Child Neuropsychology

A Journal on Normal and Abnormal Development in Childhood and

Adolescence

ISSN: 0929-7049 (Print) 1744-4136 (Online) Journal homepage: http://www.tandfonline.com/loi/ncny20

A normative study of the Children’s Color Trails

Test (CCTT) in the Cypriot population

K. Konstantopoulos, P. Vogazianos, C. Thodi & P. Nikopoulou-Smyrni

To cite this article: K. Konstantopoulos, P. Vogazianos, C. Thodi & P. Nikopoulou-Smyrni (2015)

A normative study of the Children’s Color Trails Test (CCTT) in the Cypriot population, Child
Neuropsychology, 21:6, 751-758, DOI: 10.1080/09297049.2014.924491

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Published online: 05 Jun 2014.

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 Child Neuropsychology, 2015
Vol. 21, No. 6, 751–758, http://dx.doi.org/10.1080/09297049.2014.924491

A normative study of the Children’s Color Trails Test

(CCTT) in the Cypriot population

K. Konstantopoulos1, P. Vogazianos1, C. Thodi1, and P. Nikopoulou-

Downloaded by [Florida International University] at 12:54 14 November 2015

Smyrni2
1
Speech Therapy, European University Cyprus, Nicosia, Cyprus
2
School of Health Sciences & Social Care, Brunel University, London, UK

Background: The Children’s Color Trails Test (CCTT) is a neuropsychological test that measures
attention, divided attention, and speed of mental processing. It has been increasingly used in the
assessment of children in cross-cultural environments for neurological and psychiatric disorders such
as seizures and closed head injuries, learning and/or language disabilities, attention deficit/hyperac-
tivity disorder, children with manganese exposure, and children diagnosed with HIV virus. However,
there is a paucity of studies presenting normative data. The aim of the present study was to provide
normative data for the CCTT in the Cypriot population. Methods: A total of 709 native Cypriot
children aged 7–16 years, recruited from various public schools across the island, took part in the
study. Exclusion criteria involved the existence of neurological, psychiatric, cardiological, and
metabolic diseases, premature birth, history of maternal alcohol and drug abuse during pregnancy,
low birth weight, hearing loss, visual problems, native language other than Greek, and abnormality in
fine-motor movements. Results: Age and gender were found to be important factors for the inter-
pretation of scores in all CCTT variables. Older children required less time and exhibited fewer errors,
near misses, and prompts compared to younger children. There was a consistent pattern of a 3–4
seconds improvement (less time in seconds) in the CCTT completion time as age increased.
Conclusions: CCTT is a promising tool for the measurement of attention in the native Cypriot
population. Further research is needed in children diagnosed with various neurological and psychiatric
diseases in order to estimate validity of the CCTT in clinical populations.

Keywords: Attention; Executive function; Children's Color Trails Test; Normal development;
Normative data.

The Children’s Color Trails Test (CCTT) measures sequencing, visual scanning, psycho-
motor speed, and cognitive flexibility in children (D’Elia, Satz, Uchiyama, & White,
1996; Llorente, Williams, Satz, & D’Elia, 2003), mirroring measurements in the Color
Trails Test (CTT) used in the adult population. Development of the adult population CTT
was based on the request of the World Health Organization (WHO) for a cross-cultural
study in developing countries measuring neuropsychiatric aspects in patients diagnosed
with HIV-1 infection (Maj et al., 1993). This new instrument would measure frontal

Address correspondence to K. Konstantopoulos, European University Cyprus, Speech Therapy,

1 Diogenes Street, Block A, 3rd Floor, Nicosia, 1516 Cyprus. E-mail: c.constantopoulos@euc.ac.cy

© 2014 Taylor & Francis

 752 K. KONSTANTOPOULOS ET AL.

executive function, have a cross-cultural application and avoid the linguistic limitations of
a test similar to the CTT, the Trail- Making Test (Reitan, 1958).
Motivation for the development of the CCTT spurred from the limitations of an
older similar test, the Children’s Trail Making Test A & B (TMT-A & B; Reitan, 1971). In
addition to perceptual tracking, mental processing, sustained attention, and graphomotor
skills (TMT-A), the TMT-B used a combination of the English alphabet with colors to
measure mental processing, divided attention, and sequencing skills. Because the TMT-B
supported the interaction of all the aforementioned variables and the knowledge of the
English alphabet, its use might exclude children exposed to illiteracy, children who live in
cross-cultural contexts, and children with language or learning disabilities (Llorente et al.,
2003). Therefore, the use of the English alphabet would potentially affect the cross-
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cultural application of the TMT.

