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PubMed2002

Detecting exaggeration and malingering with the trail making test.

The purpose of this study was to examine whether unusual performance on the Trail Making Test could be indicative of deliberate exaggeration. Participants were 571 patients seen as part of a hospital trauma service who had acute traumatic brain injuries, and 228 patients involved in head injury litigation. As expected, the hospital patients with more severe traumatic brain injuries performed more poorly than the patients with less severe brain injuries on Trails A and Trails B. Cutoff score tables were developed for the patients with acute traumatic brain injuries for the total sample and by injury severity groups. Scores falling at or below the 5th percentile were considered suspicious for possible exaggeration. The performances of the head injury litigants who exaggerated on at least one well-validated symptom validity test were compared to these cutoffs. Very high positive predictive values for individuals with very mild head injuries on Trails A and B were identified (i.e., both 100%); lower positive predictive values were obtained for individuals with more severe head injuries (55.6-60%). The negative predictive values were only moderate (range=66.4-78.2%), and the sensitivity was very low (range = 7.1-18.5%) for all groups. Scores that fall in the range of possible biased responding should be considered "red flags" for the clinician because they likely do not make biological or psychometric sense. However, the sensitivity of the test for deliberate exaggeration is very low, so clinicians who rely on this test in isolation to identify deliberately poor performance will fail to identify the vast majority of cases.

Adult↗
PubMed2002

Derived trail making test indices in a sample of narcotic/other opiate abusers: demographic effects.

Derived indices on the Trail Making Test (TMT), a test often used to screen for cognitive impairment, were examined in a sample of 191 narcotic/other opiate abusers in drug abuse treatment programs. A mixed race sample was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. Data were analyzed to determine the effects of demographic variables on derived indices created by adding, subtracting, multiplying, and dividing parts A and B of the TMT in this large treatment sample of substance abusers. The variables of age, ethnicity, and education were statistically significant for the total score (A + B) and interaction score (A x B/100) derived indices of the TMT. In addition, the difference score (B - A) was statistically significant for education. The ratio score (B/A) was not significant for any demographic variable.

Adolescent↗
PubMed2001

Sex, ethnicity, age and education effects on the Trail Making Test in a sample of heroin abusers.

Sex, ethnicity, age and education effects on the Trail Making test (TMT), a test often used for screening for cognitive impairment, are examined in a sample of heroin abusers in drug abuse treatment programs. A mixed race sample was drawn from electronic files of data from the Drug Abuse Treatment outcome Study (DATOS). The DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. The number of heroin abusers with TMT scores available for analysis was 1548. Data were analyzed to determine the effects of sex, ethnicity, age and education variables on the two parts of the TMT in this large treatment sample of heroin abusers. The variables of sex, age, ethnicity and education were statistically significant for both parts A and B of the TMT. Nonetheless, R-Square values for overall models were quite weak (A = .08, B = .13) suggesting that sex, ethnicity, age and education effects on the TMT, while clearly present, account for relatively little overall variance in terms of heroin users' TMT performance. These results are consistent with earlier research using a more heterogenous drug abuse treatment sample.

Adult↗
PubMed2004

Trail Making Test A and B: normative data stratified by age and education.

Normative data for the Trail Making Test (TMT) A and B are presented for 911 community-dwelling individuals aged 18-89 years. Performance on the TMT decreased with increasing age and lower levels of education. Based on these results, the norms were stratified for both age (11 groups) and education (2 levels). The current norms represent a more comprehensive set of norms than previously available and will increase the ability of neuropsychologists to determine more precisely the degree to which scores on the TMT reflect impaired performance for varying ages and education.

Adolescent↗
PubMed2003

Utility of the trail making test in the assessment of malingering in a sample of mild traumatic brain injury litigants.

The Trail Making Test (TMT) is one of the most commonly administered tests in neuropsychological assessments. It has been shown to be a valid indicator of brain damage due to traumatic brain injury (TBI), as well as a number of other neuropathological conditions. TMT error and ratio scores have been suggested as possible markers of malingering. The present study examined the utility of various TMT scores as malingering measures in 94 TBI litigants. Litigants were divided into those suspected of (n = 27) and those not suspected of malingering (n = 67) based on scores obtained on the Test of Memory Malingering and/or the Rey 15-Item Test. TMT errors did not discriminate between suspected and nonsuspected malingerers; however, the overall level of performance on the TMT was suppressed in suspected malingerers. The TMT ratio score was significantly lower in litigants suspected of malingering, although the clinical utility of this ratio is minimal. Results of the present study suggest using caution when interpreting TMT scores as markers of malingering in TBI litigants.

