Comprehensive Trail-Making Test (CTMT)

Cognitive function is a broad term that refers to mental processes involved in the
acquisition of knowledge, manipulation of information, and reasoning. Cognitive functions
include the domains of perception, memory, learning, attention, decision making, and
language abilities. Perception is the organization, identification, and interpretation of sensory
information in order to represent and understand the presented information or environment.
Memory is an important cognitive process that allows people to encode, store, and retrieve
information. It is a critical component in the learning process and allows people to retain
knowledge about the world and their personal histories. Learning requires cognitive processes
involved in taking in new things, synthesizing information, and integrating it with prior
knowledge. William James wrote that attention “is the taking possession by the mind, in clear
and vivid form, of one out of what may seem several simultaneously possible objects or trains
of thought It implies withdrawal from some things in order to deal effectively with others.
Language and language development are cognitive processes that involve the ability to
understand and express thoughts through spoken and written words. It allows us to
communicate with others and plays an important role in thought. Decision-making is
regarded as the cognitive process resulting in the selection of a belief or a course of action
among several possible alternative options, it could be either rational or irrational. These
cognitive functions have an important role in our day-to-day functioning, which could be
disrupted by various neurological disorders that affect the brain as well as the nerves found
throughout the human body and the spinal cord. These structural, biochemical or electrical
abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms.
Visual-spatial ability is a broad term that emphasizes processes such as
image generation, storage, retrieval, and transformation and includes a collection of skills in
the areas of spatial relations, visualization, visual memory, closure speed, and spatial
scanning. Because visual-spatial ability is a multidimensional construct, it is possible for an
individual to have a relative strength in one area of visual-spatial ability (e.g., visual memory
of objects) and a relative weakness in another (e.g., spatial relations; Mather & Wendling).
The visual environment can be organized into a meaningful whole through visual perception.
Visual perception of an object requires the integration of several features, such as color,
depth, separating shapes and objects from their background, and form constancy. Visual
object recognition involves integrating visual perception with previous knowledge of known

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objects. Spatial ability, on the other hand, involves the integration of visual scanning of
space, mental representation of the relative position of one’s body parts in space, ability to
perform the necessary movements for a task, and understanding of the topographical
environment . Visual-spatial ability is an area typically measured as part of
neuropsychological examinations and may include the assessment of perceptual skills,
constructional skills, and spatial awareness.
Traumatic brain injuries (TBIs) are frequently referred to as “silent” due to the
damaging, yet often invisible long-term effects demonstrated through memory loss,
attentional disorders, and executive functioning deficits (Langlois, Rutland-Brown, &
Thomas, 2006). TBIs are the leading cause of death and disability with an average occurrence
of 475,000 brain injuries every year (Jankowitz & Adelson, 2006). A childhood TBI often
results in life-long deficits. Persistent cognitive impairments affect basic psychological
processes such as attention, perception, language, memory, and abstract reasoning (Farmer,
Clippard, Luehr-Wiemann, Wright, & Owings, 1997). Often, the most frequently identified
disrupted cognitive skill is “executive functioning.” Ylvisaker and DeBonis (2000) state that
“executive system impairment is often the most debilitating disorder after TBI” (p. 35).
However, as Maricle, Johnson, and Avirett (2010) note, there is no universally accepted
definition of executive functioning, nor is there a mutually agreed upon list of the cognitive
components which comprise executive functions. Numerous subdomains of cognition have
been implicated in executive functioning, including set-shifting, problem solving, abstract
reasoning, planning, organization, goal setting, working memory, inhibition, mental
flexibility, initiation, attentional control, and behavioral regulation.