The development of the CCTT aimed to assess similar properties as the TMT
(sustained and divided attention, mental processing, graphomotor skills, and sequencing
skills) and to reduce the impact of any linguistic component including the administration
guidelines (Mok, Tsang, Lee, & Llorente, 2008). Consequently, the visual instructions in
the CCTT allowed administration without the linguistic component.
Up to date, there are only two studies that investigated relationships between the
CCTT and the children’s TMT (Mok et al., 2008; Williams et al., 1995). They showed that
both tests give emphasis on speeded visuomotor tracking and attention. Performance on
both instruments was influenced by age, intelligence (Mok et al., 2008; Williams et al.,
1995) but not gender (Mok et al., 2008). Mok et al. concluded that the second part of the
Children’s Color Trails Test (CCTT2) was less biased in completion time among different
language groups when compared to the TMT. The latter finding indicated that the CCTT
may be more useful than the TMT in the evaluation of clinical populations such as
children with language or learning disabilities. However, more studies are needed to in
order to assess the advantages of the CCTT in clinical populations.
In the CCTT itself, age (Koo & Shin, 2008; Llorente et al., 2003; Williams et al.,
1995) and gender (Llorente et al., 2003; Williams et al., 1995) were found to be associated
with CCTT1 and CCTT2 completion times. Further studies are needed to examine these
findings.
Similarly to TMT, the CCTT consists of two parts: CCTT1 and CCTT2. The
CCTT1 measures perceptual tracking, sustained attention, and graphomotor skills; to
these skills, the CCTT2 adds divided attention and sequencing (Llorente et al., 2003).
In both parts (CCTT1 and CCTT2), the respondent connects circled numbers (1–15) with
a pencil in ascending order, while in CCTT2 the numbers alternate with colors (pink and
yellow). The variables measured include completion time in seconds, errors, prompts, and
near-miss scores.
The CCTT has been used to measure executive function in a number of neurological
and psychiatric disorders like seizures and closed head injuries (Llorente et al., 2009;
Williams et al., 1995), learning and/or language disabilities (Williams et al., 1995),
attention deficit/hyperactivity disorders (Cho et al., 2010, 2011; Kennel, Taylor, Lyon,
& Bourguignon, 2010; Llorente et al., 2009; Voigt et al., 2001; Williams et al., 1995),
children with manganese exposure (Bhang et al., 2013), hearing loss (Oberg & Lukomski,
2011), and children diagnosed with HIV virus (Puthanakit et al., 2013). It has also been
used in bilingual populations (Mok et al., 2008).
Although there are several clinical studies using the CCTT, normative studies are
scarce. CCTT has been normed only in Moroccan, Korean, and American populations
 CHILDREN'S COLOR TRAILS TEST (CCTT) 753

(Fasfous et al., 2013; Koo & Shin, 2008; Llorente et al., 2003). The number of partici-
pants involved 154 Moroccan children (Fasfous et al., 2013), 678 American children
(Llorente et al., 2003), and 766 Korean children (Koo & Shin, 2008). Among these
studies, there is a great difference in the participants’ ages ranging from 7, 9, and 11 years
(Fasfous et al., 2013) to 5–15 years (Koo & Shin, 2008) and 8–16 years (Llorente et al.,
2003). There is a great need for normative studies in other languages across a wide age
range. Furthermore, there are no reports on near-miss responses and prompts apart from
the original study (Llorente et al., 2003). These variables may be of great importance,
especially as the near-miss scores may suggest the presence of cognitive slippage
(Llorente et al., 2003).
The present study aims to provide normative data about the CCTT in the Cypriot
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population (Greek language with a Cypriot dialect). Normative information about errors,
near-miss responses, and prompts is also included. Finally, relationships between comple-
tion time, age, and gender are investigated.

METHODS
Participants
Children were recruited from the four main cities (Nicosia, Limassol, Larnaca, and
Pafos) and 10 public schools across the island of Cyprus (sample of convenience). The
estimated population of children educated in the primary and secondary education in
Cyprus is 117,767 (Statistical Service of the Republic of Cyprus, 2012). The normative
sample consisted of 709 community-dwelling Caucasian native Cypriot children (Greek
language with a Cypriot dialect) aged 7–16 years old. The sample included 289 males
(41%) and 421 females (59%). The majority of the children (n = 630) were right handed
(89%). The sample was divided in 10 age groups (7–16 years) in yearly intervals.
All parents of the children were informed about the scope of the study, voluntarily
participated and signed the informed consent form.
Initial screening included a structured interview with the parents based on a ques-
tionnaire, including biographical data and the exclusion criteria. Participants were
excluded from the study if they had been diagnosed with psychiatric, cardiological,
metabolic, or neurological diseases and their native language was other than Greek.
Additionally, participants were excluded if the mother had a history of alcoholism and
drug abuse during pregnancy. Finally, factors such as premature birth, low birth weight,
hearing loss, visual problems, and abnormality in fine-motor movements were also taken
into consideration. Two hundred and twenty-seven participants were excluded from the
study (total initial sample, N = 936). The number of excluded children included low birth
weight (85 children), native language other than Greek (59 children), cardiological/
metabolic diseases (51 children), and attention deficit/hyperactivity disorder (ADHD)/
learning disabilities (32 children).