Adult↗
PubMed1987

Relationships between parts A and B of the Trail Making Test.

Two measures of relationship between Parts A and B of the Trail Making Test (TMT) were examined in a large, acute rehabilitation population (N = 497). A difference (B-A) and a ratio (B/A) score were calculated and compared to other neuropsychological measures. The difference score was found to be correlated highly with intelligence and severity of impairment and, to a lesser degree, with age, education, and memory functioning. The ratio measure was correlated moderately or showed no significant relationship with other variables. This finding supported the curvilinear nature of the relationship between the ratio measure and cerebral impairment, as suggested by Golden, Osmon, Moses, and Berg (1981). Both measures were examined for their ability to distinguish between right and left cerebral damage. Only a trend toward differentiating lateralized damage was found; the ratio measure and a geometric transformation of the ratio showed greater sensitivity than did the difference measure. Results are discussed in terms of the potential usefulness of TMT relationship measures in neuropsychological inference.

Brain Damage, Chronic↗
PubMed2003

Nondominant hand performance of the Japanese Trail Making Test and its mirror version.

OBJECTIVES: To investigate intermanual differences in the Japanese version of the Trail Making Test (JTMT) and to investigate whether a mirror version of the JTMT test sheet (JTMT-M) should be used when the task is performed with the nondominant hand. DESIGN: Intermanual differences were compared among the JTMT with the dominant hand, the JTMT with the nondominant hand, and the JTMT-M with the nondominant hand. SETTING: Rehabilitation center in a university hospital. PARTICIPANTS: A total of 150 persons (age range, 19-38y) who had no history of neurologic or musculoskeletal impairment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The time to complete the task. RESULTS: Nondominant hand performance on the JTMT and JTMT-M did not differ significantly from that of the dominant hand on the JTMT. All left hand data except 1 in each task were within the previously reported reference values obtained from the JTMT with the right hand. CONCLUSIONS: The nondominant hand can be used as an alternative in the JTMT and can be expected to perform comparably to the dominant hand. There is no need to use the JTMT-M even when the task is conducted with the nondominant hand.

Adult↗
PubMed1984

The Trail Making Test and Canter Background Interference Procedure in screening for organicity in chronic schizophrenia: a preliminary report.

For 10 male organic chronic schizophrenics scores on the Trail Making Test and Canter Background Interference Procedure were compared. These patients had severe hyponatremia, a condition that results in brain damage. The hit rate for correctly classifying the oranicity was 100% on the basis of sequence binding on Trial Making B and 50% on Canter's procedure. The findings suggested that the Trial Making Test may prove useful in discriminating organic from nonorganic schizophrenics. Implications for research were discussed.

Chronic Disease↗
PubMed2003

Clinical utility of the trail making test ratio score.

It has been suggested that a ratio score of part B to part A of the Trail Making Test (TMT) may have clinical utility as a measure of cognitive efficiency and/or dissimulation. We investigated the clinical utility of the TMT B/A ratio score in the evaluation of patients with traumatic brain injury. Part B of the TMT demonstrated a statistically significant difference between groups with mild (n = 59) versus moderate-severe (n = 41) injuries. However, the B/A ratio score did not demonstrate sensitivity to injury severity and also failed to discriminate reliably individuals who had independent psychometric indicators of possible dissimulation from those who did not. We conclude that in individuals with traumatic brain injury, the B/A ratio score does not appear to enhance the clinical utility of the TMT and that interpretation of performance on this test should instead involve comparing subtest completion times to established normative data.

Adult↗
PubMed2003

Trait characteristic of impaired visuomotor integration during Trail-Making Test B performance in schizophrenia.

