Applied Neuropsychology: Adult

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A Preliminary Study on the Trail-Making Test in

ArabicEnglish Bilingual Young Adults

Rima Abdul Razzak

To cite this article: Rima Abdul Razzak (2013) A Preliminary Study on the Trail-Making Test
in ArabicEnglish Bilingual Young Adults, Applied Neuropsychology: Adult, 20:1, 53-60, DOI:
10.1080/09084282.2012.670163

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APPLIED NEUROPSYCHOLOGY: ADULT, 20: 5360, 2013
Copyright # Taylor & Francis Group, LLC
ISSN: 0908-4282 print=1532-4826 online
DOI: 10.1080/09084282.2012.670163

A Preliminary Study on the Trail-Making Test

in ArabicEnglish Bilingual Young Adults
Rima Abdul Razzak
Department of Physiology, Arabian Gulf University, Manama, Kingdom of Bahrain

The Trail-Making Test (TMT) is used in different neuropsychological test batteries. It

consists of two parts: TMT-Part A, which tests visual scanning and psychomotor speed,
and TMT-Part B, which assesses more complex cognitive processes. TMT normative data
have been established in many non-Arab countries either using the original English ver-
sion or a version developed with the native language. The aim of this study was to com-
pare TMT performance between the English TMT and a constructed Arabic TMT in
young ArabicEnglish bilingual college students from three Arabian Gulf states. Scores
from 83 participants who took the English TMT and 52 who took the Arabic TMT were
included. Arabic TMT (both parts) scores were signicantly poorer compared with Eng-
lish TMT scores. Arabic TMT scores were also poorer than were other norms for this age
group and education level, but they were better than those reported from another study
using the Arabic TMT. Moreover, there were nonsignicant differences in performance
between participants from these three countries; however, these ndings are inconclusive
as sample sizes were small. These ndings suggest that Arabic TMT norms cannot be uni-
ed for all Arabic countries, and separate Arabic TMT norms including all age groups
and education levels must be established for each Arabic country.

Key words: Arabic bilingual young adults, different Arabic TMT norms, English and Arabic
TMT

