Clinical Neurophysiology 120 (2009) 1107–1115

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Clinical Neurophysiology
journal homepage: www.elsevier.com/locate/clinph

Executive function deficits and neural discordance in children

with Autism Spectrum Disorders
Agnes S. Chan a,*, Mei-chun Cheung b, Yvonne M.Y. Han c, Sophia L. Sze a, Winnie W. Leung c,
Hok Sum Man c, Cho Yee To d
a
Integrative Neuropsychological Rehabilitation Centre, The Chinese University of Hong Kong, Hong Kong, China
b
Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hong Kong, China
c
Neuropsychology Laboratory, Department of Psychology, The Chinese University of Hong Kong, Hong Kong, China
d
School of Education, University of Michigan, Ann Arbor, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study examined neurophysiologic activities, executive dysfunctions, and their association
Accepted 5 April 2009 in children with Autism Spectrum Disorders (ASD).
Available online 12 May 2009 Methods: Thirty-eight normal and 16 children with ASD participated with parental consent. Executive
functions were measured using neuropsychological tests and parent ratings, and neurophysiologic activ-
Keywords: ities were measured using EEG to yield cordance values, an indirect measure of brain perfusion.
Autism Spectrum Disorders Results: Children with ASD made significantly more intrusion errors and False Alarms on the Hong Kong
Executive dysfunctions
List Learning Test (HKLLT) and Object Recognition Test (OR) than normal children, but were comparable
Neural discordance
EEG
to normal children on the Rey–Osterrieth Complex Figure Test and Continuous Performance Test. They
also showed significantly poorer executive functions in everyday activities as shown on the Behavior Rat-
ing Inventory of Executive Function (BRIEF), and had lower frontal perfusion patterns than normal chil-
dren as shown in the neurophysiologic cordance measures. Frontal cordance values were found to be
significantly associated with executive dysfunctions in HKLLT Delayed Intrusions, OR False Alarms and
BRIEF.
Conclusions: Children with ASD were impaired in everyday executive functioning and response inhibi-
tion. The cordance value, which has been shown to correlate with brain perfusion in a number of studies,
was significantly correlated with executive dysfunctions.
Significance: Exploration of this measure as an index for response to intervention is warranted.
Ó 2009 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights
reserved.

1. Introduction concepts, and inhibition of inappropriate actions (Bennetto et al.,

Autism Spectrum Disorders (ASD) is a group of lifelong develop-
mental disorders characterized by poor social interaction with oth-
ers, language delay or impairment, and repetitive and stereotyped
behavior (Wing, 1997). The cause of ASD is not well-understood.
While social and language impairments have long been established
and well-researched in ASD, more recent evidence suggests that
deficient executive functions are fundamental to the cognitive def-
icits in ASD (Gilotty et al., 2002; Ozonoff, 1997). Executive function
is a broadly defined cognitive domain that includes a multidimen-
sional set of abilities required to perform complex behaviors for
the attainment of a future goal (Donders, 2002; Nyden et al.,
1999). Individuals with ASD have been found to exhibit executive
dysfunctions including disorganized actions and strategies typified
by decreased initiative, perseveration, difficulties in forming novel
* Corresponding author. Tel.: +852 2609 6654; fax: +852 2603 5019.
E-mail address: aschan@psy.cuhk.edu.hk (A.S. Chan).
1996). Since executive function is not a unitary construct (Bishop
and Norbury, 2005) and not all of its subdomains are affected in
young children with ASD (Griffith et al., 1999), numerous attempts
have been made to delineate the specific executive deficits in chil-
dren with ASD (Geurts et al., 2004).
The majority of neuropsychological studies of executive func-
tions in ASD suggested that individuals with ASD have difficulties
in response inhibitory control and slow information processing
(Bishop and Norbury, 2005; Fernandez-Duque et al., 2000; Hughes
et al., 1994; Nyden et al., 1999; Russell and Jarrold, 1998; Russell
et al., 1999; Schmitz et al., 2006), although there has been an
inconsistent finding (Ozonoff and Jensen, 1999). Given that execu-
tive tasks often involve the suppression of irrelevant thoughts and
interference to maintain focus to attain future goals (Fernandez-
Duque et al., 2000), inhibitory deficit has been suggested to be
one of the primary deficits that underlies the repetitive, stereo-
typed behaviors in ASD (Schmitz et al., 2006). In fact, a number
of studies on children with ASD have demonstrated impaired

