Color Trails Test (CTT)

Evidence Reviewed as of before: 08-11-2012
Author(s): Lisa Zeltzer, MSc OT; Valerie Poulin, OT, PhD candidate
Editor(s): Nicol Korner-Bitensky, PhD OT; Annabel McDermott, BOccThy

Purpose

The Color Trails Test (CTT) is a language-free version of the Trail Making Test (TMT) that was developed to allow for broader cross-cultural assessment of sustained attention and divided attention in adults.

In-Depth Review

Purpose of the measure

The Color Trails Test (CTT) (Maj, D’Elia, Satz, Janssen, Zaudig, Uchiyama et al., 1993; D’Elia, Satz, Uchiyama & White, 1996) is a language-free version of the Trail Making Test (TMT) that was developed to allow for broader cross-cultural application to measure sustained attention and divided attention in adults.

Available versions

There are 4 versions of the CTT (forms A, B, C, and D) but only the first version (form A) has normative data and is the only version that should be used in a clinical setting. Versions B-D are experimental and should be used in research only (Mitrushina, Boone, Razzani, & D’Elia, 2005).

Features of the measure

Items:

The CTT is comprised of two tasks:

  • CTT1: Must be administered first and requires the respondent to connect circles in an ascending numbered sequence (1-25).
  • CTT2: Must follow the CTT1 and requires the respondent to connect numbers in an ascending sequence while alternating between pink and yellow colors. Numbers are presented twice, once in pink and once in yellow, so the client must ignore the distracter item (e.g. start at pink 1, avoid pink 2 to select yellow 2, avoid yellow 3 to select pink 3, etc.).

Untimed practice trials are completed for both the CCT1 and CCT2 to ensure that the client understands the task.

Scoring and score interpretation:

Time taken to complete each part of the CTT is recorded in seconds and is compared to normative data. Qualitative aspects of the performance that may be indicative of brain dysfunction (e.g. near misses, prompts required, sequencing errors for colour and number) are also recorded.

Time:

The CTT manual reports that it takes 3-8 minutes to complete the CTT. A task is discontinued if the client takes longer than ?240 seconds to complete it.

Equipment:

  • Table and chair
  • Test
  • Pencil
  • Stopwatch

Training requirements:

This is a level “C” qualification meaning that it requires an experienced professional to administer the test.

Alternative Forms of the Colour Trails Test

  • Trail Making Test (TMT)
  • Comprehensive Trail Making Test (Reynolds, 2002)
  • Delis-Kaplan Executive Function Scale (D-KEFS): includes subtests modeled after the TMT
  • Oral TMT: an alternative for patients with motor deficits or visual impairments (Ricker & Axelrod, 1994).
  • Repeat testing TMT: alternate forms have been developed for repeat testing purposes (Franzen et al., 1996; Lewis & Rennick, 1979)

Client suitability

Can be used with:

  • Individuals with stroke
  • Clients 18-89 years old
  • Individuals who are colourblind
  • The CTT requires relatively intact motor abilities (i.e. ability to hold and manoeuvre a pen or pencil, ability to move the upper extremity). The Oral TMT may be more appropriate if the examiner considers that the participant’s motor ability may impact his/her performance.
  • Clients must be able to understand Arabic numbers and numerical sequence.

Should not be used with:

  • Clients with motor or coordination impairments (e.g. apraxia). If motor ability may impact performance, consider using the Oral TMT.
  • Should be used with caution in older adults with low education. Age and education have been reported to influence response times in both parts of the CCT, such that older individuals with low education levels have demonstrated significantly slower response times (D’Elia et al, 1996; Messinis, Malegiannaki, Christodoulou, Panagiotopoulos, & Papathanasopoulos, 2011).

In what languages is the measure available?

This is a language-free measure however cultural norms have been published for the following populations:

  • Adult Greek population with stroke (Messinis et al., 2011)
  • Turkish population with schizophrenia (Güleç, Kavakçı, Güleç, & Küçükalioğlu, 2006)
  • Healthy Turkish population (Dugbartey, Townes & Mahurin, 2000)
  • Healthy Spanish population (LaRue, Romero, Oritz, Chi Liang, & Lindeman, 1999)
  • Healthy Brazilian sample (Sant’Ana Rabelo, Pacanaro, Rossetti, Almeida de Sa Leme, de Castro, Guntert, et al., 2010)
  • Healthy sample from China (Hsieh & Riley, 1997)
  • Healthy sample from Hong Kong (Lee & Chan, 2000).

