-
Pergamon Archives of Clinical Neuropsychology, Vol. 10, No. 3,
pp. 211-223, 1995
Copyright 1995 National Academy of Neuropsychology Printed in
the USA. All rights reserved
0887-6177/95 $9.50 + .00
0887-6177(94)00041-7
Children's Color Trails
Jane Williams, Vaughn Rickert, John Hogan, and A. I. Zolten
University of Arkansas for Medical Sciences, Department of
Pediatrics
Paul Satz, Louis F. D'Elia, Robert F. Asarnow, Ken Zaucha, and
Roger Light
Neuropsychiatric Institute and Hospital, University of
California, Los Angeles
Color Trails for Children was developed in response to the need
for instruments which minimize cultural bias in neuropsychological
testing. The test, similar in format to Trail Making, was designed
to provide an evaluation of speeded visuo- motor tracking while
minimizing the influence of language. The present research involves
two exploratory studies which examine the relationship between
Color Trails for Children and Trail Making, factors that may affect
performance times, and discriminant validity. Results indicate that
the tests appear to measure the same neuropsychological domains,
and administration of Trail Making did not sig- nificantly alter
performance times on Color Trails. Increasing age and 1(2 were
related to quicker completion time for both tests. Females were
found to complete Color Trails 2 and Trail Making Part B more
quickly than males in this sample. Comparison between children
diagnosed with learning disabilities, attention deficits, or mild
neurological conditions and a preliminary standardization sample
supported the discriminant validity of Color Trails to distinguish
between normal controls and children with altered
neuropsychological functioning. Comparison between clinical
conditions indicated that Color Trails 2 was particularly sensitive
in discriminating among the groups. Although further research is
needed, results suggest that Color Trails has the potential to be
an effective research and clinical tool in child neuropsychological
assessment.
A continuing need exists for the development of instruments
which minimize cultural bias in neuropsychological evaluation. In
addition to clinical assess- ment, these tests are necessary for
cross-cultural research in conditions affecting
Address correspondence to: Jane Williams, PhD, University of
Arkansas for Medical Sciences, Department of Pediatrics, 800
Marshall, Little Rock, AR 72202.
211
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212 J. Williams et al.
neurological functioning. Due to its sensitivity in detecting
altered neurologi- cal functioning in children, the traditional
Trail Making Test (Reitan, 1959; Reitan & Davison, 1974) is one
of the most frequently administered neuropsy- chological tests in
English speaking countries (Reitan, 1971; Reitan & Herring,
1985; Rosin & Levett, 1989a). However, its application in
cross-cul- tural contexts is potentially limited due to its
reliance on the English alphabet in Part B. This feature of the
test may adversely affect performances of indi- viduals who are
unfamiliar with the English language.
The Color Trails Test (D'Elia & Satz, 1989) was developed as
part of a neuropsychological assessment battery for the World
Health Organization's (WHO) cross-cultural study of HIV-1 infection
(Maj et al., 1991). The instrument relies on the concepts of number
and color which are universally employed across cultures. It was
designed to minimize the influence of lan- guage, including
instructions which can be presented nonverbally with visu- al cues.
The test, similar in format to Trail Making, was created in an
attempt to develop a culturally fair assessment of speeded
visuomotor track- ing. Color Trails requires intact motor speed,
attention, and visual scanning for quick and accurate performance.
Versions of the test are available for both children and adults.
Research with the Color Trails Test for Adults (D'Elia, Satz, &
Uchiyama, in press) has suggested both discriminant validi- ty (Maj
et al., 1993) and robustness in its sensitivity across cultures
(Maj et al., 1994).
Color Trails for Children has the potential for being an
effective neuropsy- chological instrument for use in cross-cultural
research with children unfa- miliar with the English language, as
well as in the assessment of children who are illiterate, have
reading and language disorders, or have limited edu- cational
experiences. It is hypothesized that Color Trails for Children will
demonstrate the same discriminant validity as traditional Trail
Making in the assessment of children with brain damage (Reitan,
1971; Reitan & Herring, 1985; Rosin & Levett, 1989a),
Attention Deficit Disorder (Klee, 1986), hyperactivity (Johnston,
1986), and learning disabilities (Davis, Adams, Gates, &
Cheramie, 1989).
