Do Performance Differences on the Trail Making Test

and Brief Test of Attention in Spain vs. the USA

Reflect Culture or Neurology?
Javier Peña,3 Natalia Ojeda, 3 Godfrey D. Pearlson, & David J. Schretlen 1,2

Departments of 1Psychiatry and Behavioral Sciences, 2Neurology, and Radiology and Radiological Science
The Johns Hopkins University School of Medicine, Baltimore, Maryland
3Department of Psychology, University of Deusto, Spain

INTRODUCTION
Neuropsychological test performance is determined by many factors besides However, while Americans completed the TMT faster, Spaniards made Turning to participants aged 40 years and older, we again used ANOVA to control
the presence cerebral dysfunction. Attitudes toward testing (e.g., effort) and fewer errors Part A (t = −2.77, p < 0.01). Spaniards also made fewer errors for the fact that Spaniards completed significantly fewer years of education than
Individual differences in pre-morbid ability related to such characteristics as on Part B, but this difference fell short of statistical significance (t = 1.51, p Americans. As shown in Table 4 (marginal means +SEs), Spaniards scored higher
age and sex can also contribute. However, relatively few studies have = 0.13). than Americans on the BTA, but this approached statistical significance only for
examined the impact of cultural differences on neuropsychological test total scores. Americans completed the TMT faster than Spaniards, but they made
Because TMT-B adds a set-shifting demand to the sequencing and visual
performance in large international samples. more errors, and showed significantly greater slowing on TMT-B relative to TMT-A
scanning requirements of TMT-A, it is often considered a better measure of
executive functioning. Thus, we examined the ratio of TMT-B/TMT-A, based Spaniards.
Therefore, we compared the performance of healthy adults in the USA and
on the hypothesis that higher ratios reflect poorer executive functioning
Spain on English and Spanish versions of the Trail Making Test (TMT) and Table 4. Neuropsychological Results for Older subsample (>40 years)
because they denote greater slowing in response to the set-shifting
Brief Test of Attention (BTA).
demands of TMT-B. As shown in Table 2, Americans showed significantly USA Spain p-value
higher ratios (i.e., worse executive functioning) than the Spaniards (t =
BTA L
METHOD 4.38, p < 0.001). 7.85 +0.17 8.25 +0.17 0.12
BTA N 7.80 +0.16 8.16 +0.16 0.14
Participants Table 2. Neuropsychological Results for the Entire sample
BTA Sum 15.65 +0.29 16.49 +0.29 0.052
Participants included 203 healthy adults from the USA and 213 healthy USA Spain p-value
adults from Spain. Those from the USA were recruited for a study of normal TMT-A sec 31.75 +2.18 47.52 +2.18 <0.001
aging, mostly by calling randomly-selected telephone numbers. They were BTA L 8.25 +1.93 8.39 +1.69 0.42 TMT- A err 0.23 +0.03 0.06 +0.03 0.001
neurologically normal and free from current psychiatric illness or substance BTA N 8.23 +1.79 8.26 +1.56 0.89 TMT-B sec 89.37 +5.33 102.0 +5.33 0.10
abuse. Participants from Spain were recruited via newspaper advertising
and posted flyers. They also were neurologically normal and free from BTA Sum 16.48 +3.29 16.71 +2.80 0.43 TMT- B err 0.62 +0.07 0.33 +0.07 0.01
current psychiatric illness or substance abuse. TMT-A sec 28.50 +11.10 40.75 +27.63 TMT-B/TMT-A
<0.001 2.83 +0.09 2.20 +0.09 <0.001
As shown in Table 1, the groups were matched on age (t = 0.26, p = 0.79), TMT- A err 0.18 +0.44 0.08 +0.28 0.006
sex (χ2 = 1.74, p = 0.19) and years of education (t = 1.25, p = 0.21).
TMT-B sec 73.56 +47.59 87.62 +60.72 0.009 CONCLUSIONS
Table 1. Group Characteristics TMT- B err 0.44 +0.88 0.32 +0.75 0.13
Healthy American and Spanish adults showed nearly identical performance on the
USA Spain p-value TMT-B/TMT-A 2.61 +1.08 2.21 +0.72 <0.001 BTA. Spaniards were slower but made fewer errors and showed less decrement on
TMT-B relative to TMT-A than Americans. Closer inspection revealed that these
Age (years) 43.8 +14.3 43.5 +15.4 0.79 We next divided each sample into younger and older groups in order to test differences were restricted to older participants. Because both older groups were
Education (years) 13.9 +2.7 13.5 +3.6 0.21 whether the differences in performance are consistent across the age neurologically normal and differences in education were controlled statistically,
range. Because the age subgroups differed on years of education, we used these findings are difficult to explain on a neurological basis.
Sex (male %) 42.4% 48.8% 0.19 ANCOVA to control for this. As shown in Table 3, marginal means (and Another possibility is that a culture by generation interaction among the Spanish
standard errors) for the younger subsample did not differ significantly on participants accounts for the observed patterns of neuropsychological performance.
any BTA or TMT measure. We speculate that younger Spanish participants, who were raised after the end of
Statistical Analysis
We used the chi-squared (χ2) test to examine group differences in sex, Franco’s dictatorship and during the globalization of mass communication, have
Table 3. Neuropsychological Results for Younger subsample (<40 years)
and independent-samples t-tests to examine group differences in age, developed a speed/accuracy preference like that of American participants. In
years of education and neuropsychological test performance. The USA Spain p-value contrast, older Spanish participants who were raised or lived during a dictatorship
significance level was set at p < 0.05, two-tailed for all analyses. in which inhibitory and prudent behavior patterns were strongly reinforced, might be
BTA L 8.71 +0.16 8.66 +0.16 0.82 expected to show a greater preference for accuracy and error avoidance over
BTA N 8.81 +0.15 8.47 +0.15 0.12 speed. While obviously is speculative, this would account for the present findings,
RESULTS and represent evidence that cultural factors (separate from language differences)
BTA Sum 17.52 +0.27 17.16 +0.26 0.36 can affect neuropsychological test performance.
As shown in Table 2, the American and Spanish participants demonstrated
nearly identical performances on total BTA scores. In fact, their mean TMT-A sec 26.66 +1.16 28.71 +1.12 0.22 In addition, these results support the cross-cultural equivalence of Spanish and
scores differed by less than one-quarter point. Further no significant group TMT- A err English versions of the BTA for clinical trials in which attention is a treatment target.
0.12 +0.04 0.06 +0.04 0.40
differences emerged on either form L (Letters) or N (Numbers) of the BTA. Our data suggest that the two groups are equivalent on BTA. This was true for total
TMT-B sec 61.32 +2.63 58.51 +2.52 0.45 BTA scores and for performance on Forms L and N.
Turning to the TMT, American participants completed both Part A (TMT-A: t
= −5.95, p < 0.001) and Part B (TMT-B: t = −4.38, p < 0.01) of the Trail TMT- B err 0.28 +0.67 0.13 +0.43 0.18
Making Test faster than the Spanish participants. TMT-B/TMT-A 2.38 +0.08 2.15 +0.08 0.06

This study was partially funded by the Educational and Science Department of the Basque Goverment (beca del Programa de Formación de Investigadores del Departamento de Educación, Universidades e Investigación).