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School Neuropsychology Post-Graduate Certification Program

Copyright © KIDS, Inc. 1

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Overview of the Delis-Kaplan Executive

Function System (D-KEFS)

Part 2: Trail Making Test

KIDS, Inc. (schoolneuropsych.com)’s Continuing Education Module

Presenter: Daniel C. Miller, Ph.D., ABPP,

ABSNP, NCSP

This compiled lecture material is copyrighted by KIDS, Inc. and cannot be used in any form outside of the KIDS, Inc.’s School Neuropsychology Post-Graduate Certification Program or the School Neuropsychology Alumni Connection website or the KIDS, Inc.’s Online Continuing Education Program without the express written consent from KIDS, Inc.

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Permission generously granted to reproduce some content from the D-KEFS Administration Manual by Pearson. Delis-Kaplan Executive Function Systems (D-KEFS). Copyright © 2001 NCS Pearson, Inc. Reproduced with permission. All rights reserved. “D-KEFS” is a trademark in the U.S. and/or countries of Pearson Education, Inc.

Presentation Outline •  Part 1 – Overview of the D-KEFS and some

factorial research (20 minutes) •  Part 2 – Trail Making Test (45 minutes) •  Part 3 – Verbal Fluency and Design Fluency

Tests (45 minutes) •  Part 4 – Color Word Interference Test (30

minutes) •  Part 5 – Card Sorting Test (50 minutes) •  Part 6 - Word Context, Twenty Questions,

Tower, and Proverbs Tests (50 minutes)

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Overview of D-KEFS Tests

•  Trail-Making Test (ages 8-89) •  Verbal Fluency (ages 8-89) •  Design Fluency (ages 8-89) •  Color-Word Interference Test (ages 8-89) •  Card Sort Test (ages 8-89) •  Word Context Test (ages 8-89) •  Twenty Questions (ages 8-89) •  Tower Test (ages 8-89) •  Proverbs Test (ages 16-89)

Trail-Making Test •  First introduced by U.S. Army psychologists

as part of the Army Individual Test Battery (1944).

•  Became part of the Halstead-Reitan Batteries in the 1950s.

•  Traditional test contains two parts (A & B). – Part A – Connecting numbers in sequential

order – Part B – Connecting numbers and letters in

alternating sequential order (1-A-2-B-3-C…)

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Trail Making Test

•  Part B of the classic Trails Test was the principle clinical indicator of poor cognitive flexibility, a frontal lobe function.

•  However, it was difficult to tease out what was causing poor performance on Part B of Trails, due to the neurocognitive complexity of the test demands.



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Trail Making Test

•  Poor performance on the HR TMT could be attributed to a variety of neurocognitive deficits including: – Poor number or letter sequencing – Poor visual-spatial processing – Poor attention to detail – Poor psychomotor output speed.

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Trail Making Test

Following a process-oriented model, the D-KEFS version has five conditions, rather than the traditional two parts: –  Condition 1 – Visual Scanning –  Condition 2 – Number Sequencing (Similar to the

original Part A) –  Condition 3 – Letter Sequencing –  Condition 4 – Number-Letter Sequencing

(Equivalent to the original Part B) –  Condition 5 – Motor Speed

Trail Making Test

The goal of the D-KEFS version of Trails is to help the clinician to tease out systematically what were contributing factors to poor performance on Condition 4 (Switching) of the task.

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Trail Making Test Materials

•  Record Form •  Stimulus Booklet (Easel portion) •  D-KEFS Trail Making Response Booklets:

–  Visual Scanning –  Number Sequencing –  Letter Sequencing –  Number-Letter Switching –  Motor Speed

•  Pen •  Stopwatch

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Trail Making Discontinue Rules

•  Administer Condition 1: Visual Scanning in its entirety, even if the examinee cannot successfully complete the practice items.

•  For Condition 2-5, discontinue any condition for which the examinee makes four errors on the practice tasks.

•  In clinical practice, if the examinee performs well on Condition 4: Number-Letter Switching, it is not necessary to administer Condition 5 – Motor Speed (You will be asked to administer all 5 conditions).