Research is needed concerning discriminant validity as well as
potential fac- tors that may affect performance on Color Trails for
Children. Factors suggest- ed to affect performance on traditional
Trails include age, IQ, and gender (Rosin & Levett, 1989a).
During childhood, quicker performances on the Trail Making Test
have been demonstrated with increasing age (Rosin & Levett,
1989b) and increasing IQ (Horton, 1979; Rosin & Levett, 1989b).
Differences in performance resulting from gender have not been
supported (Leon-Carrion, 1989; Mittelmeir, Rossi, & Berman,
1989; Reitan, 1971; Rosin & Levett, 1989b). Differences in
cultural context have also been shown to affect perfor- mance times
with Spanish children performing significantly slower than American
children on Trail Making (Leon-Carrion, 1989), while South African
children with average and above average intelligence were found to
perform
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Color Trails 213
significantly faster than a random sample of American children
(Rosin & Levett, 1989b).
The present research involves two studies that were designed to
examine factors that may affect performance times and to explore
the discriminant validity of Color Trails for Children. The first
study addresses the strength of the relationship between Color
Trails and Traditional Trails, order effects when both tests are
administered, and factors that may alter performance on Color
Trails for Children. The second study addresses discriminant
validity by comparing performances of children with learning
disabilities, attention deficits, and mild neurological disorder
with an age-equivalent sample of the preliminary standardization
group on Color Trails for Children. In addition, children with
these disorders were compared with each other on Color Trails in an
attempt to determine the sensitivity of this instrument to
differentiate among the groups.
STUDY I
Method
Subjects. Subjects were 223 children who had been evaluated for
learning, emotional, or behavioral difficulties in an outpatient
developmental center (n = 163) or through the local school district
(n = 60). Each child was adminis- tered a standardized
intellectual, academic, and behavioral assessment.
The age of the children ranged from 5 years, 11 months to 16
years, 10 months (Mean = 11 years, 1 month; SD = 29 months). There
were 69 females and 154 males. The mean Full Scale IQ was within
the average range (Mean = 91; SD = 13.62; Range = 59-131).
Instrument. Color Trails for Children consists of Part 1 and
Part 2. Both parts are graphomotor tasks requiring the use of
pencil and paper. Each part is print- ed on standard 8.5 by 11 inch
paper, with a practice sample provided prior to actual test
administration. Color Trails 1 (Figure 1) requires the child to
quick- ly and correct ly sequence numbers f rom 1 to 15. All odd
numbers (1,3,5,7,9,11,13,15) are embedded within circles that have
a pink background, while all even numbers (2,4,6,8,10,12,14) are
embedded within circles that have a yellow background. Scoring
consists of time in seconds from initiation to completion of task.
The number of errors made are recorded.
Color Trails 2 (Figure 2) contains duplicates of each number
from 1 to 15 embedded within pink and yellow circles. The child is
required to quickly connect the circles in ascending order, but
alternating between pink and yel- low colors. In other words, the
child would connect Pink 1 with Yellow 2 then to Pink 3 and so on
through the number 15. Scoring consists of time in sec- onds from
initiation to completion of the task. The number of errors commit-
ted are recorded.
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214 J. Williams et al.
~@ @
@
@
@
@
@
~@ @
@
FIGURE 1. Color Trails 1 for Children. On the actual test
protocol, all odd numbers are embedded in pink circles (shown here
gray), while even numbers are in yellow circles (shown here
white).
Procedure. Color Trails and traditional Trail Making were
individually admin- istered with each child given the practice task
prior to the test proper. The child was told to work as quickly as
possible and to try and not lift the pencil from the paper. If an
error was made, the child was immediately directed to correct the
error and start at the point where the mistake was made.
In order to determine whether the order of administration had an
effect on performance, a random subset of the subjects (n = 119)
were alternately administered either Trails A and B followed by
Color Trails 1 and 2 or Color Trails 1 and 2 followed by Trails A
and B.
