Brief Report: Is Cognitive Rehabilitation Needed in Verbal Adults
with Autism? Insights from Initial Enrollment in a Trial
of Cognitive Enhancement Therapy
Shaun M. Eack•Amber L. Bahorik•Susan S. Hogarty•Deborah P. Greenwald•
Maralee Y. Litschge•Carla A. Mazefsky•Nancy J. Minshew
? Springer Science+Business Media New York 2013
potentially effective interventions for the treatment of
autism spectrum disorder, yet the applicability of these
approaches for ‘‘high functioning’’ adults who have nor-
mative levels of intelligence remains unexplored. This
study examined the initial cognitive performance charac-
teristics of 40 verbal adults with autism enrolled in a pilot
trial of Cognitive Enhancement Therapy to investigate the
need for cognitive rehabilitation in this population. Results
revealed marked and broad deficits across neurocognitive
and social-cognitive domains, despite above-average IQ.
Areas of greatest impairment included processing speed,
cognitive flexibility, and emotion perception and manage-
ment. These findings indicate the need for comprehensive
interventions designed to enhance cognition among verbal
adults with autism who have intact intellectual functioning.
Cognitive rehabilitation is an emerging set of
Cognitive rehabilitation ? Adults
Autism spectrum disorder (ASD) is a family of persistent
neurodevelopmental conditions that emerge early and
continue to present many challenges to affected individuals
in adulthood (Kanner 1971). Despite growing recognition
of the continued need for treatment and other supports in
adults with ASD, intervention research has been largely
focused on early childhood (Kasari and Lawton 2010).
Remarkably few empirically supported treatments are
available for verbal adults with these conditions who do not
have a comorbid intellectual disability. Longitudinal stud-
ies of ‘‘high functioning’’ individuals with autism have
shown consistent and persistent disability across educa-
tional, social, and vocational domains, despite supposedly
intact verbal and intellectual abilities (Howlin 2000),
indicating a significant need for effective treatments for
these functional disabilities.
As the neurobiological basis of autism is becoming
increasingly clear (Abrahams and Geschwind 2008; Min-
shew and Williams 2007), attention has been focused on
remediating the core brain deficits that underlie social and
non-social cognitive dysfunction in ASD. Impairments in
information processing are considerable in these conditions
and place significant limitations on adaptive function. A
group of treatment approaches known as cognitive reha-
bilitation have emerged in other disorders that may be
potentially effective non-pharmacologic interventions for
core information processing deficits in adults with ASD.
Although cognitive rehabilitation approaches vary widely
in their scope and targets, most use progressive computer-
based exercises that are designed to enhance specific
domains of cognitive function (e.g. attention, memory). For
S. M. Eack (&) ? A. L. Bahorik
School of Social Work, University of Pittsburgh,
2117 Cathedral of Learning, Pittsburgh, PA 15260, USA
S. M. Eack
Department of Psychiatry, University of Pittsburgh,
Pittsburgh, PA, USA
A. L. Bahorik ? S. S. Hogarty ? D. P. Greenwald ?
M. Y. Litschge ? C. A. Mazefsky
Department of Psychiatry, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA
N. J. Minshew
Departments of Psychiatry and Neurology, University of
Pittsburgh School of Medicine, Pittsburgh, PA, USA
J Autism Dev Disord
the past several decades, cognitive rehabilitation has been
used with considerable success in a wide variety of brain
disorders, such as traumatic brain injury (Ben-Yishay et al.
1985), stroke (Cicerone et al. 2005), Alzheimer’s disease
(Sitzer et al. 2006), and schizophrenia (Wykes et al. 2011).
One particularly promising cognitive rehabilitation
intervention for verbal adults with ASD is Cognitive
Enhancement Therapy (CET; Hogarty and Greenwald
2006), which was originally developed for individuals
with schizophrenia (Hogarty et al. 2004; Eack et al.
