scores when a child missed a single item (e.g., providing a correct response to 14 of 15 items
for a 9-year-old in the 0-second delay condition resulted in a standard score of 66). The
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ADHD Rating Scale assesses severity in inattention and hyperactivity/impulsivity

symptoms. This 18-item questionnaire yields two domains: inattention and hyperactivity/
impulsivity. For each question, parents use a 0–3 scale to rate the participant. A higher score
indicates greater symptom severity. The total raw score was the dependent variable of
interest. The BRIEF is an informant report of executive function in everyday situations
comprising eight subdomains. Results are reported as T-scores. Higher scores indicate
greater impairment; T-scores≥65 (i.e., 1.5 SDs≥ the mean) indicate clinically significant
ratings. The Working Memory subscale of the BRIEF was the dependent variable of interest.
All measures were part of a larger study examining the cognitive profile of ASD. Consent
from parents/guardians of children and assent from the children were obtained within the
guidelines of the hospital’s Institutional Review Board, which approved the study.

The CTT data violated Levene’s test for homogeneity of variances, so a Welch’s t-test was
used to assess group differences. Pearson’s r was used to examine the relationship between
CTT performance and ADHD symptoms and everyday working memory behaviors in the
ASD group.

Results & Discussion

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The CTT total score fell in the Average range for both groups, but the TYP group scored
significantly higher (which signifies better performance) than the ASD group, t(44)=3.15,
p≤.001. There was a large effect size associated with this group difference (Cohen’s
d=1.03). This finding reveals divided attention as a relative weakness for high-functioning
children with ASD. One of the more striking observations was the ASD group’s standard
deviation relative to that of the TYP group (see Figure 1), reflecting the considerable
variability in the ASD group’s CTT performance. There was not a significant relationship
between CTT performance and ADHD symptoms in the ASD group, r(25)=−.13, p=.55,
therefore ADHD symptoms were not included as a covariate. A significant correlation was
found between the CTT total score and the Working Memory subscale from the BRIEF in
the ASD group, r(28)=−.38, p<.05. The overall pattern of findings was not different when
the five children taking stimulant medication were removed from analyses (data not shown).

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 Yerys et al. Page 5

There is limited evidence about divided attention with strong verbal working memory
demands in children with ASD (Kenworthy et al., 2009a; Sinzig et al., 2008); our results
converge with prior investigations documenting divided attention weaknesses in an ASD
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group, however we diverge from a prior study in that our findings are independent from
ADHD symptoms. We also extend earlier work by examining the relationship between
divided attention difficulties in ASD and everyday working memory while controlling for
ADHD symptoms. Unlike ADHD symptomatology, everyday working memory correlates
significantly with CTT performance in the ASD group, providing ecological validity for this
documented divided attention/working memory weakness (Burgess et al., 2006; Kenworthy
et al., 2008). The CTT was developed as a divided attention task and not a working memory
task, (Peterson & Peterson, 1959), however recent investigations demonstrate relationships
between the two processes (Kane & Engle, 2000). The correlation between the CTT and an
ecologically valid measure of working memory support this relationship beyond
performance-based measures.

Our findings of divided attention weaknesses independent from ADHD symptoms are
distinguishable from previous findings of ASD+ADHD impairments in a cross-modal
divided attention task (Sinzig et al., 2008). One potential explanation for this difference in
findings may lie in differences in the specific task demands. The cross-modal nature of the
divided attention task -auditory and visual discrimination tasks - used by Sinzig and
colleagues (2008) requires engaging in two simple detection tasks that do not interfere at the
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sensory level. The CTT requires verbal encoding/maintenance over a delay in which
children must count backwards by one. The second task (counting) directly impedes the
child’s ability to engage in rehearsal of the letter string, and this additional feature of CTT
may drive the differences in findings. Finally, our finding of extreme variability observed in
the ASD group converges with previous investigations into cognitive and motor function
(Geurts et al., 2008; Jones & Klin, 2009; Müller, Kleinhans, Kemmotsu, Pierce, &
Courchesne, 2003), and future investigations will need to address genetic and neural
underpinnings to explain the variability of cognition.

