Regression-based normative data and equivalent scores for Trail Making Test (TMT): an updated Italian normative study.

OBJECTIVES: The Trail Making Test (TMT) is widely used to assess psychomotor speed and attentional set-shifting. Since the regression-based norms and equivalent scores (ESs) for the TMT Italian version trace back to more than 20 years ago, we aimed at providing updated normative data for basic (Part A and Part B) and derived (Score B-A and Score B/A) TMT scores collected in a larger sample with an extended age range. METHODS: Three hundred fifty-five Italian volunteers stratified for sex (166 men), age decades (age range 20-90 years), and educational level (from primary school to university) completed the TMT and the Montreal Cognitive Assessment (MoCA). RESULTS: Multiple linear regression analyses revealed that age and educational level significantly influenced performances on basic and derived TMT scores except for B/A, which was associated only with the educational level. From the derived linear equations, correction grids for basic and derived TMT raw scores were developed. Inferential cutoff scores, estimated using a non-parametric technique, and ES were computed. Basic and derived TMT scores showed a good test-retest reliability (all rs ≥ 0.50); Part B (rs = - 0.48, p < 0.001) and Score B-A (rs = - 0.49, p < 0.001) were moderately associated with MoCA total score. CONCLUSIONS: This study confirms the association of basic and derived TMT raw scores with sociodemographic variables and provides updated correction grids and ES for assessing the attentional/executive functions in clinical and research fields.

Screening for Executive Dysfunction in Late-Life Depression: Utility of Trail Making Test and Self-Report Measures.

OBJECTIVE: Prior work suggests executive dysfunction (ED) on the Stroop Color and Word Test (SCWT) and the Mattis Dementia Rating Scale-2 Initiation/Perseveration subscale (DRS IP) predicts poor antidepressant response in late-life depression. This study examined if either patient perception of ED or the Trail Making Test Part B (TMT-B) could identify patients with impairment on the SCWT or DRS IP. METHODS: Patients were 65 or older and had a diagnosis of major depression without dementia. Cognition was assessed with the TMT-B, the SCWT, and the DRS IP. A self-reported Perceived Deficits Questionnaire (PDQ) subscale assessed patients' perceptions of ED. RESULTS: In 247 participants (mean age 71.3 years), the PDQ subscale was not associated with test performance. The sensitivity of the TMT-B in identifying impairment on the SCWT or DRS IP was low (35% and 23%, respectively). CONCLUSION: Neither the TMT-B nor self-reports are useful screening tools for ED on the SCWT or DRS IP.

A new device-aided cognitive function test, User eXperience-Trail Making Test (UX-TMT), sensitively detects neuropsychological performance in patients with dementia and Parkinson's disease.

BACKGROUND: A newer generation neuropsychological tests can take advantage of touch screen and mobile technology. We have developed a new Android application termed "User eXperience-Trail Making Test (UX-TMT)" for neurocognitive assessment and training. This study investigated the utility, including the reliability and the validity, of the UX-TMT as a screening test for cognitive decline in adults. METHODS: A total of 84 individuals aged 27-86 years were divided into three groups; healthy controls ([HC] n = 29), people with Parkinson's disease (PD; n = 28), and people with mild cognitive impairment (MCI) and dementia (MCI&D; n = 27). We examined the distributions of the scores and the time required, and the effects of age and group on these distributions. We analyzed internal consistency and convergent validity in all samples and applied receiver operator characteristic (ROC) analysis to determine a cutoff score that could differentiate the MCI & D group from the HC group. RESULTS: 97.6% of the participants completed all of the tasks, and the average total test time required for UX-TMT was 428.8 (± 109.1) s in the HC, 542.0 (± 168.7) s in the PD, and 777.5 (± 256.1) s in the MCI&D groups, respectively. The MCI&D group showed significantly lower UX-TMT scores and longer total time in completing the task than the HC group. In an ROC analysis, a score of 21 showed high sensitivity (.83) and specificity (.92), and the UX-TMT score plus age improved sensitivity to .96. Additionally, the UX-TMT scores showed significant correlation with the Mini-Mental State Examination (Japanese version) scores (r = .77, p = .001), and Cronbach's alpha (.71-.83) indicated acceptable internal consistency. CONCLUSION: The UX-TMT demonstrated high reliability and validity to detect cognitive decline in Japanese adults, highlighting its utility as a screening tool for epidemiological and clinical research.

