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The Dimensional Change Card Sort (DCCS): A method of assessing executive

function in children

Article  in  Nature Protocol · February 2006

DOI: 10.1038/nprot.2006.46 · Source: PubMed

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 PROTOCOL

The Dimensional Change Card Sort (DCCS): a method

of assessing executive function in children
Philip David Zelazo

Department of Psychology, University of Toronto, 100 St. George Street, Toronto, Ontario M5S 3G3, Canada. Correspondence should be addressed to P.D.Z.
(zelazo@psych.utoronto.ca).

Published online 27 June; corrected after print 31 August 2006; doi: 10.1038/nprot.2006.46

The dimensional change card sort (DCCS) is an easily administered and widely used measure of executive function that is suitable
for use with participants across a wide range of ages. In the standard version, children are required to sort a series of bivalent test
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

cards, first according to one dimension (e.g., color), and then according to the other (e.g., shape). Most 3-year-olds perseverate
during the post-switch phase, exhibiting a pattern of inflexibility similar to that seen in patients with prefrontal cortical damage.
By 5 years of age, most children switch when instructed to do so. Performance on the DCCS provides an index of the development
of executive function, and it is impaired in children with disorders such as attention-deficit/hyperactivity disorder (ADHD) and
autism. We describe the protocol for the standard version (duration = 5 min) and the more challenging border version (duration =
5 min), which may be used with children as old as 7 years.

INTRODUCTION
The DCCS1–3 is an easily administered and widely used (see
refs. 4–10) measure of executive function that is suitable for use
across the lifespan. In the standard version of this task (Fig. 1),
which is usually used with healthy children between the ages of 3
and 5 years, children are shown two target cards (e.g., a blue rab- “Play the color game:
If it’s red, it goes here; Target cards
bit and a red boat) and asked to sort a series of bivalent test cards but if it’s blue, it goes
(e.g., red rabbits and blue boats) according to one dimension there. Here’s a red one.
(e.g., color). During a post-switch phase, they are told to sort Where does it go?”
the same types of test cards according to the other dimension Test cards
(i.e., 3 red rabbits and
(e.g., shape). Regardless of which dimension is presented first, the 3 blue boats presented
majority of normal 3-year-olds perseverate during the post-switch in a quasi-random order)
phase of the standard version by continuing to sort test cards by
the first dimension. Moreover, they do this despite being told the
new rules on every trial, despite having sorted cards by the new
dimension on other occasions, and despite correctly answering
questions about the post-switch rules (e.g., “Where do the rabbits
go in the shape game?”). In other words, most 3-year-olds show a
pattern of inflexibility on this task that resembles that exhibited on
the Wisconsin Card Sorting Test (WCST) by adult patients with
damage to dorsolateral prefrontal cortex11. By 5 years of age, most
children switch immediately when instructed to do so.
The standard version of the DCCS provides an index of the devel-
opment of executive function during the preschool years, and it has
been useful in the assessment of individual differences in executive
function in this age range; children’s performance on the DCCS
is correlated with their performance on other measures of execu-
tive function as well as measures that have been linked theoreti- “Okay, now we’re not going
to play the color game anymore. Target cards
cally to executive function, such as self- and social-understanding Now we’re going to play
(i.e., theory of mind)1,12,13. Versions of the DCCS have proven sen- a new game—the shape game. Test cards
If it’s a rabbit, it goes here; (i.e., 3 red rabbits and
sitive to disorders that involve impairments in executive function
but if it’s a boat, it goes there. 3 blue boats presented
(e.g., ADHD14 and autism15,16). Research reveals that performance Here’s a rabbit. Where does it go?” in a quasi-random order)
on the DCCS improves with training and that these improvements
generalize to performance on a measure of theory of mind9. The

Figure 1 | Sample target cards and test cards used during the pre- and post-
switch phases of the standard version of the DCCS.

NATURE PROTOCOLS | VOL.1 NO.1 | 2006 | 297

 PROTOCOL
implications of this finding for therapeutic Stimuli during the Target cards
intervention remain to be explored. pre-switch phase
(“color game”)
One advantage of the DCCS as a mea-
sure of executive function—particularly Test cards
for use with children—is its relative sim- Stimuli during the
plicity. Unlike in the WCST, for example, post-switch phase
(“shape game”)
children are told exactly what to do on
every trial. This feature of the DCCS
makes it suitable for use with young chil-
dren, and it also constrains interpretation
of the subject’s difficulties with the task.
Difficulty cannot be attributed to prob-
lems with hypothesis testing or memory
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