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Color Trails 215
@ @
@
~@
@
@
@ @
@
@ @ @
FIGURE 2. Color Trails 2 for Children. On the actual test
protocol, each number is duplicated and embedded in separate pink
(shown here gray) and yellow (shown here white) circles.
Results
As can be seen in Table 1, correlations between all types of
Trails were highly related (p < .001). Means and standard
deviations of the subjects who completed Trails A and B followed by
Color Trails 1 and 2 (n = 61) as well as those subjects who
completed Color Trails 1 and 2 followed by Trails A and B (n = 58)
are found in Table 2. In order to determine if order of
presentation affected time completion, a repeated three-way ANOVA
with one between fac- tor (administration) and two within factors
(type and difficulty) was computed.
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216 J. Williams et al.
TABLE 1 Correlations between Types of Trail Making Tests
Type Trails A Trails B Color Trails 1 Color Trails 2
Trails A 1.00 .59 .74 .74 Trails B 1.00 .54 .67 Color Trails 1
1.00 .69 Color Trails 2 1.00
There was not a siginficant three-way interaction for
Administration x Type x Difficulty (F (1,117) = .113, p > .73).
There were no two-way interactions for Administration x Type (F
(1,117) = 2.05, p > .15) or Administration x Difficulty (F
(1,117) = .10, p > .75) found. Main effects were noted for type
(F (1,117) = 15.38, p < .001) and difficulty (F (1,117) =
362.81, p < .001). As expected, children's combined times on
Trails A and B were significantly faster than combined times for
Color Trails 1 and 2, while their combined times on Trails A and
Color Trails 1 were significantly faster than combined times on
Trails B and Color Trails 2. There was no main effect for
administra- tion (F (1,117) = .64, p > .42) which involved
comparison of mean scores on all Trails.
To further examine the possible effects of administration,
Student's t-tests were computed by group on each type of Trails.
Comparison of group scores based on administration for Trails A (t
= 2. 17, p > .14), Trails B (t = 1.03, p > .31), Color Trails
1 (t =. 17, p > .68), and Color Trails 2 (t = .05, p > .82)
did not indicate any significant differences in performance result-
ing from order of administration. Findings did not suggest
improvement in performance on Color Trails resulting from having
Trails A and B adminis- tered first.
In order to analyze the effects of age, IQ, and gender, a
three-way multi- ple analysis of variance (MANOVA) was performed
(Table 3). Age consist- ed of three groups including children ages
6-8 years, 9-11 years, and 12
TABLE 2 Mean Times in Seconds and Standard Deviations According
to Order of
Administration
Group Trails A Trails B Color Trails 1 Color Trails 2
Administration 1 a Mean 23.74 59.10 24.43 64.39 SD 15.62 33.64
10.38 35.56
Administration 2 b Mean 20.16 53.41 23.41 63.02 SD 10.23 26.85
16.18 30.61
aAdministration 1 = Trails A and B fast. bAdministration 2 =
Color Trails 1 and 2 first.
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Color Trails
TABLE 3 Mean Times in Seconds on Trail Making and Color Trails
According to
Age, IQ, and Gender
217
Variable Trails A Trails B Color Trails 1 Color Trails 2
Age 6-8 yrs (n = 49) 33.97 80.84 39.24 92.35 9-11 yrs (n = 100)
21.73 54.90 23.17 60.89 12+ yrs (n = 74) 15.94 38.17 18.17
44.56
Sex Female (n = 69) 22.68 52.52 25.13 57.89 Male (n = 154) 25.07
63.42 28.59 73.98
IQ FSIQ = < 83 (n = 68) 30.62 69.74 34.42 82.39 FSIQ = 84-98
(n = 92) 22.15 58.20 24.03 60.94 FSIQ = 99+ (n = 63) 18.87 45.98
22.12 54.47
years and above. IQ was divided into three groups based on the
overall mean (M = 91.2; Range = 59-131) and standard deviation (SD
= 13.6) for the entire sample. Group 1 consisted of children with
FSIQs < 83, Group 2 consisted of children with FSIQs from 84
through 98, and Group 3 consist- ed of children with FSIQs > 99.
