Perceptual and Motor Skills, 1958, 8, 271-276.

@ Southern Universities Press 1958

VALIDITY O F T H E TRAIL M A K I N G TEST AS AN INDICATOR

O F O R G A N I C B R A I N DAMAGE'

RALPH M. REITAN'
Indiana University medical Cenler

Several studies have appeared recently indicating that persons with brain
damage tend to perform significantly more poorly on the Trail Making Test
than d o control Ss without brain damage (1, 4, 1 0 ) . This paper is based on
larger groups than have been used previously and provides preliminary norms
for evaluating the performance of adult Ss.
PROCEDURE
T h e Trail Making Test was administered individually to 200 patients with
verified brain damage and 84 persons without anamnescic or clinical evidence
of brain damage. T h e brain-damaged group was heterogeneous with respect
to the types of lesions involved, including the following: multiple sclerosis, 39;
traumatic head injury, 33; diffuse cerebrovascular disease, 25; cerebrovascular
accident, 20; intrinsic brain tumor, 20; cerebral atrophy, 11; epilepsy following
head trauma, 8; extrinsic brain tumor, 7; cerebral abscess, 7; epilepsy (idio-
pathic), 6; epilepsy (surgically treated ) , 5; subdural hematoma, 5; nvo each
with congenical brain anomaly, cerebellar degenerative disease, dementia
paralytics, encephalitis, and acoustic neuroma; and one each with porencephalic
cyst, optic nerve adhesions, barbiturate intoxication, and thalamic tumor.
Testing of the brain-damaged pacients was performed after maximal benefits
of hospitalization had been realized and the patients were ready for discharge,
although many had acute symptoms at the time of admission to the hospital.
The group was probably characreristic of patients generally seen at a university
medical center rather than representative of the long standing, chronic,
brain-damaged patients often seen at state institutions or domiciliary hospitals.
All but eight of the 84 control Ss were hospitalized at the time of testing.
Diagnoses included the following: neurological complaincs ( a complete history,
neurological examination, and observation of the course during hospicalizntion
failed to reveal satisfactory evidence of brain damage), 25; paraplegia, 21;
neurosis, 15; surgery not involving the brain, 8; normal, 8; carcinoma, 1. A
deliberate attempc was made to include a large proportion of patients who had
entered the hospital with neurological complaints but for whom no evidence
of brain damage was found, since differentiation of such patients from those
with brain damage represents an important clinical problem. T h e other con-
trol patients were selected to include factors such as chronic illness of both
'This study was s u p p o r t e d - b ~ ~ l ~ - ~ s e a r cGrant
h B-808 from the National lnstirute
of Neurological Diseases and Blindness.
'The author is indebted to Miss Elaine Tarshes for assistance with test administration
and statistical analysis.
272 RALPH M. REITAN

an organic and an affective nature, repeated hospitalizations, and the possible

anxiety associated with impending surgery. N o Ss were included in either
group who were acutely ill, uncooperative, confused, or disoriented at the
time of testing.
The group with brain damage included 83.5%-males and 16.5% females.
Comparable values for the control group were 84.5% and 15.5%. Means for
age and education in the brain-damaged group were 34.88 (SD, 10.87) and
10.56 (SD, 2.99) and for the control group, 33.45 (SD, 11.16) and 11.19
(SD, 3.43). Although the control group was slightly younger and had a
little more formal education than the brain-damaged group, these differences
were not significant statistically. Critical ratios for age and education were 0.99
and 1.47, respectively. A total of six examiners administered the tests over a
period of approximately five years.
The Trail Making Test has been described in some detail previously (1,
4, 10). It consists of two parts, each with 25 circles distributed over a white
sheet of paper. In Part A the circles are numbered from 1 to 25. S is required
to draw a line connecting the circles in numerical sequence as quickly as possible.
Part B includes numbers from 1 to 13 and letters from A to L. S is required
to alternate between numbers and letters as he proceeds in ascending sequence.
The score is obtained as the number of seconds needed to finish each part.
Errors by S are pointed out immediately by the examiner and contribute to
the score only insofar as additional time is needed for corrections. Raw scores
(in seconds) are converted to a 10-point scale with 10 as the best possible score.
The scale for converting the score in terms of number of seconds required for
completion to the 10-point scale is given in the Manual for the Army Individual
Test (10).
RESULTS
Table 1 presents frequency distributions of the results obtained with
TABLE 1
DISTRIBUTION
OF TRAILMAKINGSCORES ON PARTA FOR A GROUP
WITHAND A GROUPWITHOUT BRAINDAMAGE
Groups
Scores Control Brain-damaged
10 63 43
9 8 23
8 7 12
7 3 31
G 2 16
5 0 7
4 1 19
3 17
2 7
1 25
N 84 200
Mean 9.46 6.24
SD 1.13 3.11
CR 12.78; p < .001
 TRAIL MAKING TEST AND BRAIN DAMAGE

TABLE 2
DISTRIBUTION
OF TRAILMAKINGSCORESON PARTB FOR A GROUP
WITH AND A GROUPWITHOUTBRAIN DAMAGE
Groups
Scores Control Brain-damaged
10 6 0 'I

- -

Mean 5.73 1.84

SD 2.40 1.30
CR 13.99; P < .001
Part A. Although the difference between means is highly significant
(CR = 12.78, p < .001), i t is apparent from the distribution that a sub-
stantial proportion of misclassificacions would occur regardless of the cut-off
score selected.
T h e results for Part B shown in Table 2 suggest. the possibility of useful