INTRODUCTION batteries, such as the Halstead-Reitan Battery (Reitan

The Trail-Making Test (TMT) is one of the most
popular and frequently used neuropsychological tests
combining both briefness and simplicity of adminis-
tration. The TMT originated from a test model that
required subjects to draw lines connecting a series of
randomly scattered numbers from 1 to 50; this test
was known as the Taylor Number Series. In 1938,
Parrington reconstructed the test and renamed it as
the Test of Disturbed Attention (in Siegert & Cavana,
1997). It was then included in the Army Individual
Test of General and renamed the Trail-Making Test
and is now included in several neuropsychological test
Address correspondence to Rima Abdul Razzak, Department of
Physiology, Arabian Gulf University, Complex 329, Salmaniyah
Road, Manama, Kingdom of Bahrain. E-mail: reemala@agu.edu.bh
& Wolfson, 1993). Early studies validated TMT as a
sensitive indicator of brain damage (Reitan, 1958) as
impaired patients have longer completion times on the
test than do normal subjects. The TMT has also showed
a positive linear relation between brain-injury severity
and TMT performance (Lange, Iverson, Zakrzewski,
Ethel-King, & Frnzen, 2005).
The TMT consists of two parts, TMT-Part A
(TMT-A) and TMT-Part B (TMT-B). In TMT-A, sub-
jects are required to rapidly connect in an ascending
order a series of 25 encircled numbers distributed on a
sheet of paper. The task requirements are similar for
TMT-B, but this test involves connecting a series of
encircled numbers and letters in an alternating pattern
(1A2B3C, etc.) in the minimum time possible
(Reitan, 1958). The score on each part represents the
amount of time required to complete the task, where
54 ABDUL RAZZAK
higher scores are indicative of slower performance
(Spreen & Strauss, 1998). TMT-A appears to be depen-
dent primarily on the efciency of visual scanning and
psychomotor speed. TMT-B is believed to involve more
complex cognitive processes than that those of TMT-A;
it investigates visual-conceptual and visual-motor track-
ing skills, concentrating on psychomotor speed, divided
attention, mental exibility, and the ability to shift
(Lezak, Howieson, & Loring, 2004; LoSasso, Rapport,
Axelrod, & Reeder, 1998).
Cutoff scores for cognitive impairment are based on
normative data, and good normative data maximize
the diagnostic utility of neuropsychological tests.
Considerable research in the last 30 to 40 years has
demonstrated that it is inappropriate to generalize nor-
mative data on standard cognitive tests from one ethnic
group to another, as this may result in diagnostic and
placement errors (Ardila, 1995; Manly et al., 1998). This
stems from studies that have examined ethnic group dif-
ferences in neuropsychology and found discrepancies in
test scores despite similarity of other demographic fac-
tors. Sociocultural factors, rather than ethnic attributes,
are more powerful correlates of neuropsychological test
performance. Such factors, including exposure to
schooling, quality of education, familiarity with testing
procedures, and language prociency (Ardila, 1995,
2005; Greeneld, 1997), have to be considered for nor-
mative data. The issue of the language of the test is also
critical; neuropsychological tests are mainly available in
the English language, and even if subjects are bilinguals,
there is a lack of ethnicity-specic normative data that
take into account issues such as culture and bilingual-
ism. Even if tests were translated into other languages,
their validity may be compromised by lack of familiarity
and relevance of test items in different ethnic groups
(Puente & Ardila, 2000; Wong, 2000). As such, thor-
ough understanding of an ethnic groups culture and
familiarity with the groups language are required for
translation and test development for that ethnic group
(Puente & Ardila).
TMT normative data have been obtained in different
populations to avoid the risk of using neuropsychologi-
cal normative data with a population that is culturally
or sociodemographically different from the original
underestimating or overestimating cognitive functioning
(Ardila, 1995, 2005; Kennepohl, 1999; Soukup, Ingram,
Grady, & Schiess, 1998). In the last 10 years, many stu-
dies have improved TMT normative data stratifying
norms according to different demographic variables
such as age, education, or gender (Heaton, Miller,
Taylor, & Grant, 2004; Mitrushina, Boone, Razani, &
DElia, 2005; Strauss, Sherman, & Spreen, 2006). For
instance, norms exist for North American (Drane,
Yuseph, Huthwaite, & Klingler, 2002; Steinberg,
Bieliauskas, Smith, & Ivnik, 2005), Canadian
(Tombaugh, 2004), Australian (Hester, Kinsella, Ong,
& McGregor, 2005), Italian (Giovagnoli et al., 1996),
Chinese (Lu & Bigler, 2002), Japanese (Hashimoto
et al., 2006), Greek (Zalonis et al, 2010), Indian (Bhatia
et al., 2007), and Korean healthy populations (Seo et al.,
2006).
Even though TMT norms need to be derived from a
sample of native speakers (Lu & Bigler, 2002) to avoid
misinterpretations of TMT measures, no specic set of
TMT norms exists for any of the Arab countries. There
are an estimated 200 million native Arabic speakers, and
the classical written Arabic is the ofcial language of
more than 20 Arab states, but only one study developed
an Arabic version of the Expanded TMT for Sudanese
subjects (Stanczak, Stanczak, & Awadalla, 2001). The
authors compared performances of healthy and brain-
damaged Sudanese to U.S. normal and brain-damaged
subjects; one disadvantage of that study was that the
results were confounded by signicant sample differ-
ences in terms of age, education, and gender.
The main objective of this study is to obtain norma-
tive data for TMT in the Arabian Gulf region and
compare these data with that from other regions. Both
English and Arabic TMT scores within a sample of
young healthy, highly educated adult ArabicEnglish
bilingual subjects are documented and compared to each
other and to published normative TMT data appropri-
ate to age, sex, and education level. Implications for
the applicability of the Arabic TMT data to different
Arab countries will also be discussed.
METHODS
Participants
One hundred fty-two participants included in this
study were young-adult medical students between the
1st and 4th year. Their age ranged from 18 years to 23
years (M 19.37; SD 1.39). The participants included
had gone through physical and psychological assessment
as a requirement for admission into medical school, and
from their history, they were determined to lack any
neurological disease, psychiatric disease, or other ill-
nesses. All were informed about the objectives and pro-
cedures involved in the study, and written consent was
obtained prior to the test.
Participants were ArabicEnglish bilinguals from
Arabian Gulf nations, specically Saudi Arabia,
Kuwait, and Bahrain. All participants were dominant
bilinguals, as they were very procient with their native
Arabic language and familiar with the Arabic numerals
and alphabet, but they had variable levels of English
prociency as they had different kinds and amounts of
exposure to the English language in their schools. The
 TMT IN ARABICENGLISH BILINGUAL YOUNG ADULTS 55