Summary

What does the tool measure? Language-free measure of sustained and divided attention.
What types of clients can the tool be used for? The CTT can be used with, but is not limited to, patients with stroke.
Is this a screening or assessment tool? Assessment tool
Time to administer The TMT takes approximately 3 to 8 minutes to administer.
Versions
  • Trail Making Test (TMT)
  • Comprehensive TMT
  • Oral TMT
  • Repeat testing TMT (developed for repeat testing purposes)
  • Symbol TMT
  • Delis-Kaplan Executive Function Scale (D-KEFS)
Other Languages Language-free measure but norms established for Greek, Turkish, Chinese, Brazilian, and Spanish populations
Measurement Properties
Reliability
  • No studies have examined internal consistency of the CTT in patients with stroke.
  • No studies have examined inter-rater reliability of the CTT in patients with stroke.
  • No studies have examined test-retest reliability of the CTT in a stroke population but the authors of the measure report excellent test-retest reliability for CTT2 and adequate test-retest reliability for CTT1 in a healthy sample.
Validity

Content

No studies have examined content validity of the CTT in patients with stroke.

Criterion

Predictive validity

2 studies reported that the CTT1 predicted on-road driving test failure in samples of clients that included stroke.

Concurrent validity

1 study reported excellent correlations between the CTT1 and CTT2 and the TMT-A and TMT-B respectively.

Construct

Convergent validity

1 study reported adequate to excellent correlations between the CTT and the Useful Field of View (UFOV) subtests.

Known groups validity

1 study reported significant differences in time to complete the CCT between the patients with stroke and healthy adults.

Floor/Ceiling Effects No studies have examined floor/ceiling effects of the CTT in patients with stroke.
Does the tool detect change in patients? The responsiveness of the CTT has not formally been studied, however it has been used to detect changes in a clinical trial of 2 participants with stroke.
Acceptability The CTT is simple and easy to administer and is language-free.
Feasibility The CTT is relatively inexpensive and highly portable. The CTT must be purchased and should be administered by an experienced professional.
How to obtain the tool?

The CTT can be purchased from: Psychological Assessment Resources (http://www4.parinc.com/Products/Product.aspx?ProductID=CTT)

* Initially developed for a traumatic-brain injured population, the psychometric properties of the tool with this population are described in the administration guide of the tool.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the CTT in individuals with stroke. We identified 4 studies.

Floor/Ceiling Effects

No studies have reported on floor/ceiling effects of the CTT when used with an adult stroke population.

Reliability

Internal consistency

No studies have reported on internal consistency of the CTT when used with an adult stroke population.

Test-retest reliability

D’Elia et al. (1996) examined the test-retest reliability of the CTT in 27 healthy individuals. The CTT was administered twice, two weeks apart. Excellent test-retest reliability was reported for the CTT2 (r=0.79), and adequate test-retest reliability was reported for the CTT1 (r=0.64).

Inter-rater reliability

No studies have reported on inter-rater reliability of the CTT when used with an adult stroke population.

Validity

Content

No studies have reported on content validity of the CTT when used with an adult stroke population.

Construct

Known groups validity

Messinis, Malegiannaki, Christodoulu, Panagiotopoulos, and Papathanasopoulos (2011) examined known groups validity of the CTT with 25 clients who had recently experience a stroke and 26 healthy participants matched for age, educational level and gender (Greek population). Clients in the stroke group required significantly more time to complete the CTT1 and CCT2 than the healthy controls (p < 0.001).

Convergent/discriminant validity

Hartman-Maeir, Erez, Ratzon, Mattatia and Weiss (2008) examined convergent validity of the CTT in a sample of 30 individuals with acquired brain injury (including stroke, n=17) wishing to obtain a drivers licence, using Spearman correlation coefficients. The CTT1 and CTT2 showed adequate to excellent correlations with Useful Field of View (UFOV) subtests of processing speed (CTT1 r=0.407; CTT2 not significant), divided attention (r=0.457, 0.486 respectively) and selective attention (r=0.602, 0.629 respectively). Results support validity of the CTT as a pre-driving assessment tool.

Criterion

Concurrent validity

Elkin-Frankston, Lebowitz, Kapust, Hollis, & O’Connor (2007) examined the concurrent validity of the CTT with the TMT in 29 individuals with various medical conditions including stroke (n=8). Completion times on the CTT and TMT were highly correlated (CTT1 vs. TMT-A: r=0.91; CTT2 vs. TMT-B: r=0.72) suggesting excellent concurrent validity with the original TMT.

Predictive validity

Elkin-Frankston et al. (2007) examined the ability of the CTT to predict on-road driving test failure in 29 individuals with various medical conditions including stroke (n=8). Patients who failed an on-road driver evaluation performed the CTT1 significantly slower than those who passed (Cohens d=0.66, p<0.05). This relationship was also found for the CTT2 but it did not reach statistical significance.

Hartman-Maeir et al. (2008) examined predictive validity of the CTT in a sample of 30 individuals with acquired brain injury including stroke (n=17) wishing to obtain a drivers licence. There was a significant difference in time taken to complete CTT1 between those who passed and failed the on-road test (Cohen’s d = 0.67, p=0.02). Performance time <60 seconds on the CTT1 was found to predict passing the on-road evaluation, whereas >60 seconds was predictive of failing.

