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a Professional }'lanual
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2 ilntolin ll. llorente, phD
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a lane l{illiams, PhD
a Daul Salr,,PhD
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a louis t D'Elia, PhD
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;, Chapter 1: Introduction 1

E,t Historical Background and Description of the Trail Making Test.........

z
1

Rationale for the Development of the Children's Color Trails Test ............ 2
Developmental and Maturational Considerations............. 2
Applied, Psychometric, and Secondary Theoretical Considerations ............... 3
b,t
zb,t Improved Assessment of Children Who Are Illiterate, Use English as a Second Language,
or Have Specific Reading or Ldnguage Disorders...
Enhanced Assessment in Cross-Cultural Contexts..............
4
4

zz Dysfunction
Improved Sensitivity to Detect Subtle Neurological
Increased Reliability..
4
5

z
b,,
Enhanced Capabilities for Longitudinal
Enhanced Test Administration
$esearch.................
Additional Theoretical Considerations: Attentional and Executive Skills..........
5
5
6

? Chapter 2: Test Materials, Administration, and Scoring............. 9

- Professional Manual and Forms
zz
9
Appropriate Populations 9
Professional Requirements................ 9
Assessment Considerations for Special Populations 10
RequiredMaterialsforStandardizedTestAdminisffation.............
b,, Detailed Test Description and General Administration Guide1ines................ 10
b,, Standardized TestAdministration.... 11

Oral Administration Instructions 11

4
b,,
Pretest: CCTT-I and CCTT-2
Administration Instructions for the CCTT-I
Administration Insffuctions for the CCTT-2
11
16
16
CCTT-2
z Visual Administration Instructions for the CCTT-1 and I7

Prompt Scores .. 17
Near-MissScores 19

1
4 Interference Index......... r.................. 19

b
4
b
Chapter 3: Descriptive Statistics and Normative Data 21
Normative Sample 2I
Selection of Normative Variables 2T
Influence of Demographic Variables ................. ................... 22
Supplemental Normative Data From Clinical Groups... 24
Transformation of CCTT Time Raw Scores........ 27
Categorical Norms........ 28

Chapter 4: Interpretation ................... zg

Norm-Referenced Approach... 29
Normative Interpretation of the CCTT:1 and CCTT-2 Time Raw Scores........r...;......!......! 30
Normative Interpretation of Prompt and Near-Miss Scores .:................. 3I
Normative Interpretation of the Interference Index.......... 32
Base Rate Comparisons.................

Interpretive Case Examp1es.............. ...........:....... 34

Case 1: 10-Year-Old Child;Rule OutADD, Predominantly Inattentive Typ"......................:............... 34
Case 2:8-Year-Old Child With Severe Head Trduma ................. ................... 35
Case 3: l2{ear-Old Child With Hearing Impediments and Developmental Reading Disorder........... 37
Case 4: 8-Year-Old ChildWithADHD, Predominantly Hyperactive-Impulsive Type !-

and Dysgraphia.............. 38
J
\-
Chapter 5: Reliability and Validity 39
\-
39
/-
!*

39 \-
|J

40 tr-
4L F
\-
4T
4T
42
43
44
45
50
Test Administration Order Effects 52

53

AppendixA: Age-Corrected Standardized Score Thansformations byAge for the

CCTT-I and CCTT-2 fime Raw Scores................. 57

Appendix B: Interpretive Ranges and Their Base Rates of Occurrence for the
CCTT Normative Sample and Clinical Samples 67

Appendix C: Children's Color TFails Test Spanish Language Administration

Instructions (Instrucciones Para la Administraci6n en Espahol Para la Prueba
de Pistas de Color de Nifios) 69

Appendix D: Modified Instructions for Special Populations........... . . . . . ... 73

:.

VI
-
I
I
I
4
4
n
{ 1
{
4
{ lntloductlon
{
{
{
{ Battery and as an integral part of the more popular
{ H lsroRl(Rl BncRGRoultD flexible battery approaches (Sweet & Moberg, 1990).
{ nilD Drs(RlDlolt oF IHE Due to the capactty of the trail making method to dif-
ferentiate between healthy controls and children with
{ Innll }'lnnlltc lrsr brain damage, instruments that employ such methods
{ are used extensively as screening devices to detect
! T:re Trail \Iaking Test, Parts A & B (Reitan, altered neurological functioning in children (Horton,
t - ,-'b rs an orthographic neuropsychological instru-
:::r Tts uriiization has spanned more than 5 decades
1979; Reitan & Herring, 1985). Johnston (1986)
. found the Children's Trail Making Test to be sensitive
{ : ; -::l:cel and research settings. Originally referred to in the assessment of children who have subtle neu-
4 r' D:>.nbured Attention, the test was developed by ropsychological dysfunction without structural evi-
-! J::n Panington in 1938 as a subtest for the Leiter- dence of brain damage, as in some cases of prim ary
F::trng:cn Adult Performance Scale, which later Attention-D efrcttlHyperactivity Disorder (ADHD).
{ t*:-;.rti l"r]o\\-n as Partington's Pathways (Partington
T)^ ':,^-L^-- )^ T-t-rl- t
The Children's Trail Making Test has become one of
{ -ir l-;:iir. i 9-t9 t and was used as a nonverbal measure the most frequently administered measures in pedi-
! : :"1: :', aluation of brain injury. With slight modifica- atrrc neuropsychological practice (Lezak, L995;
! .: :i.
:he test \\-as subsequently incorporated as a
:-::: - ::t"lnce subtest in the New Army Individual Test
Mitrushina, Boone, & D'Elia, 1999)."

! : ,J;ne :rl Abilitl' (Adjutant General's Office, 1944)

The Children's Trail Making Test (Intermediate

a ::: :c:ai:-red the Trail Making Test. After further

Form, ages 9 to 14 years) is administered in two con-

t :.::*;::urnai and scoring modifications by Armitage

; jt .r,nc br Reitan and his colleagues (Reitan,
secutive trials. Children's Trail Making Test part A
requires the child to connect randomly distributed encir-
{ cled numbers from I through 15 in ascending sequence
. *--;. :.i. r. the Trail Makins TestA & B became an
2 "::-::a- component of the standardtzed Halstead-
as rapidly as possible (i.e. , I, 2, 3,...15). Children's

2 F":-i;n \europs)'chological Battery (Reitan and

Trail Making Test Part B requires the child to connect
randomly placed encircled numbers in ascending
e "''\..
-ii'rn. n993 l. order from 1 through 8, alternating with encircled let-
2 {:r abbrer iated version of the Adult Trail Making ters A through H (i.e., I, A, 2, B, 3, C, ...8, H) as

2 T;'"" :he ChitrCren's Trail Making Test A & B (Reitan,

:- " \\.xs later developed for use with children.
quickly as possible. The time needed (in seconds) to

e El ::: ::- :,Julr and children's versions of the Trail

complete each part of the test represents the depen-
dent variable and largely reflects the child's scanning
2 'i'-1::.-lJ T;s: ir- currently employed as a component ability, eye-hand coordination, mental flexibility, and
e : : : : (:;:;"t:,J Hal stead-Reitan Neuropsychological speed of information processing. Depending on age,

e
e
?
I
 Patt A is primarily a test of alternating
and sustained.
visual attention involving perceptual trackiilg,
psy_ RnnoltnlE FoR IHE
chomotor speed, and simple sequencing.
In addition
to these skills, Part B requires the chitd
to consistently
DtuEl0Pl,lEllI 0F IHE (ntlDRElt's
change categorical sets by alternating
symbols or concepts (i.e., numbers
between sets of (oroR Innt6 lrsr
and retters) and
sequencing patterns. Research suggests
thatpart B is Also known by the names Kid's color
sensitive to frontal lobe dysfunction Trails,
andnorrnal func- Kiddie Color Trails, and K Color Trails,
tioning (Boucugnan i & Jones, Iggg; Shute the Children,s
& Huertas, color Trails Test (ccTT), an orthographic
1990) and is generally a more discriminative neuropsy_
indicator chological instrument for the assessment
of cerebral dysfunction than part A (Horton, of cognitive
rg./g). functioning in children, was deveroped
For exarhple, performance on Children,s by D,Elia and
Trail satz based on concerns raised by the
world Hearth
Making Test Part B has been found to distinguish
Organrzatron (WHO ; 1990). The CCTT
between healthy controls and youths was modeled
diagnosed with closely after the color Trails Test (D,Elia,
ADHD (Boucugnan i & Jones) . satz,
uchiyama, & white, 1996), a similar
instrumen t that
Developmental and cogniqive variables assesses cognitive functioning in
have been adults. The CCTT
known to impact performance on the emerged as a result of concerns about
children,s Tiail possible limita-
Making Test. Factors that have been found tions of the sensitivity of the Children's
to affect Trail Making
completion times on this instrument incrude Test. cross-curturar strengths to broaden
&ge, the apprica_
intelligence and, in some instances, gender. bility of the test to special populations and pragm
Improved atic
performances on both parts of the factors, such as enhanced test administration
test have been proce_
noted with increasing age from childhood dures, also were key elements in its
through development.
young adulthood (Rosin & Levett, 19g9b). However, the ccTT, unrike the abbreviated
These children,s
observations are most likely the result Trail Making Test (Reitan, lgTl), was
of increased not developed
cognitive capacity associated with central as an abbreviated downscaling or downward
nervous exten_
system (cNs) maturation. completion sion of an adurt test. Its underlying foundation
times for parts was
A & B also have been demonstrated to be inversely firmly rooted in child development and maturation
correlated with intellectual ability levels (Horton, theory, developmental neuropsychology,
child neurol_
1979; Rosin & Levett). Although some ogy' and pediatric psychopathorogy. The
investigators test arso was
have found faster completion times for
girls than for the outcome of further applied, psychometric,
and
boys on Part B (Williams et al. lgg5), theoretrcal considerations, which are
, other researchers discussed in the
have noted that gender-related differences following section.
on the Tiail
Making Test A & B app ear to be minimal
during both
childhood (Spreen & Strauss, r 99g) and Deuelopmental and |laturationa
adulthood I
(Heaton, Grant, &Matthews, lggl).
(onsidelations
Despite its widespread use and relative
ability to The salient features of the CCTT are colors
discrimin ate between impaired and nonimpaired and
numbers' The selection of these features
groups, the children's Trail Making Test, is consistent
either as a with emerging cognitive maturation in the young
single screening procedure or as a component
of the child. The use of color as a salient discriminating
comprehensive Halstead-Reitan Neuropsychological fea-
ture is appropriate for a developmental test
Battery for Children, has not been free from due to the
criticism early emergence of this functional skill in
(e.g., chadwick & Rutter, l9g3; Herbert, infants and
1964; young children. Research assessing early
Rourke & Finlayson, rg7 5). Investigators catego riza-
and clini- tion of color using habituation-test paradigms
cians have attributed the limitations of has
the children,s indicated that 4-month-old infants are capable
Trail Making Test to the large variability in perfor_ of
discriminating colors (i.e., blue, green, yellow,
mance exhibited even among healthy children and
(Shute red)' More importantly, the level of discrimination
& Huertas, 1990). at
this early age is similar to that of adurts (Bornstein,
.A
-t
-_t l,a. rr rA-eiskopf . 1976a, I976b). Other research
",a become evident by the age of 3 months. An increase in
-t : * * : ;: r :.', e rer-ealed similar and consistent find- frequency to about 5 Hz occurs by the age of 5
-t -
=' - J=;ii-irg that nonverbaltztng infants and young
- months, and increases to 6 to 7 Hz by the time a child
n :::: ;:; ;apable of categorrzing the visible spec-
***" .: r;!-;. but discrete, hues of blue, green, yellow,
is 1 year of age. By 2 years of age, the wakeful state
-t -"- : ::": B,-,:nstein. 1981, 1988).
frequency reaches 7 to 8 Hz and then stabilizes at9 Hz
(alpha spectrum). By the age of 6 years, the wakeful
4 *. :: - "rs:h the data from preverbal infants and state frequency resembles the 8 to 13 Hz frequency
e :
' - "":ren
- - -.1,, could be construed as tentative due to (Blume, 1998; Neidermeyer, I98l). During arousal,4
e '*: : --:-,:ic e\pressive language abilities, data from to 8 Hz rhythmic theta waves lasting 1 to 5 seconds or

t '" : - :::.-j.:1n, e developmental literature suggests that
t :
:*r;-*r-:rl cluldren are capable of naming colors at an
*: ., 'Ji Fili erample, it is well documented that a
t -;= ;::':':,rion of chrldren are able to name at least
more may appear in children ages 7 months to 4 years.
with continued arousal, this waveform is followed by
1 to 3 Hz diffuse delta, but declines by age 5 years
(Blume) as a result of neurological development. With

t *: : , . . r bl, the age of 30 to 48 months (Gesell & Ilg,

:-: '(J-:..rn. Ig69l.In addition to the developmental
regard to neurological maturation, brain weight, a

t - :r-;s jiscussed previously, the use of color in the

gross marker of neurological development, reaches
SAVo of the adult brain weight (1250 ro 1500 g) by
t -

- ,- lT :;l cther inherent, more applied, merits. The

approximately the age of 4 years and even greater
t '"= . -:. : :,i'--olor as a prominent test characteristic was weight by the age of 6 years (Lamire, Loeser, Leech,

t - *'': l " r ::e need to make the test stimuli more appeal-
-; : ; ti,-la-.J range of young children, thus enhancing
& Alvord, I97 5). In addition, central nervous system
(CNS) myelination, particularly of the frontopontine
t "-*': tracts and reticular system (both associated with
t ;:---:'i ^n:erest and motivation during assessment.
T:.; .-ie---tion of numbers as another cardinal fea-
emerging attentional and higher order skills), was
t '*:: ": ::i CCTT \\'as based on its developmental given due consideration in the development of the

t -:;:-;:ri-ni>s. Although open to some degree of vari-

CCTT. These substrates reach a relatively advanced
level of myelination by the age of 6 years (Dodge,
t *:. .:-, :.r.i,'- number "readiness" is one of the first Prensky, & Feigin , I97 5; Yakovlev & Lecours, 1967).
t . .--.. - :: -merse in

; r - i"; I j-r
)-oung children. According to Gesell
. the number concept of "1" tends to
Developmental markers of eye-hand coordination
t
g
and visuomotor skills required for successful perfor-
I r': r : -. ::e ase of approximately 30 months. Greater
t
-
mance of the CCTT also played a major role in the

t :; --t-...: ::e
.* - -
.Jer-elopment of more complex abilities,
development of the test. The use of inclined, horizon-
tal, and vertical lines to connect the CCTT stimuli was
t .-; - -:-:E:
rr .,- lsen'etion of number (i.e., the concept that
nr: oLrjects remains the same when they are
considered developmentally appropriate for the test, as

t -:i;i.J-J s:etlall)-1. tends to occur between the ages these skills emerge by the age of 2 years in approxi-

t - - ,:,i. i e"rs rCooper, 1984; Piaget,1965).

mately l97o of children (Gesell et al., 1940; Griffiths,
1954) and are fully developed in most children by the
t tl.:e:;- J*.-rnsideration also was given to develop- approximate age of 2 years, 6 months (Cattell, 1960).
t * *
; :: "
*.-"-r, :liJ
:i;rcL'iological markers, particularly those

t ;
rth attentional skills and emerging execu-
io,

*r:-::1es. The CCTT is a multifactorial neuropsy-

tpplied, Psychometric, and Secondaty
t : - ;:; .l tro"-edure that encompasses the assessment I heoretica I (onsiderations
t ;:i::t rn an.J \\'as created using neurophysiological
* i: *r;:: ::iai markers of attention as the primary
Other guidin g factors behind the development of
the CCTT are similar to those previously addressed in
,
; * ;:"::: Electroencephalogram (EEG) markers, as
t '*:::- ,:'i rnderes of neurophysiological maturation,
the development of the Color Trails Test (CTT; D'Elia
et zl., 1996). Concerns expressed during the second
t ,.,:rt . :.; ,:i fte factors given significant consideration consultation for the WHO Multicenter Study of
, Human Immunodeficiency Virus (HIV) infection
; **- * - (lt:l-r-,:i. Dunng u'akefulness, electrophysiolog- ( 1990) were the springboard for the adult CTT.
, *-.-;il,-:es indicate that 3 to 4 Hz frequencies
t - - Applied, psychometric, and further theoretical concerns

)
,
t
I
 included improvements in the assessment of children
who are illiterate, children who have langu age or
learning disabilities, children whose primary lan-
guage is not English, children who live within cross-
cultural contexts, and children who have subtle
neurological deficits, particularly those associated
with emerging attention and executive skills. In addi-
tion, the instrument was developed to improve the
reliability and ease of administration, and to increase
the viability of conducting longitudinal research with
the instrument.
lmproued f,ssessment of ftildren xho
f,le lllitetate, use Engrish as a second
language, or Haue Specific Reading or
language Disoldels
The Children's Trail Making Test requires knowl-
edge of the English alphabet for successful comple-
tion of Part B. Poor performance on this portion of
the instrument can be linked to a lack of familiarity
with the English alphabet for children who are illiter-
ate or children who lack exposure to formal educa-
tion, as well as those who speak English as a second
language. children with langu age and/or specific
reading disorders may be at a disadv antage as well
when asked to complete such an instrument. This limi-
tation of the children's Trail Making Test has been
well articulated by Rourke and Finlayson (I97 5), who
noted that children with learning disabilities who per-
formed poorly on Part B relative to part A had prob-
lems with complex verbal and symbolic abilities;
whereas children who had normal performance on
both parts of the Trail Making Test tended to have no
significant differences between verbal and nonverbal
abilities. Elimination of this potential confounding
aspect of the instrument would, in all likelihood,
enhance the discriminative properties of the test.
Therefore, the ccTT was created to avoid reliance on
any alphabet and to diminish language influences on
performance (Laosa, 1984).
Enhanced f,ssessment in (loss-(ultural
(ontexts
Differences in cultural context affect performance
on the Children's Trail Making Test as noted in com-
parisons between Spanish and American youth
4
(Leon-carrion, 1989). similar differences in perfor-
mance associated with culture have been observed in
South African children compared to American chil-
dren (Rosin & Levett, 198 9a). use of the English
alphabet for a categorical or symbolic shift on Part B
limits the application of the Tiail Making Test in cer-
tarn cross-cultural contexts (e.g. , Lee, cheung, chan,
& chan , 2000; Stan czak, stanc zak, & Awad alla,
200I). The need for neuropsychological procedures
and screening batteries that assess the effects of con-
ditions affecting neurological functioning, including
brain trauma, infectious diseases (e.g., HIV, cMV),
and other pathologies, demands instruments that are
as culture-free as possible. The ccTT replaces the
English language alphabet on part B with colors,
which are almost universalry employed across
cultures. Although the cognitive neuropsychology lit-
erature guards against the broad assumption that the
experience of color perception is a completely
culture-free phenomenon (Bornstein, lg:.3), color is
used as the test stimulus for the categorical shifting in
the ccTT because color typically transcends most
cultural distinctions. with reg ard to the cross-
cultural applicability of the color Trails Tesr,
research with the adult version of the test has
demonstrated its sensitivity in discriminating
between HIV seropositive and HIV seronegative
individuals in cross-cultural sites, and has suggested
that the color Trails Test is culturally fam, particu-
larly color Trails Test 2 (Maj er al. , rgg3, r9g4).
lmproued Sensitiuity to Detect suDtle
)leurologica I Dysfunction
Changes in the CCTT stimuli were made in order
to elimin ate or reduce the potential confounding
effects in the performance of children who have
knowledge of the English alphabet. The repeated
instruction of the alphabet with preschool and school-
age children may affect the ability of trail making
procedures that involve letters to detect subtle neuro-
logical alterations. As noted earlier, the Trail Making
Test for children requires knowledge of the English
alphabet in order to successfully complete part B.
However, the alphabet is highly overlearned.
children educated in the u.s. and abroad not only
are taught to recite the alphabet, but to sing it as well.
Therefore , Lt is deeply encoded in memory. As a
result , it is not unusual to observe a premorbidly
a
a high-functioning child who presents with a history of
a mild-to-moderate brain injury or subtle dysfunction to
a ;a1i upon sufficient "functional reserve capactty"
a Satz. 1993), completing the Trail Making Test Part B
in times considered within normal limits. Further-
1 r-ore. these children have been noted to occasionally,
-t ,-:nough almost inaudibly, hum or sing the alphabet
-t ',', hiie solving Part B. Removal of the use of the
t E:-grish alphabet to solve the second tnal of the
f
,. CTT (i.e., CCTT-2), a trial similar to Part B, is
-, :;irgned to eliminate this potentral performance-
-l - - :-r*runding effect, while enhancing the sensitivity
-t : rhe test.
-l S;oring criteria to measure signs of subtle cogni-
' ; slippa,_ue (e.g., prompts and errors) were devel-
-t : -.j tor and incorporated into the CCTT. Scoring
-t -:.:.:rr for the children's version of the Trail Making
-t T=,i ;llou the examiner to note only gross error
"- .:;s throu.-uh the use of the empirical and process
-,
-:;r,-;Jh rKaplan, 1988); thus, quantification of sub-
a : : ::,stunction in patients is often ignored or missed.
-, *
" - . :na:ton processing tasks that would have been
' -*-I
a ._.;LCd premorbidly with ease by these children
.-:", :;qulre considerable effort due to increased dis-
a : i,:-:-1irr in task focus and problem solving.
a -*'*'r---
-.-:-;-lrrlC. the inclusion of additional criteria in the
a - ,- TT s;oring and interpretation will hopefully
a : 1.r:i., e rne assessment of children with acquired
- ts 1- *L
*-,.: ::*in injury'. particularly those whose premorbid
a ; , ;. ,--: .:r:ellectual functioning was high.
a ods have been used in past empirical research
a I nrc reased Reliability
a n - - ----,e of its ease of administration and popu-
DJ-J.l:
a *:. : \ . ihe traditional abbreviated Children's Trail
*-1rr;:ns Test has been photocopied frequently
a 1,1 : :: * shrna et al. , L999). This practice has often
a r::*-ie.l:n poor copy quality with blurred or distorted
a F*.-* \ C- 'f :'*r-uli.
. ;- " Lllll u'hich invalidates test interpretation.
a :r:: prtrrocop)' generation yields slightly larger or
":-.r--e r ,, ersions of the test, thus affecting the distance
-a
_,ri. r\ JC-- 5Lt
a :.,: ., iis;over Trail Making Test protocols where the
a ":-:-.*.- .-L-rSe st to the edge of the page have been par-
--a -.;-.', ,-,r "rlmost totally cut off. From a psychometric
':i:-J: - :n:. these factors introduce significant and
-I
*1: -:::- -,e C error r-ariance. Such problems also sig-
-.J : :l-r:.:*.- :iTrplact the comparability of research and
al
-a - :--;- :lndings from studies employing the Trail
-.J
--
-.1
)
Making Test because scores obtained from the test
partially reflect the distance traveled between stimuli
while connecting the encircled numbers. Problems
that may affect the comparability of previous norma-
tive studies call the test results into question
(Mitrushina et al.). The CCTT eliminates these alter-
ations by using professionally printed color protocols
with colors that ensure comparability with normative
studies. Most photocopying machines, including
color copiers, are unable to accurately reproduce such
test stimuli.
Enhanced (apabilities lor longitudinal
Research
Repeated administrations of the Trail Making
Test have revealed significant practice effects (Dye,
1979). The CCTT expands the possibility for longitu-
dinal research and clinical retesting applications by
providing four essentially equivalent forms of the test
(Forms K, X, X and Z). The alternate retest CCTT
forms were developed by using the standard test Form
K as the basis for the other forms; that is, Form X is
an exact mirror image of Form K; Form K is rotated
180 degrees, then positioned in a mirror image to cre-
ate Form Y; to create Forffi Z, Form K is rotated 180
degrees. This method of developing alternate retest
forms of the test assures that stimulus placement and
distance traveled between stimuli will remain gener-
ally equivalent for all forms of the test. Similar meth-
conducted with the Trail Making Test (Franzen, Paul,
& Iverson, 1996).
Enhanced lest Rdministration
The CCTT employs visual symbols (e.9., direc-
tional affows and hands signaling where to begin and
end) as instructional cues. The use of these cues
allows for the administration of the CCTT using
either verbal or visual instructions alone. This feature
of the CCTT is another property of the instrument
that enhances its administration and its use with all
children, but especially those children with specific
disabilities such as hearing impairment or severe
inattention. In addition, the use of visual symbols
and vibrant colors is likely to facilitate the administra-
tion of the CCTT with children from cross-cultural
backgrounds. Lastly, this CCTT Professional Manual

