Test review. Comprehensive Trail Making Test (CTMT) By Cecil R. Reynolds. Austin, Texas: PRO-ED, Inc., Test description

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Archives of Clinical Neuropsychology 19 (2004) 703 708 Test review Comprehensive Trail Making Test (CTMT) By Cecil R. Reynolds. Austin, Texas: PRO-ED, Inc., 2002 1.

1 Archives of Clinical Neuropsychology 19 (2004) Test review Comprehensive Trail Making Test (CTMT) By Cecil R. Reynolds. Austin, Texas: PRO-ED, Inc., Test description The Trail Making Test (TMT), parts A and B is one of the most widely used screening instruments in current neuropsychological practice. It was originally developed by Partington in 1938 to serve as a model of divided attention (Partington & Leiter, 1949; Reynolds, 2002, p. v; Spreen & Strauss, 1998). It has also been shown by Mezzich and Moses (1980) to be an excellent global screening measure that is sensitive to the integrity of cognitive performance level. Reynolds (2002) developed the Comprehensive Trail Making Test (CTMT) in order to remedy multiple shortcomings of the original form of the TMT. The original TMT measure was not well normed and no current set of published normative data for it is widely representative of performance among the current United States population. The reliability statistics for the original TMT are not based on large, representative samples and are difficult to generalize to normal controls with varied demographic characteristics as well as specific clinical populations. Reynolds (2002, p. 4) speculates that the [original] test may be too brief and too general. A test that is too brief very likely will have limited reliability and diagnostic accuracy. A test that is too general may fail to highlight specific cognitive strengths and deficits adequately. The CTMT was designed to overcome these suspected psychometric shortcomings of the original TMT. The CTMT procedure consists of five trials that are designed to highlight and isolate specific components of performance. Some of the CTMT trials present extraneous stimuli that must be ignored so that they do not distract the respondent from the target stimuli. Other trials of the CTMT provide some Arabic numerals as target stimuli (e.g., 9 ) and some written number words as stimuli (e.g., nine ). Switching between numerical and lexical cues from one stimulus to the next in a manner that is not readily predictable requires greater selective visual cue perception, more mental flexibility and greater sustained attentional ability than the original TMT tasks. The five trials of the CTMT procedure are described in the test manual as follows (Reynolds, 2002, p.2): Trial 1. The examinee draws a line to connect in order the numbers 1 through 25, each contained in a plain black circle. Trial 2. The examinee draws a line to connect in order the numbers 1 through 25, each contained in a plain black circle. Twenty-nine empty distractor circles appear on the same page /$ see front matter 2004 National Academy of Neuropsychology. doi: /j.acn

2 704 Test review / Archives of Clinical Neuropsychology 19 (2004) Trial 3. The examinee draws a line to connect in order the numbers 1 through 25, each contained in a plain black circle. Thirteen empty distractor circles and 19 distractor circles containing irrelevant line drawings appear on the same page. Trial 4. The examinee draws a line to connect in order the numbers 1 through 20, where 11 of the numbers are presented as Arabic numerals (e.g., 1, 7) and the remaining numbers are spelled out in English language form (e.g., Nine). Trial 5. The examinee draws a line to connect in alternating sequence the numbers 1 through 13 and the letters A through L, beginning with 1 and drawing a line to A, then 2, then B, and so on until all numbers and letters are connected. Fifteen empty distractor circles appear on the same page. Reynolds (2002) explains that the CTMT Trial 1 is an analog procedure to the original TMT Part A procedure. As such it is heavily dependent on sustained attention, as well as basic sequencing and visual spatial scanning skills. CTMT trials 2 and 3 increase the complexity of the sustained attention and visual search features of the task by adding simple (Trial 2) and both simple and complex (Trial 3) distractor stimuli to the visual array. The subject must sustain attention and focus attention selectively on the target stimuli for these trials. Introduction of both numerical and lexical number stimuli as targets on CTMT Trial 4 in a random alternation sequence requires the subject to seek the next logical target stimulus regardless of its appearance. More cognitive flexibility is required to complete this task than was necessary on the prior trials. CTMT Trial 5 in part mimics the original TMT Part B alphanumeric alternation sequence, but it adds the additional difficulty component of empty distractor circles. Unlike the original TMT-B, the types of target stimuli on CTMT Trial 4 do not simply alternate on every other item. The spatial array of the CTMT arrays also is more complex than that of the original TMT trials. The original TMT measure follows a spatial path that proceeds progressively outward from the center of the array. The CTMT spatial pathway is more complex and directionally variable from one sequential stimulus to the next. The CTMT measures therefore tend to be more demanding as measures of spatial scanning, sequencing, cognitive flexibility, and perceptual motor speed than the original TMT measures. 2. Test standardization The original TMT measure was not well normed and no current set of published normative data for it is widely representative of performance among the current United States population. The CTMT normative sample, in contrast, is based on a... population-proportionate stratified random sampling reflecting U.S. Bureau of the Census statistics. The CTMT normative sample consisted of 1,664 American individuals who were living in 19 states that represented the northeastern, midwestern, southern, and western regions of the contiguous United States. The normative sample was evenly divided by gender. Racial group and ethnic group sampling closely matched national normative characteristics school-age and adult U.S. population samples. The normative subjects also were nationally representative based on family income level, educational achievement level of parents of school age children or adults in the normative sample, disability status, and age (range =11 75 years). The CTMT manual (Reynolds,