1388-2457/$36.00 Ó 2009 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.clinph.2009.04.002
1108 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115
performance in tasks that involved suppression of a prepotent re-
sponse from prior learning (Bishop and Norbury, 2005; Russell
et al., 1999). Similarly, results from studies on tests of executive
functioning such as error-correction (Russell and Jarrold, 1998)
and memory tasks (Hill and Russell, 2002; Russell and Jarrold,
1999) also showed self-monitoring impairments associated with
deficient inhibitory control in children with ASD. Given that chil-
dren with ASD have impairments in inhibitory control, it is reason-
able to assume that these children would be impaired in tasks that
require the suppression of irrelevant thoughts and interference.
Studies have indeed reported a negative association between intru-
sion error and working memory (De Beni et al., 1998) and that poor
problem-solvers made more intrusion errors than controls (Pass-
olunghi et al., 1999), suggesting that increased number of intrusion
errors can be considered a useful index of poor inhibition (Chiappe
et al., 2000). Thus, it is reasonable to assume that children with
ASD should produce more intrusion errors in neuropsychological
measures than normal children.
It is widely accepted that the frontal cortex is implicated in exec-
utive functions (Duncan, 1986). Given that previous studies have
reported structural, physiologic, and functional abnormalities in
the frontal region of individuals with ASD (Harrison et al., 1998;
Mundy, 2003; Rumsey and Ernst, 2000), it is conceivable that exec-
utive dysfunction in children with ASD may be associated with their
frontal abnormalities. Indeed, results from neurobiological studies
on individuals with ASD have revealed abnormal neurobiological
processes in the frontal lobes that underlie the executive function
deficits (Mundy, 2003; Schmitz et al., 2006), and functional imaging
studies have also found altered patterns of activation, perfusion,
and glucose metabolism in various areas of the frontal lobes in indi-
viduals with ASD during neuropsychological tasks involving execu-
tive function (Ohnishi et al., 2000; Pierce et al., 2004; Schmitz et al.,
2006). Brain imaging studies on individuals with ASD have also
shown focal abnormalities in the anterior cingulate cortex (Hazne-
dar et al., 2000; Mundy, 2003; Schmitz et al., 2006), a region which
is widely documented to be involved in inhibitory control (Botvi-
nick et al., 2004; Garavan et al., 2002; Menon et al., 2001).
Since brain electrical activity represents the single greatest de-
mand on cerebral metabolism (Erecinska and Silver, 1989), a re-
cently developed quantitative EEG measure, cordance, may be
useful to examine brain activities of children with ASD. Cordance,
developed by Leuchter and colleagues (1994), is a quantitative
derivative of scalp EEG power. The cordance value combines abso-
lute and relative power to give two indices, an individual cordance
value for each electrode site and the predominant global brain
state, which were found to show a stronger correlation with cere-
bral perfusion than either power measure alone in a number of
studies using positron emission tomography (PET) and single-pho-
ton emission computed tomography (SPECT) (Cook et al., 1998,
1999; Leuchter et al., 1994, 1999). Greater brain perfusion was
found to be associated with increased cordance in the theta band,
and was effective in detecting lateralized activation associated
with a motor task compared with PET (Leuchter et al., 1999). Fur-
thermore, some studies have explored the use of cordance as a bio-
Table 1
Demographic characteristics of the normal controls (NC) and Children with Autistic Spectrum Disorders (ASD) for the whole group and the IQ-matched subgroup.
Variable Whole group
NC (n = 38)
Mean age (in years) 9.31 (2.2)
Gender (male/female) 28/10
TONI-III (deviation quotient) 114.7 (16.6)
CARS (total score) – 32.12 (3.15)
Note. Standard deviations are in parentheses. CARS, Childhood Autism Rating Scale; TONI-III, Test of Nonverbal Intelligence, 3rd ed.. The dash indicates that the CARS was not
administered to normal controls.
marker to predict treatment effects in patients with depression
(Cook et al., 1998, 1999; Hunter et al., 2006; Leuchter et al.,
2004), fibromyalgia (Bell et al., 2004) and individuals on cocaine
treatment trials (Venneman et al., 2006), and found it useful. We
thus aimed to further explore whether this method can be used
on children with ASD. Leuchter and colleagues have reported dif-
ferent computations of the cordance algorithm, and we employed
the most recent algorithm used by the group (Hunter et al.,
2006; Venneman et al., 2006). Cordance in the theta band was used
in this study as theta has been well-documented to be associated
with focused attention (Pizzagalli, 2007) in normal individuals,
and reflective of attentional and inhibitory processing in adult
(Kroptov et al., 1997) and children (Chan and Leung, 2006; Daoust
et al., 2004; Monastra et al., 1999, 2001) patient groups. Since cor-
dance is not a conventional electrophysiological measure and the
computation bears no direct relationship with the biophysics of
volume conduction (Tenke and Kayser, 2005), we also employed
the more standard power measures to check for consistency and
to provide a context for interpreting the results.
Based on the documented executive dysfunctions in ASD and
the reported physiological abnormality in the frontal lobes (Ohni-
shi et al., 2000; Wilcox et al., 2002), we examined executive dys-
functions in planning and organization, inhibitory control,
information processing speed, and parent ratings on everyday
activities, as well as the brain activities of young children with
ASD using cordance, which is relatively convenient and tolerable
for children with ASD. We also examined the utility of cordance
in reflecting executive dysfunctions and inhibitory control. We
hypothesized that children with ASD would perform significantly
poorer than normal children in executive functions as measured
by parent ratings and neuropsychological tests, particularly in inhi-
bition as measured by intrusion errors. We also hypothesized that
children with ASD would show abnormalities in cordance, and that
the abnormality in cordance is associated with executive dysfunc-
tions and especially inhibitory control in these children.
2. Methods
2.1. Participants
Thirty-eight normal children and 16 children with ASD, aged 6–
14 years, participated voluntarily in the study. Normal control (NC)
children were recruited from local primary schools or the database
of our laboratory, and had negative history of neurological prob-
lems or abnormal developmental milestones. Children with ASD
were recruited from the Parents’ Association of Pre-School Handi-
capped Children or the subject database of our laboratory. They
were previously diagnosed, based on DSM-IV criteria (American
Psychiatric Association, 2002) or the Autism Diagnostic Observa-
tion Schedule (ADOS; Lord et al., 2002) by pediatricians of Child
Assessment Centres in Hong Kong. The diagnosis was further con-
firmed by a clinical psychologist through standard clinical inter-
view and the Childhood Autism Rating Scale (CARS; Schopler
et al., 1986). Table 1 shows the demographic characteristics of
IQ-matched Subgroup
ASD (n = 16) NC (n = 29) ASD (n = 13)
10.54 (1.73) 9.53 (1.9) 10.78 (1.84)
14/2 20/9 11/2
96.75 (18.72) 109.9 (14.5) 102.3 (16.10)
– 31.83 (3.47)
 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115 1109