participants came from various educational back-

grounds; some participants education was based in
public schools, which start teaching English as a foreign
language at the beginning of middle school, while others
were introduced to the English language during earlier
stages of their childhood in private schools. Neverthe-
less, all participants had passed an English placement
exam for entry into the medical school, and they all
had undergone an English-language training course dur-
ing their 1st year at the medical school, enabling them to
continue studying independently through the medium of
English.

Materials
Subjects were administered the TMT-A and TMT-B
(Reitan, 1958; Reitan & Wolfson, 1993) according to
the guidelines presented by Spreen and Strauss (1998).
Participants were verbally instructed to complete each
part of the TMT as quickly and accurately as possible.
The TMT-A and TMT-B were administered in sequ-
ence, and there was no rest period between the two
parts. Once testing began, participants were instructed
not to lift their pencils from the paper. When an error
was made, subjects were instructed to return to the
circle where the error originated and to continue until
the test was nished.
FIGURE 1 Sample items for the Arabic TMT-A and TMT-B forms.
In addition, an Arabic version of the TMT was con-
structed according to procedures and instructions
developed by Stanczak et al. (2001) for the Expanded
Statistical Analyses
TMT. The Arabic TMT followed the format of the
original English TMT version, but the Hindi (Eastern All statistical analyses were performed using Instat3
Arabic) numerals were used instead of the Western (Graphpad, Inc). The Kolmogorov and Smirnov test
Arabic numerals (1, 2, 3, etc.), and the rst 12 Arabic was used to assess normality in the distribution of the
letters were used to replace the respective English sym- variables. The Instat3 program identies parametric
bols of the original TMT (Table 1, Figure 1). Also the and nonparametric data and selects the appropriate stat-
words begin and end were translated into Arabic. istical test suitable for the entered data. Comparison of
The same procedure of administration was followed means between any two groups or scores was done by
for the Arabic TMT. the unpaired t-test. Two-tailed p-values of 5% or less
One hundred participants (59 males and 41 females) were considered statistically signicant.
volunteered to be tested on the original English TMT,
and 52 (24 males and 28 females) volunteered to be
tested on the Arabic form of the TMT. The time to
complete each part of the TMT was measured with a RESULTS
stopwatch and designated as a direct score.
Errors Made
The frequency of errors has not been recorded. How-
TABLE 1 ever, upon observation, the most common type of error
Corresponding Numbers Between Hindi (Eastern Arabic) and in the English TMT-B was difculty to proceed from let-
Arabic Numbers and Corresponding Letters Between the
English and Arabic Alphabet for TMT-B
ter to number or vice versa because some participants
forgot the order of the English alphabet letters. Subjects
Hindi had to pause and recite the letters from the beginning of
Arabic 0 1 2 3 4 5 6 7 8 9 10 12 13 the alphabet to get to the required letter in the sequence.
Arabic
This caused a lengthening of the completion time for
English A B C D E F G H I J K L
the TMT-B in these participants. Another error was
56 ABDUL RAZZAK

confusion between the letters G and J. Participants

acknowledged that they had difculties in discriminating
the two letters because of their similar pronunciation.
Accordingly, data from 17 participants exhibiting
these difculties on the original English TMT were
discarded, because these participants lacked adequate
familiarity of the English alphabet. The distribution of
the remaining 135 participants according to which
TMT they took and their nationality is shown in
Figure 2.