2010). CET is a developmental approach designed to
remediate social and non-social cognitive deficits through
the integration of computer-based neurocognitive training
with a group-based social-cognitive curriculum focused on
the achievement of key adult social-cognitive milestones
(e.g. perspective-taking, social context appraisal). CET
may be uniquely relevant for individuals with ASD, in
that it is the only cognitive rehabilitation intervention that
takes a comprehensive approach to integrating social-
cognitive and neurocognitive rehabilitation into a single
treatment to address the broad array of social and non-
social information processing deficits experienced by this
Targeting broad brain-based cognitive deficits using
cognitive rehabilitation in verbal adults with ASD is novel
and promising. However, many verbal adults with ASD
present with average or even above-average intellectual
functioning, which has led some to raise important ques-
tions regarding the need for cognitive rehabilitation, par-
ticularly neurocognitive training, in this population. This
investigation presents the baseline cognitive characteristics
of verbal adults with ASD enrolled in an initial trial of
CET. While this trial is ongoing and treatment data will be
forthcoming, the enrollment characteristics of this study
afforded the unique opportunity to examine the degree to
which adults with high functioning ASD have specific
cognitive impairments that could indicate a need for cog-
nitive rehabilitation. It was hypothesized that despite
average or above-average intelligence scores, verbal indi-
viduals with ASD would demonstrate broad and pervasive
deficits in social and non-social cognition that would
indicate the need for a comprehensive cognitive rehabili-
tation approach to address these functionally disabling
Participants consisted of 40 verbal adults with ASD
recruited for a pilot trial of Cognitive Enhancement Ther-
apy. Eligibility criteria for the study included a diagnosis of
autism or ASD using the Autism Diagnostic Observation
Schedule (ADOS; Lord et al. 2000), age 16–45, IQ C80
assessed by the Wechsler Abbreviated Scale of Intelligence
(Wechsler 1999), ability to speak and read English, the
presence of significant social and cognitive disability based
on the Cognitive Styles and Social Cognition Eligibility
Interview (Hogarty et al. 2004), and the absence of sig-
nificant substance use problems within the past 3 months.
The Cognitive Styles and Social Cognition Eligibility
Interview is a structured interview developed specifically
for trials of CET (Hogarty et al. 2004), which is designed to
elicit information from participants on the degree to which
they experience social and cognitive disability that could
represent meaningful targets for treatment. Of the over 100
participants screened, none were excluded because they
failed to demonstrate significant cognitive and social dis-
ability during this interview. Participants were excluded
primarily due to lack of willingness to enroll in a experi-
mental treatment trial (39 %), IQ\80 (13 %), and the
absence of a research diagnosis of ASD (12 %). Sample
characteristics are presented in Table 1. Participants were
young, most were male, and the sample was predominantly
Caucasian. Over half of the participants met ADOS criteria
for autism, with the remaining meeting criteria for ASD.
While most participants had attended some college, less
than half were employed and only 6 (15 %) were living
independent of family.
A comprehensive battery of neuropsychological tests and
performance-based assessments of social cognition was
used to characterize the degree of cognitive disability
experienced by verbal adults with ASD. Neurocognitive
assessments included the NIMH-recommended MATRICS
Consensus Cognitive Battery, which was designed to
provide a broad assessment of cognitive function for use
in clinical trials of cognitive enhancement interventions in
patients with schizophrenia (Green et al. 2004). This
battery consists of a package of standardized neuropsy-
chological tests for assessing processing speed, attention,
verbal and non-verbal working memory, verbal learning,
visual learning, problem-solving, and social cognition.
The MATRICS battery was originally developed for
patients with schizophrenia, and while the cognitive
domains it covers are highly relevant to ASD, its
assessment of cognitive flexibility and social cognition is
minimal. As such, the Wisconsin Card Sorting Test was
also utilized to assess cognitive flexibility (Heaton et al.
1993), and social-cognitive assessments were greatly
Social cognition was assessed using the Mayer-Salovey-
Caruso Emotional Intelligence Test (MSCEIT; Mayer et al.