There was not a siginficant three-way interaction for Age x IQ x
Gender (Wilks' Lambda (16,611) = .95, p > .81). Nor were there
any two-way interactions for Age x IQ (Wilks' Lambda (16,611) =
.91, p > .23), Age x Gender (Wilks' Lambda (8,400) = .96, p >
.51), or IQ x Gender (Wilks' Lambda (8,400) = .94, p > .09).
Main effects were noted for Age (Wilks' Lambda (8,400) = .60, p
< .001), IQ (Wilks' Lambda (8,400) = .79, p < .001), and
Gender (Wilks' Lambda (4,200) = .91, p < .001). Follow-up
analyses using Scheffe tests for signifi- cant differences
indicated that the youngest (Group 1) and oldest group (Group 3)
differed significantly from each other in time to complete all
types of Trails. The youngest (Group 1) and middle group (Group 2)
dif- fered significantly in time to complete all types of Trails.
The middle (Group 2) and oldest group (Group 3) differed
significantly in time to com- plete all Trails except Color Trails
1 (p > .02).
For the main effect of Gender, follow-up tests indicated
significant differ- ences between males and females on Trail Making
Part B and Color Trails 2 with females performing significantly
faster. Significant differences were not found for Trail Making
Part A (p > .10) or Color Trails I (p > .04). For the main
effect of IQ, follow up tests indicated significant differences
between the lowest (Group 1) and highest group (Group 3) on all
types of Trails. Differences between the lowest (Group 1) and
middle group (Group 2) were significant for Trails A, Color Trails
1, and Color Trails 2, but not for Trails B (p > .01). The
middle group (Group 2) and highest group (Group 3) differed
significantly on Trails B, but not for Trails A (p > .13), Color
Trails 1 (p > .60), or Color Trails 2 (p > .25).
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218 J. Williams et al.
STUDY 2
Method
Subjects. Subjects were 200 children from the original
population who were diagnosed with mild neurological disorders (n =
67), learning and/or language disabilities (n = 101), and learning
and/or language disabilities with Attention Deficit Hyperactivity
Disorder (n = 32). The rationale for selection of these groups was
to examine a continuum of disorders from those postulated to
involve subtle neurological findings, such as in Attention Deficit
Hyperactiv- ity Disorder, to those with documented neurological
changes, such as in Traumatic Brain Injury.
Children diagnosed with mild neurological disorders included
primarily seizure disorders and mild to moderate closed head
injuries. Children with epilepsy involved generalized or complex
partial seizure disorders, while chil- dren with head injuries
included mild to moderate brain insult generally including a loss
of consciousness and positive MRI findings. None of these children
had been diagnosed with learning disabilities or Attention Deficit
Hyperactivity Disorder.
The diagnosis of learning disability was based on state and
federal guide- lines with all children having a significant
discrepancy between measured cognitive ability and academic
achievement in reading, math, and/or written expression. The
majority of children in this sample had reading and written
expressive disorders. The diagnosis of language disorder was based
on state and federal guidelines with children demonstrating a
significant discrepancy between measured cognitive ability and
acquired language skills. The diagno- sis of Attention Deficit
Hyperactivity Disorder resulted from significant eleva- tions on
the Conners Parent and Teacher Rating Scales (Conners, 1982),
behavioral observations in the clinic, and cognitive factors such
as computer- ized tests of attention and tasks assessing freedom
from distractibility. The majority of children in the category
involving two diagnoses had learning dis- abilities and attention
deficits with less than 10% having language disorders and attention
deficits.
Age of the children ranged from 5 years, 11 months to 16 years,
10 months (M = 11 years, 1 month; SD = 29 months). There were 60
females and 140 males. The mean Full Scale IQ was within the
Average range (M = 91; SD = 14; Range = 59-131) based on the
Wechsler Intelligence Test for Children- Revised (WISC-R; Wechsler,
1974), Kaufman Assessment Battery for Children (KABC; Kaufman &
Kaufman, 1983), or Stanford-Binet Intelligence Scale: Fourth
Edition (Thorndike, Hagen, & Sattler, 1986).