Evaluation of the Trail Making Test and interval timing as measures of cognition in healthy adults: comparisons by age, education, and gender.

BACKGROUND: Human cognitive functioning can be assessed using different methods of testing. Age, level of education, and gender may influence the results of cognitive tests. MATERIAL AND METHODS: The well-known Trail Making Test (TMT), which is often used to measure the frontal lobe function, and the experimental test of Interval Timing (IT) were compared. The methods used in IT included reproduction of auditory and visual stimuli, with the subsequent production of the time intervals of 1-, 2-, 5-, and 7-seconds durations with no pattern. Subjects included 64 healthy adult volunteers aged 18-63 (33 women, 31 men). Comparisons were made based on age, education, and gender. RESULTS: TMT was performed quickly and was influenced by age, education, and gender. All reproduced visual and produced intervals were shortened and the reproduction of auditory stimuli was more complex. Age, education, and gender have more pronounced impact on the cognitive test than on the interval timing test. The reproduction of the short auditory stimuli was more accurate in comparison to other modalities used in the IT test. CONCLUSIONS: The interval timing, when compared to the TMT, offers an interesting possibility of testing. Further studies are necessary to confirm the initial observation.

Normative data for tests of attention and executive functions in a sample of European Portuguese adult population.

OBJECTIVE: The main goal of this study was to produce normative data for the Portuguese population on five neuropsychological tests frequently used to assess executive functions and attention: the Modified Wisconsin Card Sorting Test (M-WCST), the Stroop Color and Word Test, the Trail Making Test (TMT), the Brief Test of Attention (BTA), and the Symbol Digit Modalities Test (SDMT). METHOD: The study included 300 individuals aged between 18 and 93 years, who had educational backgrounds ranging from 3 to 25 years. RESULTS: The influence of age, education, and sex was explored for each measure, as well as their contribution to explain the performance variance. CONCLUSIONS: The normative data are presented as regression-based algorithms to adjust direct and derived test scores for sex, age, and education. This study provides a calculator of normative data, derived from the results of the regression models.

The independent contribution of executive functions to health related quality of life in older women.

BACKGROUND: Cognition is a multidimensional construct and to our knowledge, no previous studies have examined the independent contribution of specific domains of cognition to health related quality of life. To determine whether executive functions are independently associated with health related quality of life assessed using Quality Adjusted Life Years (QALYs) calculated from the EuroQol EQ-5D (EQ-5D) in older women after adjusting for known covariates, including global cognition. Therefore, we conducted a secondary analysis of community-dwelling older women aged 65-75 years who participated in a 12-month randomized controlled trial of resistance training. We assessed global cognition using the Mini-Mental State Examination (MMSE) and executive functions using the: 1) Stroop Test; 2) Trail Making Test (Part B) and 3) Digits Verbal Span Backwards Test. We calculated QALYs from the EQ-5D administered at baseline, 6 months and 12 months. RESULTS: Our multivariate linear regression model demonstrated the specific executive processes of set shifting and working memory, as measured by Trail Making Test (Part B) and Digits Verbal Span Backward Test (p < 0.01) respectively, were independently associated with QALYs after accounting for age, comorbidities, general mobility, and global cognition. The final model explained 50% of the variation in QALYs. CONCLUSIONS: Our study highlights the specific executive processes of set shifting and working memory were independently associated with QALYs -- a measure of health related quality of life. Given that executive functions explain variability in QALYs, clinicians may need to consider assessing executive functions when measuring health related quality of life. Further, the EQ-5D may be used to track changes in health status over time and serve as a screening tool for clinicians.