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Discontinue a Condition is the time limits have been reached: – Condition 1: Visual Scanning (150 seconds) – Condition 2: Number Sequencing (150

seconds) – Condition 3: Letter Sequencing (150

seconds) – Condition 4: Number-Letter Sequencing

(240 seconds) – Condition 5: Motor Speed (150 seconds)

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•  If an examinee has begun to mark an item (Condition 1) or draw a connection (Conditions 2-5), allow him or her to complete that response before telling him or her to stop.

•  The response is scored as completed within the time limit.

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Trail Making Test Instructions

•  Place and leave the stimulus book in its easel position for the entire test.

•  The specific verbal directions for the examiner to read for each Trails condition are printed in the stimulus book.

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Trail Making Test Instructions

•  If during any condition, the examinee has difficulty holding the response booklets stationary, the examiner can reach over and hold down the response form with their fingertips.

•  The examinee may lift the pen from the paper at any point during any of the conditions.

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Trail Making Test Condition 1 – Visual Scanning

•  Assesses the child’s ability to rapidly locate objects on the page.

•  Alerts the examinee that the target stimuli in general appear throughout the stimulus array on the extra large pages of the response booklets.

5

C

A5

5

5

5

B

D

Mark all of the 5s on the page

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•  In the entire D-KEFS normative sample, approximately 90% marked their first target in the upper-left quadrant.

•  Another 4.4% marked their first target in the lower right quadrant.

•  If a child begins this task by marking the first target in one of the other two quadrants, this may be a “red flag” for a visual scanning deficit.

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•  Low scores in this condition may indicate: – a visual-scanning/attentional deficit – a motor impairment (check out Condition 5) – Any neurostructural or non-neurostructural

factor that may affect processing speed. •  Average to above average scores indicate:

– examinee has the visual scanning and attentional capabilities needed to perform the other D-KEFS Trails conditions.



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Trail Making Test Condition 2 – Number Sequencing

•  Assesses basic mental sequencing and numerical processing.

•  Requires visual scanning/attentional abilities and motor functions.

1

Start

2 3

4 5

End

A

B

C

D

E

This time I want you to connect just the numbers.


•  Condition 2 of the D-KEFS Trail Making Test is similar to Part A of the Haltead-Reitan version of the test.

•  The major difference between the two versions is the inclusion of both numbers and letters in the D-KEFS Trails stimuli.

•  Both numbers and letters are included in this condition because they are used in Condition 4 (Switching).

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•  Condition 2 (Number Sequencing) requires only one task demand.

•  Condition 3 (Letter Sequencing) requires only one task demand.

•  Condition 4 (Number – Letter Switching) requires a new task demand above and beyond number or letter sequencing, that of switching – designed to be a more isolated test of cognitive shifting.

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•  The inclusion of both numbers and letters on Condition 2 (Number Sequencing) and Condition 3 (Letter Sequencing) provide a measure of response inhibition – the ability of the examinee to inhibit responses to distracting stimuli.

•  An elevated number of set-loss errors on Condition 2, often represents a more serious deficit than does an elevated number of set-loss errors on the switching condition.

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•  Poor score on Condition 2 must be interpreted in light of the examinees performance on Condition 1 (Visual Scanning) and/or performance on Condition 5 (Motor Speed).

•  Poor performance could be due to an isolated impairment in number sequencing; however, this is rare because the ability to count from 1 to 16 is an overlearned skill.

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•  Low scores in this condition may indicate: – Examinees with moderate to severe

developmental math disabilities, acquired acalculia, or severe aphasia may struggle on this task due to an impairment in basic number processing.

– It is not uncommon to obtain an impaired score on Condition 2 but to perform normally on the more demanding Condition 4. This occurs because of non-neurostructural factors such as fatigue, pain symptoms, emotional problems, or inconsistent effort.



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Trail Making Test Condition 3 – Letter Sequencing

•  Assesses basic mental sequencing and letter processing. •  Requires visual scanning/attentional abilities and motor

functions.

1 Start 2

3

4 5 End

A

B

C

D E

This time I want you to connect just the letters. 26

Trail Making Test Condition 3 – Letter Sequencing

•  Low scores in this condition may signal: – Children with verbal learning disabilities

often do not have a firm grasp of the alphabetical sequence.