Depending on the type of injury, the location of the frontal lobes is highly
susceptible to the detrimental effects of a TBI. The bony protuberances at the base of the
frontal lobes, and the frontal–temporal regions inside the skull, increase the vulnerability of
the frontal lobes (Ylvisaker & DeBonis, 2000). An insult to the frontal lobes at any age can
have significant consequences later in maturity given the protracted developmental process
which continues through adolescence. Unfortunately, children may often “grow” into their
deficits depending on what type of skill deficit is being examined. The individual's deficits
may not be demonstrated until the injured brain area is needed to support a developmental
transition (Ylvisaker & DeBonis, 2000). Given the importance of executive functioning on
daily living skills, academic success, and social interactions, it is imperative to accurately

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assess these deficits in children and adolescents. For the detection of frontal lobe deficits;
problems with psychomotor speed, visual search and sequencing, and attention and
impairments in set-
Shifting can be studied .Psychomotor abilities relate to the relationship between cognitive
functions and physical movements. Psychomotor speed is the individual’s ability to detect
and respond to rapid changes in the environment, such as the presence of a stimulus. Visual
search is a type of perceptual task requiring attention that typically involves an active scan of
the visual environment for a particular object or feature (the target) among other objects or
features (the distractors).Visual search can take place with or without eye movements. The
ability to consciously locate an object or target amongst a complex array of stimuli is
important part of the normal functioning. Practical examples of using visual search can be
seen in everyday life, such as when one is picking out a product on a supermarket shelf or
when trying to find a friend in a large crowd of people Set shifting, or cognitive flexibility, is
a core executive function involving the ability to quickly and efficiently shift back and forth
between mental sets.Cognitive flexibility refers to the ability to switch
between thinking about two different concepts or to think about multiple concepts
simultaneously. Cognitive flexibility declines with age and often results in an inability to
adapt to new situations and environments. Meta-analysis suggests medium-magnitude
shifting impairments in attention-deficit/hyperactivity disorder (ADHD).

Introduction to the Inventory

CTMT is an assessment based on time-tested techniques. It is a standardized set of 5 visual

search and sequencing tasks that are heavily influenced by attention, concentration, resistance
to distraction, and cognitive flexibility (or set-shifting). Its primary uses include the
evaluation and diagnosis of brain injury and other forms of central nervous system
compromise. More specific purposes include the detection of frontal lobe deficits; problems
with psychomotor speed, visual search and sequencing, and attention; and impairments in set-
shifting. Neuropsychological testing is necessary in a variety of contexts and performed by a
variety of professionals. Neuropsychologists; clinical, counseling, school, and pediatric
psychologists; occupational therapists; speech and language professionals; physical
therapists; and others interested in objective testing of functionality in brain-behavior
relationships would all benefit from using the CTMT.

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 The CTMT is for individuals ranging in age from 8 years through 74 years.
Administration is timed and takes approximately 5 to 12 minutes. Scoring typically requires
less than 5 minutes. Normative scores are provided in the form of T-scores, having a mean of
50 and a standard deviation of 10, along with their accompanying percentile ranks. The basic
task of trail-making is to connect a series of stimuli (numbers, expressed as numerals or in
word form, and letters) in a specified order as fast as possible. The score derived for each trail
is the number of seconds required to complete the task. The composite score is obtained by
pooling the T-scores from the individual trails. The five trails are similar but also are different
in some significant way.This easily administered set of tasks is remarkably sensitive to
neuropsychological deficits of many types.

The Five Trails:

1. The examinee draws a line to connect the numbers 1 through 25 in order. Each
numeral is contained in a plain circle.
2. The examinee draws a line to connect the numbers 1 through 25 in order. Each
numeral is contained in a plain circle. Twenty-nine empty distractor circles appear on
the same page.
3. The examinee draws a line to connect in the numbers 1 through 25 in order. Each is
contained in a plain circle. Thirteen empty distractor circles and 19 distractor circles
containing irrelevant line drawings appear on the same page.
4. The examinee draws a line to connect the numbers 1 through 20 in order . Eleven of
the numbers are presented as Arabic numerals, (e.g., 1, 7); nine numbers are spelled
out (e.g., Ten, Four).
5. The examinee draws a line to connect in alternating sequence the numbers 1 through
13 and the letters A through L. The examinee begins with 1 and then draws a line to
A, then proceeds to 2, then B, and so on until all the numbers and letters are
connected. Fifteen empty distractor circles appear on the same page.