provides standardized insfructions for both administra-
tion and scoring, as well as guidelines for interpretation
of the results. The guidance provided by this manual
will support the use of the instrument in both clinical
and research applications.
ndditional lheoretical (onsidelations:
f,ttentional and Executiue Slrills
The CCTT is an orthographic neuropsychological
instrument capable of assessing cognitive functions in
children. At first glance, it appears to be a simple
graphomotdr test. However, consistent with the
authors' intentions, closer scrutiny reveals a more
complex measure that is capable of measuring several
brain functions simultaneously-particularly atten-
tion and emerging executive skills. Depending on
developmental factors, attention-concentration and
emerging executive skills in children are assessed by
the CCTT, in addition to visuomotor skills. Because
the evaluation of these skills involves such complex,
intertwined brain-behavior relationships,
it is impera-
tive that the neuropsychology, neuroanatomy, and
neurochemistry of these functions be briefly reviewed.
Aroisal, concentration, focus, and vigilance are
among the most basic functions subserved by the cen-
tral nervous system. They also are among the human
brain's most fragile skills (Lezak, L995). This preemi-
nent position is partly the result of evolutionary fac-
tors as well as pragmatic neurobiological factors.
From an evolutionary standpoint, arousal and vigi-
lance must have been critical for the survival of the
species (Jensen et al., 1997), and centers and net-
works in the brain are reserved to subserve functions
associated with flight response. Thus, researchers
recently have begun to redefine select defects in
attention, such as mild cases of Attention-Deficit/
Hyperactivity Disorder (ADHD), as evolutionarily
adaptive in some circumstances (Jensen et al.). From
a neurobiological and neuropsychological standpoint,
attentional networks and circuits are closely inter-
twined with networks supporting most other brain
functions including memory and executive skills
(Lezak). Therefore, the basic and vital nature of these
abilities is clearly surmised.
Although perceived as a homogeneous function
by a majority of lay persons, the concept of attention
should not be thought of as a unitary construct by the
neuropsychologist or practicing clinician. Attentional
6
t-
skills vary in their scope, type, functional processes TL
subserved (verbal or visual), purpose (arousal,
sustained concentration, etc.), and/or neurological
networks or substrates. For this reason, these skills
t_
should be considered heterogeneous processes sub-
serving verbally and visually driven functions that tr
can be subdivided into several subtypes including
sustained, simple, distributed, alternating, and so
forth. Subsequently, different neuropsychological
methods and procedures should be used to assess
these types of skills.
Attentional skills, due to their essential and indis-
pensable nature, also can become less distinct when
differentiating them from other types of brain func-
tions. For example, when memory functions are
described, it is occasionally difficult to differentiate
between select subtypes of attentional abilities and
memory functions such as vigilance and working
memory (Lez?k, 1995). Some researchers have
adopted a strict, narrow posture, describing atten-
tional skills as undifferentiated from any other types
of skills (cf. van zomeren & Brouwer, 1994).
with regard to brain architecture, Figure 1 shows
an outline of the brain indicating the circuitry and net-
works with hypothetical implications for attention.
The networks illustrate the feedback mechanisms and
the inputs-outputs associated with these functions. t_
The complexity of these networks is also apparent in r.*
the figure.
L
The neurochemistry of attention has been demar-
cated by the involvement of brain cathecholamines
(e.9., dopamine and norepinephrine). Dopamine-rich
receptors have been found in the nucleus accumbens, L_
and projections from this subcortical nucleus to the r-_
prefrontal cortex and medial forebrain have been
established (Cooper, Bloom , & Roth, r99l). These
projections most likely subserve attention. In fact,
the mechanism of action of stimul ant medications
that are successfully used to treat deficits in atten- lr,-
tion, has been postulated to promulgate effects on
t
dopaminergic receptors and inhibitory effects on
reuptake mechanisms.
Executive functions can be construed as a set of
higher order abilities subserved by circuits and net-
works interacting with and within the frontal lobes,
pafircularly those in the human and primate pre-
frontal cortex (Fuster, 1989). These functions ate
thought to be responsible for the regulation of
-J
1
3
-l
-,
{
1 Prefrontal cortex
I \ I
t Parietal lobe

I r"'t-
hl
I
1 Frontal lobe 4
\
I ,,{

I Inferior frontal cortex

"7
,,,*$ occipitatlobe

I /
I Tempor allobe/
Cerebellum
I
4
I Brain stem

4
4
4
4 i:..:,re 1. \europhysiological Network of Attention. 1. Ascending reticular activating system (RAS) network.2.
4 .\ni ln.s circuits from the RAS to the orbitofrontal, prefrontal, and frontal cortex. 3. Feedback circuits.
4
4
4 sehavior. emotion, and thought (Luria, 1980). In pronounced in ADHD, limited or compromised
4 ;c,Jition. these skills are partly responsible for
higher order generate-and-test hypothetical
inhibitory or regulatory mechanisms leading to
impulsivity (Douglas, I9l2), have been postulated to
4 r:ocesses and concept formation that ate key com- be the cardinal symptom of this disorder, and ate
4 Flnents in complex problem solving, long-term thought to be the result of faulty neurological
4 planning. and abstract thought. Executive skills also inhibitory circuits involving the prefrontal cortex
4 har, e been postulated to subserve the necessary rep-
resentation of time-locked behavior creating the
(Barkley, 1998). Similarly, emerging executive skills
are often disrupted in children who have sustained
4 - oxncept of space-time in humans (Barkley, L99l , moderate-to-severe trauma to the frontal lobes (Levin,
4 1998: Bros'r, 1990),, a crrtical issue when addressing Bentofr, & Grossman, 1982).
4 e\ecutir-e skills. The CCTT, through the use of several indexes,
4 The effects of problems in executive skills are permits an evaluation of these skills. For example,

4 easilr- seen in syndromes that affect the frontal lobes.

In adults. Pick's disease is a good example of a pro-
4 iot\ pical dementia affecting these substrates
4 Curnmin,_es & Benson, 1983). Patients with Pick's
4 disease usually exhibit disinhibition, perseveration,
CCTT:-I and CCTT-Z completion times provide the
clinician with gauges for assessing a child's atten-
tional mechanisms. Moreover, other indexes such as
sequence effors, prompts, and differences in perfor-
mances between the two components of the test

4 prt-ror planning, and other compromised executive

;h.ilns (e.g.. higher order abstraction). In the case of
(Interference Index) provide the clinician with addi-
tional indexes capable of teasing apafi the various
4 \ttention-Deficit Disorder (ADD), and even more components responsible for test performance.
4
4
4
t

SUMMRRY
The CCTT is an instrument designed to assess the
neuropsychological functioning of children modeled
closely after the adult Color Trails Test; thus, it pro-
vides an excellent opportunity for assessment continu-
ity. The CCTT was designed within a developmental
framework employing similar psychometric principles
to those found in the Trail Making Test. The instru-
ment is enhanced by the absence of any alphabetical
system and the reliance on universal concepts of color
and numbers. In this way, the CCTT reduces the
potential confounding effect of language and is,
therefore, more applicable to cross-cultural research
as well as to the clinical assessment of children who
have limited education, who use English as a second
language, who have readin gllanguage disorders, or
who have specific disabilities such as hearing impair-
ments. Additionally, the CCTT is able to assess subtle
neurological dysfunction, particularly attention and
emerging executive deregulation. This instrument
provides four alternate test forms for retesl applica-
tions and avoids the potential flaws that have plagued
past research due to distortions from photocopied
reproductions. Finally, the CCTT uses symbols as
instructional cues, in addition to verbal instructions,
thus enhancing the ease of test administration and
application with disabled populations.
This Professional Manual describes the important
features of the CCTT including its standardtzation,
administration and scoring procedures, and detailed
guidelines for interpretation. The manual also pro-
vides norms for children ages 8 to 16 years and pro-
vides data on test reliability and validity documented
by empirical studies.
!.?
h
h
h
h
h
I
h
- 2
h Iest Materlals,
a,
1
4 tdministration, and Scoring
E,,
zz
|,, that the CCTT can be used successfully with such
|,, PnoFEsstoltnr Mnilunl children. Table 7 (chapter 3) provides some nonnative

2 R}ID FOR}IS
The CCTT is a standardtzed, paper-and-pencil,
information from a clinical sample of children ages 5
to 7 years. Normative data for children younger than
8 years of age ate cuffently being collected. Clinicians
-J
*l orthographic neuropsychological instrument that interested in assessing persons ages 17 years or older
should be administered to children individually. It was should use the Color Trails Test (D'Elia et al. , 1996).
-t designed to provide an easily administered and objec-
Children who are administered the CCTT must be
-J tively scored measure of alternating and sustained
able to recogntze Arabic numbers I through 15, and
visual attentiofl, sequencing, psychomotor speed, cog-
- they must be able to distinguish the difference
nitive flexibility, and inhibition-disinhibition. Four
between the colors pink and yellow. Children tested
- forms for the CCTT have been developed (Form K,
with the CCTT should also possess sufficient eye-
Form X, Form Y, and Form Z). These forms are
- hand coordination to use a pencil for connecting the
essentially equivalent, but normative data is provided
- only for Form K. Therefore, Form K is the standard test stimuli circles.
-J CCTT form to be administered. Normative data for
-J the alternate forms (Form X, Form Y, and Form Z) arc
currently being collected and will be presented in a
- future update to this manual. It is strongly recom-
P noFEss toltn I R rou I R E),t ltrs
E

- mended that the alternate forms be used only fo,

Although an experienced examiner knowledge-
- experimental or research purposes at this time.
able in the assessment of children and adolescents is
- preferred, administration and scoring of the CCTT
-J can be accomplished by an individual who has knowl-

- tpPRoPRtRrE PoputRnolts edge of psychological assessment and has some test-

ing experience with children and adolescents. Such
- The CCTT was designed for use with children individuals do not need formal professional training
-J and adolescents from 8 to 16 years of age. Normative in psychology or a reLated field; however, they should
information for CCTT Form K for children ages 8 to be supervised by a qualified professional who has
-
16 years is presented in this manual. Although no received formal training in the psychological assess-
-J formal norms currently exist for children who are ment of children and adolescents (American
- either 6 or 7 years of age, it is our clinical experience Psychological Association, 1 989).
-
-
-
4
 Interpretation of the CCTT scores in patient care
and research settings requires professional training in
developmental psychology, developmental psy-
chopathology, clinical psychology, neuropsychology,
or school psychology (American Psychological
Association, 1989). In accordance with the Standards
for Educational and Psychological Testing (American
Educational Research Association, American
Psychological Association, & National Council on
Measurement in Education, 1999), a qualified profes-
sional must provide the interpretation of the CCTT
scores. In neuropsychological assessment, the inter-
pretation of the CCTT scores should be performed by
a licensed psychologist. No individual test provides
suffrcient information to interpret brain-behavior rela-
tionships, so interpretation of the CCTT should occur
within the context of a more comprehensive evalua-
tion of the examinee's neurobehavioral characteristics
and history (American Psychological Association).
tssrssilEltl (oxstlERilrcils
FoR sDEqnl Popunrrcils
Severely or profoundly disabled children (e.g.,
hearing impaired, > 71 dB hearing loss), very young
children (i.e., 6 to 7 years old), and children or adoles-
cents with limited testing experience often pose signifi-
cant challenges to test administration, and such
individuals should be given significant considerations
(Sattler, 2000). Although the CCTT has been specifi
cally designed to be visually appealing to all children,
children who are immature or who have severe devel-
opmental delays may exhibit higher levels of anxiety
and may require a greater degree of familiarity than
usual with the test materials. Otherwise, these children
may experience significant difficulty undqrstanding
and following the test requirements even after the test
materials have been presented to them. Children with
significant disabilities may feel threatened by the
examination conditions and may become reluctant to
participate, thus requiring longer warming-up periods
and greater patience on the part of the examiner
(Sattler). Similar considerations should be given to
children without previous testing experience. There-
fore, repetition or, in extreme cases, modification of the
test instructions (see Appendix D) before the actual
presentation of the test may be necessary (Saftler).
10
RtoutRED }{ntERlnts FoR
StnilDnRDlIED Irsl
f,lMtllslRRIlolt
The folowing materials are required for standard-
rzed administration of the CCTT.
1. This CCTT Professional Manual.
2. CCTT- 1 and CCTT-2 stimuli. The practice
trial is on Side 1 of both the CCTT- 1 and
CCTT-} forms, and the timed test fttal is on
the reverse side of each.
3. CCTT Record Form. The standardtzed verbal
administration instructions afe presented on
the back of the record form, but not all back-
ground information about the administration
procedures is included. Users should first
famili al:ze themselves with the administration
procedures outlined in this manual before
administering the instrument.
4. Stopwatch.
5. Pencil, preferably a Number 2 pencil. Avoid
the use of colored pencils and markers.
This manual will be required if a norm-referenced
interpretive approach is employed (i.e., to obtain the
standardrzed scores based on the age-corrected norms),
or if standar dtzed administrations for special popula-
tions or Spanish-speaking populations are required.
DrnllED ltst Dts(RlPllotl
R}ID GTilERRl
f, lxl )t l$ RRI lott G u I DEll )l Es
The CCTT is based on the use of both numbered
and colored circles and sign symbols; no item or
instruction requires knowledge of a written alphabet.
The circled numbers in CCTT-I and CCTT:Z arc col-
ored in vivid pink or yellow in an attempt to control
for possible examinee color blindness. Even in the
extreme case where a child may suffer from achro-
matopsia (i.e., complete color blindness), the pink cir-
cles will appear dark gfay and the yellow circles will
appear light gray.Care must be exercised when inter-
preting the CCTT scores of disabled populations,
 ,J
l+
J
since extensive validity studies supporting its use with as he or she proceeds. Therefore, the child is required
these groups have not been conducted. to draw a line from the Pink Circle 1 to the Yellow
-
The CCTT- I is similar to the Trail Making Test A, Circle 2, avoiding (i.e., inhibiting a response to con-
- with the exception that all odd numbered circles are nect) the distractor Pink Circle 2, and then to the Pink
- printed against a pink background and all even num- Circle 3, avoiding the distracterYellow Circle 3, and so
- bere,C circles are printed against a yellow background. on through the Pink Circle 15. Timing and treatment of
The protocol is printed on an 8/z by 1 1 inch sheet of near-misses, errors, and prompts are the same as in the
-Fl rvhite paper. A Practice trial (Figure 2) is administered CCTT:I. However, due to the dual nature of the test
to each child prior to the administration of the actual stimuli shifting categories (i.e., color and number), two
- timed Test trial (Figure 3). The Practice trial also types of errors (i.e., both Number Sequence and Color
should be used when famrhanzrng young or severely
- Sequence errors) are recorded (see Error Scores).
disabled children or adolescents with the CCTT:I or
- when repetition of the test instructions is necessary.
- In the CCTT:I, the child is instructed to draw a
- line rapidly through the circles numbered 1 through 15 SrnilDnRDlzED lrsr
- in consecutive order (i.e.,I,2,3,, ...I5). The incidental
fact that the colors altern ate with each succeeding f,lMrlusrRnuolt
- number is not mentioned. In the unusual event in which
-j To ensure that all children areassessed in a stan-
the child states that the colors altern ate with each
dardrzed manner, examinees should be instructed to
-Ft increasing number, simply acknowledge the child's
hold the pencil approximately at its center. Holding
discovery and continue with the standardrzed adminis-
tration procedures. The child is told to perform the task the pencil in this manner prevents the child's hand
-Ft as quickly as possible without making errors. If an from blocking the view of a target circle and also
error is made while performing the task, the examiner keeps instances where the child lifts the pencil from
points it out and the child is required to coffect the the paper to a minimum. A smaller pencil than a
-FJ
error and proceed with the task. Up to 10 seconds are standard Number 2 may be required, and is recom-
Ft allowed for the child to make a connection between mended for very young children.
Ft one circle and the next. Followitrg this 10-second The instructions for the CCTT can be adminis-
period, the examiner points to the position of the next tered either orally or visually (or both) using the
appropriate circle. The examiner records the number of
- instructional visual cues provided by the test. How-
near-misses, elrors, and prompts during the trial. The
ever, it is recommended that the instructions first be
- child is not formally pen ahzed for these types of per-
administered orally. To facilitate test administration,
-Ft formances, but the time it takes to coffect the effor will
the oral instructions are printed on the back of the
affect his or her performance score.
Ft CCTT'Record Form. Children may sometimes ask
Each number is printed twice on the CCTT-Z,
questions during the administration ("Will these dots
F- once in a pink colored circle and once in a yellow col-
create a picture after I connect them?"). Clinicians
1 ored circle. These circles are presented on an Sy, by 1l
inch sheet of white paper. There are no letters, and the
should discourage children from asking questions dur-
F- ing the administration of the test. For oral and visual
categorical shifts are based on color. A Practice trial
1 (Figure 4) is administered prior to the administration administration instructions in Spanish, please refer to

1 of the actual timed Test trial (Figure 5). As with the Appendix C of this manual. Please refer to Appendix D
for the modified instructions for special populations.
1 CCTT:I, the Practice trial for the CCTT-Z should be
used when famili artzing young or severely disabled
1 children or adolescents with this portion of the test or Oral Rdministration lnstructions
1 when repetition of the test instructions is necessary.
a
1 In the CCTT:2, the examiner instructs the child to Pretest: CCf f- I and CCf f-2
1 rapidly draw a line through consecutively numbered
circles, maintaining the sequence of numbers but
to 15. If he or
Ask the child to count aloud from 1
she is unable to complete this task, discontinue
1 alternating between pink and yellow colored circles administration of the CCTT.
1
1 11

1
4
 ftildten's (olol Inils lest* |
Louis F. D'Elia, PhD, and Paul Satz, PhD

Name:

ID#: Date:

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p!$ psychological Assessment Resources, Inc. . 16204 N, Florida Avenue . Lulz, FL 33549 ' 1.800.331'8378 'www.parinc'com
May not be reproduced in whole or in part in
copyright @ 198g, 1996, 2003 by Psychological Assessment Resources, lnc. All rights reserved.
of psychological Assessment Resources, lnc. This form is printed in black, pink, and
any form or by any r"un" *llti6ui-riritt"n-p"iri."ion
yello* ink on white paper. Any other version is unauthorized-
Reorder #RO-5058 Printed in the U.S.A.
987654321

Figure 2. Children's Color Trails Test 1 Practice trial sheet. (Darker circles - pink; lighter circles = yellow.)

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ftildren's (olor lrails lest* 2 r.-
Louis F. D'Elia, PhD, and Paul Satz, PhD rL

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p!$ Psychological Assessment Re$ources, Inc. . 16204 N. Florida Avenue. Lutz, FL 33549. 1.800.331.8378. www.parinc.com
Copyright @ 1989, 1996, 2003 by Psychological Assessment Resources, lnc. All rights reserved. May not be reproduced in whole or in part
in any form or by any means without written permission of Psychological Assessment Resources, lnc. This form is printed in black, pink, and
yellow ink on white paper. Any other version is unauthorized.
987654321 Reorder #RO-5059 Printed in the U.S.A.

Figure 4. Children's Color Trails Test 2 Practice trial sheet. (Darker circles = pink; lighter circles - yellow.)

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1 Figure 5. Children's Color Trails Test 2 Test trial sheet. (Darker circles = pink; lighter circles = yellow.)
4
4
I

1
1
15

b
Adninistalion tnsfiactions tot the CCff'I
Practice trial.Place the CCTT-I Practice trial
sheet on a clear flat writing surface facing the exami-
nee and say the following:
In this box are different colored circles with
numbers in them. When I say "Gor" I want
you to take this pencil and connect the cir-
cles by going from L to 2 to 3, and so on'
until you reach the number 8. (Thke the pen-
cil and point to the example below the box
while you are administering these insffuctions.)
I want you to connect the circles as fast as
you can without lifting the pencil off the
paper. If you make a mistaker l will tell you.
When I do, I want you to move the pencil to
the last correct circle and continue from
there. The line that you draw must touch
the circles in the correct order. Do you have
any questions? (Answer any questions.)
OK, let's practice. Put your pencil here
where the hand is telling you to start (poin|.
When I say "Gor" connect the circles in
order as fast as you can, until you reach
Number 8 next to the hand telling you to
stop. Ready? Go.
The instructions during the Practice ffial can be
repeated as many times as necessary. Begin timing as
soon as you detect movement toward the first circle' It
is important to note that the recording of time should
commence after the examiner has given the "Go" com-
mand but not until detection of movement toward the
first circle occurs. The "Go" command and movement
toward the first circle are necessary for recording of
time. There may be some situations where the child
begins the test before the command of "Go" is given'
Although this is not the standardized testing proce-
dures, and beginning before the "Go" command
should be discouraged, it is permissible to score the
CCTI under such circumstances. The clinician should
note that the child began the test trial before the com-
mand of "Go" was provided and make interpretations
in light of this information. Monitor the child to make
sure he or she is drawing lines that touch or go
through the circles in the correct order. Make any nec-
essary corrections as were previously described in the
instructions. Stop timing as soon as the pencil first
touches the outer part of the last circle, but do not
record the time on the record form as this is the prac-
tice trial. Provide verbal reinforcement as needed'
t6
Test trial. Remove the Practice trial sheet imme-
diately after completion so that the writing surface is
agaLn cleag and say the following:
Now I have a sheet with a lot more num-
bers and circles. Connect the circles just
tike you did a minute ago. Again, work as
fast as you can, and do not lift the pencil
off the paper as you go. Make sure that
your lines touch the circles.
Place the CCTT:I Test trial form on the writing
surface facing the child, and say:
You will start here where the hand tells
you to start (point), and end where the
hand tells you to stoP. ReadY? Go.
Begin timing as soon as you detect movement
toward the first circle and stop timing as soon as the
pencil first touches the outer part of the last circle.
Monitor the child to make sure he or she is progress-
ing through the circles in the coffect order. Make any
necess ary coffections as were previously described. If
the pencil fails to touch the circles, do not coffect dur-
ing the test, but remind the child of the proper proce-
dure after completion of the CCTT:I . On the record
form, note the time to complete the task (in seconds),
as well aS the number of prompts, near-misses, and
effor responses. Provide reinforcement as needed.
Adniniilration Instructions for the Ccff'z
Practice trial. Place the CCTT-} Practice trial
sheet on a clear flatwriting surface, facing the exami-
nee, and say the following:
In this box are dffierent colored circles with
numbers in them. This time, I want you to
take the pencil and connect the circles in
order by going from this color lrto this color
2, to this color 3, and so on' until you get to
the last number next to the hand telling you
to stop. Notice that the color changes each
time you go to the next number. (Take the
pencil and point to the example below the box
while you are administering these instructions.)
I want you to work as fast as you can. Dontt
lift the pencil off the paper once you've
started. Ifyou make a mistake, I will tell you.
when I do, I want you to move the pencil to
the last correct circle and continue from
there. Just like before, the line you draw must
touch the circles in the correct order. Do you
have any questions? (Answer any questions.)
 OK, let's practice. Put your pencil here
(point) next to the hand telling you to start.
When I say "Gor" connect the circles in
order as fast as you can, changing from one
color to the next, until you get to the hand
telling you to stop. Ready? Go.
The instructions during the Practibe fftal can be
repeated as many times as necessary. Begin timing as
soon as you detect movement toward the first circle.
\{onitor the child to make sure he or she is drawing
lines that touch or go through the circles in the correct
order. Make any coffections as needed. Stop timing as
soon as the pencil first touches the outer part of the
last circle, but do not record the time on the record
form, as this is the practice trial. Provide verbal rein-
forcement as needed.
Test trial. Remove the Practice trial sheet imme-
diately after completion so that the writing surface is
again clear, and say the following
Now I have a sheet with a lot more num-
bers and colored circles. Connect the cir-
cles like you did a minute ago. Again, work
as fast as you can.
Place the CCTT-Z Test trial form on the writing
surface facing the child, and say the following:
You will start here (point) where the hand
is telling you to start, and end where the
hand is telling you to stop. Ready? Go.
Begin timing as soon as you detect movement
toward the first circle, and stop timing as soon as the
pencil first touches the outer part of the last circle.
Monitor the child to make sure he or she is proceed-
ing through the circles in the coffect order. Make any
corrections as needed. On the record form, note the
time to complete the task (in seconds), 3s well as the
number of prompts, near-misses, and effor responses
(Number Sequence and Color Sequence). Provide
reinforcement as needed.
Uisual Rdministration lnstructions lor
the ((rr-l and ((rI-2
Nonverbal instructional cues for the CCTT:I and
CCTT-Z (i.e., the directional arrows, hands indicating
where to start and stop) are printed on each form in
order to facilitate completion of the task, as shown in
Figures 2 through 5. These instructions may be used in
cases where a child is unable to understand the verbal
instructions presented in either English or Spanish. Ask
the child to count aloud (or use sign language) from 1
to 15. If he or she is unable to complete this task, dis-
continue administration of the CCTT. The examiner
merely needs to point to the example and demonstrate
the concept to the child. Using the Practice trial sheets
and miming the task is usually sufficient to ensure that
the child understands what is required. The concept
that fast performance is also required can be communi-
cated by allowing the child to see the stopwatch and
gesturing encouragement on the practice trials to work
quickly. In certain instances where the child may have
some ability to understand the verbal instructions, the
examiner may want to use both oral instructions and
nonverbal instructions simultaneously.
Use the directional alrows and hands to instruct
the child about the procedures for completing the test.
The child is first instructed, both nonverbally and
visually, on the use of the CCTT:1 Practice trial sheet.
It is recommended that you mirne the performance on
the Practice trial. Once you are satisfied that the child
understands the task, administer the CCTT-1.
Following completion of the CCTT- 1, the child is
agatn instructed, both nonverbally and visually, on the
use of the CCTT-} Practice trial sheet. The test is
administered once the examiner is confident that the
child understands the task requirements.
ScoRlltG
J
Enter all scores derived from the CCTT:I and the
CCTT-2 on the record form (see Figure 6). The
scoring procedures require determining the time to
complete the tasks (in seconds) as well as the num-
ber of prompts, near-mis ses, and error types.
Identical scoring procedures are presented in the
Professional Manual for the adult Color Trails Test
(D'Elia et al., 1996).
Iime Scores
The CCTT:I Time raw score represents the total
time elapsed (in seconds) from detection of movement
toward the first circle until the pencil just touches the
outside edge of the final circle (Pink Circle 15). This
elapsed time is measured with a stopwatch. The
CCTT-Z Time raw score represents the total elapsed
time (in seconds) from detection of movement toward
17
 f
(hildren's (olol Inils lest'*
4
4
Recold Fom 4
4
4
Jane Williams, PhD, Louis F. D'Elia, PhD,
Paul Satz, PhD, and Antolin M. Llorente, PhD

