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The Trail Making Test and its neurobehavioral

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a a
Esther L. Misdraji & Carlton S. Gass
a
Miami VA Healthcare System , Miami, FL, USA
Published online: 20 May 2009.

To cite this article: Esther L. Misdraji & Carlton S. Gass (2010) The Trail Making Test and its neurobehavioral
components, Journal of Clinical and Experimental Neuropsychology, 32:2, 159-163, DOI: 10.1080/13803390902881942

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 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY
2010, 32 (2), 159–163

The Trail Making Test and its

NCEN

neurobehavioral components

Esther L. Misdraji and Carlton S. Gass

Neurobehavioral Components of the TMT

Miami VA Healthcare System, Miami, FL, USA

This study investigates the neurobehavioral components involved in Trail Making Test (TMT; Parts A and B)
performance and their relation to MMPI–2 measures of anxiety and depression. Consecutive patients (N = 192)
referred for a comprehensive neuropsychological evaluation at a U.S. Department of Veterans Affairs (VA)
Medical Center comprised the sample. Results: graphomotor speed and mental shifting were significantly associ-
Downloaded by [The UC Irvine Libraries] at 18:59 09 October 2014

ated with Wechsler Adult Intelligence Scale–Third Edition (WAIS–III) indexes, whereas visual scanning
efficiency was not. Graphomotor speed accounted for a substantially greater portion of the variance in TMT per-
formance within impaired than within normal groups. Levels of anxiety and depressive symptoms were unrelated
to TMT performance. Implications and directions for future research are discussed.

Keywords: Trail Making Test; Executive function; Minnesota Multiphasic Personality Inventory–2; Depression;
Anxiety; Neuropsychological assessment.

The Trail Making Test (TMT) is an easily administered
measure of visual scanning, graphomotor speed, and
mental flexibility and is widely used in neuropsychological
evaluations. Detailed background and test description
are provided by Lezak, Howieson, and Loring (2004, pp.
371–374). The neurobehavioral components involved in
successfully completing the separate subtests of the TMT
(A and B) are difficult to distinguish, because some are
shared across tasks. For example, both subtests require
sufficient attention, graphomotor speed, visual scanning
ability, and numeric sequencing, but TMT-B further
necessitates letter sequencing, mental double tracking,
and alternation (e.g., shifting between letter and number
series). Nevertheless, accurate delineation of the reasons
underlying poor performance on the TMT could have
significant diagnostic and treatment implications. In any
individual case, for instance, low scores on the TMT-B
could be almost entirely due to slowed motoric function-
ing, impaired visual scanning, or inability to alternate
between numbers and letters. A component analysis of
TMT-B performance, then, could assist the clinician in
drawing inferences regarding regional brain compromise
that could aid in diagnostic clarification. Examples
include graphomotor slowness secondary to conditions
affecting the motor area and/or underlying white matter,
scanning deficiency associated with visuoperceptual
disturbances often found in occipital-parietal damage,
and impaired shifting ability (often involving persevera-
tion) in the cases with prefrontal pathology.
Although scoring for the TMT is typically expressed
in terms of the time taken to complete each portion of
the exam, two derived scores are commonly evaluated: a
TMT-B – TMT-A difference score and a TMT-B/TMT-A
ratio (Lamberty, Putnam, Chatel, Bieliauskas, &
Adams, 1994). These derived scores reflect the unique
task requirements of TMT-B by removing the variance
attributable to the graphomotor and visual scanning
components of TMT-A. In addition, considering that
TMT performance is strongly influenced by age, educa-
tion, and intelligence, the B/A ratio score allows for
greater regulation of intraindividual variability factors by
using the examinee as his or her own control (Martin,
Hoffmann, & Donders, 2003). Thus, the derived scores
are considered “purer measures of the more complex
divided attention and alternating sequencing tasks required
in Part B” (Strauss, Sherman, & Spreen, 2006, p. 657).
Another avenue to exploring the neurobehavioral
components involved in the TMT is provided within
the Halstead Russell Neuropsychological Evaluation
System (HRNES; Russell & Starkey, 1993), which
offers a third subtest called Trails Speed. This meas-
ure is routinely presented before TMT-A and assesses

Address correspondence to Carlton S. Gass and Esther L. Misdraji, Miami VA Healthcare System, Psychology Service (116B), 1201
NW 16th Street, Miami, FL 33125–1693, USA (E-mail: elmisdraji@yahoo.com or CarltonGass@gmail.com).