TABLE 3
DISTRIBUTIONOF TRAILMAKINGSCORESON PARTA PLUSPART B
FOR A GROUPWITHA N D A GROUPWITHOUTBRAIN DAMAGE

Scores
20
19
18
17
16
15
Control
Groups

6
6
6
15
11
8
Bran-damaged

1
2
I 4.0%

1
14 10 8
13 8 13
Cut-offpoint - - - - - - - - - - - - -
12 16
11 18
10 16
9 16.7% 17
8 4 21
7 0 11
6 1 9
5 20
4 12
3 7
2 25
N 84 200
Mean 15.19 8.08
SD 3.12 3.91
CR 16.20; p < .001
274 RALPH M. REITAN

discrimination of individual patients. If a cut-off point between scores of

3 and 4 were used, 19.0% of the controls and 11.5% of the brain-damaged Ss
would be misclassified. The difference between means for the groups obviously
is highly significant ( C R = 13.99, p < .001).
Although Part B differentiates between the groups nearly as well as does
Part A plus Part B, the combined results are presented in Table 3 because it
is useful to consider the results in combination for occasional patients.
The means of 15.19 for the control group and 8.08 for the brain-
damaged group are significantly different well beyond the .001 level
( C R = 16.20). The means obtained in a previous study ( 10) are very close
to those shown above. The mean of the absolute differences between means
of the previous study and the present one for Parts A and B is .21. These
differences reflect themselves cumulatively in the sum of Parcs A and B, but
the absolute mean differences for the two studies are still only .47 for the
controls and .36 for the brain-damaged group. The best cut-off point in
Table 3 is between scores of 12 and 13, agreeing exactly with the distributions
reported previously ( 10) .
Drscussro~
The excellent differentiation of groups prompts certain comments based
upon observations of patients while taking the test. Some patients seem
to have great difficulty with the spatial distribution. They may say aloud
the correct number or letter for which they are searching but be very slow
in finding it on the sheet. Such patients have great difficulty with moves
that require a fairly long line from one quadrant of the sheet to another.
Other patients seem to have difficulty differentiating distinctly between the
numbers or letters. Even though the next required number or letter is
immediately adjacent to the point reached, the patient seems in doubt as to
whether or not he is going to the correct point. Finally, for some patients the
major problem is the shifting between numerical and alphabetical series re-
quired in Part B. These patients usually do well on Part A but have great
difficulty on Part B.
A good performance on the Trail Making Test requires S's aiertness and
concentrated attention to the task. This would seem to be true of many tests
that prove sensitive to the effects of brain damage ( 9 ) . There are, very
possibly, additional reasons for the excellent differentiation of groups with
the Trail Making - Test. One of these refers to the content. It has been
known for many years that impairment of language functions, including the
recognition and comprehension of numbers and letters, is often present with
lesions of the left cerebral hemisphere ( 11 ). Brown and Simonson ( 2 ) have
pointed out recently that impairment of reading ability is commonly associated
with left posterior temporo-parietal or left anterior occipital lesions. Reitan (8)
has presented evidence from Wechsler-Bellevue results that with damage of the
 TRAIL MAKING TEST A N D BRAIN DAMAGE 275

left hemisphere language functions are impaired wich, or to some extent, even
without clinically recognizable dysphasia. Thus it would seem that a receptive
loss in the ability to recognize the symbolic significance of numbers and letters
may be one factor in causing poor performances, particularly in patients with
lesions involving the posterior part of the left hemisphere.
Several recent studies (3, 6, 8 ) have directed attention to impairment
in the ability to comprehend or effect spatial configurations in association
wich lesions of the right hemisphere. Patients with rapidly growing, destructive
neoplasms in this area are often not able to copy the simple shape of a Greek
cross without gross distortions of the spatial configuration ( 7 ) . Since the
numbers and letters of rhe Trail Making Test are distributed in space, this
aspect of the test might pose a special problem for patients with damage of
the right hemisphere.
Part B requires S to integrate two usually independent series, shifting
back and forth between numbers and letters, but yet keeping the ascending
sequence of both clearly in mind. This task seems somewhat similar to the
requirements of the Halstead Category Test in which S must assimilate informa-
tion from one stimulus figure after another in an effort to grasp an organizing
principle that applies to the series. Halstead believes that this test has
special significance for frontal lesions regardless of their lateralization ( 5 ) .
Thus it seems that patienrs with brain damage may perform poorly on the
Trail Making Test as a consequence of several rypes of impairment associated
with variously located brain lesions. This situation presents an advantage for
the test in its use as a screening instrument but a possible disadvantage in terms
of its potential use in differential lareralization or localization of brain lesions.
SUMMARY
The Trail Making Test was administered to 200 patients with clear evidence
of brain damage and to 84 Ss without anamnestic or clinical evidence of brain
damage. The groups were comparable with respect to sex distribution, chron-
ological age, and years of formal education. The results showed striking and
highly significant differences in the performances of rhe rwo groups for Parts
A and B of the test individually as well as for their total. Frequency distributions
were given that may serve as preliminary norms for use in evaluating results
obtained with individual Ss. Some comments were offered regarding possible
reasons why the Trail Making Test differentiated the groups so well, relating
known aspects of brain function to the structure and requirements of the test.
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 RALPH M. REITAN

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Accepted August 16, 1958.

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