– Verify a letter-processing problem by looking at an individual’s performance on a standardized test of spelling ability (e.g., WIAT-II/III or WJ III-ACH).

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Trail Making Test Condition 4 – Number-Letter Switching •  Assesses complex mental processes of cognitive

flexibility, multi-tasking, simultaneous processing, and divided attention.

1 Start

2

3 4 5

End A

B C

DE

This time I want you to switch between connecting the numbers and letters.

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Trail Making Test Condition 4 – Number-Letter Switching

•  The heart of the D-KEFS Trail-Making Test is Condition 4.

•  The ability to engage in this type of cognitive flexibility is considered a classic executive function, one that is essential for higher-level skills such as multi-taking, simultaneous processing, and divided attention.

•  Children with significant frontal lobe or diffuse brain dysfunction often exhibit disproportionate impairment in flexibility of thinking.

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•  Condition 4 also contains what are called capture stimuli.

•  They are pairs of consecutive numbers (e.g., 3 then 4) or consecutive letters (e.g., B then C) placed in proximity to each other on the response booklet page.

•  Condition 4 contains eight pairs of capture stimuli, two pairs in each quadrant.

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•  When a examinee who is susceptible to set-loss errors encounters two symbols that are in capture placement, the proximity of the other symbol may pull for the more automatic response of connecting items within that symbol set (A, B, C, D…. or 1, 2, 3, 4…..) rather than across symbol sets (1-A-2-B-3-C…..).

•  Examinees who make set-loss errors primarily with capture stimuli may have less of a cognitive-flexibility deficit than those who make set-loss errors with both capture and noncapture stimulus pairs.



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Trail Making Test Condition 5 – Motor Speed

•  Assesses basic visuomotor speed.

Start

End

Draw a line over the dotted line as quickly as you can.

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Trail Making Test Condition 5 – Motor Speed

•  Low performance may be indicative of: – Diminished motor speed in drawing a line,

either due to a peripheral or central motor dysfunction.

– Pain symptoms in the upper extremity may affect motor speed.

– Motor involvement in the performance of the Trail-Making Test should be generally minimal, but Condition 5 provides a direct measure of it’s contribution.

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Trail Making Test Scores

•  Completion Times are recorded for each Condition: –  Condition 1 - Visual Scanning –  Condition 2 - Number Sequencing –  Condition 3 - Letter Sequencing –  Condition 4 - Number-Letter Switching –  Condition 5 - Motor Speed –  Combined Conditions 2 + 3

•  Provides an overall measure of performance on that task.

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Trail Making Test Contrast Scores

•  Completion Times Contrast Scores: –  Number-Letter Switching vs. Visual Scanning –  Number-Letter Switching vs. Number Sequencing –  Number-Letter Switching vs. Letter Sequencing –  Number-Letter Switching vs. combined number +

letter sequencing –  Number-Letter Switching vs. Motor Speed

•  Assesses the degree to which deficient performance on the high-level switching task (condition 4) may be explained by one or more underlying impairments measured by conditions 1, 2, 3, & 5.

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Trail Making Test Number-Letter Switching vs. Visual Scanning

•  The stimuli in Condition 1 are the same size as the stimuli in Condition 4.

•  Therefore, Condition 1 provides a direct measure of the visual scanning skills required by the higher-order switching task of Condition 4.

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Trail Making Test Number-Letter Switching vs. Visual Scanning

•  Average contrast score (7-13) = the child does not have a deficit in cognitive flexibility over and above his or her visual-scanning/attentional impairment.

•  Below average contrast score (4-6) = may suggest that the child has a deficit in flexibility of thinking beyond any visual-scanning/attentional dysfunction that may be present.

•  Well Below average contrast score (0-3) = may signal more significant problems in higher order mental processing and possible brain dysfunction.



Contrast Number-Letter Switching (4) vs. Visual Scanning Example (1)

(4) - (1) = ?

Scaled Score

What this score means in regards to cognitive flexibility.