TMT Scores
The Kolmogorov and Smirnov Test showed that data
followed a normal distribution for all Arabic TMT
scores and English TMT scores (Figure 3). The results
for the analysis of the time to complete the original
and Arabic TMT-A and TMT-B are shown in Table 2.
As anticipated, it took more time to complete TMT-B
than it took to complete TMT-A in both versions.
The mean completion time for the Arabic TMT-A
was 29.76
7.94 seconds (range 15.3753.44 seconds),
and for the Arabic TMT-B, it was 71.83
17.42 seconds
(range 31.50101.56 seconds). To test if any differ-
ences in performance on the Arabic TMT existed
between the participants of the three different nations,
one-way analyses of variance of Arabic TMT scores
were carried out. Bahraini participants (n 15) out-
performed, but only insignicantly, those from Saudi FIGURE 3 (a) Distribution of TMT-A scores. (b) Distribution of
Arabia (n 15) and Kuwait (n 22) in the TMT-A TMT-B scores.
(Bahrain, 27.55
8.92 seconds; Saudi Arabia, 33.05

9.55 seconds; and Kuwait, 29.04
5.24 seconds;
p .195) and TMT-B (Bahrain, 63.98
21.35 seconds; TMT-A, 29.76
7.94 seconds; English TMT-A, 25.74

Saudi Arabia, 76.71
16.25 seconds; and Kuwait, 7.67 seconds; t 2.94, p .004, df 133). Similarly, it
73.87
13.85 seconds; p .103). took signicantly longer time to complete the Arabic
Subjects were slower to complete the Arabic TMT TMT-B (71.83
17.42 seconds) than to complete the
(both parts) than they were to complete the English English TMT-B (58.77
12.12 seconds, Welchs
TMT. Arabic TMT-A completion time was signicantly t 4.74, p < .0001, df 81). Table 3 represents the data
longer than that of the English TMT-A (Arabic for both the English and Arabic TMT-A and TMT-B
transformed into percentile scores.

TABLE 2
Descriptive Statistics of Direct TMT Scores

Score Mean (SD) Median MinimumMaximum

TMT-A (s)
English TMT 25.74 (7.67) 24.51 12.3752.55
Arabic TMT 29.76 (7.94) 28.68 15.3753.44
TMT-B (s)
English TMT 58.77 (12.12) 59.03 33.7285.60
Arabic TMT 71.83 (17.42) 71.27 31.50101.56

Note. English TMT: n 83. Arabic TMT: n 52. Unpaired t-test

for TMT-A and unpaired t-test with Welch correction for TMT-B.
FIGURE 2 Distribution of participants according to gender and Comparison of English and Arabic TMT-B.

TMT language (color gure available online). p < .01.  p < .001.
 TMT IN ARABICENGLISH BILINGUAL YOUNG ADULTS 57