Demographically adjusted trail making test norms in a Scandinavian sample from 41 to 84 years.

OBJECTIVE: The trail making test (TMT) is one of the most widely used neuropsychological tests. TMT-A provides measures of visual scanning/visuomotor speed and TMT-B involves additional demands on executive functions. Derived scores TMT B-A and TMT B/A enhance measures of executive functioning. However, simple B-A subtraction may lead to false estimates of executive dysfunction in clinical samples. Norms for TMT have been published in several countries but are currently lacking for Scandinavia. METHODS: A total of 292 healthy controls between age 41 and 84 years were included from the Norwegian "Dementia Disease Initiation" (DDI) study (n = 170) and the Gothenburg Mild Cognitive Impairment (MCI) study (n = 122). We used a regression-based procedure to develop demographically adjusted norms for basic (TMT-A and TMT-B) and derived measures (TMT B-A and B/A). We also propose a regression-based alternative to the TMT B-A measure named "TMT-ß". The proposed norms were compared to norms from Heaton et al. and Tombaugh. RESULTS: Due to differences in the estimated normative effects of demographics on performance, the proposed norms for TMT were better suited in the Scandinavian sample compared with published non-Scandinavian norms. The proposed TMT-ß measure was highly correlated to TMT B-A (r = 0.969, p < 0.001). CONCLUSION: We here propose demographically adjusted norms for the TMT for ages 41 through 84 years based on a Scandinavian sample. We also present the regression-based derived measure TMT-ß which may resolve issues with the conventional TMT B-A measure.

Trail Making Test: normative data for the Lebanese adult population.

OBJECTIVE: Trail Making Test (TMT) is a widespread neuropsychological test used to detect cognitive impairment in diverse neuropsychological conditions. Several studies have shown that TMT performance is influenced by different demographic factors. Thus, the present study aims to explore the effect of gender, age, and education on TMT basic and derived scores and to provide normative data for the Lebanese adult population. METHOD: A total of 225 healthy Lebanese adults (aged between 18 and 64) were recruited. The two parts of the TMT were administered to the participants. Regression based strategy was applied to generate normative data. RESULTS: The results showed statistically significant effect of age and level of education on the TMT-A, TMT-B as well as the difference score TMT B -A. However, the ratio score was affected only by the age. Gender did not have any effect on TMT performance. An interactive calculator was created to calculate estimated Z-scores based on corresponding predictions of linear regression model. The calculator provides also percentile ranks. CONCLUSIONS: The present study provides the first normative data for the TMT among the Lebanese population. Neuropsychologists in Lebanon will benefit from this outcome in order to improve the accurate detection of visual scanning/processing speed and executive function deficits in clinical settings for the adult population.

Incremental utility of an extended stroop task for identifying subtle differences in cognitive performance among healthy older adults.

The Stroop Color and Word Test is a test of processing speed, response inhibition, and executive functioning (EF). This project examined whether extending the Stroop Color-Word trial beyond the standard time limit could more accurately assess performance on EF measures. Cognitively healthy older individuals (n = 198) enrolled in a study of cardiovascular health completed the Stroop as part of a neuropsychological battery. Two scores were computed for the Color-Word trial: the number of items completed within the first 45 seconds (traditional Color-Word score) and the speed of page completion beyond the first 45 seconds (Stroop-Extended score). Criterion measures included the Trail-Making Test Part B (TMT-B), Digit Span Backward, Symbol Digit Modalities Test, Short Category Test, and measures of verbal fluency. Results from hierarchical linear regression analyses indicated that the extended Stroop score accounted for small but statistically significant variance in TMT-B (additional 2.6%) and Digit Span Backwards (additional 2.6%) beyond the standard Color-Word score. These findings suggest that extending the Stroop Color-Word trial beyond the first 45 seconds provides a limited increase in predictive power within a healthy sample with restricted range of performance. The extended Stroop requires additional examination in heterogeneous samples, including clinical populations, to determine its predictive utility.