Name Teel ClienL Test Date 10 1 l02 4

4
ID# o01 Date of Birth Bl 188

4
Male Caucaeian Handedness Riqhl Age 14 yrs,,2 moe,
Gender Ethnicity
-t
Education

Form:(checkone)
Oth qrade

6rc IX IY JZ
Examiner

4
4
Raw
score
Percentile
range
Standard
score
T
score
Percentile
score
4
d
\,l
CCTT:I Time (in seconds) 16 97 1b 42

CCTT- 1 Number Sequence Errors o >16

CCTT:I Near-Misses o -'1

\
,l
L,
,l
>
CCTT:I Prompts 1 11-16

>
CCTT:Z Trme (in seconds) 50 31 72 3

CCTT:2 Color Sequence Errors 3 <1

S
CCTT:2 Number Sequence Errors 1 2-5
/4
\
CCTT-2 Near-Misses o
.1
\
CCTT:2 Prompts 3 2-5
,4
\
Interference Index
(CCTT:2 Time raw score minus CCTT-I
Time raw score) + CCTT- 1 Time raw score
2.13 2-5 d
4
Normative table A7 4
4
Notes: 4
d
4
4
-r
4
Pf$ psychological Assessment Re$ources, lnc. . 16204 N. Florida Avenue . Lutz, FL 33549 ' 1.800'331.8378'www.parinc.com
4
(r
Copyright @ 19g9, 1996, 2OO3 by Psychological Assessment Resources, lnc. All rights reserved. May not be

"ny-fo-rr
ink on white
or by any r""nr
"itnout
paper. Any other version is unauthorized.
reproduced in whole or in part in
wrirten permission of Psychological Assessment Resources, lnc. This form is printed in blue
€r
987654321 Reorder #RO-5057 Printed in the U.S.A.

-r
-r
Figure 6. Chlldren's Color Trails Test: Sample of completed record form. -r
{r
{r
4
18
It.rL-l
:he t-irst circle until the pencil just touches the outer
edge of the final circle (Pink Circle 15).
Prompt Scotes
The child is allowed up to 10 seconds to make
s-ofirle ction between one circle and the next. If no
i--oilnection between circles has been made by the
child after 10 seconds, provide a nonverbal prompt
L'r pointin..u to the position of the next appropnate
circle. The Prompt score represents the total number
oi prompts that are given during the performance of
the task.
llear-Hiss Scoles
An additional scoring category has been devised
for the CCTT to provide a qualitative evaluation of
the cognitive slippage or mild degradation in func-
troning that often occurs following mild brain dys-
function or a similar low-grade insult. The Near-Miss
scores have been added to the CCTT in afr effort to
increase the sensitivity of the test, although no Near-
\liss norms are avatlable. Only errors of omission
and commission are generally tallied on neuropsycho-
logical tests. particularly on timed or reaction time
tasks. Unfortunately, scoring only such errors (i.e.,
errors of omission and commission) tends to mask the
talse starts and impulsive attempts that children with
ADHD. brain injury, and other CNS insults often
demonstrate. For the CCTT, a Near-Miss response is
detlned as initiation of an incorrect response that is
self-corrected before a connection to a sequentially
incorrect circle or a distracter circle is made (Figure
7 r. This lype of response occurs when the child starts
to make a Number Sequence Error on the CCTT:I, or
either a Number Sequence Error or Color Sequence
Error on the CCTT-Z, but self-corrects the response
before the pencil touches the wrong stimulus. If the
child misses a correct circle, this is not coded as a
\ear-Miss response, although this type of perfoffnance
may provide important process-related information
for the clinician.
Eruor Scorcs
a An error response referred to as a Number
Sequence Error, occurs on the CCTT:I when the child
fails to connect to the next highest numbered circle in
the sequence. Because the CCTT-Z contains two dif-
ferent colored circles for each numerical choice (i.e.,
color serves as the categorical shift), two types of error
scores can be captured on this test: Number Sequence
Errors and Color Sequence Errors. A Number
Sequence Error occurs when the child fails to connect
to the next highest numbered circle in the sequence,
regardless of the color of the circle (Figure 7). A Color
Sequence Error occurs when the child consecutively
connects two or more circles of the same color
regardless of the numerical order of the circle (i.e.,
irrespective of numerical sequence); each repetition is
tallied as a separate Color Sequence Error (Figure l).
lntelfelence lndex
A derived (dimensionless) performance compari-
son score, the Interference Index, was created for the
adult Color Trails Test (D'Elia et al. , 1996) with the
intention of identifying the effect of interference in
test taking. Similar indexes have been developed for
other neuropsychological instruments and provide
information about the increase in processing time
needed to complete one task that is more complex
than another. This type of index is also useful for
understanding the neuropsychological abilities of
children, and it was therefore included in the CCTT.
The Interference Index is calculated using Time raw
scores (raw score completion time in seconds) for
both CCTT:1 and CCTT:Z as follows:
Interference Index = (CCTT:2 Time raw score - CCTT:I
Time raw score) / CCTT:I Time raw score
I9
 +Near-Miss

Near-Miss

Color Error

Number Error

<- Color & Number Error

{e@
Figure 7. Children's Color Trails Test 2 Error and Near-Miss examples. (Darker circles = pink; lighter circles = yellow.)

20
4
4
4
4
4
4
4
4
4
3
4
4 Descilptlue Statlstlcs
4
Lz and )lormatlue Data
b
b
W2
b
U2 )loRMRnuE SnxDrE
standardtzatron assessment. Children comprising the
standardtzation cohort obtained an average Peabody

b
WJ
The CCTT normative data were collected from
678 healthy childrer, ages 8 to 16 years, from the
Picture Vocabulary Test-Revised (PPVT-R; Dunn &
Dunn, 1981) standard score of 101.5 (SD - 16.6).

Dou ne), Unified School District in Los Angeles

W2 Counn'. California, who were selected to serve irl the
W2 SnE(nolt oF
b
WJ
standardtzation sample. The sample included 306
r-$5%) boys and 372 (557o) girls and the average age
of participants was 12.30 years (SD = 2.44 years).
)loRMRnuE UnRrRBlEs
The majority (897o) of the participants (n - 605) were Normative data were collected for CCTT Form K
U2 right-handed. The sample was comprised of 309 only. Whereas all four CCTT forms are physically
W) t 16% ) Caucasians , 20I (307o) Hispanic Americans, equivalent, research investigating their psychometric
U2 11 e%) African Americans, and 105 (157o) who clas-
sitjed themselves as Other (e.g., Asian American or
properties and statistical equivalence is still underway
and will be presented in a future update to this manual.

E
Uz
\atir-e American). Ethnicity was not reported for the
remainin-e 52 participants (approximately 7 7o).
Until such time, Form X, Form X and Form Z rcmain
experimental versions and should be used only for
research pu{poses. The norrnative data presented in

b Participants in the standardrzation sample were

from trvo high schools, one junior high 'school, and
one elementary school; all are representative of the
Appendix A is only applicable to children's perfor-
mance on CCTT Form K. The specific variables that
U2 socioeconomic and cultural characteristics of the were selected for the normative study included the
L2
b
UJ
Greater Los Angeles metropolitan area. In general, all
children comprising the normative cohort were
health\. volunteers with no known history of medical,
CCTT:I Time raw score, CCTT:I Number Sequence
Errors, CCTT:I Prompts, CCTT-Z Time raw score,
CCTT-2 Color Sequence Errors, CCTT-Z Number

b
b
neurolo-eical, psychiatric, or psychological problems
that u'ould interfere with neuropsychological test per-
S equence Errors, CCTT-Z Prompts, and the
Interference Index. The normative data for the
Interference Index and the errors and prompts are
b
b
tormance. Children excluded from the standardization
sample \ rere those in special school placement due to
attentional problems or learning disabilities, as well
presented primarily for research purposes.
Tables 1 and 2 present means and standard devia-

b
b
as those rvho suffered from severe visual impairments
or phl'sical disabilities that would preclude a valid
tions for the CCTT:I and CCTT:2Ttme raw scores for
the normative sample stratified by age and gender.

b
b
2L

b
Examination of these tables reveals the effects of age
on the CCTT Time raw scores. After the age of 9 years,
CCTT mean scores tend to decrease as age increases.
Tables 3 through 5 present means and standard devia-
tions for CCTT Time raw scores for Caucasian,
Hispanic American, and African American children, by
age, respectively, and are made available in an effort to
provide data for comparing the performance of chil-
dren with similar demographic characteristics to the
children in the Downey, California Independent School
District. Caution should be exercised not to equate the
performance of these children with that of children of
Caucasian, Hispanic, or African descent living abroad
with dissimilar demographic characteristics from those
in the standardtzatron sample.
lxFruElr(E oF
DTMoGRRPHI( UnRtRBtEs
Analyses were conducted on CCTT data obtained
from the normative sample to examine the potential
effects of age, gender, and ethnicity on CCTT scores.
The criticisms leveled against the limitations of the
Children's Trail Making Test A & B when assessing
children from minority cultural backgrounds partially
served as an impetus for the development of the CCTT.
Performance differences due to culture have been
observed in children and adolescents on Children's
Trail Making Test A &. B (e.g., Leon-Carrioil, 1989.
for children in Spain; Rosin & Levett, I989a, for chil-
dren in South Africa). These differences may be
caused by the use of the English alphabet for a cate-
gorical or symbolic shift on Part B, limiting the appli-
cation of the Children's Trail Making Test in certain
cros s-cultural contexts.
A series of correlation coefficients were calcu-
lated to assess the relationship between age and gen-
der on CCTT scores using the normative sample. The
results are presented in Table 6. As expected, age was
significantly associated with the CCTT- 1 Time raw
score, CCTT- 1 Prompts, CCTT-Z Time raw score,
CCTT:2 Color Sequence Errors, and the Interference
Index. However, only the associations between the
Time raw scores, the Interference Index, and age had
moderate effect sizes (accounting for I37o, 237o, and
237o of the variance, respectively), thus indicating
relationships likely to have clinical significance.
Gender was associated only with the CCTT:I Time
raw score (boys were coded as 1 and girls were coded
as 2); however the magnitude of the effect was small.
These results parallel those presented by Heaton and
colleagues ( 1 99 1 ), which showed that gender
accounted for only I7o of the variance in adult perfor-
mance on the Trail Making Test.

Table 1
CCTC1 Time Raw Score Means and Standard Deviations
for the Normative Sample Stratified by Age and Gender
CCTT-I Time raw scores (seconds)

Boys Girls

Age (years) n M SD n M .SD

8 T4 21.86 7 .r8 t7 20.7 6 7.58

9 40 24.42 Lt.70 39 22.38 Ir.I7
10 40 20.98 8.32 50 r8.7 4 .77 1

11 22 2r.41 8.42 44 15.82 5.05

I2 35 14.94 4.00 33 14.97 3.64
T3 I] 16.24 7.34 37 13.33 4.22
I4 58 15.22 6.28 67 14.61 4.99
15 49 15.59 4.82 35 15.94 3.50
I6 25 13.92 5.29 38 t4.rr 4.28
Total 300 17.94 8.09 360 16.49 6.78
Note. Data were missing for 18 participants.

22

a'
 Table 2
CCTT-2 Time Raw Score Means and Standard Deviations
for the Normative Sample Stratified by Age and Gender
CCTT-2Time raw scores (seconds)
Boys Girls

Age (years) M SD M SD

8 L4 42.15 7.93 I7 50.59 19.26

9 40 52.80 18.90 39 51.95 2t.r3
10 40 45.05 12.70 50 40.48 19.28
11 22 49.27 19.57 44 35.82 13.42
I2 35 31.14 9.05 33 35.06 1 1.50
t3 17 33.47 8.93 37 27.62 10.25
I4 58 30.62 10.39 67 28.22 9.21
15 49 30.53 9.68 35 28.69 6.50
L6 25 29.7 6 8.77 38 28.32 9.55
Total 300 37.49 15.t7 360 35.12 16.01

Note. Data were missing for 18 participants.

Table 3
CCTT-I & CCTT-2Time Raw Score Means and
Standard Deviations for Caucasian Participants in
the Normative Sample Stratified by Age

Time raw scores (seconds)

CCTT-1 CCTT-2
Age (years) M SD M ^sD

8 7 23.43 8.96 44.29 5.94

9 47 2r.04 t0.44 51.51 20.64
10 39 20.36 9.48 43.55 20.34
11 27 18.07 .58 7 36.81 13.28
I2 42 15.05 3.72 30.55 8.14
I3 27 14.63 4.25 29.81 .85 7
t4 '67
r3.7 8 4.52 27 .78 8.58
15 28 15.57 4.67 29.36 8.86
I6 22 14.32 5.22 29.14 9.18
Total 306 16.84 1.42 35.4r 15.79
Note. Data were missing for 3 participants.

23

SuPPtEMEltIRt )loRMRIluE Dntn
Fnox (uln(Rt GnouPs
Normative data stratified by age for children ages 5
to 16 5rens that were part of the CCTT validation stud-
ies (to be fully discussed in chapter 5) are presented in
Table 7 . These samples included children who had
been diagnosed with mild neurological disorders,
learning disability (LD), of comorbid ADHD lLD.
Information about these samples was initially pre-
sented in Williams, Rickeft, Hogan, Zolten, Satz,
D'Elia et al. (1995). As expected, and comparable to
the standardrzation cohort, these data reflect age-
based performance that is marked by decreasing Time
raw scores with increasing age.These scores afford a
comparison of CCTT completion times for a child
undergoing assessment with children of similar
chronological age and average intellect who demon-
strate subtle or documented neurological findings.
More detailed comparisons between children from
clinical samples and those from the normative sample
are presented in chapter 5.

Table 4
ccTT-l & CCTT-2 Time Raw Score Means and standard Deviations
for Hispanic Participants in the Normative Sample Stratffied byAge
Time raw scores (seconds)

CCTT.1 CCTT.2

Age (years) M SD M SD

8 I] 20.35 5.r2 43.94 I .34

9 t3 25.71 9.03 48.92 11.15
10 25 18.36 5.54 40.48 10.58
11 18 17.6t 8.46 43.28 16.19
I2 T3 14.T5 2.7 6 39.54 10.06
13 13 15.38 8.37 29.46 rr.r7
T4 32 r7.19 7 .65 33.4r r1.41
15 4I 15.90 4.II 29.61 8.90
I6 29 13.52 4.39 29.62 9.72
Total 20r r1 .09 6.14 35.89 12.42

Table 5
CCTT-I & CCTT-2 Time Raw Score Means and
Standard Deviations for African American Participants
in the Normative Sample Stratified by Age
Time raw scores (seconds)

CCTT.l CCTT-2

Age (years) M SD M SD

8-12 2 2r.50 12.02 48.00 31.1 1

t3 3 12.33 1.15 36.00 24.33

I4 4 19.50 4.65 31.15 10.37
I6 2 19.50 .7 r 27.00 7.07

Total 11 17.9r 5.89 35.00 11 .42

24
tr
h The Time raw score means for boys and girls in
r arious a_qe ranges from the normative sample are
and Other). As expected, given the fact that the CCTT
was designed to be less dependent on culture, no sig-
presented in Figures 8 and 9. These figures reveal the nificant differences across the ethnic groups were
eftects of age and, thus, the developmental nature of
idenffied for the CCTI-I Time raw score, F(3,62I) = .I2,
CCTT Time raw scores, &S well as the general simi-

E larin' in pattern between boys and girls. In general,

CCTT mean Time raw scores tend to decrease as
E children mature.
Univanate analysis of variance (ANOVA) statis-
tics were used to identify differences in the CCTT
scores across the four ethnic groups contained in the
sample (i.e., Caucasian, Hispanic, African American,
p = .95; CCTT:I Prompts, F(3, 617) = .47 , p = .7 l;
CCTT:I Number Sequence Errors, F(3, 620) = I.I2,,
p - .34; CcfF}Timeraw score, F(3,620) - .05, p -.98;
CCTT-2 Prompts, F(3, 617) = .70, p = .55; CCTT-2
Number Sequence Errors, F(3, 620) = .27, p = .85;
CCTT-2 Color Sequence Errors , F(3,619) - .62, p -.60;
and the Interference Index, F(3,620) = .05 , p =.98.

E
h Table 6
Influence of Age and Gender on CCTT Yariables
Variables Age Gender
CCTT-I scores

E Time raw score

Prompts
Number Sequence Errors
-.36*
.

.06
10*
*
-.10*
-.06
-.05
CCTT-2 scores
Time raw score * *
-.49 -.08

E Prompts
Number Sequence Errors
Color Sequence Errors
-.06

_.
.05
1t**
LL
-.07
-.03
-.07
Interference Index * *
-.49 -.08
Note. Values represent correlations between the variables.
*p <.05. **p < .01.

c4
=
Table 7
Supplemental Normative Data From

2
4
Clinical Groups for the CCTT-I & CCTT-2
Time raw scores (seconds)

4
4 Age group (years) M
CCTT-1

SD M
CCTT-2

,.SD

4
4
5 to 7 years
8 to 11 years
T7
T16
43.5
25.9
15.8
13.6
103.5
67.3
37.2
30.3

4
4
12+ years 6l 19.3 8.9 46.9 r4.9

4
2
4
4
4 25

b
 o
E20
o
o
a
(E
=
l-
o15
E
l=
F
tr
F
o10
o

10 11 12 13 14 15 lb

Age

Figure S. Children's Color Trails Test 1 Time raw scores for the normative sample (l/ = 660;300 boys, 360 girls).

o
E40
o
o
o
(E
=
l-
o30
E
'l=
sl
*F
820

891011121314
Age

360 girls).
Figure 9. Children,s Color Trails Test 2 Time raw scores for the normative sample (N = 660; 300 boys'

26
?
7 describe the relationship between age and the mean
3 TnnilsFoRltnnolt oF CCTT- 1 Time raw score and between age and the
a ((TI IIHE Rnx ScoREs mean CCTT-2 Time raw score. A linear model
7 appeared to be the best fitting model for the relation-

7 : ;i
to facilitate the normative interpretation
tri: r.:Cer
7 lnCiridual's CCTT performance, standardrzed
.: . re: r'\ ere calculated. As a first step, the distribu-
7 : . : .l characteristics of all of the CCTT values were
7 .", ,-;rteC. To estimate the shape of the distribution of
ships between age and the standard deviation of the
CCTT- 1 Time raw score and between age and the
standard deviation of the CCTT-} Time raw score.
Using the derived regression equations, the mean and
standard deviation for each score were predicted for

7 ' - . rc S. thre total normative sample was divided into

:"-:: ieparate a,_ge _qroups (8 years, 9 years, 10 years,
each group. Inspection revealed a good level of simi-
larity between the means and standard deviations and
7 " - ,, e r:i. 1l vears, 13 years, 14 years, 15 years, and the smoothed means and standard deviations. The
7 . | In order to examine score distributions,
\ errs r. smoothed values reflect the effects of age on the CCTT

7 ';::rrp:ir e statistics were calculated for all of the scores more accurately than the unsmoothed values.

7 ',

:.
-r.r;b,^es and the histograms for these variables were
Atier inspection of the age group distributions,
Standardrzed scores were then computed for each raw
score using the smoothed means and standard devia-
7 -'ned"
:l',
tire CCTT-I Time raw score and the CCTT-} tions. The smoothed means and standard deviations
7 11:-e :.1\\ score had distributions that approached nor- are presented in Thble 8.