J Autism Dev Disord
2003). The measure is computerized and performance-
based, in that it requires participants to solve emotional
problems, rather than relying on self-report about emo-
tional understanding and capacity. A series of 141 items
across 8 distinct tasks assess emotion perception, facilita-
tion, understanding, and management. Answers are scored
based on consensus norms, and domain scores are scaled
with a mean (SD) of 100 (15) based on a large normative
sample. Previous research has documented the reliability
and validity of the MSCEIT in healthy (Mayer et al. 2003)
and psychiatric samples (Eack et al. 2010a). All compo-
nents of the MSCEIT were utilized in this research, with
the exception of the emotion perception branch. Facial
emotion perception was more comprehensively assessed
using the Penn Emotion Recognition Test-40 (Kohler et al.
2003), which asks participants to choose the appropriate
Table 1 Demographic, cognitive, and clinical characteristics of verbal adults with autism spectrum disorders
M/N SD/% Range
Age 25.205.82 16.0044.00 .23–
White34 85 % –– – –
Attended some college 2870 % –– – –
Employed16 40 % –– – –
Autism2357 % – –– –
Autism spectrum 17 42 % ––––
Problem solving45.71 30.711.4093.30.67-.16
Facial emotion perceptionc
ADOS Autism Diagnostic Observation Schedule, WCST Wisconsin Card Sorting Test
aEffect sizes are based upon comparisons with normative test values
bScores are standardized with a mean (SD) of 100 (15)
cEmotion perception accuracy scores range from 0 to 40
dImpairment was rated on a 5-point scale (1 = rare, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe) using the Cognitive Styles and
Social Cognition Eligibility Interview
J Autism Dev Disord
emotional label associated with 40 emotional (happy, sad,
angry, and fearful) and non-emotional (neutral) facial
stimuli. Previous research has established the reliability
and validity of this measure, as well as the neural pathways
involved in its completion in non-ASD samples (Carter
et al. 2009).
Participants were recruited for a study of CET from local
organizations, support groups, and research registries. Indi-
viduals were enrolled who met study criteria and were
willing to commit to two 1.5-hour treatment sessions per
week for 18 months. Upon recruitment, participants were
assessed for ASD using the Autism Diagnostic Observation
Schedule by trained reliable research interviewers experi-
enced with autism who were members of the Subject
videotaped, reviewed, and verified by a doctoral-level
research psychologist, and IQ eligibility assessments were
conducted by trained research associates. Eligibility inter-
views to establish the degree of social and cognitive dis-
ability were completed by master’s- and doctoral-level
clinicians, with final ratings assigned based upon consensus
meetings using all available interview and screening data.
After determining eligibility, participants were assessed
using the aforementioned measures of neurocognition and
social cognition by a trained neuropsychological tester who
was supervised by a licensed clinical psychologist. This
ofPittsburghInstitutional Review Board,and allindividuals
provided written informed consent prior to participation.
Clinical and cognitive characteristics of ASD participants
are presented in Table 1. Full scale IQ scores were within
or above normative ranges (range 80–157) for the sample.
Despite mean intelligence scores for sample in the above-
average range, performance on tests of neurocognition and
social cognition were substantially impaired. Overall neu-
rocognitive performance was below the 35th percentile,
and ranged from a low of 0 % to a high of 81.60 %, with
considerable heterogeneity in ability across domains.
Nearly half (45 %) of the sample performed below the 25th
percentile for neurocognitive functioning, with the most
marked impairments observed in speed of processing,
cognitive flexibility, working memory, and visual learning.
All but four participants demonstrated moderate (C.50 SD)
or greater deficits in at least one neurocognitive domain on
the MATRICS battery, and most (75 %) displayed
impairments in multiple domains. With regard to social
cognition, participants also displayed substantial impair-
ments in overall emotional intelligence, particularly emo-
significant impairments in facial emotion perception were
observed. On average, full scale IQ scores accounted for
only 14.9 % (range 0–51 %) of the variance in perfor-
mance on these cognitive domains, and no significant dif-
ferences in level of impairment were observed in any
domain between those meeting ADOS criteria for autism
compared to ASD (all p[.172).