TABLE 3 study on Arabic TMT was by Stanczak et al. (2001) on

Percentiles for English and Arabic TMT-A and TMT-B Scores (s) Sudanese subjects, but the results of that study were
English TMT (n 83) Arabic TMT (n 52) confounded by signicant sample differences in demo-
graphics. As such, this preliminary study is the rst in
Percentile TMT-A TMT-B TMT-A TMT-B
the Arab world examining TMT scores in a small sam-
90 17 43 21 47 ple of subjects with similar demographics. We aimed
80 19 47 22 55 to determine whether English and Arabic TMT scores
70 21 53 25 64 for this intellectual ArabicEnglish bilingual group were
60 23 56 27 69
50 25 59 29 71
comparable to those of documented norms for this age
40 26 62 30 76 group and educational level.
30 29 65 34 82 The TMT scores presented here meet six of the seven
20 32 68 36 87 criteria for both English TMT and Arabic TMT to be
10 36 75 39 96 considered norms for the TMT (Mitrushina et al.,
2005). Data were collected from a sample where the sub-
jects were of the same age group (18 to 23 years old) and
TABLE 4 had the same years of education (>12 years). Gender
Gender-Defined TMT Scores distribution was reported, and means and standard
Minimum p deviations were presented for completion time (in sec-
Score Mean (SD) Median Maximum (two-tailed) onds) for TMT-A and TMT-B. As this is a preliminary
English TMT-A
study, the sample size for the Arabic TMT of 52 is small
M 25.80 (7.86) 24.10 12.3752.55 .93 but meets the recommended 50 subjects per grouping
F 25.65 (7.53) 24.83 12.6348.20 (Criterion 1), and the sample size of 83 for the English
Arabic TMT-A TMT was also greater than this recommended value.
M 31.69 (8.23) 29.76 20.0353.44 .11 However, this does not undermine the value of larger
F 28.13 (7.44) 27.76 15.3744.83
English TMT-B
samples for each demographic cell when obtaining
M 61.01 (11.53) 61.81 35.9083.99 .07 normative data for TMT.
F 56.10 (12.40) 55.79 33.7285.60 As expected, our results showed that English and
Arabic TMT-B Arabic TMT-B required more time to complete than
M 74.59 (16.81) 75.09 43.20101.42 .29 did TMT-A, and these ndings are consistent with the
F 69.29 (18.25) 67.60 31.50101.56
idea that, in comparison with TMT-A, normal perfor-
Note. All scores are in seconds (s). M male; F female. English mance on TMT-B depends on additional cognitive fac-
TMT: 45 M, 38 F; Arabic TMT: 24 M, 28 F. For comparison of M tors, irrespective of the language of the test. This is
and F scores, unpaired t-test was used. Signicance at p < .05. because TMT-B reects more complex processes than
does TMT-A, such as cognitive shifting (Lezak et al.,
2004; Oliveira-Souza et al, 2000), cognitive exibility
Gender-Related Results (Krotte, Horner, & Windham, 2002), general attention
Nonsignicantly shorter completion times were component (Stuss & Levine, 2002), and working
observed in females than in males for English TMT memory (Crowe, 1998).
and Arabic TMT scores. The only difference that nearly It is not surprising to nd different Arabic TMT
reached signicance was in performance on the English scores in the present study compared with those
TMT-B (males, 61.01
11.53 seconds; females, 56.10
reported by other countries (Bhatia et al., 2007;
12.40 seconds; t 1.87, p .07, df 81). Table 4 illus- Giovagnoli et al., 1996; Hamdan & Hamdan, 2009;
trates the gender differences in all English and Arabic Zalonis et al, 2008). Even when constructing TMT-B
TMT scores. using characters of the native language instead of the
English alphabet, normative data from different coun-
tries or cultures are not equivalent for comparable age
and education level (Fernandez & Marcopulus, 2008).
DISCUSSION For example, comparison to Greek TMT norms for a
sample with comparable age and education (age 20
Despite the widespread use of TMT, no documented 29 years; Meducation 13.64 years) shows shorter
normative data for TMT are available for any of the completion times for Arabic TMT-A (Arabic TMT-A,
countries in the Arabian Gulf region or the Arab world. 29.76
7.94 seconds; Greek TMT-A, 35.32
9.91 sec-
In general, much of the Arab population lives in onds) and longer times for Arabic TMT-B (Arabic
underdeveloped countries where neuropsychological test TMT-B, 71.83
17.42 seconds; Greek TMT-B,
batteries are not frequently used. The only documented 67.59
15.48 seconds). This further suggests that cul-
58 ABDUL RAZZAK
ture-specic variables other than linguistic factors may
inuence cognitive abilities and performance on TMT
and other neuropsychological tests; these factors may
include socioeconomic status, approaches to learning,
and quality of education (Manly, Touradji, Small, &
Stern, 2002). Even some tasks that measure basic cogni-
tive domains, such as processing speed and working
memory, may be culturally biased (Park, Nisbett, &
Hedden, 1999).
Arabic TMT-B scores from the Arabian Gulf
participants in this study (mean TMT-B score 71.83