the children. While the ASD and NC groups were matched on age,
t(52) = -2, p > .05, the ASD group had significantly lower general
intelligence as measured by the Test of Non-verbal Intelligence,
3rd ed. (TONI-III; t(51) = 3.48, p < .005). To examine whether there
is an effect of IQ on the neuropsychological and EEG results, sub-
group (NC = 29; ASD = 13) analyses were done with the children
matched on IQ.
2.2. Procedure
All children were individually administered a neuropsychologi-
cal battery that included the TONI-III (Brown et al., 1992), and
measures of executive functioning including the Rey–Osterrieth
Complex Figure Test (Rey-O; Bernstein and Waber, 1996), Hong
Kong List Learning Test (HKLLT 2nd ed.; Chan, 2006), Object Recog-
nition Test (OR), and Continuous Performance Test II (CPT II; Con-
ners, 2000). Resting EEG was recorded in the eyes-open condition.
The sequence of neuropsychological assessment and EEG recording
was counter-balanced to avoid order effect. Parent ratings of the
children’s everyday behavior were measured using the Behavior
Rating Inventory of Executive Function (BRIEF) (Gioia et al.,
2000). All children participated with parent consent, and the pro-
cedure was approved by the Joint CUHK-NTEC Clinical Research
Ethics Committee.
2.3. Instruments
2.3.1. Test of Non-verbal Intelligence
The TONI-III (Brown et al., 1992) assessed general intelli-
gence. The test consisted of 45 matrix reasoning questions, with
raw scores ranging from 0 to 45, which were then converted to
deviation quotients based on the norms provided in the test
manual.
by Rossion and Pourtois (2004). The line drawings were placed in
an array of six by four layout displayed on a computer screen for
three minutes, and participants had to memorize the items for a la-
ter recognition task consisting of 12 targets mixed with 12 distrac-
tors. Incorrect identification of distractors were counted as False
Alarms, a commonly used neuropsychological measure of intrusion
(Cornoldi and Mammarella, 2006), with scores ranging from 0 to
12.
2.3.5. Continuous Performance Test II
The CPT-II (Conners, 2000), administered on the computer,
measured sustained attention, impulse control, and information
processing speed. Participants were required to press a key as
quickly as possible in response to letters of the alphabet displayed
on the computer screen, with the exception of the letter ‘‘X”. The
Total Commission Errors measured impulse control, and Hit Reac-
tion Time measured information processing efficiency.
2.3.6. Behavior Rating Inventory of Executive Function (BRIEF)
The BRIEF (Gioia et al., 2000) consisted of 86 items of parent rat-
ings of the child’s executive functions at home and in school. It
yields two summary scores, the Behavioral Regulation Index and
Table 2
Mean performance and standard deviation on the executive functioning of children in
the normal controls (NC) and Autistic Spectrum Disorders (ASD) group for the whole
group and IQ-matched subgroup.
Measures NC ASD t-Value
M (SD) M (SD)
Whole group (NC = 38, ASD = 16)
Rey-O
Copy 26.59 (6.15) 23.56 (10.01) 1.13
Immediate Recall 13.75 (6.71) 11.17 (6.58) 1.27