3 Test review / Archives of Clinical Neuropsychology 19 (2004) ) provides breakdowns of the normative sample by age that is cross-classified with geographical area, gender, race, and ethnicity. The CTMT sample was meticulously chosen and is widely representative of the current American population on all of these key demographic characteristics. 3. Test administration All CTMT trials must be administered in numerical order. If any trial is administered out of order the results of that trial and all subsequent trials will be invalid. The CTMT is based on the concept that there is a practice effect that proceeds through the trial sequence, and this principle can not be violated if a valid administration is to be achieved. Total administration time for all trials of the CTMT by an experienced examiner is reported in the test manual to be approximately 5 to 12 min. The test setting should be quiet and well lighted from above so that the test stimuli are free of shadow. The test table should be large enough to open the CTMT booklet flat on the table surface. The examiner should be thoroughly familiar with the test directions. The subject should be provided with several pencils without easers. A stopwatch should be used to time performance on each trial of the CTMT exactly. The CTMT is appropriate for administration to American subjects who are between 11 years 0 months and 74 years 11 months of age. Potential testees must be able to understand the test directions for each of the five CTMT subtests and they must be able to pass the practice items for each subtest to demonstrate that understanding. Sample A is presented as a half-page screening task before trials 1 through 3 are administered. This sample task requires the subject to draw a line through the numerical sequence of black circles that have the numbers 1 through 5 in them and to ignore six distractor circles that are placed among the visual array. Two of the distractor circles are empty; four of them contain irrelevant visual patterns. If Sample A is completed successfully CTMT trials 1 through 3 are administered. If the testee can not complete Sample A after multiple attempts, administration of the CTMT is discontinued. Sample B is presented as a half-page screening task before Trial 4 is administered. It consists of five circles with Arabic numerals inside them and three rectangles with number words that are printed inside of them. There are also two empty distractor circles in the array. The subject is required to draw a continuous line from circle to rectangle or circle in numerical order until the eighth stimulus, which is the end of the sequence. If Sample B is completed successfully, the examiner proceeds to administer CTMT Trial 4. If Sample B is not completed successfully, Trial 4 is not administered. Sample C is presented as a half-page screening task before Trial 5 is administered. It consists of nine circles with numbers (1 5) or letters (A D) printed inside them. The task is similar to the original TMT Part B task. The subject connects the circles in alternating alphanumeric order (1-A-2-B-3-C...) until the sequence is completed. If Sample C is completed successfully, CTMT Trial 5 is administered. If Sample C can not be completed successfully, Trial 5 is not administered.

4 706 Test review / Archives of Clinical Neuropsychology 19 (2004) Test scoring Scoring of the CTMT trials is a clerical task. The examiner records the exact response time in seconds on the record booklet. Errors must be noted as they occur and must be corrected by the examinee during the test administration. There is no formal scoring of error types. Errors contribute to test performance since they require additional time for correction as they occur. Suggestions for qualitative interpretation of some error types are suggested in the test manual, and are noted in the next section of this review. Raw time scores for each trial are converted to standardized T-scores and percentile ranks according to chronological age for each trial of the CTMT according to tables in an appendix of the test manual. Uniform score conversions are provided for all subjects and are stratified by age alone. A CTMT Composite Index (global performance level score) also can be calculated by summing the time scores for the five CTMT trials and then transforming that global score into a standardized T-score or a percentile score according to the subject s chronological age. The T-score values for the five CTMT trials, for the mean performance level across these five trials, and for the Composite Index score can be plotted on a score profile that is on the face sheet of the CTMT Record Booklet to provide a graphical summary of the findings. Significant ipsative strengths and weaknesses among the five CTMT trial scores also can be calculated relative to the mean performance level for an individual. A tabular flow chart of the simple calculations that are involved to determine if a given score is a statistically significant individual strength or deficit at the.05 or the.01 level also is provided on the face sheet of the CTMT Record Form. If a trial is spoiled by extraneous distraction or interruption of the test session, that trial must not be interpreted. Reynolds suggests that a composite score still can be calculated since results of the other trials can be prorated to compensate for the spoiled trial. At least three of the CTMT trials must be administered validly if the prorating procedure is to be employed. Specific procedures for completion of these calculations are provided in the test manual. 5. Test score interpretation The initial phase of CTMT interpretation is based on global performance level analysis of the Composite Index score. The manual provides a tabular summary of descriptive levels of T-score performance and the percentile values that are associated with each of these T-score ranges. Reynolds recommends reporting of both the qualitative label and the associated percentile level for the Composite Index score. Those who score at a level that is more than 1.5 standard deviation units below the mean are considered to show impaired performance level (approximately seventh percentile level for age). The next phase of CTMT interpretation involves analysis of the ipsative differences among the five trials of the test. Deviations from the mean performance level for that individual is the basis for the analysis of relative skill strengths and deficits. Significant findings on a specific trial may be attributed to relative strengths or deficits on the component skills that are highlighted by the tasks of that trial. The findings must be interpreted in the context of the patient s history and must be based on a valid test administration.

