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Children's color trails

Article in Archives of Clinical Neuropsychology June 1995

DOI: 10.1016/0887-6177(94)00041-N

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 Archives of Clinical Neuropsychology,Vol. 10, No. 3, pp. 211-223, 1995
Pergamon Copyright 1995NationalAcademyof 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 o f 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 d e v e l o p m e n t o f instruments w h i c h m i n i m i z e

cultural bias in n e u r o p s y c h o l o g i c a l 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
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
 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 c o r r e c t l y s e q u e n c e n u m b e r s f r o m 1 to 15. All odd n u m b e r s
(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.
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.
 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 o f 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 A N O V A with one between fac-
tor (administration) and two within factors (type and difficulty) was computed.
216 J. Williams et al.

TABLE 1
Correlations between Types of Trail M a k i n g 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
M e a n Times in Seconds a n d S t a n d a r d Deviations According to Order of
Administration

Group Trails A Trails B Color Trails 1 Color Trails 2

Administration 1a
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.
 Color Trails 217

TABLE 3
Mean Times in Seconds on Trail Making and Color Trails According to
Age, IQ, and Gender

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).
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
 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.
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 LearningDisabled+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
 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
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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