The CTMT is standardized on a nationwide sample of 1,664 persons whose demographic

characteristics match the United States 2000 census data. Alpha coefficients for internal
consistency were above 0.70 for all five of the subtests and 0.92 for the Composite Index
(Reynolds, 2002). Reynolds also reported the test-retest score above 0.70, generally ranging
from 0.70 to 0.78, and the inter-rater reliabilities from 0.96 to 0.98. For validity, the CTMT

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was compared with the Developmental Test of Visual-Perception-Adolescents and Adults
(Reynolds, Pearson, & Voress, 2002) and the Draw-A-Person Intelligence Scoring (Reynolds
& Hickman, 2002). All these tests contained common visual perception and visual-motor
skill traits. The CTMT is extremely sensitive to neurological insult, disease, injury, or
dysfunction, including the subtle neuropsychological dysfunction often present in individuals
with learning disabilities. The Examiner's Manual includes discussion of the test's theoretical
and researched-based foundation, administration and scoring procedures, and more extensive
reliability and validity data.

METHOD

Aim: To assess attention, concentration, resistance to distraction, and cognitive flexibility of

the subject using Comprehensive Trail-Making Test.

Materials

Comprehensive Trail-Making Test Booklet

Manual

Writing Materials

Participant Details

Name –PA

Age -54

Gender - Female

Education – Higher Secondary Education

Experimenter

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Name- AA

Administration

See the subject comfortably near the table and establish rapport. Before beginning we should
make sure that stopwatch is around, cooperative and set by zero and the examinee has a
pencil with no eraser. Extra sharpen pencil should be available in case the examiner breaks D
pencil point during the test. If this occurs provide the examining with replacement as quickly
as possible. The quarter inch rate applies to all the five trials correction have to be made from
the same. This means that if the examining makes a circle out of order or misses a circle by
more than half an inch immediately point to the two circle in bold circle it origination and the
circle of destination and say no from here to the next. You must attach each circle and do
them in order. Specific instruction for each trial is given as per the manual for stop the fire
trials of the CTMT are to be administered in the numerical order. Having performed a trial
will aid more tested a key on the succeeding trial, so it is important to maintain the standard
procedure and to administer the triers in their proper order whenever possible.

Scoring :

There or score for each trial, is the number of seconds required for the examining to complete
the trial. Defined as making a number or letter out of sequence is. Should be noted but they
are not commented to any form of standardized descaled seen. On error has a negative impact
on the examining score because all of us are connected by the examining and disconnection
add to the time needed to complete each trial. Conversion of the raw score to T score person
Dale and the descriptive ratings are done as per the manual. To derive the CTMT Composite
Index some the T score for trials 1- 5 and then refer to the appendix B of the manual.

Interpretation Table:

T-Score Qualitative Description

Less than 30 Severely impaired

30-35 Mildly/moderately impaired

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 36-42 Below average
43-57 Average
58-64 High Average
65-70 Superior
More than 70 Very Superior

Simple v/s Complex Sequencing

The next step in evaluating the examinees performance in symbol trial versus complex trial
sequencing for stop first determine the mean T-score of the examining in the first three trials
by summing these three scores and dividing it by two. Subtracts the two means and find the
difference compare the difference between the mean T-score for the first two trials and the
last two trials if the difference in mean is significant at P<0.05 and the difference equals or
exceeds 12, the difference is significant at P<0.01.

The final step is to consider sequencing errors. Making errors on a trial making
test may be the best determinant of the frontal lobe problem on such a task. The examiner
should keep track of errors and corrected on any one of the trials. The presence of two or
more errors on anyone trial is strongly suggest.