2.3.2. Rey–Osterrieth Complex Figure Test HKLLT

Two trials of the Rey-O (Bernstein and Waber, 1996), Copy and Intrusion 1.26 (1.80) 5.0 (5.72) 2.56*
Delayed Intrusion 1.37 (1.72) 3.75 (3.49) 2.60*
Immediate Recall, assessed working memory, planning and organi-
Recognition False Alarm 0.34 (0.48) 4.8 (6.16) 2.80*
zation. The child was first asked to copy a complicated figure and
OR
the sequence and organization were scored to give the Copy score
False Alarm 0.19 (0.58) 2.82 (2.79) 3.10*
(Rey-O Copy) that ranged from 0 to 36. The figure was then taken
CPT
away and the child had to draw as accurately as possible the figure Hit Reaction Time 421.6 (65.9) 500.1 (154.5) 1.84
from memory, giving the Immediate Recall score (Rey-O IR) that Commission Error 23.86 (7.59) 23.42 (5.22) 0.20
ranged from 0 to 36. BRIEF
Global Executive 132.11 (20.68) 164.22 (17.56) 5.43**
2.3.3. Hong Kong List Learning Test Behavioral Regulation 47.74 (9.58) 60.75 (9.83) 4.52**
The HKLLT (2nd ed.; Chan, 2006) measured the frontal lobe Metacognition 84.37 (14.34) 103.47 (11.59) 4.71 **
functions of learning strategies, organization, and vulnerability to
IQ-matched Subgroup (NC = 29, ASD = 13)
interference. The test consisted of a randomly organized list of Rey-O
16 two-word Chinese characters presented once during each of Copy 27.53 (5.10) 26.62 (6.93) 0.48
three learning trials. Participants were asked to recall the words, Immediate Recall 14.79 (6.78) 12.71 (5.77) 0.93
and those that were not on the presented list were considered HKLLT
intrusions. According to the test manual, the total number of intru- Intrusion 1.17 (1.77) 4.15 (5.29) 1.98
sions during the three learning trials gave the Intrusion score, Delayed Intrusion 1.21 (1.45) 3.38 (3.31) 2.28*
Recognition False Alarm 0.31 (0.47) 3.23 (4.90) 2.14*
which is a commonly used neuropsychological measure of intru-
sion (Cummingham et al. 1997; De Beni and Palladino, 2004; Mah- OR
False Alarm 0.11 (0.32) 2.33 (2.69) 2.47*
one et al., 2001; Schnider et al., 1996; Stuss et al., 1994a,b). The
total number of intrusions during the 10- and 30-min delayed re- CPT
Hit Reaction Time 421.9 (70.18) 469.01 (106.3) 1.42
call trials were summed to give the Delayed Intrusion score. A rec-
Commission Error 23.93 (7.09) 24.17 (4.39) 0.11
ognition test of a 32-item list that consisted of the 16 target words
BRIEF
and 16 distracters was presented after the 30-min delayed recall Global Executive 133.24 (21.19) 163.42 (16.78) 4.53**
trial, and the number of False Alarms was considered intrusions Behavioral Regulation 47.97 (9.49) 59.23 (9.82) 3.52**
on the recognition test. Metacognition 85.28 (15.15) 104.19 (10.36) 4.08 **

The mean performances of Object Recognition and CPT tasks were computed based
2.3.4. Object Recognition Test on 37 NC and 14 ASD children.
This test consisted of 24 line drawings taken from the Snodgrass *
p < .05.
**
and Vanderwart’s object database (1980), modified and validated p < .001.
1110 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115

