VISUAL, VISUOMOTOR, AND AUDITORY TESTS 539 TMT is within normal limits, the deficit is more likely to be found in the spatial- perceptual and motor components of the test. In normal subjects, oral and written MT are strongly correlated (.68 for Part A; 72 for Part B). They also found this version particularly sensitive to anterior lesions in stroke patients, but found no difference for right and left lateralized lesions. For the CTT, 2-week reliability is reported as .64 for Trails 1, and .79 for Trails 2. Cor- relations with the TMT were .41 and .5 re- spectively (Maj et al., 1993). Williams et al (1995) describe a study with children be- tween 5:11 to 16 years. They found good agreement (correlations of .74 and .69 be~ tween the respective parts) with the TMT, good discriminant validity between normal controls and children with altered neuropsy- chological functions, and appropriate age~ progression of scores. In a study of factorial validity using the CTF together with the TMT, the Color Fig- ure Mazes, and the Stroop Test (Uchiyama et al., 1994) the CTT loaded primarily on a first factor, labeled “perceptual tracking and di- vided attention.” Criterion validity wes dem- onstrated with a sample of 63 patients with traumatic brain injury which differed signifi- cantly (,000 for CTT 1, .002 for CTT 2) from normal subjects. Significant impairment was also found in 383 HIV patients compared to 298 seronegative and 314 asymptomatic se- ropositive patients (Maj et al., 1993, 1994). In summary, the TMT. isa well- established, sensitive test of visual search and sequencing, backed by a solid body of research and normative data. The oral TMT is a variation of this test which omits the yisual-notor component of the TMT, and is suitable for patients with visual and severe motor handicaps. The CTT is an interesting attempt to create a “culture-fair” version of the TMT by alternating between colors in- stead of between numbers and letters. It is backed by good standardization data and some initial clinical studies. The somewhat longer times required for the CIT may be due to the addition of a Stroop effect to the test, Curiously, the manual does not show clear evidence of culture-faimess by com- paring African, Hispanic, and Caucasian- American groups nor is this point specifically discussed, although data from the WHO study in other countries appear to be available. Normative Data The use of cutoff scores designating “organic impairment,” suggested by Reitan-and Wolf: son (1985, 1988) (e.g., >85/86 seconds for Part B) and Matarazzo et al. (1974) (>40 sec for Part A, >91 sec for Part B) has been aban- doned by most authors (see Bornstein. 1986); instead, actual normative data are used. Drebing et al. (1994) included the TMT in a screening battery for the early detection of cognitive decline. Comparing 60 healthy vol- unteers and 45 subjects with neurodegenera- tive or cerebrovascular disease, mild closed- head injury, major depression, and alcohol or substance abuse, and the meta-analysis of an- other existing study (Bornstein, 1985) of the same age distribution (mean age: 43 years) they determined optimal cutoff scores of 1. and 3 $D. The scores were: Part A: 45.5, 58.7, 65.9 respectively, for men; 43.4, 52.3, 61.2 for women; Part B: 104.4, 130.5, 156.6 for men; 114.5, 141.6, 168.7 for women. Russell (1980) observed that, in 158 patients with neurologi- cal disorders, more than one-third exceeded the time limit of 300 seconds, although the re- mainder of the group showed a fairly continu- ous score distribution similar to other cogni- tive tests, ‘Table 12-13 presents normative data for adults, aged 20-85 in percentiles. Table 12- 14 presents the means and the SDs for this population, and ‘Table 12-15 shows detailed data that can be used for olderage groups. Sex differences in these age groups were minimal (Ivnik, Malec, & Smith, 1996; Yeudall et al., 1987). The age differences shown in Tables 12-13 to 12-15 are only minimal for the younger age groups; the increase of time, es- pecially for the difference between Part A and. Part B, becomes more pronounced with age. ‘This has been confirmed in studies by Davies (1986), Hays (1995), and Price et al. (1980). Iv- nik, Malec, and Smith (1996) found a correla- tion of .30 for Part A and .53 for Part Bwith age in a sample of 746 subjects between the age of| | : i 540 A COMPENDIUM OF NEUROPSYCHOLOGICAL TESTS Table 12—13. Norms for the Trail Making Test at Different Age Levels Percent 20-29 30-39 40-49 50-59 60-69 0-74 15-79 80-85 (n=35) (n= 30) (n= 45) (m= 48) (n= 61) (= 30) in = 31) PartA 90 7 20 20 4 23 7 26 3 80 20 22 mu a7 a 31 31 40 70 22 23 6 30 30 34 38 B 60 33 25 B SL 32 36, 41 Pa 50 ey 7 30 33 ot 37 46 52 40 28 39 82 34 38 38 50 59 30 30 36 34 3T 40 a 33 65 20 35 48 37 46 6 50 38 88 10 2 7 0 oe a 5T 2B 108 Part B 90 40 40 86 35 63 38. 