for the relevant rules. Instead, the DCCS

provides a more direct measure of flexible
rule use—the selection and use of a pair of
rules to sort bivalent stimuli despite inter-
ference from previous trials.
More precise assessments are also pos- Standard Partial change Negative priming Total change
sible. The task is easily adapted to assess
Figure 2 | Sample target cards and test cards used during the pre-switch phase of the DCCS (top panel).
specific aspects of flexible rule use in rela-
The bottom panel shows the target cards and test cards used during the post-switch phase for several
tive isolation. For example, by changing versions of the DCCS (based on the assumption that color is the initial, pre-switch dimension).
the target and test cards between the pre-
and post-switch phases as shown in Fig. 2
(negative priming version), it is possible to
obtain a relatively pure measure of a child’s ability to sort by stim- the DCCS, such as the border version, have been used successfully
ulus values that were not selected during the pre-switch phase—to with older children6,13 and adults across the lifespan18,19. In these
select rules that were previously inhibited17. Moreover, by chang- versions, switches are presented randomly (e.g., on 20% of trials)
ing the motivational significance of the stimulus values, it is pos- and cued via visual symbols, and participants may be instructed to
sible to assess not only more ‘cool’ cognitive aspects of executive respond as quickly as possible. Dependent measures may include
function usually associated with dorsolateral prefrontal cortex, but not only accuracy but also reaction time. The following procedure
also more ‘hot’ affective aspects that are usually associated with includes only the standard version of the DCCS and the border
the orbitofrontal cortex13. Finally, more challenging versions of version. For an overview of the entire sequence, see Fig. 3.

MATERIALS
• For the standard version of the DCCS, suitable participants include children • Fourteen standard test cards for use in the standard version. These are identical
with mental ages between about 2.5 and 5.0 years. For the border version, in style to the target cards, but half of them (n = 7) depict a red rabbit and
participants include children with higher mental ages (between 5.0 and 7.0 years) half (n = 7) depict a blue boat. Two of these standard test cards are used in the
who pass the standard version (see Step 5, below). When used together, these demonstration phase.
two versions provide an index of executive function across the mental age range • In addition to the above materials, seven border test cards are needed for the
of 2.5 to 7.0 years. Parents provide informed consent allowing their children to border version. These are identical in style to the standard test cards except that
participate, and confirm that their children have normal or corrected-to-normal they have a 5 mm black border around them (see Fig. 4). Four of these cards
vision and are not color blind. depict a red rabbit and three depict a blue boat. For the border version, these
• Two sorting trays: each tray is 11.5 cm long, 9.5 cm wide and 2 cm deep, and cards are used together with seven standard test cards (4 red rabbits and 3 blue
there is a display panel behind each tray that supports the target cards and allows boats).
them to be displayed throughout the task. Trays may be made out of wood. • Alternative shapes and colors may be used, as long as the cross-mapped relation
Target cards may be affixed to the display panel by Velcro or tape. between test and target cards is maintained (i.e., each test card matches one
• Two target cards: each card is 10.75 cm × 7 cm and laminated. These cards target card on one dimension and the other target card on the other dimension).
display color drawings on a white background. One target card shows a blue Use shapes and colors that are easily distinguishable and that will be familiar and
rabbit and the other shows a red boat. engaging to the youngest children tested.

PROCEDURE
1| Decide which dimension will be relevant during the pre-switch phase of the standard version. In the examples that follow,
it is assumed that color has been chosen as the pre-switch dimension.

2| During the demonstration phase, place the two sorting trays side by side in front of the subject, ensuring that they are
within reaching distance. Sit beside the child so that you are able to view the display panels. Affix target cards to the display
panels behind the sorting trays (e.g., a blue rabbit behind the tray on the child’s left and a red boat behind the tray on the
child’s right). Label the target cards by both dimensions. Say, “Here’s a blue rabbit and here’s a red boat.” Then say, “Now, we’re

298 | VOL.1 NO.1 | 2006 | NATURE PROTOCOLS

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going to play a card game. This is
Standard version: Standard Version: Standard version:
the color game. In the color game, Demonstration Pre-switch Post-switch
Border version
(12 trials)
all the blue ones go here [pointing phase (2 trials) phase (6 trials) phase (6 trials)
to the tray on the left], and all the
red ones go there [pointing to the
Figure 3 | Summary of the phases involved in the standard and border versions of the DCCS (see text for
tray on the right].” Sort one type detail). Children who pass the post-switch phase may proceed to the border version.
of test card (e.g., a blue boat) by
color, saying, “See, here’s a blue
one. So it goes here [place it face
down in the tray on the left].” Repeat the pre-switch rules, “If it’s blue it goes here, but if it’s red it goes there.” Show children
the other type of test card (e.g., a red rabbit), and say, “Now here’s a red one. Where does this one go?” If the child takes the
card and sorts it correctly, or simply indicates the correct tray by pointing, say, “Very good. You know how to play the color
game.” If they point, say, “Can you help me put this red one down?” Ensure that the card is placed face down in the appropriate
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

tray, turning the card over if necessary. If the child sorts incorrectly, say, “No, this one’s red, so it has to go over here in the
color game. Can you help me put this red one down?” Ensure that the card is placed face-down in the appropriate tray.