Metacognition Index, which were further combined into Global
Executive Composite. Higher scores indicated poorer executive
functioning.
2.3.7. EEG recording
All parents and children were briefed on the procedure, and in-
formed consents were obtained before EEG recording. Resting EEG
was collected in the eyes-open condition using an electrode cap
with 19 electrode sites (International 10–20 System) referenced
to linked ears. The EEG signal was digitized at 256 Hz with a low
pass filter of 30 Hz, and impedances below 10 kX. The children
were asked to focus on a figure (e.g., a car) displayed on a computer
screen, and body movements were time-marked for off-line analy-
ses. EEG data were stored and later displayed on computer, and
visually examined for eye movements and muscle artifacts. Only
data that had at least 1 min of artifact-free data were selected
(John et al., 1988 for discussion of qEEG method) and spectrally
processed using the fast Fourier Transformation (FFT) to compute
absolute and relative power data for the theta band (4–7.5 Hz).
This band was used based on its demonstrated correlation with
brain perfusion (Leuchter et al., 1999) and reports of theta abnor-
malities in children with ASD (Chan and Leung, 2006; Daoust
et al., 2004).
2.3.8. Cordance value
Cordance was computed for 19 electrode sites (Fp1, Fp2, F3, F4,
F7, F8, Fz, T3, T4, T5, T6, C3, C4, Cz, P3, P4, Pz, O1 and O2) using a
three-step algorithm (Cook et al., 2002; Leuchter et al., 1999). First,
electrodes were remontaged off-line to bipolar channel pairs of
nearest-neighbor electrodes that shared a common electrode. For
example, Fp1 was referenced to Fp2, F3, and F7; Fp2 was refer-
enced to Fp1, F4, and F8, followed by averaging of the absolute
power values for the bipolar pairs. EEG power values were com-
puted for absolute (amount of power in theta at a given electrode,
in lV2) and relative theta (the percentage of power in theta relative
to the total power in the overall frequency spectrum). Next, spatial
normalization was done on the absolute (Anorm) and relative
(Rnorm) theta power values across electrode sites using a z-trans-
formation statistic at each site with values expressed in z-scores.
Finally, cordance was quantified by summing the z-transformed
Anorm and Rnorm scores for each electrode site. Cordance values
from the 19 electrodes were grouped topographically into the
anterior (Fp1, Fp2, F3, F4, F7, F8, Fz, Cz), centrotemporal (C3, C4,
T3, T4, T5, T6), and posterior (P3, P4, Pz, O1, O2) regions to provide
a measure of mean cordance intensity for each region (Cook et al.,
1998). This algorithm was consistent with the most update version
used by the group (Hunter et al., 2006; Venneman et al., 2006).