Using concurrent recording of eye and hand movements during the performance of the Trail-Making Test B (TMT-B), Wölwer and Gaebel have recently reported impaired visuomotor integration in patients with acute schizophrenia, which mainly accounted for patients' poor test performance. In order to replicate these exploratory findings in an independent sample of patients and to further investigate their stability during different stages of the illness, the performance process during a computerized TMT-B was assessed in 22 remitted outpatients with schizophrenia, 12 unaffected first-degree relatives and 26 healthy controls. As an estimate of longitudinal stability, a partial sample of 12 patients and 19 controls was reassessed after a period of 3 months. Remitted schizophrenia patients showed exactly the same strategic problems during the performance process of TMT-B as previously found in acute patients. Compared with healthy controls, patients more often sequenced searching ('planning') and connecting targets instead of time-sparing parallel execution, and their planning periods contained more and longer planning fixations (i.e. fixations outside the cursor area), which was related to longer performance time. Unaffected relatives mostly scored between patients and healthy controls without statistically significant differences to either group. Thus, the abnormalities in the process of TMT-B performance proved to be reliable and stable trait characteristics in schizophrenia.

Adult↗
PubMed1998

The role of speed of processing, inhibitory mechanisms, and presentation order in trail-making test performance.

The roles of speed of processing, inhibition, and presentation order in the Trail Making Test (TMT) performance were examined. One-hundred ten undergraduates performed the TMT (1/2 received order Part A-Part B, 1/2 received order Part B-Part A) and also completed computerized tests of inhibitory functioning and speed of processing. Neither speed of processing nor inhibitory functioning affected TMT performance. However, order of presentation significantly affected TMT performance. Presentation order is an important variable to consider in TMT performance.

Adult↗
PubMed2002

Derived trail making test indices in a sample of alcohol abusers: demographic effects.

Derived indices on the Trail Making test (TMT), a test often used for screening cognitive impairments, were examined in a sample of alcohol abusers in drug abuse treatment programs. A mixed race sample of 1000 subjects was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. Data were analyzed to determine the effects of demographic variables on derived indices created by adding, subtracting, multiplying, and dividing parts A and B of the TMT in this large treatment sample of alcohol abusers. The variables of age, ethnicity, and education were statistically significant for the total (A + B), interaction (A x B/100), and difference score (B-A) derived indices of the TMT. The ratio score (B/A) was only significant for education.

Adult↗
PubMed2006

Effect of age and education on the Trail Making Test and determination of normative data for Japanese elderly people: the Tajiri Project.

The Trail Making Test (TMT) is a common two-part neuropsychological test, in which visuospatial ability (TMT-A) and executive function (TMT-B) are evaluated. Normative data for this test have not been reported for Japanese subjects; therefore, the purpose of the present paper was to investigate the effect of age and education on the TMT in 155 healthy elderly adults with clinical dementia rating 0 (healthy). The participants were classified into three groups based on age (70-74 years, 75-84 years and >or=85 years), and also into three groups based on educational level (6 years, 8 years and >or=10 years). The time to complete TMT-A and TMT-B were measured, and the difference in score between TMT-A and TMT-B (B-A) and the ratio of the score (B/A) were calculated as indices of executive function. The time for completion of both parts of the TMT increased markedly in the >or=85-years group. For TMT-A, there was a significant difference between the 6-years and 8-years groups, and between the 6-years and >or=10-years groups, and for TMT-B, there was a significant difference between the 6-years and >or=10-years groups, and between the 8-years and >or=10-years groups. The difference and ratio scores increased in the >or=85-years group, but the educational level did not significantly influence these scores. Our data suggest that cognitive functions evaluated by TMT-A and TMT-B are not affected by aging until the subjects are >or=85 years old. For TMT-A, an educational effect becomes apparent when the population includes poorly educated subjects, but this part of the test is not affected by educational level provided that the subjects have some education (>6 years). The time to complete TMT-B is affected by educational level, consistent with previous reports. However, when adjusted using the results for TMT-A [(B-A) or (B/A)], the educational effect on executive function disappeared. Thus, the effect of educational level on executive function was unclear in normal elderly subjects.

Aged↗
PubMed2000

Comparison of time and error rates on the trail making test among patients with head injuries, experimental malingerers, patients with suspect effort on testing, and normal controls.