Materials
The CCTT test was administered to the participants according to the test guidelines
(Llorente et al., 2003). The CCTT1 administration involved the connection of circled
numbers (1–15) with a pencil on an A4 page (21 cm x 28 cm). The CCTT2 administration
involved connecting an alternating sequence of numbers (1–15) and colors (yellow/pink).
 754 K. KONSTANTOPOULOS ET AL.

Both parts (CCTT1 and CCTT2) involved variables such as completion test time in
seconds, number of errors (number of times the respondent connects a circle in an
improper numerical sequence), number of near-misses (number of times that the respon-
dent initiated a line towards an incorrect circle and he/she self-corrected), and number of
prompts (number of times that the tester points to the correct circle after the respondent
delayed the initiation of line drawing for more than 10 seconds). One additional variable
was applied to the CCTT2, the number of color errors (number of times the respondent
incorrectly connects a circle with an improper color).
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Procedure
The interview took place in the house of every participant. The parents were
informed about the scope of the study and signed a consent form before entering the
study. The completion of the history form was followed by the CCTT administration. The
local ethics committee reviewed and approved the consent form. During administration,
all variables were recorded.

Statistical Analysis
Descriptive analysis involved means and standard deviations of all variables fol-
lowed by multiple regression analyses (“enter” method in SPSS). The multiple regression
analyses were used to investigate the relationships of age and gender (predictors) with
CCTT completion time (outcome).

RESULTS
The mean age of the sample was 11.23 years (SD = 32.44), and the mean education
was 5.58 years (SD = 2.70). The mean score of the total sample for the CCTT1 was 34.58
seconds (SD = 13.59), and for the CCTT2, the mean score was 56.78 seconds
(SD = 22.68). The mean score of the female subgroup for the CCTT1 was 34.07
(SD = 13.58) and was 55.70 for the CCTT2 (SD = 22.48). The mean score of the male
subgroup for the CCTT1 was 35.33 (SD = 13.59) and was 58.36 for the CCTT2
(SD = 22.93). Table 1 shows normative data for each of the 10 age groups and
Figure 1 shows the percentile scores for the CCTT test.
To investigate the predictive nature of demographic variables (age and gender) on
the CCTT completion time, a multiple regression analysis was used. Significant associa-
tions of age and gender with the completion time of the CCTT1 and CCTT2 were found.
Age and gender accounted for 74.4% of the variation in the CCTT1 completion time.
Along the same lines, age and gender accounted for 72.9% of the variation in the CCTT2
completion time. Opposite to the normative analysis for the adult form of the Greek Color
Trails Test (Konstantopoulos, Issidorides, & Spengos, 2013), gender contributed to the
scores of the CCTT completion time by about 13%. Table 2 shows the results of the
multiple regression analysis for both subtests of the CCTT.
 CHILDREN'S COLOR TRAILS TEST (CCTT) 755

Table 1 Means and standard deviations (in parentheses) for all CCTT variables by age.

Age (yrs) 7 8 9 10 11 12 13 14 15 16

(n = 63) (n = 115) (n = 101) (n = 86) (n = 98) (n = 39) (n = 70) (n = 49) (n = 37) (n = 51)
CCTT1 Mean 48.37 44.53 37.62 34.85 30.72 26.57 29.93 27.03 24.32 23.31
(13.43) (12.51) (12.86) (11.25) (11.53) (9.47) (8.92) (8.78) (8.68) (8.10)
CCTT1 Errors 0.32 0.03 0.13 0.05 0.02 0.03 0.03 0.06 0.05 0.10
(0.18) (0.18) (0.37) (0.26) (0.14) (0.16) (0.17) (0.24) (0.23) (0.30)
CCTT1 Near Misses 0.75 0.53 0.41 0.44 0.49 0.28 0.73 0.69 0.62 0.65
(1.16) (1.05) (0.85) (0.98) (0.92) (0.60) (1.26) (1.19) (1.19) (1.07)
CCTT1 Prompts 0.08 0.06 0.02 0.00 0.00 0.03 0.04 0.04 0.00 0.00
(0.33) (0.24) (0.14) (0.00) (0.00) (0.16) (0.20) (0.20) (0.00) (0.00)
CCTT1 SEM 1.69 1.17 1.28 1.21 1.16 1.52 1.07 1.25 1.43 1.13
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CCTT2 Mean 84.40 76.16 62.65 54.23 49.56 44.71 46.11 41.60 37.97 37.59
(22.39) (25.38) (16.71) (17.47) (14.53) (10.54) (10.42) (9.66) (12.50) (11.31)
CCTT2 Near Misses 0.84 0.61 0.81 0.69 0.55 0.74 0.69 0.57 0.35 0.53
(0.85) (0.96) (1.00) (0.97) (0.89) (0.97) (0.91) (0.71) (0.54) (0.90)
CCTT2 Prompts 0.33 0.27 0.15 0.81 0.06 0.00 0.06 0.06 0.08 0.04
(0.62) (0.60) (0.43) (0.28) (0.28) (0.00) (0.23) (0.24) (0.28) (0.20)
CCTT2 Color Errors 0.44 0.30 0.31 0.21 0.18 0.18 0.14 0.20 0.16 0.27
(0.78) (0.61) (0.60) (0.53) (0.41) (0.51) (0.39) (0.50) (0.44) (0.53)
CCTT2 Number 0.00 0.01 0.03 0.03 0.01 0.00 0.04 0.00 0.00 0.00
Errors
(0.00) (0.09) (0.17) (0.18) (0.10) (0.00) (0.20) (0.00) (0.00) (0.00)
CCTT2 SEM 2.82 2.37 1.66 1.88 1.47 1.69 1.25 1.38 2.06 1.58