Fig. 1. (a) Topographical maps demonstrating the averaged values for cordance intensity for normal children (NC), and children with autistic spectrum disorders (ASD). White
dots indicate the spherical positions of the recording sites (nose at top) derived from triangle-based cubic interpolations. Orange–red indicates higher cordance value, and
green–blue indicates lower cordance value. (b) Children with autistic spectrum disorders (ASD) showed significantly lower mean cordance value at theta frequency band in
the anterior region, but not the centrotemporal and posterior regions, than that of normal controls (NC). (c) IQ-matched subgroup analysis: Children with autistic spectrum
disorders (ASD) showed significantly lower mean cordance value at theta frequency band in the anterior region, but not the centrotemporal and posterior regions, than that of
normal controls (NC).**p < .001. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115
2.3.9. Global brain state
Global brain state was assessed by determining the proportion
of electrodes showing concordance or discordance along the two
dimensions of absolute and relative power, visualized as four
quadrants along the two dimensions. If both absolute and relative
power were above (Abs+ and Rel+) or below (Abs and Rel ) the
mean value for a particular site, the electrode was ‘‘concordant”.
Otherwise, the electrode was ‘‘discordant” (Abs+ and Rel ; Abs
and Rel+). Data from simultaneous qEEG and PET studies (Cook
et al., 1998) revealed that brain regions with concordant electrodes
showed higher perfusion while discordant electrodes showed low-
er-perfusion, which may be useful as a categorical indicator of rel-
ative brain activity (Leuchter et al. 1999).
2.4. Data analyses
ASD and NC children were compared on each of the 11 scores
from the Rey-O, HKLLT, OR, CPT-II, and BRIEF using independent
t-tests; on global brain state of concordant and discordant elec-
trodes in the four quadrants using independent t-tests; and on
the three regional cordance values using repeated measures anal-
ysis of variance (ANOVA), with the three brain regions as within-
subject and group as between-subject factors, and post hoc F-tests
to pinpoint the regions with significant differences. To provide a
context for interpreting the cordance results and to see whether
the cordance algorithm was consistent with traditional EEG mea-
sures, absolute and relative theta power values for the three brain
regions were analyzed using two separate repeated measures AN-
OVAs. Relationship between executive functioning and qEEG activ-
ities were examined using correlation. Given that specific
hypotheses were tested and that the number of participants were
relatively small, we did not adjust the alpha level to avoid lowering
the power of the tests.
3. Results
3.1. Executive functioning
3.1.1. Neuropsychological assessments
No significant difference was found between the ASD and NC
groups on Rey-O Copy (t = 1.13, p > .05) and Rey-O IR (t = 1.27,
Fig. 2. Mean values of absolute and relative power in (a) theta, (b) alpha, and (c) delta in NC and ASD groups.
1111
p > .05). The ASD group, however, showed significantly higher
Intrusion (t = 2.56, p < .05), Delayed Intrusion (t = 2.60, p < .05)
and False Alarms (t = 2.80, p < .05) than normal children on the
HKLLT, as well as significantly more False Alarms (t = 3.10,
p < .05) on the OR. For the CPT-II, two children in the ASD group
have been excluded in the analysis because of the unreasonably
large amount of omission errors suggesting that the children did
not follow the instructions to perform the test. Independent t-tests
showed no significant difference between the ASD and NC groups
on Hit Reaction Time (t(14.83) = 1.84, p > .05) and Total Commis-
sion Error (t(49) = .20, p > .05) (Table 2). Results from the IQ-
matched subgroup analysis was generally consistent, in that no
significant difference was found on NC and ASD children’s perfor-
mance on the Rey-O (all ps > .05) and CPT (all ps > .05); and chil-
dren with ASD showed significantly higher Delayed Intrusion
(t = 2.28, p < .05) and False Alarms (t = 2.14, p < .05) than nor-
mal children on the HKLLT, as well as significantly more False
Alarms (t = 2.47, p < .05) on the OR. However, the significantly
higher intrusion score of children with ASD disappeared in the sub-
group analysis (t = 1.98, p > .05), which is possibly due to the low-
er power as a result of the reduction in the number of participants
in the subgroup analysis.
3.1.2. BRIEF
ASD children had significantly higher scores on Behavioral Reg-
ulation (t = 4.52, p < .001), Metacognition (t = 4.71, p < .001),
and the Global Executive Composite score (t = 5.43, p < .001) sug-
gesting poorer executive functions in everyday behavior as re-
ported by their parents. Results from the IQ-matched subgroup
analysis was consistent, in that ASD children had significantly
higher scores on Behavioral Regulation (t = 4.53, p < .001), Meta-
cognition (t = 3.52, p < .001), and the Global Executive Composite
score (t = 4.08, p < .001).
3.2. Neurophysiological measures
3.2.1. Cordance value
Maps showing regional cordance intensity of ASD and NC chil-
dren are presented in Fig. 1(a). Visual examination showed that
cordance intensity was reduced in the ASD group. Repeated
measures ANOVA results showed a marginally significant region
1112 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115

(anterior, centrotemporal and posterior) by group (normal, ASD)
interaction effect, F = 3.14, p = .05, and a significant between-sub-
ject effect, F = 12.1, p < .005. Tests of simple effects indicated that
children with ASD demonstrated a significantly lower cordance va-
lue than normal children in the anterior (F(1, 52) = 15.40, p < .001)
but not the centrotemporal (F(1, 52) = 1.32, p > .05) or posterior
(F(1, 52) = 3.97, p > .05) regions (Fig. 1(b)). The averaged cordance
value for the ASD group is negative in the anterior but not the more
posterior regions. Given that cordance has been found to be asso-
ciated with perfusion, this may suggest reduced perfusion in the
anterior region. Results from the IQ-matched subgroup analysis
were also consistent (Fig. 1(c)).
Analyses on both absolute and relative theta power were con-
sistent with the cordance measure and showed significant de-
crease of absolute (t = 2.46, p < .02) and relative (t = 3.09, p < .02)
power values in the anterior brain region of the ASD group
(Fig. 2(a)), providing physiologic support to the cordance findings.
In order to establish the spectral specificity of the theta depression
found for the ASD group, analyses were also done on the alpha and
delta bands in the anterior region. Results (Fig. 2(b and c)) showed
that there was no significant difference between the ASD and the
NC group on absolute alpha (t = 1.91, p > .05) and delta (t = 1.43,
p > .05) power. While the two groups showed significantly differ-
ent relative alpha (t = 2.38, p = .02) and delta (t = 2.44, p = .018)
power, the differences were in opposite directions. These results
suggested that the theta depression was specific to the cognitive
function being measured, and not to greater signal to noise ratio
across all bands in the ASD group. The consistency between the
cordance measure and the more traditional power measures has
provided a more physiologic context for interpreting the results
on cordance.
3.2.2. Global brain state
Using the cordance value for each electrode site, the total per-
centage of electrodes displaying discordance is significantly higher
in the ASD (Mean = 49.0, SD = 16.2) compared to the NC
(Mean = 34.9, SD = 14.7) group (t = 3.127, p < .01). A comparison
of the distribution of concordant and discordant electrodes be-
tween the ASD and NC group showed that the ASD group had sig-
nificantly higher proportions of electrodes in the two discordant
(suggesting lower-perfusion) quadrants (Fig. 3).
3.3. Association between executive functions and anterior cordance
value