7 :--r-:ii. Distributions and ranges of scores for CCTT-1

\ *:t be r Sequence Errors , CCTT- 1 Near-Misses, Thble 8
7 I:CTT-1 Prompts, CCTT-Z Color Sequence Errors, Smoothed Means and Standard Deviations for
7 (ICTT-I \umber Sequence Errors, CCTT-} Near- the CCTT Time Raw Score Stratified by Age

t ),1:.r-s. CCTT-? Prompts, and the Interference Index Time raw scores (seconds)
7 ',i,:re lr--)o highl1, skewed and were too restricted in
:i:si to uarrant calculation of Z scores and, there- CCTT:1 CCTT.2
7 :.:.. l-\"ere treated with categorical methods. Age (years) M SD M .tD
t The transformation of the CCTT- 1 Time raw 8 23.rr 8.93 5r.46 18.39
t i- -rf s and the CCTT:ZTrme raw scores was based on 9 20.94 8.29 46.45 17.05
7 ::e fltted (smoothed) means and standard deviations 10 19.09 7 .66 42.04 t5.7 |
7 : -': the total noffnative sample. The descriptive values
',;,ire srnoothed in order to reduce the impact of sam-
11
I2
17.54 7.02
16.30 6.39
38.2r 14.37
34.98 13.02
t :"::.g en'or on the norrnative information. Smoothing I3 15.37 5.15 32.33 11.68
t :-.:niques have been used successfully with other I4 r4.7 5 5.r2 30.28 10.34
-::i ltectual and neuropsychologi cal assessment 15 14.44 4.48 28.81 9.00
t -::irurnents (e.g., D'Elia et ?I., I996; Wechsler, T6 14.44 3.85 27.93 7.66
7 -"y
- . The smoothing process was accomplished
7 *:tnr hierarchical polynomial regression techniques.
Note. Derived from the CCTT normative sample, ly' = 663.
Data were missing for 15 participants.

t E;;ruse age was identified as the only demographic

'*;r1ab'le to account for a clinically significant level of All CCTT scores were scaled such that higher
t ::.i '', ariance in CCTT Time raw scores (I37o of the standardtzed scores reflect better test performance.
7 '. -x.r: ance in CCTT- 1 Time raw score and 237o of the The linear transformations of the CCTT- 1 and
t '- ',:j ence in CCTT-2 Time raw score), these scores CCTT-Z Time raw scores are presented in Appendix

7 ,;,-:i i'imed using age.Means and standard deviations

l, r :he CCTT Time raw scores for each of the age
A. The available standardtzed scores include linear
Z scores (M = 50, SD = 10), standard scores (M =
-t jr-, ;ps \\'ere calculated. These variables were ana- 100, ^SD = 15), and percentiles. Linear Z-score
-a .",2-d separately using polynomial regression with transformation was selected over a number of alter-
7 -1J- r til'J its r-arious powers) as predictors. A quadratic
.t- -'.iel \\ as identitied as the best fitting model to
native transformations for several reasons. First, the
linear Z score is easily calculated and interpreted with
-a
-a
-.a 21

7
-.a
respect to units of standard deviation. Second,
because most clinical phenomena afe not normally
distributed in the general population, normahzrng
transformations to force all scales into normal dis-
tributions is questionable. Therefore, the simplic-
ity and interpretability of the linear T score was
seen as preferable to problematic and more com-
plex alternatives.
fttEGoRIffit )loRxs
Normative data for CCTT- 1 Number Sequence
Errors, CCTT- 1 Prompts, CCTT-Z Color Sequence
Errors, CCTT-} Number Sequence Errors, CCTT-Z
Prompts, and the Interference Index were determined
for each normative age group (see Appendix A).
28
It was decided that categorical presentation would
more accurately reflect the skewed and restricted
nature of the distributions of these scores. A11
CCTT variables were scaled in such a way that
higher standardtzed scores (e.g., Totle score ranges)
reflect better test performance. Raw score ranges
were then determined for the following five cate-
gories: (a) scores greater than the 16th percentile,
(b) scores within the 1 lth through the 16th per-
centiles, (c) scores within the 6th through the 1Oth
percentiles, (d) scores within the Znd through the
5th percentiles, and (e) scores less than or equal to
the 1st percentile. In some instances, these variables
were smoothed to correct for irregularities due to
sampling elror. The frequencies and descriptive statis-
tics for each of the scores across the different age
groups were calculated and this information served as
the basis of the smoothing process.
 4
lnterpretatlon

This section provides interpretive guidelines for over time relative to his or her established baseline
CCTT scores. The CCTT should be viewed as only without reliance on normative information.
one of a number of neuropsychological procedures
capable of providing information on important
domains of neuropsychological functioning and from
u'hich to develop diagnostic inferences. In accordance
lloRlt - REFEREII(ED f, pPRoR(H
u ith the Standards fo, Educational and Psychological
The norm-referenced approach facilitates inter-
Te stirt g (American Educational Research Association,
pretation of a child's score through a simple compari-
American Psychological Association, & National
son with normative data. Base rate data for the CCTT,
Council on Measurement in Education, 1999), the
presented in AppendixB, allow further comparisons
interpretation of test results should be conducted
with the normative sample and select diagnostic
u ithin the broader context of a comprehensive clini-
groups. Using the norm-referenced approach, CCTT
ca1 assessment including clinical and historical infor-
scores for an individual child are compared with
mation. Other test data should also be considered in
scores from the normative sample in order to deter-
conjunction with the information obtained from the
mine the child's level of performance relative to the
CCTT in an effort to support or reject specific con-
normative group. This comparison allows for test
clusions derived from the Children's Color Trails
score interpretation and diagnostic inferences regard-
Test results. Interpretation of the CCTT should be
conducted by a licensed psychologist. ing cerebral disorder and brain dysfunction. For neu-
ropsychological diagnostic purposes, we recommend
Two approaches, either norm-referenced or
using the age-corrected noffnative scores presented in
ipsative, can be readily adopted for interpreting the
Appendix A. Comparisons using age-corrected scores
CCTT data. The norm-referenced interpretive
are necess ary as research has demonstrated that faster
approach involves making inferences about a child's
performance times are associated with increasing age
cognitive functioning based on his or her CCTT per-
from early childhood through young adulthood (Rosin
formance when compared to the normative values
8L Levett, 1989b; Kennedy, 1981). The CCTT exhib-
presented in this manual. The ipsative interpretive
ited similar decreases in performance time as a result
approach is accomplished through repeated adminis-
of progression in chronological age (see Figures 8 and
tration of the test to children, allowing them to estab-
9 in chapter 3).
lish their own baseline. This approach is further
enhanced by the existence of multiple CCTT forms. The normative data presented in Appendix A per-
Using the ipsative approach, an examiner may be able mit the transformation of CCTT Time raw scores to
to make inferences regarding a child's performance standard scores, T scores, and percentile scores.

29
CCTT Standard scores have been constructed to have
a mean of 100 and a standard deviation of 15,
whereas Z scores have a mean of 50 and a standard
deviation of 10. CCTT scores have been scaled in
such a fashion that higher standardrzed scores (i.e.,
standard scores,, T scores, and percentiles) reflect
better test performance.
A popular and clinically useful approach to the
interpretation of neuropsychological test performance
is to classify performance scores in terrns of ability on
the basis of a categorical classification system.
Although Wechsler (1958) developed an ability clas-
sification for adults, Heaton and his colleagues ( 1991.,
1993) proposed a broader categorical system for
interpreting normative data than that proposed by
Wechsler, particularly in the classification of imp aff-
ment. Table 9 presents the standard scores, T scores,
and percentiles that define the suggested clinical inter-
pretation levels recommended for use with the CCTT.
Although a subtle distinction, interpretation of test
scores should focus solely on the child's level of per-
formance, and not on intrinsic characteristics of the
individual child. This differentiation is critical when
conducting evaluations because tests do not directly
reveal traits or innate abilities. Tests only allow for
inferences about a child's performance and brain-
behavior relationships based on samples of behavior
(Lezak, 1995; Sattler, 2000).
lloRMRr ruE I nr ERPRETRT tolt OF
IHE ((ff-l nilD ((ff-z
Jur Rnx ScoREs
CCTT time variables are omnibus information
processing measures that emerge durin g a child's per-
formance and involve several skills: perceptual track-
ing, Sequencing, graphomotor skills, sustained
attentiotr, and divided attention. CCTT:1 requires per-
ceptual tracking, sustained attention, and graphomo-
tor skills. CCTT-Z, because of the additional task
requirement to alternate color and number sequences,
requires these same three skills plus divided attention,
sequencing skills, and inhibition-disinhibition.
Sequencing skills and alternating between categori-
cal sets have been associated with the need to disin-
hibit a familiar response for a more complex one.
Because these skills have often been associated with
frontal lobe functioning, performance on the CCTT-2
may involve emerging skills thought to be subserved
by the frontal lobes.
Validity evidence (see chapter 5) demonstrates
that performance on the CCTT-Z is a more sensitive
indicator of neurological dysfunction than perfor-
mance on the CCTT- 1. Thus, under most circum-
stances, impaired performance on the CCTT-},
regardless of the level of CCTT:I performance, ffi&y

Thble 9
Suggested Guidelines for the Clinical Interpretation
of CCTT Standard Scores, ? Scores, and Percentiles
Standard Z-score Percentile Suggested clinical
score range range range interpretation
> r07 >55 >69 Above average
92-106 45-54 3r-66 Average
85-91 40-44 L6-27 Below average
77 -84 35-39 7 -r4 Mildly impaired
70-76 30-34 2-5 Mild-to -moderately imp aired
62-69 25-29 .6-2 Moderately impaired
55-61 20-24 . 1-.5 Moderately-to- severely impaired
0-54 <.1 Severely impaired

Note.From Comprehensive Norms for an Expanded Halstead-Reitan Battery (pp. 14-16),

by R. K. Heaton, I. Grant, and C. G. Mathews, 1992, Odessa, FL: Psychological
Assessment Resources. Copyright A 1992 by PAR. Adapted with permission.

30
re Jonsidered evidence of cerebral dysfunction. In
crrrrff&st. the reverse result should not necessarily lead
tc the same conclusion; our clinical experience sug-
gests that poor performance on the CCTT:1 followed
b'r intact performance on the CCTT-} often reflects
Iest anriety. limited test experience, or "learning to
learn" difficulties (Heaton et aI., 1993). Because the
CCTT is a multimodal procedure, peripheral motor
problems responsible for psychomotor slowing
should be ruled out when interpreting test results.
Similarll', the effects of medications, particularly psy-
ctrotropic agents capable of influencing CNS perfor-
mance. should be given due consideration when
rnterpreting CCTT results. Test scores may be signifi-
cantlr influenced by these medications (e.g., pheno-
b'arbital to control seizures). Finally, if a child is
suspected of suffering from a mood or an anxiety dis-
order. caution must be exercised when interpreting
CCTT time scores because these states are capable of
infrin'ein..9 on neurop sychological performance
r Sn eet. Newman, & Bell, 1992).
\\-hen CCTT Time raw scores fall significantly
belou' expectation compared to the age-corrected nor-
matir-e values ., altered neurologi cal functioning
should be considered. Altered neurological function-
ing should be suspected if the patient's history sug-
qests reasons for possible neurological damage or
trauma (e.g., head injury, infectious diseases). The
child's performance on other neuropsychological
measures should also be used to further refine inter-
pretir,e hypotheses. For example, a diagnosis of
ADHD based on the diagnostic criteria as stated in
the Diagrtostic and Statistical Manual of Mental
Di sorders, Fourth Edition, (DSM-IV; American
Psr,chiatric Association, 1994) should be suspected in
a child referred for neuropsychological examination
due to inattentiveness who obtains impaired scores on
CCTT- 1 and CCTT-Z Time raw scores along with
impaired scores on the Test of Variables of Attention
(T.O.V.A.; Greenberg &. Kindschi, 1996), the
Freedom from Disftactibility Index (WISC-III;
\\Iechsler, L99I), and parent's and teacher's rating
scales measuring attention, and who also presents
u'ith overt behavioral impairments in attention.
Similarly, impaired performance on the CCTT-Z, in
conjunction with deficient performance on the
\\Iisconsin Card Sorting Test (WCST; Heaton et &1.,
1993), verbal fluency on the Multilingual Aphasia
Examination (MAE; Benton & Hamsher, 1989), and
the Stroop Color and Word Test, Interference Index
(Golden, 1978), in a l6-year-old adolescent with a
history of moderate head trauma as a result of an
automobile accident would suggest the presence of
frontal lobe involvement as a result of that injury
(Teasdale & Jennett, 1914). As demonstrated in the
cases presented later in this chapter, it is strongly rec-
ommended that any clinical hypotheses concerning
central processing dysfunction be explored through
additional collateral neuropsychological test data
and, when accessible by collateral diagnostic meth-
ods (e.g., neuroimaging) because the diagnosis of
brain damage should never be reached based on the
results of any one measure (American Psychological
Association, 1989).
)loRMRnuE lnrERpRErRnolt oF
Pnoxpr RltD llrnR-Mlss ScoREs
Normative values for the Prompt scores are pre-
sented in Appendix A. The Near-Miss scores are con-
sidered experimental at this time, and normative
values will be presented separately in a future update
of this manual. However, as noted earlier, these quan-
tifiable variables are believed to reflect features some-
times observed in children with mild cognitive
impairment (e.g., impulsivity), particularly children
with sequelae after a mild head injury or mild cere-
bral dysfunction (e.9., ADHD). These behaviors were
observed in the normative sample, as well as in stud-
ies by Llorente et al. (2002), Voigt et al. (2001), and
Williams et al. ( 1995). Elevated rates of Prompts sug-
gest the presence of some cognitive impairment, but
should be interpreted in light of the CCTT- 1 and
CCTT-Z Time scores. Elevated rates of Prompts in
conjunction with CCTT Time raw scores that are
within normal limits are much less suggestive of cog-
nitive impairment. Near-Miss scores occurred infre-
quently, making it difficult to establish normative data
as a result of negatively skewed distributions and,
thus, precluding appropriate interpretations. Further
research will more clearly define the benefit of these
markers. However, the presence of Near-Miss effors
in a child's performance suggests the presence of cog-
nitive slippage.
3I
t-
llonxnnur lmrRDRErffi rolr oF
rnr lmERFERElrcr hux
Most neuropsychological measures are multi-
modal instruments incapable of independently assess-
ing a single realm of functioning (Kaplan, 1988;
Lezak, 1995). The CCTT-I requires cognitive flexi-
bility, psychomotor speed, sequencing, and sustained
visual attention as the child tracks a specified numeri-
cal sequence. The ability to perceptually track a sin-
gle specified sequence (number) is a less demanding
task and is a component of both CCTT tests. This
shared component between the two portions of the
CCTT makes it difficult to identify the relative effects
of visual attention and simple perceptual tracking
required on the CCTT-I from the more demanding
sustained divided attention and more complex percep-
tual tracking required by the CC'[T-2. Similar to the
CCTT-1, the CCTT-2 requires cognitive flexibility
and other executive skills, psychomotor speed, and
sequencing, but it also requires sustained divided
attention when the child is simultaneously tracking
both a specified number sequence and a separate
color sequence. The Interference Index is an indicator
capable of elucidating these added task requirements
for the CCTT-2. As noted earlier, the Interference
Index is a measure that reflects the comparison of a
child's performance on the CCTT:I relative to his or
her performance on the CCTT-2. This index is
expressed as a function of the level of performance on
the CCTT-I. Therefore, it is a relatively 'opure" mea-
sure of the interference, or lack thereof, attributable to
the more complex divided attention and the alternat-
ing sequencing tasks required in the CCTT-2. For
example, an Interference Index score of 0 indicates
that the child's performance time on the CCTT-I is
the same as his or her time to complete the CCTT-2
(i.e., no interference). An Interference Index score of
1.0 indicates that the child required twice as long to
complete the CCTT-2 as it took to complete the
CCTT:I, whereas an Interference Index score of 5.0
indicates that it took the child six times as long to
complete the CCTT-2 relative to the CCTT-I (i.e.,
signifi cant interference).
Consider, for example, a 9-year-old who obtains
CCTT-I and CCTT-2Time scores of 44 seconds
(T score = 22; see Appendix A, Table A2) and 9l
seconds (I score - 24), respectively. The child's Time
32
scores correspond to an Interference Index of 1 . 1
(>16th ToIIe). Although the child's Time scores clearlr-
reflect impairment (<1st TorIe), the Interference Inder
fell within normal limits. Combined, these findings
suggest that the impairment observed in this child is
more general and cannot be specifically attributed to
cognitive interference due to simultaneous alternatin.-e
and sequencing. Compare this case with that of another
9-yearold child who agarn obtains impaired CCTT- 1
and CCTT:ZTime scores of 45 seconds (Zscore = 21)
and 225 seconds (Z score
Time scores produce an Interference Index score of
4.0 (<1st 7o1Ie). Unlike the previous case, the much
greater difference between the CCTT:I and CCTT-2
scores suggests the presence of susceptibility to
cognitive interference and poor alternating and
sequencing skills.
Using a conservative cutoff score to define
impairment (i.e., scores <16th Toile), Interference
Index scores ranged from I.7 to 2.0 in the normative
sample. Generally, this indicates that it is acceptable
for children to take 2.7 to 3.0 times longer to com-
plete the CCTT-Z than to complete the CCTT- 1.
Depending on the normative table used in Appendix
A, Interference Index scores greater than 3.0 provide
strong evidence for a child's susceptibility to cogni-
tive interference and poor alternating and sequencing.
Bn* Rmr (oxpnRrsolrs
The base rate data presented in Appendix B are
useful to determine how a child's performance com-
pares with that of children in the nonnal population.
This comparison is often required because some
healthy, neurologically intact children obtain low scores
on the CCTT, just as some neurologically impaired
children obtain average or higher scores on the CCTT.
In fact, to determine whether a relationship exists
between a plausible diagnostic sign (i.e., perfofinance)
and a specific disorder, it is insufficient to simply know
the frequency of their co-occuffence or the magnitude
of their relationship. The clinician should know how
often the diagnostic sign or perfoffnance occurs in chil-
dren without the disorder. Frequently then, interpreta-
tion is concerned with whether a child's performance is
more like the performance of a neurologically intact
individual or like that of a neurologically impaired
individual (Arkes, 1981; Heaton et a1., 1993).
H To assisr in the interpretation of the CCTT, child's performance appears to be more similar to
.\ppendir B provides base rates, or proportions that of unmedicated children with ADHD as opposed
e\pressed as percentages), of both normative partici- to children in the noffnative sample.

E
panrs and children who have been diagnosed with
The data presented in Appendix B also may be
reurological or psychiatric disorders. Age-corrected
used to establish interpretive ranges and categories
ccTT Time scores were classified accorditrg to the
different from those suggested in this manual. Based
clinicallr- relevant score ranges (presented in Thble 9).
on training and experience, professionals can estab-

E
h
Base rates address the frequency with which a spe-
cltrc performance (in this case, a child's performance
on ccTT- 1 and ccrr-2) occurred in the normative
lish more or less stringent interpretive categories by
combining or relabeling clinical categories. For
example, using the data presented in Appendix B, a
sample and in other samples of children diagnosed
borderline performance category may be created by
u ith psl'chiatric or neurological disorders. ADHD
combining the mild and mild-to-moderate categories
Sample 1. which included children who were unmed-
(e.9., z scores ranging from 30-39). A category of
icated. came from Llorente and colleagues (2002);

E and the other clinical samples came from Levin,

Lo._esden. Abrams, and Satz (2003). ADHD Sample 2
\\.as medicated at the time of testing. Without base
deficient performance may be created by relabeling
the moderate category (e.g., T scores below 25).
Alternatively, the severe and moderate-to-severe cate-
gories may be combined to form a significantly defi-
rates. it is difficult to determine whether a specific

E performance is valid.
Appendix B presents base rate classification data
u'here the specificity of the CCTT was held constant at
approximately 867o; that is, a cutoff of a Z score of 39
\\'as used to define impaired performance. Using the
cient performance category (e.g., z scores ranging
from 0-24). clinicians also may use the percentages
for the normal samples presented in Appendix B to
establish categories that provide optimum rates of
classification (i.e., true positives and true negatives) in
comparison with the base rates of brain dysfunction

E
l.?
CCTF 1 age-corrected Time score as an example, the
prevalence of impaired performance in the ADHD
reflected in individual clinical settings.

4 sample 1 was approximately 52To,9vo in ADHD

Sample 2, approximately 46To in the LD sample, and
lpsnrruE lxrEnpRErnnolt
|? approximately 46Vo in the comorbid ADHD/LD sam-
p1e. By contrast, the prevalence of impaired perfor-
|'? ccTT scores can also be interpreted using an

rE
mance within the normative sample was about Ij To.
|? Similarly, when looking at the CCTT-} age-corrected
ipsative approach that does not rely on normative
data. Ipsative interpretation is accomplished through
Time score, the prevalence of impaired performance in

rE
repeated administration of the test to children, allow-
the ADHD Sample I was approximately 43Vo,25vo rn
ing them to establish their own baseline. using this
ADHD Sample 2, approximately 48vo in the LD sample,
interpretive approach, an examiner may be able to
and around 367o in the comorbid ADHDILD sample.
make inferences regarding a child's performance over
By contrast, the prevalence of impaired performance
time relative to that child's established baselire,
I? within the normative sample was l4%o. In general,
4 these data demonstrate sensitivity of the ccTT perfor-
instead of to normative information. complex meth-
ods of establishing baselines that deal with practice

1 mance to the presence of brain injury.

To illustrate the use of these base rates, consider the
case of a l3-yen-old boy who obtained a CCTT:I Time
effects as a result of multiple test administrations have
been devised (McCaffrey & westervelt, lFrgl) and
may be useful when using an ipsative approach with
- raw score of 31 seconds. This raw score is equivalent to Form K only. Additionally, because nonnative data are
--a a T score of 23 (see Thble A6,Appendix A). Turning to
7t Appendix B, this normative score falls in the moderate-
not used, the alternate ccTT forms may facilitate this
approach. This interpretive approach should not be
to-severe range of impairment. Locating the base rate
- used for diagnostic purposes because there is no com-
data for CCTT:1, approximately 97To of the normative parison with a normative group or a diagnostic group.
- sample obtained scores in higher performance ranges, However, it may be employed to supplement findings
- whereas only 8I7o of ADHD Sample 1 obtained from other measures or to examine the treatment out-
- scores in higher performance ranges. Therefore, this come of a child's performance over time. This method
-
- 33

-
is of significant benefit when using a single-case
research design to study the effects of medication on
a child's performance.
Consider the case of a 9-year-old child who has
been diagnosed with leukemia. She is about to
undergo treatment involving a bone marrow trans-
plant and chemotherapy. She is referred for assess-
ment to establish a baseline prior to treatment onset.
Her CCTT:I and CCTT-} Time scores were 78 sec-
onds and 165 seconds at baseline, respectively. As
Table A2 shows, her performance is in the severely
impaired ran ge at this time. She is then evaluated sub-
sequent to treatment onset. During the examination at
Week 12, she obtained a CCTT:I Time raw score of
35 seconds and a CCTT-} Time raw score of 82 sec-
onds. During the examination at Week 52, she
obtained a CCTT- 1 Time raw score of 26 seconds and
a CCTT-} Time raw score of 57 seconds. It is clear,
despite the possibility of practice effects, that her per-
formance improved from baseline to 12 weeks. Aside
from noting that her scores reached a greater level of
improvement when categorically interpreted, her per-
formances at 12 weeks after baseline improved by
557o and 507o on CCTT:I and CCTT:Z, rcspectively.
Similarly, her scores on CCTT:I and CCTT-Z at the
52-week evaluation after treatment onset increased by
67 7o and 657o relative to her baseline, respectively. It
is clear from the magnitude of these changes, coupled
with her enhanced performance and other test data, as
well as clinician, parental, and child reports, that she
benefited from treatment. More important because of
its direct bearing on the ipsative evaluation approach,
the CCTT was able to quantify and monitor the
protracted treatment effect.
IxTERPREIIUE (nsr ExRMptEs
The four clinical cases presented in this section
briefly describe performance interpretation for the
CCTT:I and CCTT-Z. As is the case with most case
illustrations, those presented are ideal in the sense that
they qualify as prototypical for specific disorders and
conditions and in no way represent profiles that will
be observed in every child. It also should be noted that
the CCTT is not a dtagnostic instrument for any disor-
der, and the scores presented are not exclusive to the
cases or conditions presented.
34
These case examples ate provided to underscore
several issues. First, aside from being an attractive
instrument for use with children, the CCTT is a test
that lends itself to good use with hearing impaired
children because it provides visual instructions (see
CCTT protocols). In addition, because the CCTT uses
numbers and color as shift categories, rather than let-
ters, the CCTT is appropnate for use with children
who have reading disorders. It also is appropriate for
use with children whose first language is not English
(in one of the sample cases, Spanish instructions were
employed), and it may be particularly useful with
children who are not familiar with the English lan-
guage alphabet. To date, Spanish instructions are a\/ail-
able (in addition to English) and are presented in this
manual (see Appendix C), but the CCTT instructions
may be adapted into other languages as well. Fina1l1'.
the CCTT is likely to provide direct and useful
information about children who may be suspected of
suffering from overt (e.g., disinhibition and poor
planning) or more subtle (e.9., poor planning) exec-
utive probleffiS, particularly when other neurodia-e-
nostic data (e.g., structural or functional imaging)
are not available.
(ase l: l0-Yeal-0ld (hild, Rule Out RDHD,
Predominantly lnattentiue lype
Client 1 is a right-handed, Caucasian male attend-
ing the fifth grade, who was referred by a pediatric
neurologist for neuropsychological examination to
rule out subtle deficits in attention and concentration
and a diagnosis of ADHD Inattentive Type. Parents
and teachers had reported a chronic history of impul-
sivity, inattention, and restlessness infringing on acad-
emic attainment (grade fluctuations from A to C and
inability to place him in gifted and talented program
despite an above average intellect), with onset of diffi-
culties "in the third grade." His symptoms waxed and
waned over time, and an evaluation or treatment was
not recommended earlier because of the noted fluctua-
tions. Emotional and psychosocial domains were
reported as unremarkable. Past family history was sig-
nificant for ADHD and dysgraphia. The child was not
receiving any medication at the time of the evaluation.
Behavioral observations during the assessment
supported parental and teachers' reports, suggesting
the presence of restlessness (e.9., constant.feet
dangliilg, inability to sit still for any length of time).
h
-
h
h
Er-aluation of the results revealed that intellectual
functioning, ?S assessed with the Wechsler Intelli-
gence Scale for Childreil, Third Edition (WISC-il;
long performance time in all likelihood permitted the
child to complete the task without making an effor.
The results from his CCTT-2 scores revealed a slow

ch \\ echsler. I99I), was within the very superior range

tFull Scale IQ, 136 to I45). Verbal and Performance
IQ scores fell in the same categorical range with a
performance (83 seconds), placing his score in the
moderately-to-severely impaired range suggestive of
attention problems. The patient also required more

h
h
nonsi,_enificant discrepancy favoring verbal skills,
partlr'o the result of inattention during a timed
Pertormance subtest (Block Design). The child's aca-
prompts than is usually necessary for children his zge,
suggesting mild impairment. The need for these
prompts on the CCTT-2, particularly given his
h
h
demic achievement performance fell within normal
trimits across all domains. On a reaction time task, he
chronological age and very superior intellect, leads to
tentative concerns about the cognitive slippage and/or

h
h
erhibited moderately-to-severely impaired perfor-
mance ( 1st Toile) marked by an overtly high number
of omissions, commissions, and slower than expected
mild degradation in functioning often seen in children
with ADHD. Although his Time scores clearly reflect
impairment, as is also the case with his qualitative

h
h
reaction time. Similarly, on a paper-and-pencil test of
r igilance (Leiter-R, Attention Sustained; Roid &
scores on the CCTT-Z, his Interference Index was
within the range of expectation. This finding suggests

h
h
\Iil1er. I99l), his score fell in the moderately
rrnpaired range (2nd TotIe). Not only was his Leiter-
R performance marked by a lengthy duration, but he
more general impairment and impulsivity rather than
more specific simple cognitive interference second ary
to simultaneous alternating and sequencing probleffiS,

h
h
also exhibited a haphazard symbol cancellation
approach (i.e., left-to-right, right-to-1eft, top-bottom,
andl or poor inhibitory-disinhibitory mechanisms.