This study has several limitations. The confound of working memory and divided attention
demands in the CTT task limits our ability to pinpoint the area of difficulty in ASD, and the
reciprocal nature of correlations prevents causal interpretations of the relationship between
the CTT and everyday working memory. However, this confound of multiple demands is
common in neuropsychological research, as evidenced by the demands for sustained
attention (Sinzig et al., 2008) and language (Kenworthy, Black, Harrison, Della Rosa, &
Wallace, 2009b) inherent in divided attention tasks used in children with ASD. We can say
that while past literature suggests intact verbal working memory in ASD without ADHD
(Kenworthy et al., 2008; Yerys et al., 2009) weaknesses are observed with divided attention
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tasks with working memory demands, such as the CTT. Furthermore, the CTT relates to
everyday working memory behaviors, and we speculate that targeting divided attention for
intervention may have a cascading effect on these real world behaviors. An additional
limitation is that our dependent measure only captured performance on one of the two CTT
tasks, which is consistent with CTT administration (Paniak et al., 1997). Because we only
measured performance on one task, it is unclear if children performed both tasks well or
sacrificed performance on the counting task to perform well on the other letter memory task.
Also, the ASD group was high-functioning with a mean IQ near the High-Average range;
thus, our findings may not hold for lower-functioning children with ASD. Finally, 25% of
the ASD group participating in the current study also took part in our prior study
(Kenworthy et al., 2009a); however, the divided attention measures and dependent variables
are independent across the two studies.

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 Yerys et al. Page 6

These findings pinpoint a cognitive skill relevant to outcomes and interventions. Real world
associations have been elusive in past investigations of non-social cognition, other than
intelligence, in ASD (Kenworthy et al., 2009a). Future research should: identify tasks that
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parse divided attention and working memory as much as possible; and more thoroughly
investigate divided attention in ASD at the neural level and as an intervention target. This
could include examining the developmental trajectory and neural correlates of divided
attention skills in children with ASD. Finally, divided attention may serve as a lab-based
index of poor “responsivity to multiple cues”, a targeted area of intervention in several ASD
treatments, such as pivotal response training (Koegel, Koegel, & McNerney, 2001).

Acknowledgments
We thank the children and families that offered their time and energy for the current study. One author (LK)
receives financial compensation from the BRIEF. There are no conflicts of interest, financial or otherwise, for the
remaining authors involved directly or indirectly with this manuscript. This work was supported by the Frederick
and Elizabeth Singer Foundation, the Gudelsky Foundation, and the Studies for the Advancement of Autism
Research and Treatment (STAART: NIMH U54 MH066417) for supporting data collection. BEY, and in part this
work, was supported by the Intellectual and Developmental Disabilities Research Center at Children’s National
Medical Center (NIH IDDRC P30HD40677) and the General Clinic Research Center (NIH GCRC M01-RR13297).
GLW was supported by the Intramural Program of the NIH, National Institute of Mental Health.

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Figure 1.
This boxplot figure shows the total performance standard score (M=100, SD=15) on the
consonant trigrams test (CTT) for the autism spectrum disorder (ASD) and typically-
developing matched control (TYP) groups. The ASD group scores significantly lower than
the TYP group. Note the large variability in the whiskers of the ASD group’s boxplot.
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Table 1
Participant demographics and mean ratings by parents and guardians
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Total N TYP 18 ASD1 28 p-value

Chronological Age (Years)

M (SD) 11.07 (1.32) 10.89 (1.50) .69
Range 9.39–13.81 8.50–13.66

Full Scale IQ2

M (SD) 118.89 (12.94) 113.86 (15.49) .26
Range 100–140 85–143
Gender (male/female) 13/5 21/7 .83
Family Socioeconomic Status
M (SD) 23.78 (9.14) 25.25 (11.93) .66

Race3

AI/AN4 0 1 .41

Black/African American 0 2
Caucasian 15 20
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Other 1 4
Missing 2 1

ADI/ADI-R5
Social -- 19.76 (5.44) --
Communication -- 16.20 (4.90) --
Repetitive Behaviors -- 6.12 (2.52) --

ADOS6
Communication -- 3.68 (1.97) --
Social -- 8.12 (2.95) --

ADHD Rating Scale7

Total Raw Score M (SD) 3.67 (2.72) 24.92 (14.21) <.001
Range 0–9 2–54
BRIEF – Working Memory
T-Score M (SD) 43.11 (6.97) 65.36 (11.49) <.001
Range 36–58 39–87
NIH-PA Author Manuscript

1
A total of 5 children with ASD were missing either the ADI/ADI-R or ADOS, but not

both. Also, these 5 children are not the same children who received one of the WISCs

rather than the WASI (see superscript 2).

2
Weschler Intelligence scale (Wechsler Intelligence Scale for Children–3rd Edition,

Wechsler Intelligence Scale for Children–4th Edition, or Wechsler Abbreviated Scale of

Intelligence)
3
No children of Asian, Native Hawaiian or Other Pacific Islander descent participated.
4
American Indian or Alaskan Native

Child Neuropsychol. Author manuscript; available in PMC 2012 August 22.

 Yerys et al. Page 11

5
ADI/ADI-R= Autism Diagnostic Interview (n= 25)
6
ADOS= Autism Diagnostic Observation Schedule (n=25)
7
TYP Group: n=15; ASD Group: n=25
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Child Neuropsychol. Author manuscript; available in PMC 2012 August 22.