Reliability and construct validity of a novel motor-cognitive dual-task test: A Stepping Trail Making Test.

AIM: This study aimed to examine the reliability and construct validity of the Stepping Trail Making Test (S-TMT) in community-dwelling older adults. METHODS: This study comprised a cross-sectional study based on a population sample. Participants comprised 1224 community-dwelling older Japanese women aged 65-81 years without functional disability, dementia, depression, Parkinson's disease, or cognitive and visual impairments. The S-TMT measured the time taken to step on a sequence of numbers (1-16) positioned on a mat (1 m2 ). Participants were instructed to step as quickly and accurately as possible. Motor functions were assessed by walking speed and knee extensor strength tests, while cognitive functions were assessed by the Symbol Digit Substitution Task (SDST) test, verbal and logical memory test, and TMT-A and -B. RESULTS: As a result of test-retest reliability over 6 months, the intraclass correlation coefficients of the S-TMT was 0.82 (95% confidence interval, 0.68-0.90). An adjusted multiple regression model indicated that the S-TMT was significantly associated with walking speed for motor function, and associated with the SDST, TMT-A and TMT-B for cognitive functions (P < 0.001). CONCLUSIONS: These results suggest that the S-TMT is a reliable dual-task test comprising mobility for motor function and a visual-dependent execution function for cognitive function in older women. Geriatr Gerontol Int 2020; 20: 291-296.

Cognitive prerequisites for fitness to drive: Norm values for the TMT, UFOV and NorSDSA tests.

Background: Fitness-to-drive assessment is a growing area for occupational therapists. There are few off-road tests specially developed to assess fitness to drive, and several cognitive tests have no age-specific norms.Aims/objectives: The aim was to identify and describe age-related norm values for the Trail Making Test, Nordic Stroke Driver Screening Assessment and Useful Field of View test, and to study inter-correlation between test results.Materials and methods: The sample included 410 volunteers; 149 men and 261 women, mean age 52 ± 16.8 years. Commonly used off-road tests were used: TMT A and B, UFOV and NorSDSA.Results: Normative data for the specific subtests and total score for NorSDSA and UFOV are provided and presented in four age groups. Age correlated with the results for most of the subtests.Conclusions: Off-road cognitive test scores are necessary and valuable for occupational therapists in their contribution to the final decision on continued driving. In clinical practice, it can be difficult to interpret cognitive test results when working with driving assessments. Age-based norm values are suggested to be a way to provide clinicians with a benchmark against which scores can be compared.Significance: Age-based norms can guide occupational therapists working with fitness to drive.

Cross-validation of non-memory-based embedded performance validity tests for detecting invalid performance among patients with and without neurocognitive impairment.

INTRODUCTION: Embedded performance validity tests (PVTs) allow for continuous and economical validity assessment during neuropsychological evaluations; however, similar to their freestanding counterparts, a limitation of well-validated embedded PVTs is that the majority are memory-based. This study cross-validated several previously identified non-memory-based PVTs derived from language, processing speed, and executive functioning tests within a single mixed clinical neuropsychiatric sample with and without cognitive impairment. METHOD: This cross-sectional study included data from 124 clinical patients who underwent outpatient neuropsychological evaluation. Validity groups were determined by four independent criterion PVTs (failing ≤1 or ≥2), resulting in 98 valid (68% cognitively impaired) and 26 invalid performances. In total, 23 previously identified embedded PVTs derived from Verbal Fluency (VF), Trail Making Test (TMT), Stroop (SCWT), and Wisconsin Card Sorting Test (WCST) were examined. RESULTS: All VF, SCWT, and TMT PVTs, along with WCST Categories, significantly differed between validity groups (ηp2 =.05-.22) with areas under the curve (AUCs) of.65-.81 and 19-54% sensitivity (≥89% specificity) at optimal cut-scores. When subdivided by impairment status, all PVTs except for WCST Failures to Maintain Set were significant (AUCs =.75-94) with 33-85% sensitivity (≥90% specificity) in the cognitively unimpaired group. Among the cognitively impaired group, most VF, TMT, and SCWT PVTs remained significant, albeit with decreased accuracy (AUCs =.65-.76) and sensitivities (19-54%) at optimal cut-scores, whereas all WCST PVTs were nonsignificant. Across groups, SCWT embedded PVTs evidenced the strongest psychometric properties. CONCLUSION: VF, TMT, and SCWT embedded PVTs generally demonstrated moderate accuracy for identifying invalid neuropsychological performance. However, performance on these non-memory-based PVTs from processing speed and executive functioning tests are not immune to the effects of cognitive impairment, such that alternate cut-scores (with reduced sensitivity if adequate specificity is maintained) are indicated in cases where the clinical history is consistent with cognitive impairment. In contrast, WCST indices generally had poor accuracy.