Assessing for the presence of other comorbid or

b
h
bottom-up approaches, etc.). Parental behavioral rut-
lngs scales revealed no significant findings. However,
an observer-report assessment of attention problems
co-occurring disturbances that may have affected the
child's performance (e.9., below-average intellect or
mood disturbances) is critical in such cases.
h
h
completed by the parents revealed a borderline eleva-
tion on one of the rating scales. His scores fell within
Nevertheless, the preponderance of evidence from the
CCTT- 1 and CCTT-} performance, in conjunction

h
h
norrnal limits on a self-report depression scale.
With regard to the CCTT, his performance on the
CCTT- 1 fell into the mild-to-moderately impaired
with the results from other neuropsychological instru-
ments and family history, preclude a rule-out of

h
h
range (3 1 seconds, Z score = 34, 5th TolIe); and his
performance on the CCTT:Z feII into the moderately-
ADHD, Predominantly Inattentive Type. Such a hypo-
thesis is further supported by parental and teacher
reports, as well as by behavioral observations

h
h
to-se\rerely impaired range (83 seconds, f score = 24,
<ist Tcr\e). He made no errors, but required two
prompts on the CCTT-Z. The number of Prompts
suggesting the presence of inattention and restlessness.
It also is important to note that the aforemen-

h
h
fell into the 1lth to 16th Votle range. He also
obtained an Interference Index of 1.67 , corre-
tioned CCTT:I and CCTT-} findings, in most cases,
can lead to suggested interventions. For this client,
behavioral strategies to increase concentration and

h
h
sponding to the >16th Vorle.
Given the client's reported history and reason for
referral, his performance is consistent with that typi-
attentior, in both the home (e.g., quiet time for aca-
demic pursuits, dedicated study space) and the school

h
h
ca1ly observed in children with primary ADHD. His
very superior intellectual abilities and appropriate
(e.g., seating near the front of the classrooffi,
redirection) were recofirmended.

h
b
academic achievement assessment scores cannot
account for his academic underachievement. A simi-
Iar conclusion about his grade fluctuations can be
(ase 2: 8-Vear-0ld (hild Xith Seuere
Head llauma
h
h
reached from these scores.
The CCTT- 1 results suggest the presence of prob-
Chent 2 is an S-year, 6-months old, left-handed,
Caucasian male. He was referred for neuropsycho-
lems in concentration marked by an extremely long logical evaluation subsequent to a severe closed.head
12
h
4
information processing time (31 seconds). The overly injury involving the left frontotemporal regions (coup

b 35

b
effects), extensive loss of consciousness (approxi-
mately 15 days) and posttraumatic amnesia, low
Glasgow Coma Scale scores (2 to 6), and Magnetic
Resonance Imaging (MRI) findings documenting a
depressed skull fracture necessitating a craniotomy and
a left frontotemporal cranioplasty. His injury was the
result of a 15- to l7-foot fall from a roof, onto a steel
balustrade and subsequent immediate contact with a
hard surface. He now presents with problems in behav-
ioral and emotional regulation. After discharge from the
hospital, the child attended rehabilitation, where he
received extensive speech therapy, occupational ther-
apy, and physical therapy. He continues to receive these
ffeatments as an outpatient. He is free of seizures with-
out the use of medication.
Behavioral observations supported parental reports
suggesting the presence of labile mood, behavioral and
emotional disinhibition, and mild aggression. Overall
intellectual abilities, as measured with the WISC-UI
(Wechsler, l99I), fell in the low average range (81-87).
However, within this overall profile, verbal information
processing skills fell within the borderline range,
whereas nonverbal information processing skills fell in
the average range. The discrepancy between these
domains was found to be statistically significant and
was observed in a small group of the children compris-
ing the WISC-il standardization sample (Wechsler),
suggesting the presence of differential processing levels
favoring the nonverbal skills.
Neuropsychological screening revealed left-handed
dominance. However, he was right-handed prior to the
accident. History of familial sinistrality was unremark-
able, and an abrupt shift in dominance is suspected
(Satz, Orsini, Saslow, & Henry, 1985) as a result of the
injury. Performance on an informal gross motor task
revealed severe grip strength weaknesses with his right
hand, but spared grip strength with his left hand. On a
test of finger dexterity, he was unable to perform the
task with his right hand. His score with his left hand fell
in the low average range. Language skills were assessed
with a test capable of measuring both receptive and
expressive language abilities; his scores were in the
impaired range (60 t 5). His score fell within the
impaired range for ability to decode nonsense words
using a phonics-based strategy. Rote verbal list learning
scores fell within the borderline range. Over the course
of five ffials, he demonstrated a learning curve marked
by fluctuations with little increment in slope. Delayed
recall (20-minute) and immediate recall (remembered 4
36
out of 16 items) fell in the upper end of the borderline
range and were below expectation on both trials.
Unfortunately, limitations in attention were also noted
in this test. Scores on the subtests assessing verbal
attention also fell in the borderline range for a task
requiring digit repetition. All measures of emerging
executive functions (e.g. , Wisconsin Card Sorting kst;
Heaton et a1., 1993) fell in the impaired range. Results
of behavioral ratings scales completed by the mother
revealed clinically significant intern ahztng behavior
problems marked by withdrawal. His profile also
revealed a clinically significant elevation on indexes
assessing aggression and social problems. Problems in
adaptation across all domains also were evidenced
(activities, academics, and sociali zatton) .
On the CCTT-1 and the CCTT:2,hts performance
fell in the impaired range. His performance on the
CCTT:1 was 46 seconds (Z score = 24, <1st Vol7e) and
his performance on CCTT-} was 168 seconds (f score
< 19, <IstTotle). He required three prompts on CCTT:1.
which is a clinically significant number of prompts. He
made three Color Sequence Errors and two Number
Sequence Errors and required four Prompts on the
CCTT-2, despite his slow performance. These aspects of
his perfoffnance were also significant. He also obtained
an Interference Index of 2.65, corresponding to the 2nd
to 5th Votle range (mildly-to-moderately impaired).
The CCTT- 1 results suggest the presence of prob-
lems in concentration marked by extremely long infor-
mation processing time. However, the presence of
further involvement is inferred from the need for three
prompts even after an exceedingly long performance
time. CCTT:2 results require more complex interpreta-
tion. His Time score revealed severely impaired perfor-
mance suggestive of attention problems. In addition,
executive problems are surmised, marked by disinhibi-
tion, impulsivity, and poor planning resulting in several
color and number sequence errors and the need for mul-
tiple redirecting prompts. Cognitive slippage and/or mild
degradation in functioning, detected by the CCTT:Z, are
often seen in children who have sustained such cata-
strophic head trauma and are further inferred from these
effors. Unlike Case L, the fact that his Interference
Index fell well below expectation suggests the presence
of severe and specific alternating and sequencing prob-
lems, and disinhibition, regardless of the presence of the
generaltzed attention and information processing diffi-
culties that are often encountered in clients who have
sustained severe brain injury affecting the frontal lobes.
E CCTT:I and CCTT-Z findings led to recommen-
dations for behavioral interventions targeting
increases in concentration and attentioil, increased
These findings were consistent with the diagnosis
developmental reading disorder. Speech and language
scores were within noffnal limits. Social problems and
of a

lrnpulse control and regulation, and increased organi- aggression emerged as borderline impaired on parental
zation and planning. Home interventions (e.g., quiet and teacher rating measures.

E
h
time for academic pursuits, dedicated study space) as
u ell as a therapeutic program addressing social skills
trainin._e was recommended. With regard to school
Her performance fell within normal limits on the
CCTT-I and CCTT:2. She took 16 seconds to complete
the CCTT:I (Z score = 50, 50th VoIle) and she took
recommendations, ?S a result of the traumattc brain 34 seconds to complete the CCTT-2 (Z score = 51,
injury the child sustained, he qualified for academic 54th %olle). She required one Prompt on CCTT-2,
serr-ices. Specific curriculum alterations (e.g., extra
which was within normal limits. She obtained an

E time to complete long written assignments, computer-

ized instructional programs with immedtate feedback
and reward, shortened assignments, instruction in key-
Interference Index of 0 .3I, which was also within
normal limits (>16th Totle).
The results from CCTT- 1 and CCTT-2 suggested
boarding skills and other types of assistive technolo-
a lack of problems in concentration or executive
gies. use of criterion-based outcome measures) and
skills. Although one Prompt was required on CCTT-Z,

E classroom accommodations (e.g., seating near the

front of the classrooffi, redirection) also were recom-
mended. Multisensorial instruction and use of a pri-
this is within the normal range. Her Interference
Index fell within normal limits, suggesting a lack of
r ate tutor to address future academic difficulties and
alternating and sequencing problems.
provide supplemental instruction were requested. CCTT- 1 and CCTT-} findings, in conjunction
with results from other procedures, led to a conclu-
E Gir.en the child's executive skills deficits, he may be
at nsk for undue influences, and issues sulrounding
his safety are an important consideration. For this rea-
sion that her aggression was not being caused by an
emerging frontal lobe dysfunction or a lack of regula-
son. it was reconlmended that he be protected against tory executive functions. Such a conclusion was later

E such pressures and potential harm at all times.

(ase 3: l2-Yeal-0ld (hild Xith Heating

supported because her aggression was attributed to
frustration secondary to her newly-diagnosed progres-
sive sensorineural hearing impairment (subsequent to

E lmpediments and Deuelopmental

asymptomatic cytomegalovirus) and reading problems.

h Reading Disorder
Client 3 is a l2-year,7 -months old, right-handed,
Latina (Mexican-American) female who is currently
attending the sixth grade; she repeated the third grade.
Recommendations in this case addressed her hearing
impairment through the use of technology (e.g., hear-
ing aids to be used in a closed-captioned classroom),
behavioral interventions targeting her aggression, as
well as a therapeutic program addressing social skills

E
V)
She was referred for neuropsychological evaluation
for programming recommendations subsequent to a
recent onset of aggression. She suffered from mild
training. Curriculum alterations (e.g., extra time to
complete reading assignments, computenzed reading
instructional programs with immediate feedback and

b
4
bilateral hearing los s (23-34 dB) and chronic devel-
opmental dyslexia. She was not receiving medica-
reward, and lab resources) and classroom acconlmoda-
tions (e.g., seating near the front of the classroom) also

4 tion at the time of the examination.

Overall intellectual abilities, as assessed with the
were recommended. Multisensorial instruction and use
of a private tutor to address reading difficulties and
provide supplemental instruction also was requested.

2
4
N{exican revision of the WISC (WISC-RM; Wechsler,
G5mez Palacio, Padilla, & Roll, 1984),
a\rerage range. Her nonverbal score also
fell in the
fell within (ase 4.$-Year-Old (hild Xith RDHD,

b the average range, but her verbal score

upper end of the low average range. Academic
fell in the
Predomina ntly Hyperactiue- lmpulsiue

4 achievement fell in the impaired range on an overall Iype and Dysgraphia

b index of reading language arts, but within normal lim- Case 4is a talkative and active, right-handed,

b its on written language arts and overall mathematics. African-American male. He is currently in the third

b
b 37

b
grade. He was referred for evaluation secondary to a
protracted and severe history of attention problems
with hyperactivity complicated by dysgraphia. At the
time of the evaluation, he was receiving stimulant
medication with little improvement in concentration
or reduced activity, prompting this evaluation by a
pediatric neurologist requesting treatment recommen-
dations. The child had received no behavioral inter-
ventions. Electroencephalographic (EEG), genetic,
laboratory (e.g., urine, blood assays), and neuro-
imaging studies revealed no remarkable findings.
Behavioral observations revealed failure to pay
close attention and overall lack of focus, difficulty
sustaining attention, reluctance to engage in tasks
that require sustained mental effort, severe distrac-
tion, and hyperactivity. Significant impulsivity and
overt dysgraphia also were noted.
Intellectual assessment with the WISC-III
(Wechsler, 1991) revealed overall intellectual scores in
the average range (91 + 7). This finding is important
because it permitted a rule-out of problems in cogni-
tion as etiology for his behavior problems. Despite the
presence of dysgraphia, no signiticant scatter was
observed in his profile, except for a relative weakness
on a test requiring copying symbols (WISC-[I, Coding
subtest) and on a measure requiring digit repetition.
The patient did not meet DSM-IV criteria for
Oppositional-Defiant Disorder (ODD). Parental rating
scales revealed elevated scores only on a scale measur-
ing ADHD symptomatology.
His performance fell within normal limits on the
CCTT. He completed the CCTT- 1 in 28 seconds
g score = 45, 3 l st To|le) and he completed the
38
CCTT:2 tn 59 seconds (Z score = 46, 34th Torle). He
made three effors on the CCTT:I, which is clinicall1,
significant. He made two Number Sequence Errors.
four Color Sequence Errors, and he required four
Prompts on the CCTT-2. This performance was also
clinically signiticant. He obtained an Interference
Index of 1.1, which is within normal limits.
The CCTT- 1 results predominantly, but tenta-
tively, suggested the presence of problems in impul-
sivity, marked by an appropriate response time but an
overly high number of errors. CCTT-Z results were
similar; his Time raw score revealed normal perfor-
mance. However, there were a high number of effors
as a result of disinhibition, poor impulse control, and
poor planning. He made several Color and Number
Sequence Errors and he needed multiple redirectin,_e
Prompts. His Interference score, similar to that of
Case 1, does not suggest the presence of specific
sequencing problems.
Recommendations included behavioral and reha-
bilitative interventions focused on reducing impulsir'-
ity. It was also recommended that he be reevaluated
for a different stimulant medication (e.9., fast actin.-u
and slow release). Parent-child interaction therapy and
specific classroom and curriculum accommodations
were also recommended.
It is important to note thatthe CCTT scores reflect
the effect of medication being administered to this
child resulting in scores within normal limits. These
results should be compared with those from a child
suffering from ADHD who was not being medicated,
and whose scores fell within the mild-to-moderately
impaired range (i.e., Case 1).
E
n
n 5
-

2
h RellaDlllty and Ualldlty

This chapter presents information from studies .SD = 1.5 years) outpatient children who were of

2 conducted to assess the psychometric properties of

the inferences resulting from studies with the CCTT.
Reliability studies provide information regarding the
stability of the inferences derived from the test,
=
ll'hereas validity investigations address the extent to
u'hich the CCTT is able to appraise the constructs that
it purports to measure (Anastasi, 1988).
average intellect,with a mean IQ of 95 (SD = 5.9).
They were strictly diagnosed with vertically-acquired
asymptomatic congenital cytomegalovirus (CMV)
infection using viral culture and were participating in a
parent study (Noyola et a1.,2001) investigating the lon-
gitudinal sequelae of this infectious disease. Each form
(standard Form K and Form X prototype) was adminis-

h
h
tered in a counterbalanced order to minrmrze test-retest
effects. Test scores from both test forms were subse-

h
h
=
Rr1nBI1ril
From a theorettcal standpoint, the CCTT is a
quently analyzed to determine the extent of their rela-
tionship. Despite the small and restrictive nature of the
clinical sample (i.e., CMV), the results revealed statis-
speed test (Anastasi, 1988). As such, alternate-form tically significant (p

2
h
reliability and temporal stability are among the most
appropriate estimates of consistency for the test.
(Llorente, 2000). The relationship of the CCTT:I Form
K and Form X Time raw scores revealed a corelation

h
h ilternate- Form ReliaDility
in the high range (r =.85). A similarly high correlation
(r -.90) was evidenced between Form K and Form X
of the CCTT:2. In spite of these results and the fact
h
h
Alternate forms of the CCTT were developed by
spatially rotating, invertitrg, or both rotating and invert-
ing the original Form K (see chapters 1 and 2). This
that all forms of the CCTT:I and CCTT:2 are physi-
cally equivalent to one another, research that estab-

h
h
method of developing altern ate forms of the test
assured that the stimulus placement and the distance
lishes the psychometric and noffnative equivalence of
the alternate forms is ongoing. The normative data
presented in Appendix A were obtained using Form K

h
h
between stimuli would be generally equivalent for all
forms of the instrument (Franzen et tI., 1996).
Although the alternate-form reliability for the CCTT is
only. Form K is the only form that should
employed during the course of clinical examinations.
be

h
h
tentative due to limitations in design and the prelimi-
nary stimuli used, it was assessed in a pilot study
Form X, Form X and Form Z are considered experi-
mental versions at this time and should only be used
in research settings. Future research should establish
4
h
employing Form K and an experimental prototype of
Form X (the test that was inverted into a mirror-image
of Form K). Both test forms were administered to a
the reliability and equivalence of the alternate forms
in large samples of both healthy children and clinical

4
h
group (l/ = 12) of 8- to lO-year-old (M = 8.5 years; groups with different neurobehavioral disorders.