85 80 a 6 0. 60 np 7 om x 50 48 65 6 8h 88 102 60 53 53 Ter R 4 7 IL 30 37 62 7B ® 4 16 4 40 61 64 4 1 302 ws 138 30 65 69 4 4 110 142 154 20 67 83 8 94 135 158 2ut Source: Tombaugh, Rees & Melntyre (1996), based on 308 community-dwelling adults with an average education of 12.7 years. 55 and 95+, but no effects of gender or educa- tion. Libon et al. (1994) investigated age- related decline for Part B by testing healthy young-old (64-74) and old-old (75-94 year old) controls, and they found an average in- crease from 87.6 to 134.4 sec (similar to the in- crease shown in Table 12-15), slightly higher in females. The norms agree reasonably well with those published by Cripe and Dodrill (1988), des Rosiers and Kavanagh (1987), Dod- rill (1978), Ernst (1987), Harley-et al. (1980), Grant etal. (1984), Russell and Starkey (1993), Stanton et al. (1984), and Stuss et al. (1988), but not with those of Alekoumbides et al, (1987) and Davies (1968), who reported much longer times in the older age range. A steady, accelerating increase in time (from 100 sec. for 20-year-olds to 400 sec. in 80-year-olds for Part B) was also reported by Salthouse and Fristoe (1995); the strikingly longer time scores were probably due to the fact that the authors used a computerized version of the test. Scores are strongly affected by the educa- tion level and intelligence of the subject. Heaton et al. (1986) reported that to complete Part B, normal 40- to 60-year-old adults with less than 12 years of education needed 102.2 sec., those with 12-15 years of education, 69,7 sec., and those with 16 and more years of education, 57.9 sec. Correlation coefficients Table 12—14, Means and SDs for Adults on the ‘Trail Making Test Trails A TrailsB Agen MSD) MSD) 15-19 8% 95.78) 498 15.2) 2-29 35 4 BO) 5B. 59) 30-32-30 80.2 G04) 60. B.A} 10-49-45 90.7 8) BL 183) 50-59. 48351 (106) 777.38) 60-69 Gl 858 UL) BL 8.5) 0-74 30.413. 15.0), MA 72.3) 79 Bl ATS ni94 50.2) 5B 607 1522 63.1) «Extrapolated from Yeudall etal, (1987) and Tombangh et al. (1996). Source: Tombaugh, Rees, & Mcintyre, 1996.VISUAL, VISUOMOTOR, AND AUDITORY TESTS, Table 12—15. ‘Trail Making Test: Normative Data for Older Subjects 541 87-97 66-71 RT 81-86 in = 286) fn = 238) (n= 162) (n= 162} Percentile PartA Part Part Part PartA” = PartB PartA PartBPartA Part B 90 20 45 5 52 cs 56 29 15 29 16 5 5 57 29 6 30 15 38-101 38 tot 50 aL 70 35 % 38 102 bea 125 35, 38 90 4 1048 156 @ 1 60 165 10 130 60 180 5 210 79 80 235, ‘Richardson and Marottoli (1996) provide « further breakdown by education level based on a total of 101 subjects. For Trails B, they found means of 197.2 (8 = 71.0) and 119.2 (SD = 33.5) for age 76 to 80 with education levels of less than I2 and, 12 and better respectively: The corresponding values for age 81-91 were 195.5 (SD = 69.7) and 137.3 (SD = 155.9) respectively. Source: Adapted from Ivnik, Malee and Smith (1996). With permission of the authors and Swets Publishing Company. between education and TMT A and B have been reported as .19 and .33 (partialing out the effect of age; Bornstein, 1985; Ernst, 1986; see also Stanton et al., 1984; and Stuss et al... 1987; but see Ivnik et al., 1996). The effect of 1Q is somewhat more pronounced but most noticeable on Part B (Dodrill, 1987). Warner etal. (1987) reported correlations with 1Q be- tween .42 and .30 for Part A and between .48 and .42 for Part B. Waldman etal. (1992) found significant IQ effects especially in the low av- erage (mean 25.7 and 51.5, respectively, for Parts A and B) and borderline (means 47.7 and 111.6) ranges in 69 18- to 30-year-olds. Heaton, Grant, and Matthews (1991) pre- sent norms in scaled scores, corrected for gen- der, education, and age, and based on 553 normal subjects. These norms should be used with caution since the cell sizes are not pro- vided and may be quite small. A study by Arnold et al. (1994) found no acculturation differences between Anglo- American, Mexican-American, and