5 Test review / Archives of Clinical Neuropsychology 19 (2004) Simple versus complex sequencing analysis constitutes the next level of analysis. CTMT trials 1 3 require only simple sequencing skills. Trials 4 and 5, in contrast, require a higher level of set shifting or cognitive flexibility analysis. Reynolds recommends calculation and comparison of mean test scores for CTMT trials 1 3 and trials 4 and 5. He provides mean score difference values for these Simple Sequencing versus Complex Sequencing mean scores that can be used to calculate performance level differences that are significant at the.05 and the.01 levels of statistical significance. These values were derived from statistics that were based on the CTMT normative sample. Error analysis is the final step in CTMT interpretation. Reynolds (2002) hypothesizes that two or more errors on any given CTMT trial strongly suggest impairment of frontal lobe function, but he offers this formulation only as a conjecture that requires experimental study. He encourages examiners who use the CTMT in their practice to keep track of errors that the examinee makes and to note the total number and the pattern of errors across trials. 6. Test reliability and validity The CTMT meets rigorous standards for reliability. Since the CTMT is a speeded test, internal consistency was estimated by means of alternate form reliability estimation. Correlational values were calculated between each of the five CTMT trial scores and... a composite score comprised of the remaining four trials... (Reynolds, 2002, p. 26). Age effects were controlled by conversion of all raw score values to T-score equivalents before the calculations were performed. All internal consistency values for the five CTMT trial measures meet or exceed a value of.70, and the reliability value for the Composite Index score is.92. Internal consistency estimates of.80 or higher are reported for composite samples of elderly subjects, some ethnic minority groups, and a sample of stroke patients. Detailed reliability statistics are presented for various demographic, developmental, and diagnostic groups in the test manual (Reynolds, 2002, p. 27). Test retest reliability values for the five trials of the CTMT range from.70 to.78, which are quite high values for a speeded measure. Interrater reliabilities are exceptionally high for the five trials of the CTMT (range.96.98). Reynolds (2002) devotes a chapter of the CTMT manual to discussion of preliminary studies of the test s construct, concurrent, and content validity. Critical analysis of all of these studies is beyond the scope of this review. Factor analytic findings strongly support the differentiation of simple (trials 1 3) and complex (trials 4 5) dimensions within the CTMT test structure. The internal consistency values of the measure are nearly equivalent across the age range. The Composite Index shows excellent psychometric characteristics as a measure that summarizes and estimates the level of performance in the score values of the five CTMT trials. Similarities of the reliability values across gender and age groupings shows no consistent or large difference. The task constructs that are estimated by the test scores appear to be invariant across these variables. Correlational analyses of the five CTMT trial measures and the Composite Index with other non-ctmt measures that ostensibly measure similar theoretical constructs show convergence

6 708 Test review / Archives of Clinical Neuropsychology 19 (2004) with measures from other tests that require... the integration of visual perceptual skills and motor speed (Reynolds, 2002, p. 39). Other findings show a small visual working memory component in the CTMT, a modest visual perceptual component, and a modest motor speed component. The CTMT measures show expected patterns of convergent and divergent validity and appear to be specific for measurement of the integrative executive function attributes that they are designed to evaluate. 7. Synopsis The CTMT is an invaluable, meticulously constructed, nationally normed, reliable and valid new psychometric instrument. It provides clinicians and research workers with a hierarchy of specific as well as global summary measures that operationally define important basic and complex components of executive function. Its component skills have been widely validated for application across the life span and across important demographic groups in which it has been studied. This revision and extension of the original TMT shows great promise that should provide us with opportunities to deliver enhanced service to our patients. It is an important new psychometric instrument that should be studied intensively and applied widely in clinical as well as basic and applied research settings. References Mezzich, J. E., & Moses, J. A., Jr. (1980). Efficient screening for brain dysfunction. Biological Psychiatry, 15, Partington, J. E., & Leiter, R. G. (1949). Partington s Pathway Test. The Psychological Service Center Bulletin, 1, Reynolds, C. R. (2002). Comprehensive Trail Making Test: Examiner s manual. Austin, Texas: PRO-ED. Spreen, O., & Strauss, E. (1998). A compendium of neuropsychological tests: Administration, norms, and commentary (2nd ed.). New York: Oxford University Press. James A. Moses Jr VA Palo Alto Health Care System (116B) 3801 Miranda Avenue, Palo Alto CA , USA address: jmoses@pgsp.edu (J.A. Moses Jr.)

Running head: CPPS REVIEW 1

Running head: CPPS REVIEW 1 Please use the following citation when referencing this work: McGill, R. J. (2013). Test review: Children s Psychological Processing Scale (CPPS). Journal of Psychoeducational