Relevance of the assessment mode in the digital assessment of processing speed.

Introduction: Many medical facilities and research institutes start using digital assessment methods to assess cognitive abilities, such as processing speed, instead of the traditional pen and paper versions. Even though many of the new digital assessment methods have shown to have a stable internal validity, the comparability of results across assessment modes is unclear. The study investigated whether results for assessing processing speed via (i) the traditional pen and paper version, (ii) a tablet and pen version, and (iii) a tablet and finger version are comparable. Methods: In a within-subject design, each participant (N= 30) completed the 90-number version by Oswald and Roth (1987) of the trail-making test (TMT) in three different assessment modes in randomized order. Each participant completed four TMT versions in each assessment mode (3 × 4 within-subject design). Results: Repeated measures ANOVA and mixed-effects analyses adjusted for age, gender, mode order, and trial number reveal significantly faster test TMT completion times (about 5 s) for the tablet and pen version compared to the pen and paper and the tablet and finger version. Conclusions: Our findings indicate that assessing processing speed can lead to different results with different digital versions depending on their setup, especially different input devices. Medical professionals and researchers who use digital assessment methods to assess cognitive abilities need to be aware of mode effects, even within the digital assessment domain, because the results may not be comparable and the available norms may not be applicable.

Trail Making Test: Comparison of paper-and-pencil and electronic versions.

The Trail Making Test (TMT) was adapted for the iPad by Parker-O'Brien, which uses the 2004 Tombaugh norms. This study investigated the equivalency of this electronic test by (a) examining the test-retest reliability of the iPad-TMT, and (b) calculating the concurrent validity between the two versions. The sample included 77 healthy adults. Reliability was assessed by Pearson product-moment correlation and intraclass correlation coefficient, while validity was assessed by MANOVA. Results indicate that Part A of the iPad-TMT did not demonstrate adequate test-retest reliability over 1 week (r = 0.15-0.70); Part B demonstrated adequate test-retest reliability in the majority of groups (r = 0.33-0.80). Conversely, Part A of the electronic TMT demonstrated adequate concurrent validity, whereas Part B did not; however, validity in Part A has minimal significance without adequate reliability. Handedness had a significant effect on performance, with left-handers performing slower on the electronic TMT Part A (p < .05) and the traditional TMT Part B (p < .05). Clinicians should use caution when using electronic versions of traditional tests, as they may assess different constructs. New norms should be developed. The role of handedness on TMT performance should be further assessed.

Normative data for Farsi-speaking Iranians in the United States on measures of executive functioning.

As the Farsi-speaking Iranian population continues to grow in the United States, examination of their cognitive performance is an imperative first step to providing this group with culturally competent services. Thirty-six healthy primarily Farsi-speaking Iranian adults completed Farsi-translated and adapted versions of three frequently used measures of executive/subcortical functioning: Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT), and Color Trails Test (CTT). Participants' performance on each measure was compared to published normative data resulting in 0-85% of cognitively and medically healthy individuals being classified as impaired depending on the executive/subcortical test score examined, with the highest impairment rates for specific WCST outcome scores. These findings raise questions for the use of published norms with Farsi-speaking Iranians residing in the US. The present study provided normative data from this group of Farsi-speaking Iranians on the Farsi-translated and adapted versions of the WCST, TMT, and CTT.