© 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/jcen DOI: 10.1080/13803390902881942
 160 MISDRAJI AND GASS
graphomotor speed and numeric sequencing, but vis-
ual scanning demands are minimized in two ways.
Specifically, the circled numbers on Trails Speed (1
through 25) are sequentially organized in an array of
columns so that the correct path to connecting the cir-
cles alternates predictably in a uniform zigzag forma-
tion. In addition, Trails Speed is administered twice
consecutively, with the first trial serving as a practice
to the second, ensuring that the zigzag path is
rehearsed and is familiar to the examinee. The score of
only the second trial (time in seconds) is retained as a
comparison to subsequent performance on TMT-A
and TMT-B. Thus, as a more direct measure of graph-
omotor speed, Trails Speed data could help better dis-
tinguish the neurobehavioral components involved in
TMT-A and TMT-B.
Depression and anxiety are often invoked as
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explanations for deficient neuropsychological test perform-
ance. For example, these factors have been shown to relate
to neuropsychological test performance in studies of mem-
ory and executive functioning (Gass, 1996; Gass, Ansley, &
Boyette, 1994; Ross, Putnam, Gass, Bailey, & Adams,
2003). As applied to the TMT, however, studies have gener-
ally suggested that the impact of these emotional states is
minimal or nil (Chavez, Brandon, Trautt, & Stayaert, 1983;
Gass, 1991; Gass & Daniel, 1990; Horton & Roberts, 2003;
Smitherman, Huerkamp, Miller, Houle, and O’Jile, 2007).
As far as we are aware, the potential impact of emotional
factors such as depression and anxiety on specific neurobe-
havioral components involved in TMT performance has not
been examined.
The purpose of the present study is to examine the neu-
robehavioral components that contribute to performance
on the TMT in a neuropsychological referral sample. To
the best of our knowledge, no published studies to date
utilize Trails Speed to control for the graphomotor speed
component in TMT-A and TMT-B performance. Specifi-
cally, the ratio, TMT-A/TMT-Speed, would help distin-
guish the independent contributions of graphomotor
speed and visual scanning efficiency on TMT-A perform-
ance. Similarly, further analyses using TMT-Speed can
help identify the relative importance of graphomotor
speed in TMT-B performance. Finally, this study investi-
gates how depression and anxiety interact with these neu-
ropsychological abilities and TMT performance outcomes.
Hypothesis 1
As a measure of graphomotor speed, Trails Speed
time-to-completion is expected to show a significant neg-
ative relationship with Finger Tapping speed, a measure
of pure motor speed, as well as with the Wechsler Adult
Intelligence Scale–Third Edition (WAIS–III; Wechsler,
1997) Processing Speed index, which incorporates a compo-
nent of graphomotor speed. Trails Speed is expected to
show a significant negative association with the average
impairment score (AIS; Russell, Neuringer, & Goldstein,
1970; Russell & Starkey, 1993), a global measure of gen-
eral neuropsychological functioning. Emotional indices,
as measured by the Minnesota Multiphasic Personality
Inventory–2 (MMPI–2; Butcher et al., 2001) Depression
and Anxiety content scales, are predicted to show no
significant relationship with graphomotor speed
(Trails Speed).
Hypothesis 2
To distinguish the various neurobehavioral compo-
nents involved in TMT-A, a measure of visual scanning
efficiency was operationally defined by the ratio TMT-A/
Trails Speed. Visual scanning efficiency is expected to
show a significant negative relationship with WAIS–III
Perceptual Organization (PO) index scores, given the
visual spatial component involved in the TMT. Visual
scanning efficiency is also expected to show a
significant negative association with the AIS. Anxiety
and depression are predicted to show no significant
relationship with visual scanning efficiency.
Hypothesis 3
A measure of mental shifting was obtained from the
ratio TMT-B/TMT-A. This index is predicted to
encompass the working-memory and processing-speed
demands involved in TMT-B performance, thereby
showing a significant relationship with WAIS–III
Working Memory (WM) and Processing Speed (PS)
index scores. Mental shifting efficiency (TMT-B/
TMT-A) is expected to show a significant negative
association with the global measure of neuropsychologi-
cal ability, AIS. Levels of depression and anxiety are
predicted to show no relationship with mental shifting.
METHOD
A sample of 333 consecutive neuropsychological referrals
was drawn from archival data in the neuropsychology
clinic of a U.S. Department of Veterans Affairs (VA)
medical facility. Of the 333 patients, 128 had failed to
complete the TMT and/or the MMPI–2 due to excessive
cognitive impairment or failure to return to the clinic to
complete the evaluation. As such, 205 records were
retained for the study. Raw data on each of the TMT
subtests were collected as well as data of suspected
relevance to TMT performance, including motor speed
(Finger Tapping) and intelligence (WAIS–III: Verbal
Comprehension, Perceptual Organization, Working
Memory, and Processing Speed indices). Average
impairment scores were also extracted. As described
above, a measure of visual scanning efficiency was
derived from the ratio TMT-A/TMT-Speed, and a meas-
ure of mental shifting was obtained from the ratio TMT-
B/TMT-A. Demographic variables related to age, sex,
handedness, and years of education were also obtained.
Measures of anxiety and depression were drawn from
the MMPI–2 profiles completed at the time of the
neuropsychological evaluation. Specifically, T scores for
MMPI–2 content scales, Depression and Anxiety, were
extracted.
Of the 205 records investigated, 8 were omitted from
the final analysis due to outlier data, reducing the dataset
to 197 records. These 8 participants had extremely high