Mexican subjects. Table 12-16 presents norms for normal school children, aged 6-15, using the inter- mediate form of the test. Values for 6-, 7-, and 14- to 15-year-old children were extrapolated from other sources as indicated. Since the test is dependent on knowledge of number and letter sequences, norms for the youngest age groups must be intepreted with caution. The norms presented here are slightly lower than those reported by Klonoff and Low (1974), but similar to Knights (1970), Knights and Nor- wood (1980), and Reitan (1971). Trites (1977) reports values that are somewhat higher for all age groups, but show a similar age progres- sion. Sex-related differences appear to be minimal in children for this test. First normative data for the oral TMT sug- gest that both parts require only half the time needed for the drawing form of the FMT. Part ‘A (counting) in particular is performed very quickly. Scores increase with age similar to the drawing form. Normative data for the Color Trails Test (D Elia et al., 1996) are based on the perfor- mance.of 1,528 healthy volunteers, including subsamples of 182 African-Americans and 292 Hispanic-Americans between the age of 18 and 89 years 12 months. These norms are pre- sented separately for education levels of 8 years and below, 12 years, 13-15 years, 16 years, and higher than 16 years. In general, time in seconds for the CTT is somewhat long- er than for the TMT (e-g., in 20- to 30-year- olds 37 and 82 see. for the CTT L and CTT 2, respectively, compared to 26 and 56 sec. for the TMT A and TMT B). The means presented for African- and Spanish-Americans suggest that these populations perform the CIT. somewhat slower than Caucasian-Americans, although the tables presented in the manual are confounded by the effects of age and edu- cation level. Errors, near-misses, prompts, and an interference index of >2.0 occur only in the below 16th percentile range, ie., they542 A COMPENDIUM OF NEUROPSYCHOLOGICAL TESTS Table 12—16. Trails Test: Normative Data for Children (Intermediate Version): Time Score in Seconds Part A Part B Age mn Mean SD_-Median Range =n Mean. = SD. Median’ “Range Male 8 824 17 905 6-55 MTS STS RIB 9 2 68 89 25 1345 2 50 LB BTS 8-190 10 2% 913 61 OS DCLG TRS 8D u 2 456 48 88D BB 200 BS HDD 2 8 166 «59S SS HHS TBO 3 7 160 101 133 889 TO BO TD (415) «5160 20" 160 88D BG HS Female 8 064 ST BS GHZ TLR 880TH ATG 8 1 Bl Sl. 20 Bs OTS STO, 10 2% 2 467, 10-98 «4B SO 4.0 BH ul 30 180 «GGT, ORT 8 HSH 12 “0 BAT 7 BSL LB TL 3 7 7 19 BS. IST BOT BG ws tas (4-5) «5023 18 ITB BO AllNormals °: ( 9 40 : 45 133 BL @ il 36 96 a 8 8 SL +305 16-8 B 30 765 26-176 8 4 35 8B BO MBL 190 LB 22-130 10 sl 1987 A OL 4 458 18-8 a Sl M4 63 638TH 18-388 15-122 2 @ 163 ST M9 THR 25 BO 1-80 1B MW 8 76 38 195 2951-99 (5 10 GG 8180" “Eistimate, based on Knights & Norwood (1980), ‘Estimate, based on Rhode Island normas and Klonoff & Low (1974), Estimate, based on Reitan (1971) and Klonoff & Low (1974) Estimate, based on Knights & Norwood (1980) and Klonoff & Lov (1974). Source: Spreen & Gaddes (1969). are relatively rare and require special explora- tion if they occur. In children, age 5 years 11 months to 16, a steady age-progression was noted. Female children completed Color ‘Trails 2 and Trail Making Part B more quickly than males (Williams et al., 1995). References Abraham, E., Axelrod, B.N., & Ricker, J.H. (1996). Application of the oral Trail Making Test toa mixed clinical sample. Archives of Clinical Neuropsychology, 11, 697~701. Acker, M.B., & Davis, JR. (1989). Psychology test scores associated with late outcome in head inju- ry. Neuropsychology, 3, 1-10. Alekoumbides, A., Charter, R.A., Adkins, .G., & Seacat, C.F. (1987). The diagnosis of brain dam- age by the WAIS, WMS, and Reitan Battery uti- lizing standardized scores corrected for age and education. International Journal. of Clinical Neuropsychology, 9, 11-28. Anderson, C.Y., Bigler, E.D., & Blatter, D.D. (1995). Frontal lobe lesions, diffuse damage, and neuropsychological functioning in. traumatic brain-injured patients. Journal of Clinical and Experimental Neuropsychology, 17, 900-908. Annelies, A., Pontius, A.A., & Yudowitz, L.B. (1980). Frontal lobe system dysfunction in some criminal actions as shown with the Narratives Test. Journal of Nervous and Mental Disease, +168, 111-117. Army Individual Test Battery. (1944). Manual of