Rapid improvement in verbal fluency and aphasia following perispinal etanercept in Alzheimer's disease.

BACKGROUND: Recent clinical studies point to rapid and sustained clinical, cognitive, and behavioral improvement in both Alzheimer's disease and primary progressive aphasia following weekly perispinal administration of etanercept, a TNF-alpha inhibitor that acts by blocking the binding of this cytokine to its receptors. This outcome is concordant with recent basic science studies suggesting that TNF-alpha functions in vivo as a gliotransmitter that regulates synaptic function in the brain. We hypothesized that perispinal etanercept had the potential to improve verbal function in Alzheimer's disease, so we included several standarized measures of verbal ability to evaluate language skills in a clinical trial of perispinal etanercept for Alzheimer's disease. METHODS: This was a prospective, single-center, open-label, pilot study, in which 12 patients with mild-to-severe Alzheimer's disease were administered etanercept, 25-50 mg, weekly by perispinal administration for six months. Two additional case studies are presented. RESULTS: Two-tailed, paired t-tests were conducted comparing baseline performance to 6-month performance on all neuropsychological measures. Test batteries included the California Verbal Learning Test-Second Edition, Adult Version; Logical Memory I and II(WMS-LM-II) from the Wechsler Memory Scale-Abbreviated; the Comprehensive Trail Making Test (TMT); Boston Naming Test; and letter(FAS) and category verbal fluency. All measures revealed a significant effect except for the Boston Naming Test and the TMT-4, with WMS-LM-II being marginally significant at p = .05. The FAS test for letter fluency was most highly significant with a p < 0.0007. In addition, rapid improvement in verbal fluency and aphasia in two patients with dementia, beginning minutes after perispinal etanercept administration, is documented. CONCLUSION: In combination with the previously reported results of perispinal etanercept in Alzheimer's disease and primary progressive aphasia, these results further argue that larger scale studies of this therapeutic intervention, including Phase 3 trials, are warranted in dementias. In addition, these results may provide insight into the basic pathophysiologic mechanisms underlying Alzheimer's disease and related forms of dementia, and suggest the existence of novel, rapidly reversible, TNF-mediated pathophysiologic mechanisms in Alzheimer's disease which are worthy of further investigation.

Discrepancy analysis and Australian norms for the Trail Making Test.

OBJECTIVE: Discrepancy analyses refer to comparison methods that evaluate the relationship or differences between two measures in the same individual. A common type of discrepancy analysis involves the comparison of two trials within a measure, such as, Trails A and B of the Trail Making Test (TMT). The TMT is well-suited to this role as the two measures are highly correlated, assess similar underlying constructs, and most importantly demonstrate differential vulnerability to the impact of pathology. While the inclusion of these types of data in the form of difference scores or ratios has become more frequent, this information has been presented only for demographically adjusted subgroups and has not taken into account the level of performance of the comparison trial, Trails A. METHOD: The role and advantages of discrepancy analysis with the TMT stratified by level of Trails A performance were demonstrated with an Australian normative sample of 647 participants and a heterogeneous clinical sample consisting of 2,292 Australian and U.S. RESULTS: The ability to differentiate between the influence of slowed visual scanning and/or graphomotor speed, and reduced mental flexibility was demonstrated by applying the normative data to clinical case discrepancies. The importance of accounting for the variability in discrepancy scores associated with the level of performance of Trails A was also highlighted. CONCLUSION: A simple, efficient, and effective approach to examining the basis for differences between TMT-A and TMT-B performances is provided to examine the relative contributions of perceptual/motor abilities, and mental flexibility.

Assessing cognitive capacity for participation in a research study.