and deviant ratio scores that were strongly suggestive of
inconsistent effort. A total of 5 records containing
invalid MMPI–2 profiles were also discarded. MMPI–2
profiles were deemed invalid if the Variable Response
Inconsistency or True Response Inconsistency scales
were above a T score of 80; F(p) was above a T score of
100; FB was above a raw score of 27; or the F scale was
above a raw score of 23. Of the remaining 192 records,
males comprised 93.8% of the sample. Participants
ranged in age from 21 to 87 years, with a mean age of
59.3 years (SD = 14.5). Education ranged from 6 to
19 years (M = 13.2, SD = 2.2). WAIS–III Full Scale IQ
revealed a group mean of 98.05 (SD = 14.0). The mean
average impairment score was 96.0 (SD = 5.2). The sam-
ple was diagnostically diverse and consisted of individu-
als with known or suspected brain dysfunction who were
referred for neuropsychological evaluation by the prim-
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ary care, neurology, psychiatry, and rehabilitation serv-
ices of the medical center. In addition, MMPI–2 T scores
for Depression ranged from 36 to 99 (M = 62.6, SD =
15.2) and for Anxiety ranged from 35 to 92 (M = 61.7,
SD = 14.2), indicating the presence of a wide range of
emotional symptomatology within the sample.
RESULTS
Initial analyses
A correlational analysis was first conducted to explore
the relationship between demographic variables and
TMT derived component scores. Fisher’s method
(Fisher, 1947) was applied post hoc to reduce the proba-
bility of Type I error. Specifically, the alpha-coefficient
(.05) was divided by the total number of investigations
conducted in this subset of analyses, and the resulting
coefficient, .008, was adopted as the new criterion alpha-
coefficient. Age correlated with Trails Speed, r = .20, p <
.008, and mental shifting, r = .26, p < .008, but not with
visual scanning efficiency, r = .06, ns. Years of education
were not associated with any of the TMT derived compo-
nents: Trails Speed, r = .02, ns; visual scanning efficiency,
r = −.08, ns; or mental shifting, r = −.17, ns.
Correlational analyses were next conducted to explore
the extent to which graphomotor speed (TMT-Speed),
visual scanning efficiency (TMT-A/TMT-Speed), and
mental shifting (TMT-B/TMT-A) are related to measures
of motor speed (Finger Tapping), intelligence (WAIS–III
index scores), average impairment scores, and emotional
factors (anxiety and depression). Fisher’s method
(Fisher, 1947) was again applied post hoc to reduce the
probability of Type I error. The resulting coefficient of
.004 was adopted as the new criterion alpha-coefficient
for the following set of analyses.
Hypothesis 1
The hypothesized relationship between graphomotor
speed and pure motor speed received support, r = −.39, p <
.004. Faster graphomotor speed (fewer seconds to comple-
tion) was associated with greater speed in finger tapping.
Graphomotor speed was also associated with mental
NEUROBEHAVIORAL COMPONENTS OF THE TMT 161
TABLE 1
Correlations of cognitive and emotional variables and TMT
components
Speed Scanning Shifting
PO −.257* −.141 −.256*
WM −.220* −.151 −.206*
PS −.353* −.128 .187
AIS −.471* −.079 −.372*
Anxiety .018 .037 .026
Depression .052 .011 .072
Note. TMT = Trail Making Test. PO = Wechsler Adult Intelli-
gence Scale–Third Edition (WAIS–III) Perceptual Organiza-
tion index; WM = WAIS–III Working Memory index; PS =
WAIS–III Processing Speed index; AIS = average impairment
score.
*p < .005 level.
processing speed, r = −.35, p < .004. The average impair-
ment scores correlated with Trails Speed, r = −.47, p < .004.
Trails Speed performance showed no significant relation-
ship with Depression or Anxiety indexes (see Table 1).
Hypothesis 2
Contrary to prediction, visual scanning efficiency
(TMT-A/TMT-Speed) was not significantly associated
with perceptual organization ability, as measured by the
WAIS–III PO index, r = −.14, ns. Visual scanning was
also not significantly related to average impairment
scores, r = −.08, ns. As Table 1 indicates, depression and
anxiety showed no significant relationship with visual
scanning efficiency, as predicted.
Hypothesis 3
Mental shifting (e.g., TMT-B/TMT-A) was signifi-
cantly related to working memory, as measured by the
WAIS–III WM index, r = −.21, p < .004. Contrary to
prediction, however, mental shifting was not significantly
associated with mental processing speed (WAIS–III PS
index), r = −.19, ns. Average impairment scores and
mental shifting were significantly associated, r = −.37,
p < .004. No relationship emerged between mental shift-
ing and depression or anxiety (see Table 1).
Post hoc analyses
Post hoc correlational analyses involving time-to-com-
pletion raw scores on Trails Speed, TMT-A, and TMT-B
were carried out to further explore the neurobehavioral
components associated with the TMT. A significant cor-
relation emerged between Trails Speed and TMT-A (r =
.64, p < .01), indicating that graphomotor speed
accounted for 41% of the variance in TMT-A. The