The functional consequences of this vast array of cog-
nitive impairment were clear, as all individuals demon-
strated at least moderate vocational impairment based on
the Cognitive Styles and Social Cognition Eligibility
Interview (Hogarty et al. 2004) that was completed during
eligibility screening. Evidence also suggested that poorer
performance on the overall neurocognitive composite was
significantly associated with the severity of ASD symp-
tomatology on ADOS domain scores regarding reciprocal
social interaction (rs= -.40, p = .010) and stereotypic
behavior and restricted interests (rs= -.33, p = .039), as
well as greater social-cognitive impairment as assessed
using the MSCEIT (rs= .50, p = .001). Taken together,
these findings indicate significant cognitive disability
among verbal adults with ASD.
The development of effective interventions designed to
address core cognitive deficits in adults with ASD is an area
of great need. Neurocognitive and social-cognitive impair-
ments have a significant impact on social, vocational, and
academic functioning and quality of life. Cognitive reha-
bilitation interventions, and CET in particular, offer signif-
icant promise for remediating the broad social and
non-social cognitive impairments associated with ASD.
However, questions have been raised regarding their appli-
cability to high functioning verbal adults, especially those
with normal IQ scores. This study sought to examine the
nature and degree of cognitive deficits experienced by high
functioning adults with autism, in an effort to elucidate the
relevance of applying cognitive rehabilitative interventions
to this population. The initial cognitive characterization of a
sample of 40 verbal adults enrolled in a pilot trial of CET
marked cognitive impairments were observed across every
domain, with considerable heterogeneity in performance.
impairments in neurocognition, with most exhibiting
impairments in multiple domains. Social-cognitive deficits
were equally prominent, and related to degree of non-social
J Autism Dev Disord
cognitive impairment. These deficits were almost univer-
sally unappreciated as issues by treating clinicians who had
previously seen participants.
Several limitations should be noted and the implications
of this research should be considered in the context of these
limitations. The sample size of this characterization study
was modest, although purposely reflective of those seeking
cognitive rehabilitation. Further, the predominance of Cau-
to women and minority groups. Finally, the absence of a
matched sample of healthy control individuals precludes
definitive conclusions regarding the magnitude of perfor-
mance impairments, although all cognitive measures
employed have been rigorously normed with large samples
from the general population. Despite these limitations, the
results of this research have important implications for the
treatment needs of verbal adults with ASD. The results
suggest the presence of substantial cognitive disability that
could be easily overlooked when using standardized intel-
ligence testing. The absence of a general intellectual dis-
ability and the presence of developed formal speech did not
spare such individuals from significant cognitive and func-
tional impairment, and the significant degree of cognitive
impairment in the sample indicates the need for targeted
intervention approaches designed to address these deficitsin
social and non-social cognition. CET was originally
schizophrenia through the integration of computer-based
neurocognitive training in attention, memory, and problem-
solving with a structured small-group social-cognitive
treatment curriculum (Hogarty and Greenwald 2006). The
treatment has demonstrated considerable success in reme-
diating social and non-social cognitive impairments, as well
as adaptive function (Hogarty et al. 2004; Eack et al. 2010).
The results of an adaptation and application of this com-
the feasibility of targeting cognitive impairments in this
population using cognitive rehabilitation.
85851 (SME and NJM), MH-95783 (SME), RR-24154 (SME), and
HD-55748 (NJM), as well as grants from Autism Speaks (5703, SME
and NJM), the Department of Defense (AR100344, SME and NJM),
and the Pennsylvania Department of Health (NJM).
This work was supported by NIH grants MH-
Abrahams, B. S., & Geschwind, D. H. (2008). Advances in autism
genetics: On the threshold of a new neurobiology. Nature
Reviews Genetics, 9(5), 341–355.
Ben-Yishay, Y., Piasetsky, E. B., & Rattok, J. (1985). A systematic
method for ameliorating disorders in basic attention. In M.
J. Meir, A. L. Benton, & L. Diller (Eds.), Neuropsychological
rehabilitation (pp. 165–181). New York: Guilford Press.