3| Proceed immediately to the pre-switch phase. On the first pre-switch trial, say, “Now it’s your turn. So remember, if it’s
blue it goes here, but if it’s red it goes there.” Randomly select a test card (e.g., a red rabbit), show it to the child, and label
it by the relevant dimension only. Say, “Here’s a red one. Where does it go?” The child may take the card and place it in a tray
or simply point to one of the trays, in which case you may sort the card for them. In either case, ensure that the card is placed
face down in the appropriate tray. Whether or not children sort correctly, simply say, “Let’s do another one” (or, for variety,
“Let’s do it again,” or “How about another one?”), and proceed to the next pre-switch trial; that is, respond to children in a
neutral, non-evaluative, non-corrective fashion (e.g., do not say, “Okay”). On each pre-switch trial, repeat the pre-switch rules,
select a test card (ensuring that the same type of test card, e.g., a red rabbit, is not selected on more than two consecutive
trials), show the card to the child, label
it by the relevant dimension only, and
ask the child where it goes: “Here’s a
red one, where does it go?” or “Here’s a
Target cards
red one, where does this one go?”

4| After six pre-switch trials, say,

“Now we’re going to play a new game.
“If there’s a black border, you
We’re not going to play the color have to play the color game.
game anymore. We’re going to play But if there’s no black border,
the shape game. In the shape game, you have to play the shape game.
Here’s one with a black border. Test cards
all the rabbits go here [pointing to Where does it go?” (i.e., 3 red rabbits without borders,
3 blue boats without borders,
the tray on the left], and all the boats 3 red rabbits with borders, and
go there [pointing to the tray on the 3 blue boats with borders,
presented in a quasi-random order)
right]. Remember, if it’s a rabbit, put
it here, but if it’s a boat put it there.
Okay?” Do not remove the target
cards or the cards that were sorted
during the pre-switch phase, and do
not pause between pre- and post-
switch phases. Select a test card (still
ensuring that the same type of test
card is not selected on more than two
consecutive trials), show the card
to the child, label it by the relevant
dimension only, and ask, “Where does
this one go?” Whether or not the child
sorts correctly, simply say, “Let’s do
another one” (or, for variety, “Let’s
do it again,” or “How about another
one?”), and proceed to the next post-
switch trial. Figure 4 | Sample target cards and test cards used during the border version of the DCCS.

NATURE PROTOCOLS | VOL.1 NO.1 | 2006 | 299

 PROTOCOL
5| Children who are 36 months of age and older usually sort correctly on all six pre-switch trials. Scores on the post-switch
phase of the DCCS are usually bimodally distributed (i.e., either correct or incorrect on all post-switch trials), so children are
usually classified as passing or failing the DCCS. A child needs to sort at least five out of six post-switch trials correctly in order
to pass. Analyses of post-switch performance are usually based only on children who sort five or more out of six pre-switch
trials correctly (but see ANTICIPATED RESULTS below).

6| Children who pass the post-switch phase of the standard version of the DCCS may proceed immediately to the border
version, which uses the same target cards as the standard version. Remove the already-sorted cards from the sorting trays,
reserving four red rabbits and three blue boats. Set the remaining cards aside. Combine the four red rabbits and three blue boats
with the additional Border test cards. Say, “Okay, you played really well. Now I have a more difficult game for you to play. In
this game, you sometimes get cards that have a black border around it like this one [showing a red rabbit with a border]. If
you see cards with a black border, you have to play the color game. In the color game, red ones go here and blue ones go there
[pointing to the appropriate trays]. This card’s red, so I’m going to put it right there [placing it face down in the appropriate
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

tray]. But if the cards have no black border, like this one [show them a red rabbit without a border], you have to play the shape
game. In the shape game, if it’s a rabbit, we put it here, but if it’s a boat, we put it there [pointing to the appropriate trays].
This one’s a rabbit, so I’m going to put it right here [placing it face down in the appropriate tray]. Okay? Now it’s your turn.”

7| The border version consists of 12 trials. On each trial, repeat the rules (“If there’s a border, play the color game. If there’s
no border, play the shape game”), select a test card (ensuring that the same type of test card—with or without a border—is not
selected on more than 2 consecutive trials), label the card as having a border or not, and ask the child where it goes. After the
child sorts it, simply say, “Let’s do another.” For example, “Remember, if there’s a black border, you have to play the color game.
But if there’s no black border, you have to play the shape game. Here’s one with a black border. Where does it go? [Children sort]
Let’s do another.” As in the standard version, respond to children in a neutral, non-evaluative, non-corrective fashion.