h 39

fr

Iempolal StabilitY
As noted above, the CCTT is a speeded test; thus
temporal stability is one of the approprrate methods
of calculating its reliability. Temporal stability is
obtained by computing the degree of relationship of
an instrument's Scores at two or more different points
in time for the same cohort of participants (Anastasi,
1988). In'other words, temporal stability is examined
through the correlation coefficient obtained from the
first and second, of Iateg administrations of a test to
the same group of participants. Unfortunately, the
ranges of the error, prompt, and near-miss CCTT
scores afe restricted due to the infrequent occulrence
of these scores, and this artificially reduces the mag-
nitude of the reliability coefficients. For this reason, it
was decided that test-retest correlations would only
be presented for CCTT variables with a sufficient
range and distribution of scores, namely CCTT:I and
CCTT:2Ttme raw scores.
The temporal stabitity of the CCTT was assessed
by Llorente et al. (2002). These investigators adminis-
tered the CCTT to a group of outpatients (l/ = 63)
ages 6- to I2-years (M = 9.3 years, SD = I.9 years).
These children were part of a randomtzed,, placebo-
controlled, double-masked investigation assessing the
effectiveness of dietary supplementation with
Docosahexanoic acid (DHA) to reduce ADHD symp-
tomatology (Voigt et al. ,2001). The sample was com-
posed of mostly boys (787o) and mostly Caucasian
(85 7o) parlicipants. These children were selected from
an overall sample of 250 potential participants and
had been strictly diagnosed with ADHD by a develop-
mental pediatrician using the DSM-IV (American
Psych ratnc Association , 1994). In additioil, other
stringent criteria (e.g., psychologist coratings and
exclusion criteria) were used to rule out potential
Table 10
Temporal Stabitity (Test-Retest Reliability)
Coefficients for the Children's Color Trails Tests L and' 2
0-2 months
CCTT:1 .46**
CCTT-2 .66**
Note. N= 63. CCTT-I = Children's Color Trails Test
Trails Test 2.
**p < .01.
40
It_
L
comorbid conditions as part of the parent inr-estiga-
Il*
tion. To investig ate the temporal stabilitl' of the
CCTT, the same participants underwent longitudinal l,_
assessment with the test at baseline and at 2 and + t_
months posttreatment. The results revealed statisti-
cally significant (p
shown in Table 10. The coefficients appeared to be
higher for CCTT-} relative to CCTT:I (except at the
0- to 4-month interval). This result was most 1ike11
due to the fact that CCTT-} is longer than CCTT- 1 .
Although the coefficients of stability observed for the
CCTT were below the level recommended for clinical
decision making of approximately rtt=.80 (Anastasi-
1988; S attker,2000), it should be noted that these rec-
ommendations usually apply to much shorter test-
retest intervals (Sattler) than those used in the studl'
by Llorente and his colleagues (i.e., 8 and 16 weeks;.
Had the CCTT been administered at shorter test inter-
vals (e.g., 2 weeks) as is customary when assessin-u
resr-reresr reliability, it is highly likely that the reliabil-
ity coefficients would have achieved greatet magnitude.
because as time between assessments increases, stabil-
ity coefficients decrease (Sattler). In addition, it is also
likely that test-retest reliability scores for a speeded test
from a more heterogeneous sample, with less restriction
in range of scores, rather than from such a homogeneous
research sample with ADHD, would have been greater.
Therefore, these scores appear to be appropriate for both
the long interval between test administrations and the
restricted population investigated.
Although the results shown in Table 10 address
the temporal stability of the CCTT when computed
for a group of children, traditional (correlational)
temporal stability coefficients fail to provide informa-
tion regarding the stability of individual test scores.
It is unfortunate that results that provide a gauge of
individual score variability historically have been
2-4 months 0-4 months
.45** .68**
.56* * .60**
l; CCTT-} - Children's Color
ignored because clinical cases involve the evaluation
of one individual (N = 1). For this reason, individual
test-retest mean difference scores with limits of
agreement using the method of Bland-Altman
(Altman & Bland, 1983) were computed for CCTT-I
and CCTT-Z completion times for the ADHD data
reported above, comparing the assessments obtained
at baseline, 2 months, and 4 months against each other
(these results are available from thefirst author). The
Bland-Altman procedure permits the plotting of indi-
vidual score differences against the average of the
test-retest values to determine if agreement between
test scores is related to response scores.
The reproducibility of individual scores using the
Bland-Altman procedure revealed less agreement
than temporal stability assessed using correlational
methods. There was more bias in individual comple-
tion times for CCTT-2 than for CCTT:I. In addition,
there was less overall bias in the comparisons
between the assessments obtained at baseline and 2
months than in the other comparisons between the
other assessments. The observed bias was the result
of increases in the difference of individual scores
from assessment to assessment as a function of
increasing average performance. The fact that
CCTT:Z completion time scores exhibited greater bias
(less individual test-retest score agreement) relative to
CCTT:1 completion time scores may be associated
with the lesser complexity of the CCTT:I relative to
that of the CCTT-Z subsequent to the reduced execu-
tive demands of the latter test, increasing the amount
of variability that participants are able to exhibit on the
test. It is also possible that the effect is the result of the
fact that the CCTT:I is always administered first, a
combination of these two factors, or other factors.
In general, the variability observed in individual
CCTT scores, although expected, has significant impli-
cations in applied settings, including assessment and
diagnosis. Consistent with the recommendations of
the Standards fo, Educational and Psychological
Te sting (American Educational Research Association,
American Psychological Association, & National
Council of Measurement in Education, 1999), CCTT
scores should be interpreted within the context of a
more comprehensive evaluation including the exami-
nee's history, neuropsychological test profile, and neu-
robehavioral characteristics because no individual
assessment component provides sufficient information
to interpret brain-behavior relationships. As the pre-
sent investigation additionally suggests, individual
CCTT test scores from single examinations should be
interpreted with due caution, as they may exhibit sub-
stantial interses sion variability.
Finally, it is also important to note that clinicians
are sometimes more concerned with diagnostic relia-
bility (i.e., the ability of a test to provide consistent
and stable nosological conclusions) than with consis-
tency of scores (Lacks , 1984). This has been termed
clinical reliability and is distinctly different from psy-
chometric reliability (Matarazzo, Matar azzo, Wiens,
Gallo, & Klonoff, I97 6). Therefore, the percentage of
agreement in the clinical interpretation was calculated
from CCTT- 1 and CCTT-2 in the Llorente et al.
(2002) investigation. The percentile range associated
with each raw score (i.e., ( 1 ,2 to 5, 6 to 10, 1 1 to 16,
>16th TolIe) was calculated and used to classify raw
scores into clinical interpretive ranges using the
demographically corrected norms presented in
Appendix A. CCTT:I and CCTT-} Time raw scores
exhibited good temporal clinical reliability (rs = .90
to .99) across various time intervals (i.e. , A to 2, 2 to
4, and 0 to 4 months).
UnuDrrY
(onstruct Ualidity
Construct Ualidity for tlaturafion
The scores of children of increasing age on the
CCTT should reflect the developmental changes con-
nected with central nervous system maturation, in
addition to measuring alterution in level of function-
ing in such domains. Increases in age were generally
associated with decreases in completion times for the
CCTT standardrzatron sample (see Figures 8 and 9 in
chapter 3). This finding is important because it indi-
rectly establishes the construct validity of the CCTT
with the children participating in the standardtzatton
of the test. The results suggest that the test is able to
capture increases in attentional, graphomotor, and
executive skills associated with nascent maturational
factors that emerge with increasing chronological age
and neurological development that are responsible for
faster performance-separate from any measurement
of altered functioning.
4I
Factorial Ualidity
Prompts, CCTT-2 Color Sequence Errors, and CCTT-
Most neuropsychological procedures and tests are
2 Number Sequence Errors. This factor was labeled
developed on the basis of hypothetical constructs
believed to be measured by these instruments.
Neuropsychological measures, including the CCTT,
also depend on the simultaneous use of several skills
(e.g., attention, executive, and graphomotor skills in
the case of the CCTT) for successful performance.
Factor analysis provides an excellent method of deter-
mining whether the CCTT actually measures some of
the constructs and skills it is presumed to assess. The
factorial validity of the inferences derived from the
CCTT also can be examined through factor analysis
of the primary factors with which the test correlates
and their proportional variance in the test.
Study l. Factor analysis was used to examine the
internal structure of the CCTT (Llorente et al. ,2002).
Initially, scores from all CCTT variables from the
normative sample (l/ = in chapter 3,,
657), described
were entered into a principal components factor
analysis. Based on the scree plot and eigenvalues (i.e.,
factors with eigenvalues > 1 were considered for
inclusion) from the unforced solution, three factors
were retained and subjected to varimax rotation. The
three factor solution accounted for 78.67o of the vari-
ance. Table 11 presents the rotated factor solution for
the normative sample. Factor 1 which accounted for
37 .47o of the variance, was defined by high loadings
of the two CCTT time variables as well as the
Interference Index. Because CCTT- 1 and CCTT-}
time variables and the Interference Index were well
accounted for by this factor, the factor was labeled
speed of perceptual tracking and susceptibility to
interference. Factor 2, which accounted for 225Vo of
Thble 11
Factor Anatysis of CCTT Variables in the Normative Sample
Factor
CCTT:ZTrme raw score
Interference Index
CCTT:1 Time raw score
CCTT:2 Prompts
CCTT:2 Color Sequence Errors
CCTT:2 Number Sequence Errors
CCTT:1 Prompts
CCTT:I Number Sequence Errors
Note. N = 657 .Datawere missing for 21 participants. Principal components factor analy-
sis was used with variance rotation. Factor loadings less than 1.101 are not displayed'
42
the variance, was defined by high loadings of CCTT-2
inattention and impulsivity because the variables
comprising this factor emerged as a result of complex
CCTT-} effors (Color Sequence Errors and Number
Sequence Errors) and examiner corrections
(Prompts). Factor 3 accounted for L8.77o of the vari-
ance and was defined by high loadings of CCTT- 1
Number Sequence Errors and CCTT-1 Prompts.
Unlike Factor 2, these effors and prompts were sim-
pler because they occurred on CCTT- 1 . Therefore.
Factor 3 was labeled simple inattention.
Study 2. The internal structure of the CCTT also
was evaluated in a sample of 366 children with mild
head injury (this sample is described in detail in the
Discriminant Validity section of this chapter) that
resulted from relatively minor trauma. A11 CCTT vari-
ables were entered into a principal components factor
analysis. Based on the scree plot and eigenvalues
from the unforced solution, three factors were again
retained and subjected to varimax rotation. Loadings
similar to those identified in the normative sample
emerged. The three factor solution accounted fot 8I%
of the variance. Table 12 presents the rotated factor
solution for the children with mild head injury. Factor
L, which accounted for 39 .97o of the variance, was
defined by high loadings of the CCTT:I and CCTT:2
time variables as well as the Interference Index.
Similar to Factor 1 for the normative sample, this fac-
tor was again labeled speed of perceptual tracking
and susceptibility to interference. Factor 2, which
accounted for 24.47o of the variance, was defined by
high loadings of CCTT- 1 Prompts and CCTT- 1
L Factor 2 Factor 3
.93 .25
.93 .25
.81 -.1 1 .2r
.18 .94
.20 .87
.49
.93
.93
\umber Sequence Errors. This factor, similar to
Factor 3 for the normative sample, was therefore
labeled simple inattention. Factor 3 accounted for
16.7% of the variance and was defined by high load-
ings of CCTT-2 Prompts and CCTT-} Color
Sequence Errors, similar to Factor 2 rn the normative
sample. This factor was therefore labeled inattention
and impulsivity.
Study 3. Finally, scores from a third group of chil-
dren (l/ = 355) with injuries other than mild head
injury (non-head injury) also were submitted to a fac-
tor analysis to investigate the factorial validity of the
inferences derived from the test with such a group.
The results revealed similar findings as those previ-
ousl1' presented for the norrnative and the mild head
injury groups.
5ummary
In sum, the factor structures obtained in the nor-
mative, mild head injury, and other injury samples
\\.ere similar. A11 three had factors that reflected speed
of perceptual tracking and sequencing. The factor
structures in all three samples also suggested that the
error and prompt variables tap constructs that are dis-
sociable from those captured by the time variables and
interference. In addition, it may be that these qualita-
tive variables capture different approaches to the
speed-accuracy tradeoff of CCTT performance. For
example, children may attempt to maximtze their
speed on the task at the expense of committing errors.
Conversely, they may minimize the number of errors
thel' cofirmrt at the expense of increased time scores.
It should also be noted that these results are somewhat
Table 12
Factor Analysis of CCTT Yariables in the Mild Head Injury Sample
Factor
Interference Index
CCTT:2Time raw score
CCTT:I Time raw score
CCTT:I Prompts
CCTT:I Number Sequence Errors
CCTT-2 Prompts
CCTT:2 Color Sequence Errors
CCTT-2 Number Sequence Errors
Note. N- 366. Principal components factor analysis was used. Factor loadings less than
I . 101 are not displayed.
similar to those for the adult Color Trails Test 1 and 2
(CTT; D'Elia et al., T996), but there are certain
poignant differences. For example, it is interesting to
note that both time scores were captured by one fac-
tor. However, for the CCTT, the Interference score
was also pooled and captured by the same factor
accounting for CCTT:I and CCTT:Z completion time
factor scores. In contrast, adult CTT time scores are
independent of interference and captured by two dif-
ferent factors. It is possible that developmental vari-
ables account for this difference. Adults, relative to
children, may be able to diseng age resistance to inter-
ference functions from perceptual tracking speed
leading to the differences in their factorial representa-
tion. This may be due to well-established matura-
tional variables in the adult brain, particularly frontal
lobe circuits and networks, that are not fully matured
but are emerging in children.
The aforementioned finding is important for
another reason. It suggests that the factor analyses for
these three groups are similar as expected. In fact,
differences in factorial representation should not be
found in three groups of participants with compara-
ble CCTT performance. For instance, including a
group of participants with the mildest of head injury
possible in the spectrum of traumatic head injury (see
the Discriminant Validity section) is not likely to pro-
duce different results when the performance is com-
pared to those from a group of children who have
sustained physical trauma without injury to the head
or to a group of children without any type of trauma
whatsoever who were paft of the normative sample.
1 Factor 2 Factor 3
.94 .25
.94 .25
.76 .39
.97
.96
.19 .91
.2r .90
.20 .41
43
 In conclusion, the results from factor analytic
studies support the construct validity of the CCTT as
a measure of attention, perceptual trackiflg, and
emerging executive skills including control of sus-
ceptibility to interference, inhibition, and planning
(set shifting).
(oncurrenl Ualidity
The CCTT should exhibit high correlations with
raw scores and the Children's Trail Making Test A
and B scores. A11 of the correlations reached moderate-
to-high elevations and all reached statistical signifi-
cance. As it relates to concuffent validity, this finding
suggests that both tests appear to measure similar
functional domains (Williams et a1.).
Study 2. Because the CCTT is a measure of atten-
tion and information processing, CCTT scores should
also be correlated with scores from other neuropsycho-

similar graphomotor measures, or other neuropsycho-
logical procedures, partLcularly those that assess
domains similar to those hypothesized to be measured
by the CCTT.
Study l.In an attempt to assess the concurrent
validity of the CCTT with similar instruments,
Williams et al. (1995) assessed the extent of the rela-
tionship between the CCTT and the Children's Trail
Making Test A & B. This study compared the perfor-
mance on both measures, using 223 children who
were evaluated for learniflg, emotional, of behav-
ioral difficulties either through a multidisciplinary
team in an outpatient developmental center or
through a local school district. The children ranged
in age from 5 years, 11 months to 16 years, 10 months
(M = 1 1.1 years; SD - 2.4 years) and were of average
intellect, with mean WISC-il Fu[ Scale IQ scores of
9I (SD = 13.6). The study sample was composed of
69 gtrls and I54 boys. Each child was administered a
battery of tests assessing academic, intellectual, and
behavioral domains. Both the Children's Trail
Making Test A and B and the CCTT-I and CCTT-Z
were administered according to their standatdrzed
administration guidelines. Table 13 shows the correla-
tion coefficients for the CCTT- 1 and CCTT-} Time
logical measures that also purport to measure such con-
structs. The CCTT exhibited concuffent validity with a
computenzed measure of attention and information
processing, the T.O.V.A. (Greenberg & Kindschi.
1996),, in an investigation conducted by Llorente et a1.
(2002) with children diagnosed with ADHD. These
children initially had been part of a study conducted b1'
Voigt and colleagues (200I; see Temporal Stabilitl'
section). Although modest in magnitude, the CCTT
time scores exhibited statistically significant correla-
tions with the reaction time (RT) measure and an index
of inattention (errors of omission) on the T.O.V.A. as
depicted in Thble 14. Despite the divergent nature of
the CCTT and the T.OV.A. (i.e., graphomotor vs. com-
putenzed procedure, respectively) and the modest cor-
relations, this finding suggests that the CCTT may
indeed assess attentional, information processing, and
executive variables (inhibition, etc.) that are measured
by other neuropsychological instruments capable of
providing accurate inferences about such functions. On
the other hand, due to the divergent nature of how each
test measures such constructs, as well as the restrictive
clinical sample under investigation (children with syn-
dromal ADHD only), they should not be expected to
exhibit much greater association.

Thble 13
Correlations Between Timed Scores (Seconds) Children's Color
Trails Test L and 2 and Standard Children's Trail Making Test
Timed test SCTMT.A SCTMT-B CCTT.I CCTT.2

SCTMT.A 1.00 .59 .74 .74

SCTMT-B 1.00 .54 .67
CCTT.1 1.00 .69
CCTT-2 1.00

Note. N = 223. SCTMFA = Standard Children's Trail Making Test Part A (Reitan, 1971);
SCTMT:B = Standard Children's Trail Making Test Part B (Reitan, 1971); CCTT-I =
Children's Color Trails Test l; and CCTT:2 = Children's Color Trails Test 2. Reprinted
from Archives of Ctinical Neuropsychology, 10, J. Williams, V. Rickert, J. Hogan, A' J.
Zolten, P. Satz, L. F. D'Elia, et al., "Children's Color Trails l' p' 215, Copyright 1995' with
permission from Elsevier Science. All correlations significant atp < .05 level.

44
 Thble 14
Pearson Product-Moment Correlations Between Children's
Color Trails Test 1 and 2 Time Raw Scores (Seconds) and
T.O.V.A. Reaction Time (RT) and Errors of Omissions (OMM)
CCTT test interval
Baseline
CCTT.1
CCTT-2
2 months
CCTT-1
CCTT-2
4 months
CCTT.1
CCTT-2
Note. N = 63. T.OV.A. = Test of Variables of Attention (Greenberg & Kindschi, 1996);
CCTT:I = Children's Color Trails Test 1; CCTT-2 = Children's Color Trails Test 2.
*p <.05.**p <.01.xxxp <.001.
Dis(riminant Ualidity
Although a neuropsychological procedure should
be able to discriminate between the performance of
children with known or suspected functional impair-
ments from the performance of healthy childrer,
neuropsychological procedures should be capable of a
more arduous type of discrimination-namely the dif-
ferentiation of the performance of children with dis-
tinct known or suspected dysfunctions. In addition,
the Standards fo, Educational and Psychological
Te stirt g (American Educational Research Association,
American Psychological Association, & National
Council on Measurement in Educatron, 1999)
mandates such a level of discrimination of neuropsy-
chological procedures. Studies addressing both types
of discrimin ant validity from the inferences derived
from CCTT scores were evaluated as part of the
development of the instrument.
Study /. To assess the discriminant validity of the
CCTT, a comparison was made between children
n'ith suspected or documented alterations in neuro-
logical functioning and a control group of children
free from insult drawn from the normative sample
(\\'illiams et al. , 1995). The clinical groups predomi-
nantly consisted of outpatient children with mild
neurological disorders (predominantly mild closed
T.O.V.A.
RT OMM
.47*** .4I***
.51*** .35**
.40** .27*
.34* .55***
.39** .43**
.49* * .47**
head injuries with documented loss of consciousness
and positive MRI findings and epilepsy with generul-
tzed or complex partial seizures), learnin g and/or lan-
guage disabilities, and Attention-Deficit/Hyperactivity
Disorder (ADHD) with learning and/or language dis-
abilities. Children received a diagnosis of ADHD on
the basis of significant elevation on several markers
including behavioral rating scales, such as the
Conners' Parent and Teacher Ratings Scales (CRS;
Conners, 1973),, behavioral observations in a clinical
setting, other indexes of inattention such as computer-
tzed tests of attention (CPT; Loong, 1988), and tasks
assessing freedom from distractibility such as the Digit
Span and Arithmetic subtests of the third edition of the
Wechsler Intelligence Scale for Children WISC-il
(Wechsler, I99I). Children with learning disorders
were diagnosed according to state and federal guide-
lines. All met criteria for learning disability involving a
significant discrepancy between measured cognitive
ability and academic achievement in reading, mathe-
matics, and/or written language skills. Children's ages
ranged from 5 years, 11 months to 16 years, 10 months
(M = 1 1.1 years; SD - 2.4 years), with a mean intel-
lectual ability (IQ; as assessed with the WISC-III) for
each group falling within the average range (overall
general intellect for all groups (M = 9I; SD - I4), Table
15 depicts the CCTT results obtained.
45
 Thble L5
Children's Color Thails Test 1 and 2 Time
Raw Scores as a Function of Diagnostic Groups
Diagnostic group scores

Mild Learning
Learning neurological disabled
Test Controlsa disabledb impairmentc with ADHDd
CCTT.l
M fl.7 2r.2 25.3 27.4
sl) 7.9 10.3 15.3 12.2

CCTT.2
M 31 .2 5s.6 60.5 7 6.8
sl) 15.6 23.r 24.8 3 8.9

Note. N = 568. CCTT-I = Children's Color Trails Test l; CCTT-2 = Children's Color
Trails Test 2. From Williams et al. Reprinted fuom Archives of Clinical Neuropsychology,
10, J. Williams, V. Rickert, J. Hogan, A. J. Zolten, P. Satz, L. F. D'Elia, et al., "Children's
Color Trails," p. 215, Copyright 1995, with permission from Elsevier Science.
az bn=93.cn 58. dn=29.
= 388. =

Comparisons indicated a significant difference
between the diagnostic groups on the CCTT:I and
CCTT:2. Post-hoc analyses using Scheff6 tests for sig-
nificant differences indicated that the normal control
group performed faster than the learning disabled
group, the mild neurologically impaired group, and
the learning disabled and ADHD group on both
CCTT:I and CCTT-Z.
Study 2.In addition to a comparison between a
healthy group and clinical groups, Williams et al.
(1995) set out to examine the discriminant validity of
the CCTT in groups of children with different neu-
ropsychological disorders. Their goal was to study
the discriminating ability of the CCTT in children
suffering from insult within the continuum of mild or
subtle neurological insult (e.g., ADHD) to those with
tests indicated that the LD group performed signifi-
cantly faster than the ADHD ILD group. The mild trau-
matic brain injury group was not significantly different
from either the LD or the ADHD ILD group.
Study 3. Another attempt to study the discriminant
validity of the inferences derived from the CCTT
comes from the results from an unpublished study con-
ducted by Levin et a1., (2003) that represents a recent
attempt to replicate a major finding in the Williams et al.
Thble 16
Comparison of CCTT-I and CCTT-2 Time
Raw Scores According to Clinical Group
Clinical group scores
Test LDA Mild TBIb ADHD II-,DC

documented, more severe neurological altetations

CCTT.1
(e.g., traumattc brain injury).
M 22.8 21 .3 27.9
The clinical group from the Williams et al. SD t2.8 15.8 12.6
(1995) study and an additional group of 6- and CCTT-2
7 -year-olds, who were excluded from the preceding M 60* 64.r I5.5*
analysis, were compared on both CCTT:I and CCTI-Z SD 28.6 29.4 38.4
using a one-way analysis of variance (ANOVA).
Note. LD = Learning disability; Mild TBI = Mild traumatic
Thble 16 shows means and standard deviations for the brain injury. ADHD ILD = Comorbid Attention-Defi crtl
three groups of children. Although the results did not Hyperactivity Disorder/LD. Reprinted from Archives of Clinical
Neuropsychology, 10, J. Williams, V. Rickert, J. Hogzn, A. J.
reveal a statistically significant finding for CCTT:I,
Zolten, P. Satz, L. F. D'Elia, et al., "Children's Color Trails,"
F(2, I97) = 2.85, p p.215, Copyright 1995, with permission from Elsevier Science.
result , F(2, I97) = 3.I4, p un= 101.
bn=67.cn=32.
CCTT:2. Follow-up post-hoc analyses utilizing Scheffd *p <.05.

46
{ 1995 ) study already discussed. It
was designed to
determine the relationship of the CCTT to the WISC-
m and to evaluate the validity of the CCTT for dis-
criminating among children with different types of
learning and behavioral disorders.
The sample consisted of I45 consecutive referrals
to the HELP/UCLA Neuropsychological Assessment
Laboratory during the past 3 yea$. The HELP group
represents one of the largest diagnostic and treatment
centers in the western U.S. for children with various
developmental problems including ADHD, autistic-
spectrum disorders, and learning disabilities. The sam-
ple consisted of children, predominantly Caucasian
(,717c) and male (7I7o), ranging in age between 6 and
16 years (M - 10.52 years, ^SD - 2.45 years), in grades
1 through 10. Seventy-nine percent of the children
\\'ere right-handed. The sample consisted of children
diagnosed with ADHD (n = 15), LD (n = 52),
ADHD/LD (n - I7), psychiatnc disorder (n - 39), and
children with no diagnoses (n - 22).
CCTT:1 Z scores were significantly correlated
r,r'ith the WISC-ru Fuil Scale IQ scores (r - .23, p
.05), Performance IQ scores (, - .32, p
Perceptual Organtzatronal Index (r - .28, p 1.01), and
the Processing Speed Index (r = .32, p
CCTT:I exhibited a moderate level of convergence with
-qeneral intellectual skills and nonverbal
functioning.
CCTT:2 T scores were significantly correlated with the
WISC-ru Full Scale IQ scores (r = .37, p
Verbal IQ scores (r = .23, p
scores (r - .45, p
Index (r - .20, p <.05), the Freedom from Distractibility
Index (r - .27, p <.01), and the Perceptual Organrzatton
Index (r = .4I, p
more broadly associated with all types of intellectual
functioning than the CCTT:I. These results are consis-
tent with other studies that have demonstrated associa-
tions between trail making tests and intellectual
functioning (e.g., Rosin and Levett, 1989b).
Statistical analyses were also used to contrast
CCTT performance Z scores (adjusted for age) between
the different diagnostic groups and a random sample
selected from the CCTT normative sample (n - 97). The
use of the CCTT Z scores controlled for age effects.
Given the small sample sizes in the diagnostic groups,
/ tests were used instead of other statistical procedures
in order to conserve statistical power. The descriptive
statistics for the different samples are presented in
Table I7. The results demonstrated robust differences
between the different samples. Children diagnosed
with LD had significantly lower performance than the
nonnative children on the CCTT:I, t(I43) - -5 .23, p <
.001, and the CCTT-2, t(L40) = -6.24, p
Children diagnosed with ADHD exhibited no signifi-
cant differences from the normative subsample on
CCTT-1, /(106) = -.62, fts., and on the CCTT-Z,
r(106) - -1 .56, n,s. This finding may be attributable to
the fact that at the time of testing these children were

Table L7
CCTT T Scores for the Normative Subsample and Clinical Samples
and TMT 7 Scores for the Clinical Samples
Samples

Test Normativea ADHDb LDC ADHDrLDd

CCTT.1
M (SD) s0.80 (10.4) 48.74 (10.7) 37.32 (20.1) 34.er (22.0)
CCTT-2
M (sD) s0.32 (8.7) 4s.e4 (r2.e) 37.e3 (1s.0) 33.3e (26.4)
TMT.A
M (sD) s2.63 (e.8) 48.e6 (10.7) 44.20 (ls.e)
TMT-B
M (sD) s0.e8 (13.e) 48.28 (10.4) 36.87 (30.1)

Note. Normative = Normative subsample. ADHD = Attention-Deficit/Hyperactivity

Disorder; LD = Learning disability; ADHD/LD = ComorbidADHD/LD. TMT.A = Trail
Making Test PartA. TMT-B = Trail Making Test Part B.
an cn dn
= 97 .bn = 11. = 48. = ll. Z scores were not able to be calculated for some of the
clinical participants due to missing data.

4l
receiving stimulant medication to treat their ADHD'
Children diagnosed with comorbidADHD/LD had sig-
nificantly lower performance on the CCTT-I, /(106) =
p<
-4.18,p < .001, and the CCTI-2, (105) = -4'59,
.001, when compared with the normative subsample'
Another goal of the study was to compare CCTT
scores with scores from the Children's Trail Making
Test in order to determine if one test was more sensi-
tive to these diagnostic conditions than the other'
7 scores for the CCTT were used and T scores were
calculated for the Children's Trail Making Test (TMT)
based on the normative data for children presented in
Spreen and Strauss (1998). For each diagnostic group
(ADHD, LD, ADHD/LD), one sample ttests were used
to determine if the Z scores from the TMT were signifi-
cantly different from the mean Z scores from the corre-
sponding CCTT scores. The CCTT means within each
diagnostic group were used as the test values' The
descriptive statistics for the TMT performances are pre-
sented in Table 17. Within the ADHD sample, / tests
revealed no significant difference between CCTT-I and
TMT:A, t(14) = I.54, ns., and between the CCTT-2 and
the TMT-B, t(I4) = l.4l,ns. This finding is likely to be
attributable to the fact that the ADHD group was
receiving stimulant medications at the time of assess-
ment. Within the LD sample, CCTI-I scores were sig-
nificantly different than TMT-A scores, t(50) = 7 '77,
p < .001, and CCTT-2 scores were significantly differ-
ent than TMT-B scores' t(49) = 7'03' p <'001' within
the comorbid sample, CCTT-I scores were signifi-
canfly different than TMT-A scores, t(16) = 2'4t, p <
.05, but CCTT-2 scores were not significantly different
than TMT-B scores' (15) = '46' ns' Examination of
Table 17 reveals that CCTT scores were significantly
lower than TMT scores within the LD sample and the
CCTI-I was lower than the TMT-A in the comorbid
sample. These results suggest that in some cases the
CCTI may be more sensitive to the cognitive impair-
ment associated with LD and comorbidADHD/LD'
Study 4. The UCLA Study of Mild Closed Head
Injury (MHI) in Children and Adolescents (Asarnow et
al., 1995) was designed to determine the effects of MHI
in children and adolescents on academic, behavioral, and
cognitive measures at l-,6-, and 12-months post injury'
The rationale for this study was to help resolve much of
the conffoversy regarding morbidity in children at the
mildest end of the spectrum of head injuries' As noted in
a recently updated review of the literanre (Satz, 2001),
the field is still polarized between those claiming the
48
outcome aS "a silent epidemic" to those questionlng
whether any adverse effects are involved. The UCLA
project started with the premise that much of this contro-
versy was linked to three major uffesolved methodologi-
cal problems, namely subject ascertainment, definitions
of mild head injury and control of pre injury risk factors.
For this reason, the design included a large represen-
tative community sample of children identified through
a prim afy portal of 1 4 emergency -cafe rooms in three
different counties in the Los Angeles basin. The cohort
also included frequently understudied African-
American and Latino populations to avoid some of the
biases based on selection of primarily symptomatic
clinic referrals.
Because of the absence of operational definitions of
mild and moderate head injury in children, we chose to
study youth with uncomplicated MHI at the mildest end
of the spectrum of injury using a standardrzed abbrevi-
ated injury scale score of only 1 (only two concussive
symptoms), 2 (coma less than t hour), of 3 (coma
between 1 and 6 hours). This classification meant that
all children in the MHI group (n - I37) had at least fwo
concussive symptoms. Thirfy percent of the group had
three concussive symptoms and 3L7o had four or more
symptoms. A unique feature of this longitudinal design
is that it included an "Other Injury" (non-head trauma)
group of 132 chrldren matched to the MHI group using
abbreviated injury scale criteria. The design also
included a matched non-rnjury control sample (n = I34)'
A11 participants underwent academic, behavioral, and
neuropsychological assessments at 1-, 6-, and L2-
months post injury. Unlike most prior studies, children
with previous history of academic, behavioral, and
learning problems were not excluded. This design
ensured a more representative sample of children in the
actual population of mild head injuries. Because this
manual focuses on the standardizatron and validation of
the inferences derived from the CCTT, only a brief
overall summ ary of the study results will be presented
followed by a corlment on the CCTT.
The CCTT results from 1 month post injury ate
presented in Table 18. The means and standard devia-
tions for the normative sample also are included in
Table 18 for comparison purposes. The entire results at
L,6, and 12 months failed to show any adverse effects
of neuropsychologi cal, behavioral, or academic func-
tioning for the MHI group. Although a higher rate of
preinjury behavior problems were noted in the MHI
tr group. they were within normal limits and similar to found on the comprehensive clinical and experimental

n the other injury group. Therefore, there was no speci-

tlcitr- for behavioral difficulties associated with MHI.
A similar finding was observed for a few of the neu-
ropsvchological measures (memory and attention).
Thel' were similarly higher though within normal
neuropsychological battery lends further evidence for
the validity of negative findings in the CCTT. In clinical
assessment, the examiner should consider the validity of
both positive and negative test signs to ensure both sen-
sitivity and specificity.