Carter, C. S., Barch, D. M., Gur, R., Gur, R., Pinkham, A., & Ochsner,
K. (2009). CNTRICS final task selection: Social cognitive and
affective neuroscience-based measures. Schizophrenia Bulletin,
Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M.,
Felicetti, T., Kneipp, S., et al. (2005). Evidence-based cognitive
rehabilitation: Updated review of the literature From 1998
Through 2002. Archives of Physical Medicine and Rehabilita-
tion, 86(8), 1681–1692.
G. E., & Keshavan, M. S. (2010a). Assessing social-cognitive
deficits in schizophrenia with the Mayer-Salovey-Caruso Emo-
tional Intelligence Test. Schizophrenia Bulletin, 36(2), 370–380.
Eack, S. M., Hogarty, G. E., Cho, R. Y., Prasad, K. M. R., Greenwald,
D. P., Hogarty, S. S., et al. (2010b). Neuroprotective effects of
cognitive enhancement therapy against gray matter loss in early
schizophrenia: Results from a 2-year randomized controlled trial.
Archives of General Psychiatry, 67(7), 674–682.
Green, M. F., Nuechterlein, K. H., Gold, J. M., Barch, D. M., Cohen,
J., Essock, S., et al. (2004). Approaching a consensus cognitive
battery for clinical trials in schizophrenia: The NIMH-MAT-
RICS conference to select cognitive domains and test criteria.
Biological Psychiatry, 56(5), 301–307.
Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G.
(1993). Wisconsin card sorting test manual: Revised and
expanded. Odessa, FL: Psychological Assessment Resources Inc.
Hogarty, G.E, & Greenwald, D.P (2006). Cognitive enhancement
therapy: The training manual. University of Pittsburgh Medical
Center, Authors. Available through www.CognitiveEnhancement
Hogarty, G. E., Flesher, S., Ulrich, R., Carter, M., Greenwald, D.,
schizophrenia. Effects of a 2-year randomized trial on cognition
and behavior. Archives of General Psychiatry, 61(9), 866–876.
Howlin, P. (2000). Outcome in adult life for more able individuals
with autism or Asperger syndrome. Autism, 4(1), 63–83.
Kanner, L. (1971). Follow-up study of eleven autistic children
originally reported in 1943. Journal of Autism and Develop-
mental Disorders, 1(2), 119–145.
Kasari, C., & Lawton, K. (2010). New directions in behavioral
treatment of autism spectrum disorders. Current Opinion in
Neurology, 23(2), 137–143.
Kohler, C. G., Turner, T. H., Bilker, W. B., Brensinger, C. M., Siegel,
S. J., Kanes, S. J., et al. (2003). Facial emotion recognition in
schizophrenia: Intensity effects and error pattern. American
Journal of Psychiatry, 160, 1768–1774.
Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L.,
DiLavore, P. C., et al. (2000). The autism diagnostic observation
schedule—generic: A standard measure of social and commu-
nication deficits associated with the spectrum of autism. Journal
of Autism and Developmental Disorders, 30(3), 205–223.
Mayer, J. D., Salovey, P., Caruso, D. R., & Sitarenios, G. (2003).
Measuring emotional intelligence with the MSCEIT V2.0.
Emotion, 3(1), 97–105.
Minshew, N. J., & Williams, D. L. (2007). The new neurobiology of
autism. Archives of Neurology, 64(7), 945–950.
Sitzer, D. I., Twamley, E. W., & Jeste, D. V. (2006). Cognitive
training in Alzheimer’s disease: A meta-analysis of the literature.
Acta Psychiatrica Scandinavica, 114(2), 75–90.
Wechsler, D. (1999). Manual for the wechsler abbreviated intelli-
gence scale. San Antonio, T: The Psychological Corporation.
Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P.
(2011). A meta-analysis of cognitive remediation for schizo-
phrenia: Methodology and effect sizes. American Journal of
Psychiatry, 168(5), 472–485.
J Autism Dev Disord