RESULT

Table 1 shows Raw score, T-score, Percentile and corresponding Descriptive rating of Trail
1-5

Trial Raw Score T-score Percentile Descriptive

Rating
1 25 57 75 Very Superior
2 29 52 58 High Verage
3 27 50 75 Very Superior
4 24 55 69 Superior
5 19 85 99 Very Superior
Total 299

Table 2: Composite Index, T-score, Percentile and Descriptive Rating

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 Trial T-Score Percentile Descriptive Rating
Composite Index 60 75 Very Superior

The subjects have score on this test comes within the 75th percentile which indicate very
superior cognitive functioning.

DISCUSSION

The aim of the test was to assess attention, concentration, resistance to distraction, and
cognitive flexibility of the subject. Name of the subject was PA. She is a 54-year-old house
wife with higher Secondary level education. She was well groomed, cooperative and
articulated herself clearly, and she has no history of mental or physical illness, and reported
stress free experimental session.

The subject’s performance that is very superior level of scoring in this test might indicate
that she doesn’t have any impairments in psychomotor speed, visual search and sequencing,
and attention and impairments in set-Shifting. Psychomotor speed is the individual’s ability
to detect and respond to rapid changes in the environment, such as the presence of a stimulus.
Psychomotor abilities relate to the relationship between cognitive functions and physical
movements. Visual search is a type of perceptual task requiring attention that typically
involves an active scan of the visual environment for a particular object or feature (the target)
among other objects or features (the distractors). Since the ability to consciously locate an
object or target amongst a complex array of stimuli is important part of the normal
functioning, the performance on this test might be considered as the evidence of subjects
proper functioning in such cognitive visual tasks. Practical examples of using visual search
can be seen in everyday life, such as when one is picking out a product on a supermarket
shelf or when trying to find a friend in a large crowd of people. Another important domain
assessed in this test is cognitive flexibility or set shifting. Set shifting, or cognitive flexibility,
is a core executive function involving the ability to quickly and efficiently shift back and
forth between mental sets. Meta-analysis suggests medium-magnitude shifting impairments
in people with attention-deficit/hyperactivity disorder (ADHD). The subject’s performance
can be also taken as evidence for her efficient cognitive set shifting capacity and absence of
neurological conditions such as ADHD, Frontal lobe deficits etc.

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 Overall, the subject’s performance on this test might indicate lack of severe issues relating
to attention, concentration, resistance to distraction, and her normal ability to quickly and
efficiently shift back and forth between mental sets.

CONCLUSION: The subject has no impairments in attention, concentration, resistance to

distraction, and cognitive flexibility according to Comprehensive Trail-Making Test.

References

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brain injury. Psychological Monographs, 60(1).

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Reitan Battery in a normal sample. The Journal of nervous and mental disease,

175(4), 229-232.

DesRosiers, G., & Kavanagh, D. (1987). Cognitive assessment in closed head injury:

Stability, validity and parallel forms for two neuropsychological measures of

recovery. International Journal of Clinical Neuropsychology.

Dikmen, S. S., Heaton, R. K., Grant, I., & Temkin, N. R. (1999). Test–retest reliability and

practice effects of expanded Halstead–Reitan Neuropsychological Test Battery.

Journal of the International Neuropsychological Society, 5(04), 346-356.

Ehrenstein, W. H., Heister, G., & Cohen, R. (1982). Trail Making Test and visual search.

Archiv für Psychiatrie und Nervenkrankheiten, 231(4), 333-338.

Jankowitz B. T., Adelson P. D.. Pediatric traumatic brain injury: past, present and future,

Developmental Neuroscience, 2006, vol. 28 (pg. 264-275)10.1159/000094153

Langlois J. A., Rutland-Brown W., Thomas K. E.. , Traumatic Brain Injury in the United

States: Emergency Department Visits, Hospitalizations, and Deaths., 2006Atlanta,

GACenters for the Disease Control and Prevention, National Center for Injury

Prevention and Control.

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