In addition to the clinical groups, normal controls were
obtained from the preliminary standarization group for Color Trails
for Children. This group was part of an NIH-funded study of mild
head injuries in children (Asarnow, Satz, Lewis, Zaucha, &
Light, 1993). It consisted of 388 children ages 8-16 from
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Color Trails 219
the Downey Unified School District in Los Angeles County. The
mean age of the children at the time of testing was 12 years, 1
month (SD = 27 months) with a mean PPVT-R standard score of 102 (SD
= 17). Children were exclud- ed from the standardization group if
they were in special placement for any learning, attentional, or
psychological disability.
Procedure. Procedure for the clinical groups was identical to
the previous study. Normal controls were administered Color Trails
for Children only.
Resul~
Statistical analysis of group differences involved the use of
one-way anal- ysis of covariance (ANCOVA) on Color Trails 1 and
Color Trails 2 with age as a covariate due to the older mean age of
the standardization group. Children below 8 years and above 16
years were eliminated from the clinical groups to equate the age
range of all groups. Comparisons indicated a signif- icant
difference on Color Trails 1 (F(3,563) = 14.77, p < .001) and
Color Trails 2 (F(3,563) = 58.47, p < .001) between the groups
(Table 4). Follow- up analyses using Scheffe tests for significant
differences indicated that the normal controls were quicker than
the Learning Disabled, Mild Neurological, or Learning
Disabled/Attention Deficit groups on both Color Trails 1 and 2.
Statistical assessment of group differences involved the use of
one-way analysis of variance (ANOVA) on Trail Making A, Trail
Making B, Color Trails 1, and Color Trails 2. As seen in Table 5,
comparisons did not indicate a significant difference on Trails A
(F(2,197) = 1.65, p > .19), Trails B (F(2,197) = .94, p >
.39), or Color Trails 1 (F(2,197) = 2.85, p > .06) among the
Learning Disabled, Mild Neurological, or Learning
Disabled/Attention Deficit groups. A significant difference was
found for Color Trails 2 (F(2,197) = 3.14, p < .05). Follow-up
analysis using Scheffe tests indicated that the Learning Disabled
group performed significantly quicker than the Learning
TABLE 4 Comparison of Mean Times in Seconds and Standard
Deviations of Clinical
Groups and Normal Controls on Color Trails
Con~'ols LD Mild Neurological LD + ADHD Group (n = 388) (n = 93)
(n = 58) (n = 29)
Color Trails 1 Mean 17.68 21.22 25.27 27.37 SD 7.9 10.3 15.3
12.2
Color Trails 2 Mean 37.22 55.61 60.48 76.76 SD 15.6 23.1 24.8
38.9
Note. LD = Learning Disabled; LD + ADHD = Learning Disabled with
Attention Deficits.
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220 J. Williams et al.
Disabled/Attention Deficit group on Color Trails 2. The Mild
Neurological group did not differ from either the Learning Disabled
or Learning Disabled/ Attention Deficit groups.
Discussion
Present findings suggest a high correlation between Color Trails
for Children and Trail Making, indicating that these tasks measure
similar neu- ropsychological domains. The relationships are
similar, although stronger than those suggested in adult studies
with Color Trails. Maj et al. (1993) found sig- nificant
relationships between Trails A and Color Trails 1 (r = .41, p <
.05) and Trails B and Color Trails 2 (r = .50, p < .001) in a
sample of normal sub- jects in which the order of administration
was counterbalanced. In the present study, order of administration
in which Trail Making was given first did not suggest that previous
experience with Trails A and B had a significant impact on
quickness to complete Color Trails. Consistent with previous
findings, increasing age and IQ resulted in quicker performance
times on Color Trails for Children and Trail Making. In contrast to
previous studies, gender was a differentiating factor for Color
Trails 2 and Trails B with girls performing more quickly on these
two tasks.