(a) Relationship between Absolute and Relative Power (NC) Given that both the anterior cordance value and some measures
1.5 of executive functions were significantly different between ASD and
NC children, we examined the association between anterior cor-
(17.9 %) dance and these measures using Pearson correlations on the whole
1 group of children (Table 3). Results indicated that the anterior cor-
dance value was significantly correlated with HKLLT Delayed Intru-
Normalized Relative Power

0.5
sion (r = .32, p < .05), OR False Alarm (r = .30, p < .05), BRIEF
Behavioral Regulation (r = .31, p < .05), BRIEF Metacognition
(r = .29, p < .05), and BRIEF Global Executive (r = .33, p < .05)
0 score. Results from the IQ-matched subgroup analysis were consis-
-1.5 -1 -0.5 0 0.5 1 1.5 tent and even more pronounced, in that anterior cordance value
was significantly correlated with HKLLT Delayed Intrusion
-0.5 (r = .43, p < .05), OR False Alarm (r = .40, p < .05), BRIEF Behav-
ioral Regulation (r = .32, p < .05), BRIEF Metacognition (r = .29,
(17.0 %)
p < .05), and BRIEF Global Executive (r = .35, p < .05) score.
-1

-1.5 4. Discussion
Normalized Absolute Power
The main purposes of the present study were to examine exec-
(b) Relationship between Absolute and Relative Power (ASD) utive dysfunction in children with ASD, and whether these deficits
1.5 were associated with cordance, a relatively new EEG measure that
has been shown in some studies to correlate with brain perfusion.
(28.3%) Results showed that children with ASD made significantly more
1 intrusion errors than normal children on the HKLLT and the OR,
and they also performed significantly poorer in everyday activities
Normalized Relative Power

as reported by their parents. Consistent results from the IQ-

0.5
matched subgroup analysis suggested these findings were due to
ASD and not differences in IQ. Our findings are in agreement with
0 previous studies that suggested inhibitory control as the major
-1.5 -1 -0.5 0 0.5 1 1.5 executive dysfunction in individuals with ASD (Hughes et al.,
1994; Nyden et al., 1999; Schmitz et al., 2006).
-0.5 Children with ASD in our study performed comparably to nor-
mal children on the Rey-O and CPT-II, suggesting that they were
within the normal range in sustained attention, planning and orga-
-1
(20.7%) nization. These results are in line with some prior findings that
children with frontal lobe damage performed relatively normally
-1.5 on some cognitive tests but showed disorganized strategies and ac-
Normalized Absolute Power tions in daily activities (Mangeot et al., 2002; Ozonoff and Strayer,
2001). As some researchers have pointed out, executive function is
Fig. 3. Global Brain State: Distribution of concordant and discordant electrodes of
(a) NC and (b) ASD children. Each point represents the pair of normalized absolute a broadly defined cognitive domain involving ‘‘on-line” coordina-
and relative power values for each of the 19 electrodes. tion of a multidimensional set of abilities to perform complex
 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115 1113

Table 3
Correlations between anterior cordance value, IQ, and measures of executive functioning for the whole group and the IQ-matched subgroup.

Anterior TONI-III HKLLT HKLLT HKLLT OR False BRIEF BRIEF BRIEF Global
cordance Intrusion Delayed Recognition Alarm Behavioral Metacognition Composite
Intrusion False Alarm Regulation
Whole group (N = 54)
Anterior Cordance 1.00
TONI-III .11 1.00
HKLLT Intrusion .13 .36** 1.00
HKLLT Delayed Intrusion .32* .36** .50*** 1.00
HKLLT False Alarm .07 .49*** .76*** .46*** 1.00
OR False Alarm .30* .34** .53*** .39** .59*** 1.00
BRIEF Behavioral Regulation .31* .32* .50*** .41** .45*** .44** 1.00
BRIEF Metacognition .29* .41** .22 .33* .18 .42** .60*** 1.00
BRIEF Global Composite .33* .42** .37** .41** .32* .48*** .85*** .93*** 1.00
IQ-matched subgroup (N = 42)
Anterior cordance 1.00
TONI-III .06 1.00
HKLLT Intrusion .18 .31* 1.00
HKLLT Delayed Intrusion .43* .31* .38** 1.00
HKLLT False Alarm .14 .32* .79*** .24 1.00
OR False Alarm .40* .16 .62*** .61*** .62*** 1.00
BRIEF Behavioral Regulation .32* .05 .46** .38** .42** .39* 1.00
BRIEF Metacognition .32* .31* .26 .46** .24 .37* .58*** 1.00
BRIEF Global Composite .35* .23 .38** .48*** .35* .43** .84*** .93*** 1.00
*
p < .05.
**
p < .01.
***
p < .001.