17.42 seconds, corresponding to mean natural logarithm
[ln] TMT-B 4.24
0.26) and separate scores from each
country (mean ln TMT-B: Bahrain, 4.11
0.33; Saudi
Arabia, 4.32
0.23; Kuwait, 4.28
0.19) are better than
those reported in another study on healthy Sudanese
subjects using the Arabic alphabet (mean ln TMT-B
score 4.80
0.58; Stanczak et al., 2001). It seems
unlikely that Arabic TMT norms may be uniform for
all Arabic countries. Overall, the Arabic countries share
the same classical form of the written Arabic language,
but language is not the only cultural factor that should
be considered. The Arabian Gulf states are wealthier
countries with better educational facilities and higher
socioeconomic status than other Arab countries; socioe-
conomic status may inuence brain development or
functioning because those of lower socioeconomic class
may have poorer nutrition, education, and access to
health care.
The English TMT completion times for both TMT-A
and TMT-B in this study are compared to pooled norms
published in a recent study (Greer, Brewer, Cannici, &
Pennett, 2010). These pooled norms for core Halstead-
Reitan variables produced in that study were from 206
compiled studies (311 samples) during 1950 to 2003.
The English TMT completion times in the present study
(TMT-A, 25.74
7.67 seconds; TMT-B, 58.777
12.12
seconds) are longer than those of the pooled norms
(for age <35 years and education of 1214 years,
TMT-A completion time 25.21
9.29 seconds,
TMT-B completion time 57.93
24.69 seconds; and
for education >15 years, TMT-A completion time
23.00
7.04 seconds, TMT-B completion time
49.36
17.11 seconds). Moreover, our completion times
are longer than those reported by Tombaugh in 2004
(age of 18 to 24 years old, TMT-A completion
time 22.93
6.87 seconds; TMT-B completion time
48.97
12.69 seconds). Other than cultural variances,
one would attribute this to language bias and would
expect better performance on the test constructed with
the participants native language. However, an unexpec-
ted nding in the present study is the signicantly better
score on the English TMT (both parts) than on the
Arabic TMT among the participants in this study who
use Arabic as their native language. For TMT-B, this
is inconsistent with a study comparing performance of
American and ChineseEnglish bilingual college stu-
dents, which reported longer TMT-B completion time
on the original English TMT than on the Chinese
TMT-B (Lu & Bigler, 2002) by the Chinese participants.
However, in another study by Ibrahim, Eviatar, and
Aharon-Peretz (2002), adolescent ArabicHebrew bilin-
guals who mastered Hebrew as a second language per-
formed better on the Hebrew TMT than on the Arabic
TMT. The authors attributed this to the high complexity
of the Arabic orthography, which increases its percep-
tual load leading to its slower processing. In the Arabic
alphabet, many letters have similar or even identical
structures and are distinguished only on the basis of
the existence, location, and number of dots (Abu-Rabia,
2002). On the Arabic TMT-B, the 12 letters used are
categorized as four sets with either 2 letters or 3 letters
per set with the same basic shape but differing in the
number of dots on, in, or under the letter, and 2 individ-
ual letters. This resemblance of the letter shapes could
induce visual letter confusion errors, slow down the vis-
ual search process required, and prolong completion
times on the Arabic TMT-B.
The effects of gender on TMT performance have
been controversial. In the present study, there was no
signicant effect of sex on the English TMT-A and
TMT-B or the Arabic TMT-A and TMT-B. The results
in this study are consistent with many previous studies
that reported a nonsignicant effect of sex on TMT-A
and TMT-B performance (Hamdan & Hamdan, 2009;
Oliviera-Souza et al., 2000; Tombaugh, 2004; Zalonis
et al., 2010). However, other studies have reported
shorter TMT-A times for females than for males in uni-
versity populations (Arbuthnott; Gaudino, Geisler, &
Squires, 1995;), while others have reported longer
TMT-A times (Giovagnoli et al., 1996).
Limitations and Conclusion
This preliminary study includes TMT data gathered
from a nonclinical sample of ArabicEnglish bilingual
young college students, narrowing the normative data
to one age and educational level. Arabic TMT data
for this group are different from English normative
data or norms for other countries for the same age
and education level. Even though Arabic TMT com-
pletion times exceeded those for the English TMT,
applicability of the English TMT for the Arab states is
restricted to ArabicEnglish bilinguals, and TMT norms
for Arabic countries should also include Arabic mono-
linguals. The Arabic TMT developed in this study is
valid for all Arab-speaking nations who have different
dialects but share the same written form of the Arabic
language, because the test items for the TMT only
include the basic Arabic letters used by all Arabic
 TMT IN ARABICENGLISH BILINGUAL YOUNG ADULTS
nations. However, because cultural differences exist
among the Arabic states, Arabic TMT norms may not
be standardized for all Arabic states.
In conclusion, this study supports and conrms nd-
ings of other investigators about the signicance of cul-
tural factors in neuropsychological testing, specically
TMT. Norms of Arabic TMT stratied by age and edu-
cation are required to reduce discrepancies that occur
when using English or other normative data. This will
increase sensitivity, reliability of Arabic TMT, and also
its utility in experimental and clinical practice when
administered to Arabic native speakers.
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