remaining 59% of the variance in TMT-A, therefore,
could be largely attributed to visual scanning efficiency.
TMT-A and -B were also significantly associated, r =
.61, p < .01, suggesting that those neurobehavioral com-
ponents measured by TMT-A accounted for 37% of the
 162 MISDRAJI AND GASS
variance in TMT-B performance. Proportionate to the
earlier correlation between Trails Speed and TMT-A,
which attributed 41% of the variance in TMT-A to
graphomotor speed and 59% to visual scanning effi-
ciency, the correlation between TMT-A and TMT-B
suggests that 15.2% of the variance in TMT-B is attribut-
able to graphomotor speed and 21.8% to visual scanning
efficiency, which totals 37%. The remaining 63% of the
variance in TMT-B, then, could be largely attributable
to mental shifting.
A similar analysis was conducted after dividing the
total sample into neuropsychologically impaired and
nonimpaired subgroups, with impairment status opera-
tionally defined by the average impairment score (AIS).
Using the empirically established cutoff score of 95 (see
Russell & Starkey, 2001), 60% of the patients were classi-
fied as “normal” (n = 115), and 40% were classified as
Downloaded by [The UC Irvine Libraries] at 18:59 09 October 2014
neuropsychologically “impaired” (n = 77). Within the
normal group, 93.9% of the sample was male. Mean level
of education and age were 13.5 (SD = 2.2) and 59.2
(SD = 15.1) years, respectively. The mean average
impairment score was 99.5 (SD = 2.4). Within the
impaired group, 93.5% of the sample was male. Years of
education and age averaged 12.7 (SD = 2.2) and 59.5
(SD = 13.7) years, respectively. The mean average
impairment score was 91.0 (SD = 3.0).
Correlational analyses were carried out for each group
(e.g., normal and impaired). As Table 2 indicates, graph-
omotor speed accounted for 14% of the variance in
TMT-A scores within the normal group, but it
accounted for 45% of the variance within the impaired
group (p < .0001). This suggests that visual scanning effi-
ciency also differentially contributed to the TMT-A per-
formance of the normal and impaired groups (86% vs.
55%, respectively, p < .0001). Regarding TMT-B
performance, the portion of the variance accounted
for by graphomotor speed and mental shifting was
statistically different between groups. Specifically,
graphomotor speed accounted for about 2% of the
variance in TMT-B performance variability within the
normal group and 14% within the impaired group.
Mental shifting accounted for about 88% of the vari-
ance in TMT-B performance in the normal group and
TABLE 2
Neurobehavioral component variance in TMT performance
Normal
n = 115
r % variance
TMT-A
Graphomotor speed .38 14.4
Scanning .92 85.6
TMT-B
Graphomotor speed .13 1.8
Scanning .33 10.6
Shifting .94 87.6
Note. TMT-A = Trail Making Test Part A. TMT-B = Trail Making Test Part B.
69% in the impaired group. Visual scanning efficiency
was not statistically different between groups (see
Table 2).
DISCUSSION
The present study examined the neurobehavioral compo-
nents involved in performing the TMT and the potential
influence certain emotional variables have on these compo-
nents. Compared to earlier published studies, the incorpo-
ration of Trails Speed in this investigation is unique and
offers a distinct opportunity to statistically control for
graphomotor speed and examine the relative importance of
some other neurobehavioral skills that TMT-A and
TMT-B measure. As predicted, graphomotor and pure
motor speeds were positively associated, indicating that
persons with faster pure motor speed are able to carry
out graphomotor tasks more efficiently. Graphomotor
speed also showed a significant relationship with mental
processing speed, as measured by the WAIS–III PS index,
which was expected given the written component involved
in both measures. Unexpectedly, graphomotor speed was
associated with perceptual organization as well.
Contrary to expectation, visual scanning efficiency did
not show a significant relationship with visual spatial
organization, as measured by WAIS–III PO index. In
fact, visual scanning efficiency had no significant rela-
tionship with any of the WAIS–III index scores. The
most likely explanation for this finding is that the scan-
ning requirements in TMT-A are very simple, yielding a
major floor effect and therefore failing to explain vari-
ance in WAIS–III index scores. Mental shifting was sig-
nificantly associated with working memory and
perceptual organization ability. Contrary to prediction,
however, mental shifting was not related to cognitive
processing speed (see Table 1).
Current findings indicate that the relative contribution
of graphomotor speed to TMT-A and TMT-B perform-
ance is small in relatively unimpaired patients, but sub-
stantially greater in the presence of neuropsychological
compromise. For example, in normals, visual scanning was
nearly six times more important than graphomotor speed
Impaired Significance
n = 77 between groups
r % variance p
.67 45.4 .0001
.74 54.6 .0001
.37 13.9 .01
.41 16.8 .36
.83 69.3 .0001