E ranses in the two injury groups, but not specific to the

\IHI group. Mean achievement test scores were simi-
lar to pre injury scores at 6- and l}-months post injury.
Study 5. Another study investigating the discrimi-
nant validity of the CCTT was conducted through a

E A trnal analysis questioned whether severity of injury

MHI spectrum might have had
ratings within the an
comparison between children with syndromal ADHD
from the investigation described previously (Voigt et al.,
2001) and an age- and gender-matched random sample
effect on neuropsychological measures at 6 or 12 of children in the standardrzatron cohort (Llorente et d-.,
months. The results were again null. 2002). Only the baseline visit, prior to undergoing sup-

E
The preceding results show quite similar perfor- plementation with DHA (treatment), in which the chil-
mance times between the clinical groups and the dren with ADHD were unmedicated (i.e., had received

h healthy controls. The fact that similar null results were no stimulant medication for 24 hours) and exhibited

Table 18
CCTT Performance Time Means and Standard Deviations for the

E UCLA Groups 1 Month Post Injury and the Normative Sample

Groups

c Test
Mild
head injurya
Other
injuryb
Healthy
controlsc
CCTT
normative
sampled

CCTT.l
M 2t.5 2T.I 17.9 T7.T5

E ,SD 12.9 19.3 8.8 7.4

h
L.2
CCTT:2
M
SD
45.4
29.0
39.6
13.7
37.8
n.9
36.r9
15.7

h
h
un
= I37 .bn = 132. "n = 134. dn = 662.

b
L.a
T-Score Performance
Table 19
Means and Standard Deviations

h
h
for an ADHD Group and a CCTT Standardization Group
Groups

4
b Test ADHDA
CCTT
Standardizationb

4
4
CCTT-1
M
SD
34.96
20.88
51.10
9.89

4
h
CCTT.2
M 34.04 5 1.38

4
4
SD 20.98

Note . ADHD = Attention-Deficit/Flyperactivity Disorder.

un
-
8.88

b
= 63.bn 65.

49

2
I
the untreated correlates associated with ADHD, was
used for comparison with the standardtzatron sample.
This course of action was taken to avoid introducing
treatment variables that could obscure the discriminant
validity of the CCTT. Means and standard deviations
were computed for both groups and are shown in Table
19. CCTT- 1 and CCTT-Z group means (raw scores
were converted to Z scores to control for age) were
submitted to a / test for independent samples between
the two groups for CCTT: I, t(I27) - -5 .65, p <.001,
and for CCTT-2 t(L26) = -$.I2, p < .001' The results
revealed statistically significant differences. Faster
CCTT- 1 and CCTT-} performance times were
observed in the standardtzatron sample compared to
the ADHD sample (note Z scores). More importantly,
the CCTT was able to discriminate between these two
groups of participants, supporting the discriminant
validity of the instrument. It is important to note the
differences between this study and the study by Levin
et al. (2003). Levin and colleagues found no differ-
conditions and those of children in the standardrza-
tion sample are presented.
In summary, comparisons between clinical groups
of children and age-equivalent standardtzatron or healthy
control groups support the discriminative validity of the
CCTT to distinguish children with altered neuropsycho-
logical functioning from those free from insult. These
validity studies suggest that the CCTT is able to distin-
guish children from various clinical categories as well.
These results afe consistent with the Standards fo,
Educational and P sychological Testing (American
Educational Research Association, American
Psychological Association, & National Council on
Measurement in Education, 1999) that mandates psy-
chological tests have the ability to distinguish not just
between healthy and abnormal states but within abnor-
mal states. Although both portions of the test were able
to discriminate between diagnostic groups, CCTT-}
appears to be more sensitive than CCTT:I in discrimi-

ences between healthy children and children diagnosed
with ADHD, which is inconsistent with our findings.
However, it should be noted that the cuffent children
were not medicated whereas the children examined
by Levin et al. were receiving medications at the time
of the testing. Refer to Appendix B for an illustration
of the sensitivity of the CCTT to the effects of stimu-
lant medication. The reader also is referred to
Appendix B where the base rates of different CCTT
performance levels of children with ADHD and other
nating among children with learning disabilities, affen-
tional deficits, or neurological conditions.
(onculrent Ualidity Xith
Biological ilalkers
A large proportion of the solid content of neural
tissue is composed of lipids, particularly essential
fatty acids (Cooper et zl., l99I). These fatty acids
suppoft anatomical or structural and functional brain

Table 20
Pearson Product-Moment Correlations Between
Children's Color Tlails Tests 1 and2 Time Raw Scores and Biological Markers
Plasma phospholipid fatty acid concentration (mole Vo) at 4 monthsu

20:4t.lc6 22:5.lc3 20:4a6 + 22:5a3

CCTT.1 -.24^ -.28* -.25^

CCTT-2 -.23 -. 18 -.23

Urine monoamine metabolites at 4 monthsb

Dopamine Norepinephrine Epinephrine

CCTT.1 .39* .4r* .28

CCTT.2 .40* .47* .31

Note. 20:4a6 = &f&chidonic acid; 22:5a3 = oleic acid; CCTT- 1 = Children's Color Trails Test 1; CCTT-Z -
Children's Color Trails Test 2.
np
..08 - .09 tren d.*p < .05.
an=49.bn = 31.

50
e ,--;. :;:1sms. Simil arly, neurotransmitters such as
: :;::-tnc ' DA I and norepinephrine (NE) support the
Although similar in magnitude, the correlations between
these polyunsaturated fatty acids and CCTI-2 Ttme raw

E
lL--
*: *: - :he nrical brain functions partly responsible for
:: *: -:s\ rhological processes. Alterations in levels of
:; *r --,lf .1nsmitters, in some instances, have been
scores did not reach statistical significance.

More relevant to the CCTI as it purports to mea-

sure brain function, Llorente et al. (2002) also investi-

1-- -:t-.:--cated in childhood neuropsychiatric distur- gated the relationship between CCTT Time raw scores

l; r;r,e s .1s is the case in ADHD (Barkley, 1998).

r- -.,r;ingl). the degree of association between select
and monoamine (dopamine, norepineprine, and epi-
nephrine) urine metabolites after 4 months of DHA
ll-- :-*r'r''frological markers responsible for brain func-
t;
G
:- .':> .:.nC CCTT variables was examined.
supplementation, controlling for total creatinine out-
put as a way of controlling the effects of renal func-

g
g
In an anempt to investi gate the concuffent validity
:: the CCTT- 1 and CCTT-} with biological markers
lu:ri-q childhood. Llorente et al. (2002) investigated the
tion. The results revealed statistically signiticant
correlation coefficients that were moderate in magni-
tude (see Table 20). Because monoamine metabolites
:c,a::cnshrp beru'een CCTT scores and plasma phospho- are indirect markers of brain neurotransmitters, unlike
l;
u
l'-:
"-l-.j markers of essential fatty acids, as well as urine
il -otos.rrrine metabolites in the cohort of children with
plasma fatty acid in blood level content that does not
necessarily indicate brain levels (e.g., select cells in

u
"iDHD described earlier (Voigt et al., 2001). Children the brain, including astrocytes, have been shown to
e :e asked to provide urine and blood samples; these
',,i, produce their own DHA [Moore, Yoder, Murphy,

rj
rj
r;niples subsequently underwent assays to determine
,-', eis of select urine monoamines metabolites and
r -,r-sna pho spholipid fatty acid concentrations.
Dutton, & Spector, L9911), the monoamine-CcTT
correlation coefficients were greater than those
obtained from the plasma phospholipid fatty acid

rj
rj
CCTT- I scores exhibited concurrent validity with
piasnia phospholipid fatty acid concentrations (percent
rrt-rie r of arachidonic acid and oleic acid after 4 months
contents and CCTT variables. Altogether, these
results buttress the convergent validity of the CCTT,
particularly when the restrictive nature of the sample
1-: ,r: Cocosaheraenoic acid (DHA) supplementation (Thble under investigation and the divergent nature of the

I; :{-} . Althou_eh the magnirude of the correlations fell in the variables under scrutiny (biological markers vs. cog-

I,i lurr,r, range. CCTT:I Time raw scores exhibited statisti-

--eilr sienificant associations with these markers.
nitive variables in ADHD children as measured by a
graphomotor test) are considered.
Ij
lj
rj
r-:
Thble 21
Mean Time Scores (in Seconds) and Standard Deviations
According to Order of Test Administration
lj
t-: Tests

l-: TMT-A TMT.B CCTT:I CCTT-Z

rj
rj
Administration la
M
SD
23.7
15.6
s9.t
33.6
24.4
r0.4
64.4
35.6

lj Administrati on 2b

lj M 20.2 53.4 23.4 63.0

l; SD t0.2 26.9 16.2 30.6

Note. N = 119. TMT-A = Trail Making Test Part A; TMT-B = Trail Making Test Part B.
Reprinted from Archives of Clinical Neuropsychology, 10, J. Williams, V. Rickert, J. Hogan,
A. J.Zolten, P. Satz, L. F. D'Elia, et al., "Children's Color Trails," p. 215, Copyright 1995,
with permission from Elsevier Science.
aTMT A & B administered first (n 6l). bccT-ll and CCTT-2 administered first (n 58).

E = =

h 51

E

Irsr f,tilrlrslRRIlolt
0 RDER ETFE(IS
Recent investigations in the adult (Franzen,
Smith, Paul, &. Maclnnes, 1993) and pedi afttc
(Llorente, Sines, Rozelle, Turcich, & Casatta, 2000)
literature have revealed the importance of order
effects during the course of neuropsychological
assessment. Clearly, the sequential presentation of
two neuropsychological procedures may, under spe-
cific circumstances, impact upon the outcome on the
second test as a result of sequential presentation of the
first test (Franzen et aI.; Llorente et a1.). Such an out-
come may be more likely to occur if the two measures
or tests share the same or similar administration pro-
cedures, constructs, andlor brain functions underlying
performance (cf. Llorente et al.).
Williams et al. (1995) sought to study the effects
of administration order on performance times for Trail
Making Test A & B followed by CCTT:I and CCTT-Z
and vice versa in a small sample of children. Table 2I
shows means and standard deviations of participants
for both administration orders. Order of test presenta-
tion failed to impact completion times.
The study by Levin et aI. (2003) also was designed
to replicate the Williams et al. (1995) investigation
addressing the effectsof administration order for per-
formance times, but only for Trail Making Test A
(TMT-A) and Trail Making Test B (TMT-B) followed
by CCTT:I and CCTT-Z. The study involved a small
sample of children (l/ = 35). As noted earlier for the
Williams et al. ( 1995) study, the researchers examined
the effects of order for both tests and found no
improvement in performance time on either test when
the other was sequentially administered. Table 22
shows the mean times in seconds and standard devia-
tions for order of administration for TMT:A and TMT-
B followed by the CCTT-I and CCTT-Z for the Levin
et aI. and Williams et al. studies for comparison.
Student's / tests were computed by clinical groups com-
bined for each test. Similar to the findings by Williams
et zl., Levin et aL. found no improvement in perfor-
mance on the CCTT when preceded by the TMT.
These findings are important because they allow
examiners to use both tests, if desired, for comparison
andlor breadth during the evaluation process. Com-
bined, these results also suggest that, although the
TMT and the CCTT measure similar domains and
processes, one test may not infringe on the other test
when they are sequentially administered. This findin-.e
may be the result of differences between the two tests,
including the most obvious and major distinction
related to a lack of lexical processing for the CCTT.

Table22
Mean Time Scores (in Seconds) and Standard Deviations
According to Order of Test Administration
Administration Order

Study TMT:A TMT.B CCTT:I CCTT-2

Williams et al.r l995a

M 23.7 59.r 24.4 64.4
SD 15.6 33.6 r0.4 35.6

Levin et al., 2003b

M 20.0 46.5 25.0 54.8
SD 9.7 34.3 12.8 27.9

Note.TMT-A = Trail Making Test PartA; TMT-B = Trail Making Test Part B.
uN
=223. Reprinted from Archives of Clinical Neuropsychology, 10,J. Williams,V' Rickert,
J.Hogan, A.J.Zolten,P.Satz,L.F.D'Elia,etal.,"Children'sColorTrails,"p.2l5,
Copyright 1995, with permission from Elsevier Science.
bN 35. From "Temporal Reliability of the Children's Color Trails Test by P. M.
=
Levin, D. Logsden, L. Abrams, & P. Satz, 2003, Manuscript in preparation. Adapted by
permission.

52
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t-
4
,l

4
4
1
1
1
1 lppendix f,
1
1 f,ge-(orrected Standaldized Scole llanslormations
1 Dy tge lor the ((II-l and ((II-2 lime Rax Scores
1
1
?
4
1
1
1
1
1
1
1
1
1
1
4
1
4
4
A
,t
;,J
;,J
4
;.,-
1
1
l-
.-
;
1
1
1
1 51
,2
b
I
 ThbleAl
Age: 8 Years 0 Months 0 Days Through I Years 11 Months 31 Days
CCTT-I CCTT.2 CCTT.I CCTT-?
Standard T (time in (time in Standard T (time in (time in
Toile score score seconds) seconds) Toile score score seconds) seconds)

>gg >145 81 46 98 49 24 53-s4

>99 r45 80 42 97 48 25 55-56
>99 r43 79 38 96 4l 26 5l
>99 r42 78 34 94 46 27 5 8-59
>99 L4t 77 3I 93 45 28 60-61
>99 r39 t6 2l 9I 44 62-63
99 138 75 24 90 43 29 64-65
99 r36 74 2I 88 42 30 66-67
99 134 73 10 18 86 4I 3I 68
99 r33 72 11 I6 85 40 32 69-tA
98 r32 7I 5 12-13 I4 83 39 33 7 r-72
98 130 70 I4-15 I2 82 38 34 73-7 4
97 r28 69 6 r6-tl 10 80 37 35 75-76
96 r27 68 7 18- 19 8 79 36 36 t7 -78
96 r25 67 8 20-21 7 78 35 37 79
95 r24 66 9 22 5 76 34 80-81
93 r23 65 10 23-24 4 75 33 38 82-83
92 I2T 64 11 25-26 4 73 32 39 84-85
90 r20 63 t2 27 -28 3 72 3I 40 86-87
88 118 62 I3 29-30 2 70 30 4l 88-89
86 w 6I T4 3r-32 2 68 29 42 90-9r
84 115 60 33 1 67 28 43 92
82 rt4 s9 15 34-35 1 66 27 44 93-94
79 I12 58 T6 36-37 1 64 26 45 9s-96
16 110 57 17 38-39 1 63 25 97 -98
73 109 56 18 40-4r <1 6I 24 46 99-100
69 108 55 T9 42-43 <1 59 23 4l 101-r02
66 106 54 20 44-45 <1 58 22 48 103
62 t04 53 2I 46 <1 57 2I 49 T04-105
58 103 52 22 47 -48 <1 55 20 50 106- 107
54 r02 51 49-50 <1 <55 <Ig 5 1- r20 108-180
50 100 50 23 5r-52

Raw scores
CCTT-1 CCTT.2
Voile Color Number Interference Voile
range Errors Prompts effors errors Prompts index range

>16 <1 <1 0.0 - 2.0 >16

1 1-16 2 2 2.1 - 2.3 1 1-16
6-10 1 2.4 - 2.6 6- 10
2-5 2 3 1 3 2.7 - 3.9 2-5
<1 >2 >3 >4 >2 >4 > 4.0 <1

58
L-
t:
E ThbleA2

h
h Standard
Age: 9 Years 0 Months 0 Days Through

T
CCTT-I
(time in
CCTT.2
(time in
9 Years 11 Months 31 Days

Standard T
CCTT.I
(time in
CCTT.z
(time in
%ile score score seconds) seconds) Voile score score seconds) seconds)

E >99
>99
>r45
145
81
80
46
42
98
97
49
48
22
23
48-49
50
):
J: >99 r43 79 38 96 47 5r-52

t:
):
>99
>99
>gg
142
I4I
r39
78
77
76
34
3L
27
94
93
9I
46
45
44
24
25
26
53-54
55
56-57

r:
):
99
99
99
138
136
134
75
74
73
24
2I
18
90
88
86
43
42
4I
27

28
58-59
60
6r-62
99 r33 72 9 I6 85 40 29 63-64
):
l: 98
98
97
r32
130
128
7T
70
69 5
10-11
12-13
14
T4
L2
10
83
82
80
39
38
37
30
3l
32
6s-66
67
68-69
): 96 r27 68 6 15- 16 8 79 36 70-7 r
): 96 r25 67 7 I7 -T8 l 78 35 33 72
): 95 r24 66 8 19-20 5 76 34 34 73-l4
93 r23 6s 2I 4 75 33 35 75-t6
): 92 r2t 64 9 22-23 4 73 32 36 7t-78
): 90 r20 63 10 24-25 3 72 3I 31 t9
J: 88
86
118
117
62
6I
11
I2
26
2t -28
2
2
70
68
30
29 38
80-81
82-83
):
t;
):
8-t
82
79
115
114
T12
60
59
58
13

t4
29-30
31
32-33
1

1
67
66
64
28
27
26
39
40
4L
84
85-86
87-88

t:
):
76
73
69
110
109
108
57
56
55
15
I6
I7
34-35
36-37
38
1

<1
<1
63
6I
59
25
24
23
42

43
89
90-91
92-93
66 106 54 18 39-40 <1 58 22 44 94-95
): 62 104 53 4I-42 <1 57 2I 45 96
): 58 103 52 I9 43 <1 55 20 46 97 -98

L; 5-t
50
r02
100
51
50
20
2I
44-45
46-47
<1 <55 <19 47 -120 99- 1 80

):
):
):
E
1- CCTT.l
Raw scores
CCTT.2

E Toile
range Errors Prompts
Color
effors
Number
effors Prompts
Interference
index
Voile
range

E 1
>16
1-16
6- 10
0

1
<1
2
<1
2
0.0 - 2.0
2.t - 2.3
2.4 - 2.6
>16
11-16
6- 10

E 2-5
<1 >2 >3
2
>4
3
>2
1

>4
3 2.7 - 3.9
> 4.0
2-5
<1

E
); 59

E
 ThbleA3
Age: L0 Years 0 Months 0 Days Through L0 Years 1L Months 31 Days
CCTT.I CCTT.z CCTT-I CCTT.2
Standard T (time in (time in Standard T (time in (time in
Voile score score seconds) seconds) Toile score score seconds) seconds)

>99 >r45 81 46 98 49 20 43-44

>99 145 80 42 97 48 2I 45
>99 r43 79 38 96 47 46-47
>99 t42 78 34 94 46 22 48-49
>gg I4I 7l 3I 93 45 23 50
>99 t39 76 27 9I 44 24 5t-52
99 138 75 24 90 43 53
99 r36 t4 2L 88 42 25 54-55
99 134 73 18 86 4I 26 56
99 r33 72 I6 85 40 27 57 -58
98 r32 7l 9 I4 83 39 59-60
98 130 70 10-11 T2 82 38 28 6I
97 t28 69 I2 10 80 37 29 62-63
96 r27 68 5 13-14 8 t9 36 30 64
96 r25 67 6 15- 16 7 78 35 6s-66
95 r24 66 l 17 5 t6 34 3I 6l
-l .t
93 r23 65 18- 19 4 75 JJ 32 68-69
92 r21 64 8 20 4 73 32 33 t0-1r
90 120 63 9 2L-22 3 72 31 34 72
88 118 62 10 23 2 70 30 l3-l4
86 nl 6I 11 24-25 2 68 29 35 75
84 115 60 26-21 1 6l 28 36 7 6-11
82 I14 59 I2 28 I 66 27 37 18
t9 I12 58 T3 29-30 1 64 26 79-84
76 110 57 L4 31 1 63 25 38 81-82
73 109 56 32-33 <1 6I 24 39 83
69 108 55 15 34 <1 59 23 40 84-8s
66 106 54 T6 35-36 <1 58 22 86
62 104 53 17 37 -38 <1 57 2T 4I 87-88
58 103 52 39 <1 55 20 42 89
54 r02 51 18 40-4r <1 <55 <19 43-r20 90- 1 80
50 100 50 I9 42

Raw scores
CCTT-1 CCTT.2
Toile Color Number Interference Toile
range Errors Prompts effors effors Prompts index range

>16 <1 <1 0.0 - 2.0 >16

1 1-16 2 2.1 - 2.3 1 1-16
6- 10 1 1 2 2.4 - 2.6 6- 10
2-5 2 2 3 1 3 2.7 - 3.9 2-5
<1 >3 >3 >4 >2 >4 >4.0 <1

60
 I
--:i

Thble L4

E Standard
Age: 11 Years 0 Months 0 Days Through 11 Years 11 Months 31 Days

T
CCTT.I
(time in
CCTT-2
(time in Standard T
CCTT-I
(time in
CCTT-2
(time in
Vcile score score seconds) seconds) Toile score score seconds) seconds)

E >99
>99
>99
>r45
r45
t43
81
80
46
42
98
97
49
48
18
I9
39-40
4I
79 38 96 47 42-43
>99 r42 78 34 94 46 20 44
>99 T4I 77 3I 93 45 2I 45-46
>99 r39 76 27 9I 44 22 47
99 138 75 24 90 43 48
99 136 l4 2I 88 42 23 49-50

E 99
99
98
134
r33
r32
73
72
7I
18
I6
T4
86
85
83
4I
40
39
24

25
51
52-53
54
98 130 70 10 I2 82 38 26 55-56
9l t28 69 11 10 80 37 27 57
96 r27 68 12-t3 8 79 36 58-59
96 r25 67 I4 7 78 35 28 60

E 95
93
92
124
t23
t2r
66
6s
64
6
7
8
15
I6-17
18
5
4
4
76
75
73
34
33
32
29

30
6T
62-63
64
90 r20 63 L9-20 3 72 3I 3T 6s-66
88 118 62 9 2I 2 10 30 67

E 86
84
82
I17
115
II4
6I
60
59
10

11
22-23
24
25
2
1

1
68
67
66
29
28
27
32
33
34
68-69
70
7l
79 I12 58 L2 26-27 1 64 26 72-13

E 76
73
69
110
109
108
57
56
55
I3
I4
28
29-30
3I
1

<1
<1
63
6I
59
25
24
23
35
36
74
75-76
7l
66 106 54 15 32-33 <1 58 22 37 78-79

E 62
58
54
r04
103
t02
53
52
51
I6
I7
34
35-36
37
<1
<1
<1
57
55
<55
2I
20
<19 39-r20
38 80
81-82
83- 1 80
50 100 50 38

Raw scores
CCTT.1 CCTT-2
Toile Color Number Interference Toile
range Errors Prompts effors effors Prompts index range
<1 <1 >r6
b
>16 0 0.0 - 2.0
1 1-16 2 2.1 - 2.3 1 1-16
6- 10 1 1 2 2.4 - 2.6 6- 10
U2
b 2-5
<1 >3
2 2
>3 >4
3
>2
1