behaviors (Denckla, 2002). It is possible that clinical instruments
such as standardized neuropsychological assessments measuring
very specific areas of cognitive processes may not be sensitive to
the complex executive functions involved in everyday behaviors
(Donders, 2002). This may explain why children with ASD in the
present study showed impaired performance in intrusion and False
Alarms on the HKLLT and OR, as well as parent ratings on the BRIEF
(Gioia et al., 2002), all of which are tasks that involve complex and
multiple executive functions (Stuss et al., 1994a,b), but were rela-
tively unimpaired in Commission Errors on the more simple CPT-II
task. The unimpaired CPT-II Hit Reaction Time may also explain the
relatively normal performance of children with ASD on the Rey-O,
as it has been argued that the ability to apprehend, scan, and pro-
cess visual information may be more important than organiza-
tional skills for accurate reproduction of the complex figure (Fujii
et al., 2000; Poulton and Moffitt, 1995).
In addition to the executive dysfunctions in behavioral mea-
sures, results from the EEG measurements also indicated that chil-
dren with ASD in the present study had lower cordance patterns,
which may suggest lower-perfusion, in the frontal region than nor-
mal children. Specifically, children with ASD showed a significantly
higher proportion of discordant electrodes and lower cordance va-
lue in the anterior region of the brain compared with normal con-
trols. The increased proportion of electrodes showing discordant
state is consistent with previous findings that discordant global
brain state is seen over areas of brain dysfunction (Cook et al.,
1999; Leuchter et al., 1994, 1999). However, it should be noted that
discordance per se is not synonymous with brain dysfunction, but
should be regarded as an indicator of relative activity of the brain
(Leuchter et al., 1999). In fact, most normal individuals have about
30% of their electrodes in the discordant state (Cook et al., 1999).
The fact that children with ASD were found to have significantly
higher percentage of discordant electrodes in the present study
highlighted the need for further studies to delineate the relation-
ship between global brain state and brain disorders.
In addition to the discordant global brain state associated with
ASD, our findings of altered anterior cordance pattern, which sug-
gested altered perfusion pattern in the anterior part of the brain,
are also in line with previous neuroimaging findings that reported
reduced glucose metabolism and decreased blood flow to the fron-
tal areas in the brain of individuals with ASD (George et al., 1992;
Ohnishi et al., 2000; Wilcox et al., 2002). In addition, our findings
showed that the anterior cordance value was significantly associ-
ated with executive dysfunctions as shown in HKLLT Delayed
Intrusion, OR False Alarm, and the BRIEF parent ratings (Gioia
et al., 2002), all of which are tests that measure executive functions
in complex and everyday activities (Mangeot et al., 2002). This
finding highlighted a possible clinical application of the cordance
measure, as an objective physiological indicator of executive func-
tioning for young children. Since cordance is non-invasive and rel-
atively easy to measure, it has potential to become an objective
indicator for clinicians to monitor children’s response to interven-
tion particularly with executive dysfunctions and frontal lobe
problems, since more pervasive imaging methods or lengthy neu-
ropsychological assessments may not be easily applied on these
children.
While findings from the present study raised some interesting
questions in respect to the relationship between inhibitory control
and frontal neurophysiological activities, it should be noted that
intrusion errors are relatively simple and indirect measures of poor
inhibitory control (De Beni and Palladino, 2004). Further research
with additional measures of inhibition is necessary to clarify the
relationship between intrusion error, inhibitory control, and ante-
rior EEG cordance. In addition, the relatively small sample-size, the
overrepresentation of high functioning children with ASD and the
young age-group may limit the generalization of the findings to
children with ASD in general. Given the potentially useful clinical
application of the cordance measure, further studies are warranted
to extend the application to individuals with ASD from a larger age
range and different levels of functioning, and even to other clinical
populations in which executive dysfunction is a major symptom.
Acknowledgement
This study is funded by the Research Grants Council of Hong
Kong (Grant no. CUHK4648/05H).
1114 A.S. Chan et al. / Clinical Neurophysiology 120 (2009) 1107–1115

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