Responsiveness

Liu, Chan, Lee, and Hui-Chan (2004) used the CTT to evaluate the effectiveness of mental imagery in clients with stroke (n=2). In this study, the CTT detected change in both clients with reduced time to complete the CTT1 and CTT2 post-intervention.

Sensitivity/ Specificity

No studies have reported on sensitivity/specificity of the CTT when used with an adult stroke population.

References

  • Barncord, S. W. & Wanlass, R. L. (2001). The Symbol Trail Making Test: test development and utility as a measure of cognitive impairment. Applied Neuropsychology, 8, 99-103
  • D’Elia, L. F., Satz, P., Uchiyama, C.L., & White, T. (1996). Color Trails Test. Odessa, FL: PAR.
  • Dugbartey, A. T., Townes, B. D., & Mahurin, R. K. (2000). Equivalence of the Color Trail Making Test in nonnative English-speakers. Archives of Clinical Neuropsychology, 15, 425-31.
  • Elkin-Frankston, S., Lebowitz, B. K., Kapust, L. R., Hollis, A.M., & O’Connor, M.G. (2007). The use of the Colour Trails Test in the assessment of driver competence: preliminary reports of a culture-fair instrument. Archives of Clinical Neuropsychology, 22(5), 631-5.
  • Franzen, M., Paul, D., & Iverson, G. L. (1996). Reliability of alternate forms of the trail making test. The Clinical Neurologist, 10(2), 125-9.
  • Güleç, H., Kavakçı, O., Güleç, M. Y., & Küçükalioğlu, C. I. (2006). The reliability and validity of the Turkish Color Trails Test in evaluating frontal assessment among Turkish patients with schizophrenia. Düşünen Adam, 19(4), 180-5.
  • Hartman-Maeir, A., Erez, A. B., Ratzon, N., Mattatia, T., & Weiss, P. (2008). The validity of the Color Trails Test in the pre-driver assessment of individuals with acquired brain injury. Brain Injury, 22, 994-1008.
  • Hsieh, S. & Riley, N. (1997, November). Neuropsychological performance in the People’s Republic of China: Age and educational norms for four attentional tasks Presented at the National Academy of Neuropsychology, Las Vegas, Nevada. In Mitrushina, M. Boone, K., & D’Elia L. Handbook of Normative Data for Neuropsychological Assessment. (pp.70-73). New York, NY: Oxford University Press.
  • LaRue, A., Romero, L., Ortiz, I., Liang, H.C., & Lindeman, R. D. (1999). Neuropsychological performance of Hispanic and non-Hospanic older adults: an epidemiologic survey. Clinical Neuropsychologist, 13, 474-86.
  • Lee, T. M. & Chan, C. C. (2000). Are Trail Making and Color Trails Tests of equivalent constructs? Journal of Clinical and Experimental Neuropsychology, 22, 529-34.
  • Lewis, R. F. & Rennick, P. M. (1979). Manual for the repeatable Cognitive-Perceptual-Motor Battery. Grosse Point Park, MI: Axon Publishing Company.
  • Liu, K. P., Chan, C. C., Lee, T. M., & Hui-Chan, C.W. (2004). Mental imagery for relearning of people after brain injury. Brain Injury, 18(11), 1163-72.
  • Maj, M., D’Elia, L. D., Satz, P., Janssen, R., Zaudig, M., Uchiyama, C., Starace, F., Galderisi, S., & Chervinsky, A. (1993). Evaluation of two new neuropsychological tests designed to minimize cultural bias in the assessment of HIV-1 Seropositive persons: a WHO study. Archives of Clinical Neuropsyhology, 8, 123-35.
  • Messinis, L., Malegiannaki, A. C., Christodoulou, T., Panagiotopoulos, V., & Papathanasopoulos, P. (2011). Color Trails Test: normative data and criterion validity for the greek adult population. Archives of Clinical Neuropsychology, 26(4), 322-30.
  • Mitrushina, M., Boone, K. B., Razzani J., & D’Elia, L. F. (2005). Handbook of normative data for neuropsychological assessment. (2nd ed.). New York: Oxford University Press.
  • Reynolds, C. (2002). Comprehensive Trail Making Test. Austin, TX: Pro-Ed.
  • Ricker, J.H. & Axelrod, B. N. (1994). Analysis of an oral paradigm for the Trail Making Test. Assessment, 1, 47-51.
  • Sant’Ana Rabelo, I., Pacanaro, S.V., de Oliveira Rosetti, M., de Sa Leme, I.F., de Castro, N.R., Guntert, C. M., Correa Miotto, E., & Souza de Lucia, M. C. (2010). Color Trails Test: a Brazilian normative sample. Psychology and Neuroscience, 3, 93-9.

See The Measure

How to obtain the CTT

The CTT can be purchased from Psychological Assessment Resources (http://www4.parinc.com/Products/Product.aspx?ProductID=CTT)

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