on TMT-A, but only slightly more important (1.2 times) in
neuropsychologically compromised patients. Similarly,
in normals, the single distinguishing factor in TMT-B
performance was mental shifting efficiency. Specifically,
mental shifting was seven times more important than
graphomotor speed or visual scanning ability. However,
in the impaired sample, mental shifting ability was only
2.2 times more important than graphomotor speed and
scanning, which accounted, respectively, for 14% and
17% of the variance in scores on TMT-B.
Depression and anxiety are often erroneously invoked
as explanations for deficient neuropsychological test per-
formance, whereas current results indicate that severity
of these symptoms has little or no significance for graph-
omotor speed, scanning, or mental shifting efficiency.
This finding is consistent with previously cited studies
that failed to find clinically significant associations
Downloaded by [The UC Irvine Libraries] at 18:59 09 October 2014
between emotional status and performance on the TMT.
However, it extends previous findings by showing an
absence of a relationship to any of the specific neurobe-
havioral components involved in TMT performance.
The weight of the evidence to date suggests that clini-
cians should be reluctant to attribute poor performance
on the TMT (Speed, A, or B) to symptoms of anxiety or
depression. However, thought disorder such as that
found in schizophrenia was not examined in this study,
and this has been linked with bizarre or random appear-
ing patterns and premature giving up (Goldstein &
Neuringer, 1966).
The diagnostic diversity of the present sample is likely
representative of many neuropsychological evaluation
settings involving general medical and psychiatric
patients. Although the present findings probably gener-
alize to a variety of assessment contexts, they might not
apply as well to diagnostically homogeneous groups. In
addition, although there are no a priori reasons to
suspect male–female differences in patterns of TMT per-
formance, future studies that include larger female sam-
ples are warranted. This study was limited by the fact that
additional components to the TMT were not examined.
For example, TMT-B includes a language component
(i.e., letter sequencing), which makes it relatively sensitive
to dominant hemisphere dysfunction (Reitan & Tarshes,
1959). Similarly, bizarre performance on the TMT task
might be a fairly distinctive manifestation of severe psy-
chiatric disorders involving disturbed thinking (Gold-
stein & Neuringer, 1966). In addition to considering
factors such as these, future research would benefit from
the inclusion of an objective measure of effort. The rela-
tionship between effort level and various component
requirements on the TMT remains unknown.
Original manuscript received 29 January 2009
Revised manuscript accepted 9 March 2009
First published online 20 May 2009
NEUROBEHAVIORAL COMPONENTS OF THE TMT 163
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