8| Performance on the border version is scored as the number correct out of 12. Children are considered to pass this task if
they sort nine or more cards correctly out of 12 test trials.

● TIMING
Steps 2–4, 5 min; Steps 6+7, 5 min.

? TROUBLESHOOTING
See Table 1.

TABLE 1 | Troubleshooting table.

PROBLEM SOLUTION
Steps 2–4, 6+7
Children hesitate Label the card by the relevant dimension and ask where it goes (e.g., “Here’s a rabbit, where does it go?”).
If the child still hesitates, say, “Let’s do another one,” return the skipped card to the pile of to-be-sorted
cards, select a new card, label it by the relevant dimension, and ask where it goes.
Children refuse to complete the If a child refuses to continue sorting, suggest that he or she may point to the correct box and show you
task where each card goes. If the child refuses to do this, then terminate the task, as their data will be unusable
unless all trials are completed.
Children change response Allow children to change their responses, scoring only their final response. Do not provide evaluative
feedback. Simply say, “Are you sure?” and then proceed to the next trial, saying, “Let’s do another one.”
Children ask for feedback Do not provide evaluative or corrective feedback. Simply encourage them to keep playing, saying, “Sort the
card,” or “Let’s do another one,” as appropriate.
Children pick up previously Prevent children from picking up previously sorted cards. Tell them, “Those cards have to stay there, but
sorted cards let’s do another one.”
Children take a break during the Discourage children from taking a break until the procedure has been completed, saying, “We’re almost
task done.” If children need to take a break during Steps 2, 3, 6 or 7, repeat the interrupted step when they
return and then complete the procedure. Only use data from the completed (re-administered) step, not the
interrupted one. Children should not take a break during Step 4; this would render the data unusable.

300 | VOL.1 NO.1 | 2006 | NATURE PROTOCOLS

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ANTICIPATED RESULTS
The majority of healthy 3-year-old children (i.e., children between 36 and 47 months) fail the post-switch phase of the standard
version of the DCCS; the majority of 4- and 5-year-olds pass this phase. Most 4-year-olds fail the border version of the DCCS,
as do approximately half of all 5-year-olds. The precise percentages of children passing in any particular sample will vary. Data
from the standard version are usually scored categorically, as passing or failing. Data from the border version may be treated
continuously or categorically. When both versions are used in a single study, it is possible to score performance as follows:
assign a score of 0 if children fail the pre-switch phase of the standard version; assign a score of 1 if they pass the pre-switch
phase of the standard version but fail the post-switch phase; assign a score of 2 if they pass both the pre- and post-switch
phases of the standard version but fail the border version; assign a score of 3 if they pass both phases of the standard version
and pass the border version.
Both versions of the DCCS assess the flexible use of rules to govern behavior—a key aspect of executive function. According
to the Cognitive Complexity and Control theory-Revised3, switching on the DCCS (both versions) requires the formulation and
use of a higher-order rule for selecting which pair of rules (i.e., the color rules or the shape rules) to use on any particular trial.
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

That is, both the post-switch phase of the standard version and the border version require children to formulate and use a rule
that says, in effect, “If shape game, then if rabbit here and if boat there; if color game, then if red here and if blue there.”
The ability to use higher-order rules may be tied to the development of self-reflection20, and it is hypothesized to rely on the
function of specific regions within the prefrontal cortex21.

ACKNOWLEDGMENTS Preparation of this article was supported, in part, by a 9. Kloo, D. & Perner, J. Training transfer between card sorting and false belief
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by a Canada Research Chair. Many individuals have been involved the creation 1823–1839 (2003).
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acknowledge in particular the valuable contributions of D. Frye and T. Palfai, co- knowledge and action disappear. Psychol. Sci. 12, 335-337 (2001).
authors of the article in which the protocol was first described. 11. Milner, B. Effects of different brain lesions on card sorting. Arch. Neurol. 9,
100–111 (1963).
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competing financial interests. theory of mind. Child Dev. 72, 1032–1053 (2001).
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Published online at http://www.natureprotocols.com/ executive function: Age-related changes and individual differences. Dev.
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com/reprintsandpermissions/ 14. Mulas, F. et al. Shifting-related brain magnetic activity in attention-deficit/
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 ERRATUM

Erratum: The Dimensional Change Card Sort (DCCS):

a method of assessing executive function in children
Philip David Zelazo
Nat. Protocols 1, 297–301 (2006); published online 27 June 2006; corrected after print 31 August 2006.

In the version of the article originally published, the boat in the upper right of the figure was blue. It should be red. The error
has been corrected in the HTML and PDF versions of the article.
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

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