Clinical utility of completion time and performance errors was investigated for the Trail Making Test (TMT; Reitan, 1958). Archival neuropsychological files for patients with mild and moderate/severe head injuries, as well as patients with suspect effort on neuropsychological testing, were examined and compared to controls and experimental malingerers. Time-to-completion scores differentiated the participants who were malingering and who gave suspect effort from those patients with head injuries. There were no differences in error rates among the head-injury groups or controls for either the TMT-A or TMT-B. Errors were also not uncommon among normal controls; 12% and 35% of the controls made at least one error on TMT-A and TMT-B, respectively. However, error rates for both the suspect-effort and malingering groups were inflated on TMT-B as compared to the head-injured and control groups. Results suggest that performance errors on the TMT lack diagnostic utility for persons with head injuries, and time-to-completion is still the best indicator of neuropathology. However, performance errors, in conjunction with inflated time scores on the TMT, may be useful in the assessment of malingering.

Analysis of Variance↗
PubMed2001

Sex, ethnicity, age and education effects on the Trail Making test in a sample of cocaine abusers.

Sex, ethnicity, age and education effects on the Trail Making test (TMT), a test often used to for screen for cognitive impairment, were examined in a sample of cocaine abusers in drug abuse treatment programs. A mixed race sample of 5116 males and 2614 females was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. The number of cocaine/crack abuser scores available for analysis was 4306. Data were analyzed to determine the effects of sex, ethnicity, age and education variables on the two parts of the TMT in this large treatment sample of cocaine abusers. The variables of sex age, ethnicity and education were statistically significant for both parts A and B of the TMT. In addition, R-Square values for overall models were quite weak (A = .08, B = .11) suggesting that sex, ethnicity, age and education effects on the TMT, while clearly present, account for relatively little overall variance in terms of cocaine users TMT performance. These results are consistent with earlier research using a more heterogenous drug abuse treatment sample.

Adolescent↗
PubMed2003

Psychometric properties of the Mid-Range Expanded Trail Making Test. An examination of learning-disabled and non-learning-disabled children.

By systematically varying the stimuli within the Mid-Range Trail Making Test (MTMT), it may eventually be possible to isolate the cognitive demands of this test. Toward this end, the Mid-Range Expanded TMT (METMT) was developed by adding five new forms to the original forms A and B. To insure its appropriateness for clinical and experimental use, the current study sought to quantify the psychometric properties of this new test. The results indicate that the METMT is reliable and has adequate construct, criterion, and factoral validity. The results also cross-validated the findings of Davis et al. [J. Clin. Psychol. 45 (1989) 423.], suggesting that brief neuropsychological evaluations can effectively differentiate normal learners from learning-disabled children. The present study suggests that the MTMT is robust to alterations of its stimulus dimensions. Preliminary METMT normative data are presented.

Adolescent↗
PubMed1989

Analysis of errors on the Trail Making Test.

This study was designed to determine whether the number and/or types of errors on the Trail Making Test differentiated head-injured and normal control subjects. Errors on Part B were categorized into two types of shifting errors (from number to letter and from letter to number) and two types of sequencing errors (number and letter). Subjects consisted of 133 head-injured patients and 145 normal controls. Analysis showed that the frequency of errors on Parts A and B did not differ significantly between the groups nor did the percentage of subjects making errors. Total shifting and sequencing errors also did not differentiate between the two groups. Although head-injured subjects were more likely than controls to err in shifting from letters to numbers, this finding was of no apparent clinical usefulness. The discriminative value of time scores was confirmed.

Brain Damage, Chronic↗
PubMed2006

A normative study of the Trail Making Test in Korean elders.

OBJECTIVE: The purpose of this study was to explore the effects of age, education and gender on the performance of the Trail Making Test (TMT) and provide normative information in Korean elders. METHODS: The TMT was administered to 997 community-dwelling volunteers aged 60-90. People with serious neurological, medical and psychiatric disorders, including dementia, were excluded. RESULTS: Education and age had significant effects on both parts of the TMT. Gender also had an effect on part A of the TMT (Trail A). Based on these results, the norms of Trail A stratified by age (four overlapping tables), education (four strata) and gender, and the norms of part B of TMT (Trail B) stratified by age (four overlapping tables) and education (three strata). CONCLUSIONS: Age and educational level had a considerable influence on both Trail A and B. Our normative information on the Trail A will be useful in the elders with poor educational attainment and can be utilized for cross-cultural comparison of the Trail A performance. The fact that a large number of elders fail to complete Trail B indicates a limited applicability of Trail B in elderly population, particularly with poor educational background.

Age Factors↗