Note. SEM = Standard Error of Measurement.

DISCUSSION
The purpose of the present study was to provide normative data on the CCTT test in
a Cypriot sample of 709 children aged 7–16 years. Additional data such as near-miss
scores and prompts were also measured and reported.
Results showed that age and gender are essential variables to interpret the scores
for the CCTT completion time. Older children with more years of education completed
the test faster than younger children with less years of education. This trend was
apparent in all ages except 12-year-old participants who produced faster scores than
13-year-old participants. The number of the sample of the 12-year-old participants
(n = 39), which was less than any other group, may explain this result. The present
data are in agreement with the general trend of the data of the original study (Llorente
et al., 2003) even though the mean scores in every category of age were higher in that
study.
Data are also in agreement with the original study of Llorente et al. (2003), who
reported means less than 1 in variables such as errors, prompts, and near-miss scores.
Except Llorente et al. (2003), no other study has reported results in the near-miss scores
and, therefore, there is no other basis for comparison. The present prediction model
showed that gender has an effect of 13% on the CCTT completion time, in agreement
with the results of the original study (Llorente et al., 2003).
There is a general lack of neuropsychological testing in the Cypriot educational
system. Worldwide, this study is among the few (Fasfous et al., 2013; Koo & Shin, 2008;
Llorente et al., 2003) that provided normative data for the CCTT. The large sample (little
less than 1% of the total population of children in schools 7–16 years) and the reporting of
 756 K. KONSTANTOPOULOS ET AL.

(A)
70

60
CCTT Score (seconds)
50

40 10

30 50
90
20

10
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7 8 9 10 11 12 13 14 15 16
Age (years)
(B)
120

100
CCTT Score (seconds)

80
10
60
50
40 90

20

7 8 9 10 11 12 13 14 15 16
Age (years)

Figure 1 Percentiles across age and CCTT for the (A) CCTT1 and (B) CCTT2.

Table 2 Contribution of age and gender to the CCTT completion time.

Predicted variables

Predictor variables Standardized Beta t value p value

CCTT1 completion time

ANOVA (regression) F(2, 706) = 1027.349
p = .000, Adjusted R2 = .744
Age 0.760 26.043 .000
Gender 0.129 4.430 .000
CCTT2 completion time
ANOVA (regression) F(2, 706) = 953.000
p = .000, Adjusted R2 = .729
Age 0.747 24.877 .000
Gender 0.136 4.517 .000

Note. ANOVA = analysis of variance.

 CHILDREN'S COLOR TRAILS TEST (CCTT) 757

normative data about variables such as near-miss and prompts provide validity to the
reported norms. These variables, especially the near-miss scores, may suggest the pre-
sence of cognitive slippage (Llorente et al., 2003).
In the future, these norms may help to the assessment of attention/speed of mental
processing in a number of cognitive disorders such as traumatic brain injury (TBI),
ADHD, learning/language disabilities, hearing loss, and developmental delay in Greek-
speaking children. Limitations such as no standardized intellectual, academic, and beha-
vioral assessments of the participants may affect the generalization of our findings.
Further research is needed to focus on the clinical utility of the proposed norms and
their relationship with other neuropsychological measures. We are in the process of
collecting data among populations such as premature children and children diagnosed
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ADHD in order to add clinical value in the proposed norms.

Original manuscript received November 11, 2013

Revised manuscript accepted May 10, 2014
First published online June 6, 2014

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