To give informed consent in research, persons must be mentally capable of understanding the study, risks, and benefits. An objective screening tool may assess cognitive capacity better than brief conversations or clinician input. The purpose is to explore the validity of the Mental Alternations Test (MAT) to assess the cognitive capacity of older (ages 50 years +) HIV+ persons (N = 81). Descriptive correlational quantitative method was used. About 12% of the sample was cognitively impaired. Contrary to expectations, primary language was the only variable with a significant relationship with the MAT (r = -.22, p = .02); there were no significant relationships between the MAT and age, education, alcohol, smoking, injection drug use, street or mind-altering drug use, physical functional status, depressive symptoms, comorbidities, or being diagnosed with AIDS. Our findings suggest caution in using the MAT as an instrument for assessing cognitive impairment in a linguistically diverse population.

Trail Making Test: Normative data for the Latin American Spanish-speaking pediatric population.

OBJECTIVE: To generate normative data for the Trail Making Test (TMT) in Spanish-speaking pediatric populations. METHOD: The sample consisted of 3,337 healthy children from nine countries in Latin America (Chile, Cuba, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Peru, and Puerto Rico) and Spain. Each participant was administered the TMT as part of a larger neuropsychological battery. The TMT-A and TMT-B scores were normed using multiple linear regressions and standard deviations of residual values. Age, age2, sex, and mean level of parental education (MLPE) were included as predictors in the analyses. RESULTS: The final multiple linear regression models showed main effects for age on both scores, such that as children needed less time to complete the test while they become older. TMT-A scores were affected by age2 for all countries except, Cuba, Guatemala, and Puerto. TMT-B scores were affected by age2 for all countries except, Guatemala and Puerto Rico. Models indicated that children whose parent(s) had a MLPE >12 years of education needed less time to complete the test compared to children whose parent(s) had a MLPE ≤12 years for Mexico and Paraguay in TMT-A scores; and Ecuador, Mexico, Paraguay, and Spain for TMT-B scores. Sex affected TMT-A scores for Chile, Cuba, Mexico, and Peru, in that boys needed less time to complete the test than girls. Sex did not affect TMT-B scores. CONCLUSIONS: This is the largest Spanish-speaking pediatric normative study in the world, and it will allow neuropsychologists from these countries to have a more accurate approach to interpret the TMT in pediatric populations.

Ecological validity of executive function tests in moderate traumatic brain injury in Ghana.

OBJECTIVE: While executive functioning (EF) tests are frequently administered in several Sub-Saharan African countries, studies examining their predictive relationships with real-world behaviors (i.e. ecological validity) are nonexistent. The present study investigated the predictive relationship between the Stroop Test, Controlled Oral Word Association Test, and Trail Making Test (TMT), a general cognitive screening test, Revised Quick Cognitive Screening Test (RQCST), and measures of activities of daily living, quality of life, and cognitive failures in Ghana. METHOD: A total of 50 literate urban dwellers who were diagnosed with moderate traumatic brain injury (TBI) were administered the neuropsychological tests and the self-report measures stated above. The informant version of the Cognitive failure questionnaire (CFQ) was completed by 50 'significant other' who knew the patients very well. RESULTS: There was no statistically significant difference between the self and informant versions of the CFQ. Some EF test scores, specifically the Stroop Test, TMT and EF composite scores, correlated significantly with the outcome measures, with correlations ranging from .29 to .55. The RQCST explained 40-49% variance in the outcome measures, while the addition of the EF composite score not only resulted in 57-62% variance accounted for but also added incremental validity to the RQCST in predicting the behavioral measures, with the exception of cognitive failures. CONCLUSION: This study has shown that although EF test scores, specifically the Stroop Test, TMT and EF composite scores, can be used to predict real-world behavior after moderate TBI in Ghana, such predictions are likely to be limited. The general implication for cross-cultural neuropsychology is that the (limited) ecological validity of EF tests may not necessarily be affected by whether the tests were administered in settings where they have not been standardized. This argument is, however, tenable granted that the test taker's backgrounds are similar to those on which the tests have been standardized.