Results from comparisons of performance times on Color Trails
between clinical groups and normal controls suggest discriminant
validity for this instrument. Color Trails appears to be
sufficiently sensitive to differences in neuropsychological
functioning as normal controls were found to perform sig-
nificantly more quickly than children with learning disabilities,
mild neurolog- ical conditions, or learning disabilities with
attention deficits.
TABLE 5 Comparison of Mean Time in Seconds and Standard
Deviations on the Trail Making
Test and Color Trails According to Clinical Group
Learning Disabled Mild Neurological Learning Disabled +ADHD
Group (n = 101) (n = 67) (n = 32)
Trails A Mean 21.18 22.90 25.56 SD 10.87 10.25 18.41
Trails B Mean 55.24 56.43 63.44 SD 30.64 28.04 30.47
Color Trails 1 Mean 22.84 27.31 27.90 SD 12.77 15.84 12.59
Color Trails 2 Mean 59.96* 64.06 75.50* SD 28.55 29.36 38.40
*< .05
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Color Trails 221
Examination of group performances indicated that children with
learning disabilities, uncomplicated by attention deficits, were
the quickest in completion of all types of Trails even though they
performed significantly more slowly than normal controls. Children
with mild neurological variability, such as epilepsy, were not
significantly different from the learning disabled children, but
consis- tently performed at a slower pace. The factor that resulted
in the slowest perfor- mance on all types of Trails was when
attention deficits were present. The poor- er performance by
children with attention deficits supports past research
demonstrating the sensitivity of Trail Making in differentiating
this group.
It would be of interest to determine whether children in
previous studies with learning disabilities who performed
significantly slower than normal con- trois on Trail Making had
problems with attention. In one study, it was noted that
performance on subtests from the freedom from distractibility
factor of the WISC-R (Arithmetic, Digit Span, and Coding) was a
discriminating vari- able for a group of boys with reading
disabilities (McManis, Figley, Richert, & Fabre, 1978).
Significantly lower scores on these subtests would suggest that
these learning disabled children, who had slower times on Trails,
may have had difficulty with attention to task.
In the present sample, Color Trails 2 appeared to be the most
sensitive of the tasks in discriminating among groups of children
with altered neuropsy- chological functioning. Three possible
explanations are offered concerning this increased sensitivity.
First, the variable of color may more significantly interfere with
the peformance of children diganosed with altered neuropsycho-
logical functioning. This would be supported by the near signficant
finding (p = .06) of Color Trails 1 among the clinical groups.
Second, Color Trails 2 is similar to Trails B in that it
requires an ability to shift cognitive sets which is not found in
Trail Making Part A or Color Trails 1. In past studies, Trail
Making Part B has demonstrated greater sensitivity to cerebral
dysfunction in contrast to Part A (Horton, 1979). Trail Making Part
B has been shown to distinguish between normal controls and
children with Attention Deficit Hyperactivity Disorder (Boucugnani
& Jones, 1989), proba- bly due to its sensitivity to frontal
lobe functioning (Boucugnani & Jones, 1989; Shute &
Huertas, 1990). The similarities in task demands may con- tribute
to Color Trails 2 increased discrimination.
Third, Color Trails 2 may reduce the confounding effect of
language found in Trail Making Part B. Previous research has
demonstrated that an experi- mental Trail Making test, based on
spatial rather than language cues, was more sensitive in
distinguishing between children with learning disabilities and
normal controls than traditional Trails (Davis et al., 1989).
The present research represents an exploratory analysis in the
use of Color Trails for Children. A standardization sample of
normal controls stratified by age, IQ, gender, and geographic
location is needed before the test can be used with great
confidence. Findings suggest that Color Trails has the potential of
being an effective tool in test batteries used to detect altered
neuropsychological
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222 J. lkflliams et al.
functioning in children. Confounding effects introduced by
language, illitera- cy, reading disabilities, or educational
experience may be minimized with this instrument, making it an
asset in cross-cultural research.
Acknowlegements - - Special appreciation is expressed to Amy
Hendon and Joe Smith of Arkansas Children's Hospital for graphics
and computer assistance.
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