>4
3 2.7 - 3.9
> 4.0
2-5
<1

6T

E
 TableA5
Lge: 12 Years 0 Months 0 Days Through 12 Years 1L Months 31 Days
CCTT-I CCTT-2 CCTT.I CCTT-2
Standard T (time in (time in Standard T (time in (time in
Toile score score seconds) seconds) Voile score score seconds) seconds)

>99 >r45 81 46 98 49 L7 36
>99 145 80 42 97 48 37 -38
>99 143 79 38 96 47 18 39
>gg r42 78 34 94 46 I9 40
>99 T4L 77 3I 93 45 4r-42
>99 r39 76 27 9T 44 20 43
99 138 75 24 90 43 2I M
99 r36 74 2I 88 42 45-46
99 134 73 18 86 4T 22 47
99 r33 72 T6 85 40 23 48
98 132 7T I4 83 39 49
98 130 70 I2 82 38 24 50-51
97 r28 69 10 10 80 37 52
96 r2l 68 IT.12 8 79 36 25 53
96 125 67 I3 7 78 35 26 54-5s
95 r24 66 6 T4 5 76 34 56
93 t23 65 7 15- 16 4 75 33 27 51
92 I2I 64 I7 4 73 32 28 58-59
90 r20 63 8 18 3 72 3I 60
88 118 62 19-20 2 70 30 29 6I
86 rt7 6T 9 2l 2 68 29 30 62
84 115 60 10 22 1 67 28 63-64
82 I14 59 23 1 66 27 3I 65
t9 I12 58 11 24-25 1 64 26 66
76 110 57 I2 26 I 63 25 32 67 -68
73 109 56 27 <1 6I 24 33 69
69 108 55 I3 28-29 <1 59 23 70
66 106 54 I4 30 <1 58 22 34 7I-72
62 104 53 3I <1 57 2I 35 l3
58 103 52 15 32-33 <1 55 20 74
54 102 51 34 <1 <55 <rg 3,6-I20 7 5-180
50 100 50 I6 35

Raw scores
CCTT-1 CCTT.2
Voile Color Number Interference Voile
range Errors Prompts effors effors Prompts index range

>16 0 <1 <1 0.0 - 2.0 >16

1 1-16 1 2 2.r - 2.3 1 1-16
6- 10 1 2.4 - 2.6 6- 10
2-5 2 2 1 3 2.7 - 3.9 2-5
<1 >3 >3 >3 >2 >4 > 4.0 <1

62
E
l--t TableA6
Age: 13 Years 0 Months 0 Days Through 13 Years 11 Months 31 Days
,;
J; % ile
Standard
score
T
score
CCTT.I
(time
seconds)
in
CCTT-2
(time in
seconds) Toile
Standard
score
T
score
CCTT-I
(time
seconds)
in
CCTT.2
(time in
,; seconds)

l; )--
):r
> 1+5
1-15
81
80
46
42
98
97
49
48
I6 33-34
35
); > -r'i 1-r3 79 38 96 47 n 36
); -- -.., I 112 78 34 94 46 31

,; >.9 I4I t7 3I 93 45

t;
18 38
>gg r39 t6 27 9T 44 I9 39

t;
J;
)e
i9
99
138
136
t31
75
74
73
24
2I
18
90
88
86
43
42
4I
20
40-4r
42
43

t;
l;
e9
9S
133
r32
72
7T
l0
I6
\4
85
83
40
39
2I 44
45

t;
YS 130 T2 82 38 22 46
9- r28 69 10 10 80 37 23 47 -48
e5 r2l 68 11 8 79 36 49
,;
1;
e5 r25 67 12-13 7 78 35 24 50
e5 r24 66 6 I4 5 76 34 51
93 r23 6s 7 15 4 75 33 25 52
,; 9: I2I 64 I6 4 73 32 26 53
,; 9t-t 120 63 I7 3 l2 3T 54-55

,; EE 118 62 18 2 70 30 2l 56
E6 nl 6I 9 19-20 2 68 29 57
,; s-l 115 60 2t 1 6l 28 28 58
,; S] rru 59 10 22 1 66 27 59
-9 I12 58 11 23 64 26 29 60
,; r6 110 5l 24
1

I 63 25 30 6r-62
,; ,1 109 56 l2 25 <1 6L 24 63
,; 69 108 55 26-27 <1 59 23 3I 64
66 106 54 I3 28 <1 58 22 65
,;
1; 6l
58
r04
103
r02
53
52 I4
29
30
<1
<1
57
55
<55
2I
20
<19 33-r20
32 66
67

,; 5-+ 51 15 31 <1 68- 1 80

50 100 50 32
,;
t;
,;
t;
,;
CCTT-1
Raw scores
CCTT-2

t;
t;
Toile
range Errors Prompts
Color
EITOTS
Number
effors Prompts
Interference
index
Voile
range

t;
l;
>16
i 1-16
6- 10 1
0
1
<1 <1
2
0.0 - 2.0
2.r - 2.3
2.4 - 2.6
>16
TL-T6
6- 10

l; 2-5
<1 >3
2
>3
2
>2
1

>4
a
J 2.7 - 3.9
>4.0
2-5
<1

l:
>3

t;
63

n
 TableAT
Age: L4 Years 0 Months 0 Days Through 14 Years 1L Months 31 Days
CCTT.I CCTT-2 CCTT.I CCTT.2
Standard T (time in (time in Standard T (time in (time in
Toile score score seconds) seconds) Toile score score seconds) seconds)

>99 >r45 81 46 98 49 3I
>99 r45 80 42 97 48 t6 32
a-
>99 r43 79 38 96 47 JJ
>99 r42 78 34 94 46 I7 34
>99 T4I 77 3I 93 45 35
>99 r39 76 27 9T 44 18 36-31
99 138 75 24 90 43 38
99 136 74 2I 88 42 I9 39
99 134 73 18 86 4I 40
99 r33 t2 I6 85 40 20 4I
98 r32 7I I4 83 39 42
98 130 70 10 I2 82 38 2T 43
97 r28 69 11 10 80 37 44
96 r2l 68 I2 8 79 36 22 45
96 r25 67 I3 7 78 35 46
95 t24 66 I4 5 76 34 23 41
93 r23 65 15 4 75 33 48
92 I2I 64 I6 4 73 32 24 49
90 120 63 I] 3 72 3I 50
88 118 62 18 2 70 30 25 51
86 TIl 6t T9 2 68 29 52
84 115 60 20 1 67 28 26 53
82 r14 59 10 2I 1 66 27 54
79 T12 58 22 1 64 26 2l 55
76 110 57 11 23 1 63 25 56
73 109 56 24 <1 6T 24 28 5l
69 108 55 I2 25 <1 59 23 58
66 106 54 26 <1 58 22 29 59
62 r04 53 I3 2l <1 57 2I 60
58 103 52 28 <1 55 20 30 6r
54 r02 51 t4 29 <1 <55 <19 3r-r20 62-180
50 100 50 15 30

Raw scores
CCTT-1 CCTT-2
Voile Color Number Interference Voile
range Errors Prompts EITOTS effors Prompts index range

>16 0 0 <1 <1 0.0 - 1.7 >16

1 1-16 1 2 1.8 - 1.9 TT-16
6-10 1 2.0 - 2.2 6-10
2-5 2 2 1 3 2.3 - 3.1 2-5
<1 >3 >3 >3 >2 >4 >3.2 <1

64
E
t; Thble A8

H
H
Age: 15 Years 0 Months 0 Days Through 15 Years 11 Months 31 Days
CCTT.I CCTT-2 CCTT-I CCTT-2
in
l; % ile
Standard
score score
T (time
seconds)
(time in
seconds) Toile
Standard
score
T
score
(time
seconds)
in (time in

H )*' '* > 1-t5 81

seconds)

H
46 98 49 15 30
> -.r! 1-t5 80 42 9l 48 3l
l; > J!,1
i -13 79 38 96 47 I6

l;
.-r
>' 1+2 78 34 94
"r 46 32
; -rr, 1-l 77

l;
1
3L 93 45 33
) l-! r39 76 27 9I 44 T7 34

l; 99 138 75 24 90 43 35

J:
99 136 74 2L 88 42 18 36
99 r34 73 18 86

l;
4T 37
y9 133 72 16 85 40 I9

t;
38
9S r32 7I 10 t4 83 39 39
9S 130 70 11 12 82 38 20 40
9: r28
,; 69 12 10 80 37

l; 96 r2l 68 I3 8 79 36 4I

t;
,;
96
95
93
r25
r24
r23
67
66
65
T4
15
7
5
4
78
76
75
35
34
33
2I

22
42
43
44

l; 9l r21 64 I6 4 73 32 45

l; 90 r20 63 17 3 72 3t 23 46

t;
88 118 62 18 2 70 30 4l
86 IL7 6I I9 2 68 29 24 48

l; 84
8l
115
I14
60 10 20
2t
1 67 28 49

l;
59 1 66 27
79 It2 58 11 22 1 64 26 25 50

l; 76
73
110
109
57
56 23 <1
1 63
6I
25
24 26
51
52
);
t; I2
69 108 55 24 <1 59 23 53
66 106 54 25 <1 58 22 27 54
62 104 53 I3 26 <1 57 2I 55
]; 58 103 52 27 <1 55 20 28 56
); 51 102 51 I4 28 <1 <55 <Ig 29-r20
l;
57 -180
s0 100 50 29

H
L;
.-t
L- Raw scores

t-,
..J

%oile
CCTT-1
Color
CCTT-2
Number Interference
;.J range Errors Prompts EITOTS effors Prompts index
Voile
range
l-,
tr
?,
>16
II-16
6- 10 1
,0
1
<1 <1
2
0.0 - r.7
1.8 -
2.0 - 2.2
1.9
>16
11-16
6- 10
2-5 2 2
ar >3
1 3 2.3 - 3.5 2-5

h
<.1 >3 >3 >2 >4 > 3.6 <1

1
1
1 6s
 TableA9
Age: L6Years 0 Months 0 Days Through 16Years Ll Months 31Days
CCTT-1 CCTT.2 CCTT-I CCTT.2
Standard T (time in (time in Standard T (time in (time in
Voile score score seconds) seconds) Toile score score seconds) seconds)

46 98 49 15 29
>99 >r45 81
80 42 97 48
>99 145
>99 r43 79 38 96 4l 30

34 94 46 r6 3I
>99 t42 78 .t al

>99 I4I 17 3I 93 45

>99 r39 76 2l 9I 44
24 90 43 17 33
99 138 t5
2I 88 42 34
99 r36 74
134 73 10 18 86 4I 18 35
99
85 40
99 r33 l2 11 T6
I2 l4 83 39 36
98 r32 7l
I2 82 38 t9 37
98 130 10
I3 10 80 37 38
91 r28 69
96 r27 68 I4 8 t9 36 20 39

15 1 78 35
96 r25 67
T6 5 t6 34 40
95 r24 66
4 75 33 2L 4T
93 r23 65
4 73 32 42
92 t2r 64 T1

r20 63 18 3 72 3I
90
2 70 30 22 43
118 62 10 T9
88
2 68 29 44
86 Lt7 6T
67 28 23 45
84 115 60 20 1

2I 1 66 27
82 IT4 59 11
64 26 46
79 t12 58 22 1

1 63 25 24 47
76 110 57
<1 6r 24 48
73 109 56 I2 23
24 <1 59 23 25
69 108 55
<1 58 22 49
66 106 54 13 25
26 <1 57 2T 50
62 r04 53
<1 55 20 26 51
58 103 52
2l <1 <55 <19 27 -120 52- 1 80
54 r02 51 t4
50 100 50 28

Raw scores

CCTT.1. CCTT-2

Voile Color Number Interference Voile

range Errors Prompts EITOTS EITOTS Prompts index range

<1 <1 0.0 - 1.7 >16

>16 0
2 1.8 - 1.9 1 1,16
1 1-16 1
2.0 - 2.2 6- 10
6- 10 1
1 3 2.3 - 3.5 2-5
2-5 2 2
>3 >2 >4 >3.6 <1
<1 >3 >3

66
E
E
t;
t;
,;
t;
l; f,ppendix B
l:
l: lnterpretiue Ranges and lheir Base Rates ol Occurrence
t;
l;
(fiI
for the llormatiue SamDle and (linital SamDles
l,-:
l:
l;
l;
t;
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a Dara la PrueDa de Distas de (olor de llifrosl
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 Plsrns DE (oroR DE lllfros- |
t(fir, lI
Examen Dleliminar
Pida al sujeto que cuente en voz alta del 1 al 15.
Si el sujeto tiene problemas del habla, pidale que
escriba los nfmeros del 1 al 15. Si 6ste es incapaz de
completar la tarea oralmente o por escrito, no
administre la prueba Pistas de Color de Nifios.
Eiercicio de Pfictica
Coloque la hoja de examen de Pista de Color de
Nifios I, con el ejercicio de pr6cttca orientado hacia
anrba, delante del sujeto y encima de una superficie
plana. Con un l6piz seflale el rcctfngulo de prdctrca y
diga 1o siguiente:
En este rectdngulo hay algunos circulos de
colores. Cada circulo contiene un nfmero.
Cuando yo diga "Comiencer" quiero que
tome este l6piz y conecte los circulos
empezando por el 1 (apuntar al 1), sigu-
iendo hacia el 2 (apuntar al 2), al3 (apuntar
al 3), y asi sucesivamente hasta llegar al
final de la prueba.
Quiero que conecte los circulos en el orden
correcto lo mr{s rdpido que pueda, sin levan-
tar et l6piz del papel. Si comete un error yo
se lo voy a sef,alar, en cuyo caso quiero que
vuelva a poner el l6piz en el riltimo cfrculo
correcto y que continrie desde allf. El trazo
tiene que atravesar los circulos. La secuencia
ha de ser correcta. lTiene alguna pregunta?
Muy bien, practiquemos. Coloque el l6piz
aqui, donde este dibujito de una mano le
indica que empie ze. Cuando yo diga
ttcomiencertt conecte los circulos por orden
num6rico lo m6s r6pido que pueda hasta
llegar al circulo que estd al lado del dibu-
jito de la mano que indica el final de la
prueba. ll-,isto? Comience.
Comience a cronometrar aI momento que detecte
movimiento por parte del sujeto hacia el primer
70
cfrculo. Observe al sujeto para asegurarse de que las
lineas ftazadas aftavresan los circulos en el orden
correcto. Apunte errores o corrija al sujeto cuando
sea necesario. Pare el cron6metro tan pronto como
el l6ptz toque la parte exterior del riltimo cfrculo.
No anote el tiempo en el protocolo ya que este es un
ejercicio de prdctrca. Anime al sujeto en la medida de
1o necesario.
frdninistracion de Ia Frueba
D6 vuelta alahoja de examen de Pistas de Color I
de manera que la prueba Pistas de Color / est6 colocada
en frente del sujeto y diga lo siguiente:
He aqui otra hoja con mds nfimeros y cir-
culos. Conecte los circulos en orden con-
secutivo como lo ha hecho hace algunos
momentos durante la prdctica. Proceda lo
mds rdpido que pueda y no levante el l6piz
del papel al avanzar. Asegrirese de que las
lineas que traza toquen los circulos.
Seflale el Primer Circulo y Diga lo Siguiente:
Empiece aqui donde este dibujito de una
mano indica el principio de la prueba.
Terminard Usted donde este dibujito de
una mano que seffala el final de la prueba.
;Estd listo? Comience.
Comience a coronometrar en seguida que detecte
movimiento hacia el primer circulo. P are el
cron6metro tan pronto como el trazo toque la parte
exterior del riltimo circulo. Observe la ejecucidn
detenidamente para asegurarse de que el sujeto
efectivamente atraviesa los circulos en orden correcto.
Apunte effores o corrija al sujeto en la medida de 1o
necesario. Anime al sujeto verbalmente si juzga que es
apropiado hacerlo. Si el trazo del sujeto llega cerca
pero no toca los cfrculos, no 1o corrrja durante la
prueba. Espere hasta el final de la prueba y recu6rdele
el procedimiento apropiado. En el espacio
coffespondiente del protocolo anote, en segundos, el
tiempo que le tom6 aI sujeto completar Ia prueba
Pistas de Color de Nifros /. Tambien anote el nfmero
total de elrores, el nfmero total de near-misses y el
nfmero total de apuntes en los espacios apropiados.
 t
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al lado del dibujito de la mano que indica
el final de la prueba. ;Listo? Comience.
1- ((II-2J
l; t Comience a cronometrar al momento que detecte

l; movimiento por parte del sujeto hacia el primer circulo.

t;
l;
Eiercicio de Frictica
Coloque la hoja de examen de Pistas de Color
Observe al sujeto para asegurarse de que sus trazos
atraviesan los circulos en el orden correcto. Apunte
effores o colTrja al sujeto cuando sea necesario. Pare
tle \-inos 2, con el ejercicio de prdctica hacia arctba,,
l; delante del sujeto y encima de una supercicie plana.
Cuando de las instrucciones para esta prueba
el cron6metro tan pronto como el l6piz toque la parte
exterior del riltimo circulo. No anote el tiempo en OI
); protocolo ya que 6ste es un ejercicio de prdctrca.
' Pistas de Color 2 de I{ifios) evite nombrat los Anime al sujeto si es necesario.
);
l; colores (amarillo, rosa o bien rosado).
Adninistration
l; )
En lu-ear de nombrar los colores, seflale el circulo
diga "este color." Con un l6piz seflale el rcctftngulo
de Ia Prueba
D6 vuelta ala hoja de examen de Pistas de Color 2
l; de prdctica y diga 1o siguiente: de manera que la prueba Pistas de Color 2 de Nifios

l; En este rect6ngulo hay circulos de colores. este colocada en frente del sujeto y diga 1o siguiente:

l; Cada circulo continene un nfmero. Esta

\-ez quiero que conecte los circulos por
Ahora tengo una hoja con m6s nfmeros y

J; orden empezando por este color (seflale el

rosa 1), siguiendo hacia este color (seflale el
circulos de color. Conecte los circulos en
orden consecutivo como lo ha hecho hace
algunos momentos durante la prdctica.
);
J; amarillo 2), continuando hacia este color
(seflale el rosa 3), etc, hasta que llegue al
Proceda lo m6s r6pido que pueda sin lev-

J; numero junto al dibujito de la mano que

antar et l6piz del papel al avarrzar.

J; indica el final de la prueba. Seflale el primer circulo y diga 1o siguiente:

J; Con el 16piz, sefiale el ejemplo situado debajo del

Empiece aqui, donde este dibujito de una
mano indica el principio de la prueba.
J; rect6ngulo y diga:
Tome nota de que el color cambia cada vez
Terminard Usted donde este dibujito de
una mano seflala el final de la prueba.
); que avanza al nfimero siguiente. Proceda lo
J; m6s rdpido que pueda. No levante la punta
;Estd listo? Empiece.

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del l6piz del papel una vez que haya
empezado la prueba. Si comete un error, yo
Comience a cronometrar en seguida que detecte
movimiento hacia el primer circulo. P
cron6metro tan pronto como el ftazo toque la parte
are el

t;
l;
se lo yoy a sefialar, en cuyo caso quiero que
ruelva a poner el l6piz en el riltimo circulo
correcto y que siga desde alli. El trazo tiene
exterior del riltimo circulo. Observe la ejecuci6n
detenidamente pata asegurarse de que el sujeto

t;
);
que atravesar los circulos. La secuencia ha
de ser correcta. Tiene alguna pregunta?
efectivamente atraviesa los circulos por orden. Apunte
effores o corrija al sujeto si es necesario. Anime al
sujeto verbalmente si juzga que es apropiado hacerlo.

t;
);
Seflale el rect6ngulo de practtca y diga:
Muy bien, practiquemos. Coloque el l6piz
aqui, donde este dibujito de una mano le
En el espacio colrespondiente del protocolo anote,
en segundos, el tiempo que le tom6 aI sujeto completar

l; indica que empiece. Cuando yo diga la prueba Pistas de Color 2 de Nifios. Tambi6n anote el

t;
j;
"comiencertt conecte los circulos por orden
lo m6s r6pido que pueda alternando los
colores hasta que llegue al circulo que est6
nfmero total de errores tipo color, el nfmero total de
elrores tipo nrimerico, el nfmero total de ngar-misses y
el nrimero total de apuntes en los espacios apropiados.

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 lppendlx D
)lodified lnsnuctions for special DoDulations

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 The standardrzed administration of the CCTT
presented in this manual in English or in Spanish
should be used whenever possible. However, there are
times when testing very young children or children
with a disability where a modified, shortened version
of the standardrzed administration of the test is
required. These instructions have been used by the
authors with young children less than 8 years of age.
The standardrzed visual instructions provided in
chapter 2 of this manual should be employed in the
case of severely hearing impaired children (71-90 dB
hearing level) or children suspected of having com-
plete hearing loss.
In an attempt to standardtze such modificationS,
brief version of the instructions to be used with
special populations is presented.
Prior to beginning the task(s), please instruct the
child to count aloud (or use sign language) from 1 to
15. If the participant is unable to complete this task,
discontinue the administration of the Children's
Color Trails Test.
((rI-l
Practice frial
Place the CCTT- 1 Practice trial sheet on a flat
writing surface facing the child and say:
You are going to draw a line through the
circles in order as fast as you can without
lifting the pencil off the paper. (Answer
any questions).
Put your pencil here (point). When I say
'oGor" draw a line through the circles in
order as fast as you can, until you reach
the circle next to the hand telling you to
stop (point). Ready? Go.
Monitor the child to make sure he or she is draw-
ing lines that touch or go through the circles in the
correct order. Make any necessary cofrections as
described in the comprehensive instructions in chap-
ter 2. Provide oral or visual reinforcement as needed.
Present the CCTT:I Practice trial sheet and allow the
child to practice until you are completely sure that the
child understands the task.
74
fest frial
Remove the Practice trial sheet immediately after
completion so that the writing surface is agarn clear,
and say:
I want you to draw another line through
the circles in order as fast as you can. Do
not lift the pencil off the paper. Make sure
that your line touches the circles.
Place the CCTT- 1 Test sheet on the writing
surface in front of the child and say:
Start here (pointing to the "start" hand) and
draw a line through the circles in order.
Stop where the hand tells you to stop
3
(point). Ready? Go.
Begin timing as soon as you detect movement
toward the first circle (see timing note in the compre-
hensive instructions), and stop timing as soon as the
pencil first touches the outer part of the last circle.
Monitor the child to make sure he or she is progress-
ing through the circles in the coffect order. Make any
necess ary coffections as described in the comprehen-
sive instructions. If the child fails to touch the circles,
do not make a correction during the test, but remind
him or her of the proper procedure after completion
of the CCTT:I. On the record form, note the time to
complete the task (in seconds), &S well as the number
of prompts, near-misses, and enor responses. Provide
reinforcement as needed.
c(rr-2
Pnclice frial
Place the Children's Color Trails Test 2 Practice
trial sheet on a flat writing surface facing the child
and say:
Now f want you to draw a line through the
circles as fast as you can in order by going
from this color 1 (point), to this color 2
(point), to this color 3 (point), and so on.
Stop where the hand tells you to stop
(point). The color changes each time you go
to the next number. (Answer any questions).
tr-
ri
l-, Place the CCTT-l Test sheet on the r','riting
1: Put your pencil here (pointing to the "start"
hand). When I say ttcor" draw a line surface in front of the child and sa)':
); through the circles in order as fast as you You wilt start here (pointin.-e to !h. "start''
J; can, changing from one color to the next.
Stop where the hand tells you to stop
hand) where the hand tells you to start, and
end where the hand tells You to stoP
); (point). ReadY? Go. (point). Ready? Go.
); \,tonitor the child to make sure he or she is draw- Begin timing as soon as you detect movement
); ing lines that touch or go through the circles in the toward the first circle (see timing note in the compre-
); correct order. Make any necessary corrections aS hensive instructions), and stop timing as soon as the
described in the comprehensive instructions in chap- pencil first touches the outer part of the last circle.
);
t;
l;
[er 1. Provide oral or visual reinforcement as needed.
A11or',' the child to practice until you ate completely
Monitor the child to make sure he or she is proceed-
ing through the circles in the correct order. Make
sure that the child understands the task. any necess aty corrections as described in the com-
l; prehensive instructions in chapter 2. On the record
l; f est f rial form, note the time to complete the task (in sec-

t;
l;
Remove the Practice trial sheet immediately after
completion so that the writing surface is again clear,
onds), as well as the number of prompts, near-
misses, and error responses (Number Sequence and
and sall: Color Sequence Errors) on the record form. Provide
,; )iow I have a sheet with more numbers reinforcement as needed.
and colored circles. Draw a line through
); the circles like you did before.'Work as fast
,; as You can.tt
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