13 - 10 = 3 13 There is no deficit in cognitive flexibility over and above any visual scanning or attentional impairment. 10 - 7 = 3 13

7 - 4 = 3 13

10 - 15 = -5 6 A deficit in flexibility in thinking is above and beyond any visual scanning or attentional impairment. 7 - 12 = -5 6

4 - 9 = -5 6

6 - 14 = -8 3 May signal more significant problems in higher order mental processing and possible brain dysfunction. 5 - 13 = -8 3

4 - 12 = -8 3 37 38

Trail Making Test Contrast Scores •  Number-Letter Switching vs. Number Sequencing

–  Allows the examiner to parcel out the contribution of number sequencing difficulties to a switching problem.

•  Number-Letter Switching vs. Letter Sequencing –  Allows the examiner to parcel out the contribution of

letter sequencing difficulties to a switching problem. •  Number-Letter Switching vs. combined number + letter

sequencing –  Allows the examiner to parcel out the contribution of

sequential processing difficulties to a switching problem.

•  Number-Letter Switching vs. Motor Speed –  Allows the examiner to parcel out the contribution of

motor speed difficulties to a switching problem.

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Trail Making Test Error Scores Optional Error Analyses:

Visual Scanning

Number Sequencing

Letter Sequencing

Number-Letter

Switching

Motor Speed

Omission Errors √

Commission Errors

√

Sequencing Errors

√ √ √

Set-Loss Errors

√ √ √

Time- Discontinue Errors

√ √ √ √

All Error Types

√

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Trail Making Test Error Scores

•  Generally, slow completion time coupled with many errors is worse than slow completion time with limited errors.

•  Condition 1 - Visual Scanning –  Omission errors - impulsive or careless response style. –  Omission errors + slow completion time = can signal

serious problems in visual scanning and attention. –  Commission errors (rare) - may indicate a marked

impairment in sustained focused attention or in maintaining cognitive set.

•  Look for other slow completion on NEPSY-II Visual-Motor Precision or WJIII COG Pair Cancellations

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Trail Making Error Scores •  Sequencing errors (Conditions 2 & 3) - may signal a

fundamental deficit in numerical or letter processing, or sequential processing difficulties.

•  Set-loss errors (Conditions 2 & 3) -typically occurs because of the examinee’s failure to maintain the set while performing the fundamental task of number or letter sequencing. Set-loss errors are usually indicative of high distractibility.

•  Set-loss errors on Condition 4 are typically related to problems in shifting cognitive sets rather than in maintaining the set. May reflect problems with cognitive flexibility rather than in sustaining focused attention.

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Trail Making Test Error Scores

•  Time discontinue errors - occur when a child failed to connect one or more items because of the time limit for that condition had elapsed. –  All connections that should have been made but

were not because of the expired time limit are counted as time discontinue errors.

–  A high time discontinue score would indicate a slow processing speed, or a potential obsessive need for accuracy.



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Trail-Making Overall Interpretation •  Examine for global deficits in processing speed. •  Assesses visual attention (condition 1) •  Assesses basic number and letter skills

(conditions 2 & 3) •  Examine contrast scores.

–  Low scale scores (5-7) signal mild difficulties in higher order processing.

–  Very low scores (<4) signal more significant problems in higher order mental processing and possible brain dysfunction.

•  Examine error scores.

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Recommendations for Using TMT •  Should be administered on a routine basis. •  Should be used in replacement of the Halstead-

Reitan Trails A & B •  Short administration time •  Easy to learn to administer and score. •  Sensitive to brain dysfunction •  Identifies possible academic weaknesses as well

as problems in processing speed, attention, multi-tasking, divided attention, and cognitive flexibility.

•  Task is difficult for 8 year olds, use with higher ability children only for this age group.

Reporting Trail Making Test Scores in the School Neuropsychology Report Model

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Sensorimotor Functions

Instrument / Subtest Well Below

Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level

Psychomotor Speed D-KEFS: Trail Making Condition 5 - Motor Speed: Tracing a dotted line as quickly as possible.

(5)

Condition 5: Motor Speed of the Trail Making Test is a pure measure of psychomotor speed. Visual scanning is minimized because there are lines that connect the boxes.

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Attentional Processes


Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level

Visual Shifting of Attention D-KEFS: Trails Condition 4 – Number-Letter Switching: A psychomotor task that requires switching between number and letter sequences (e.g., 1-A-2-B…).

• Trail Making Condition 2 (# Sequencing): Quickly connecting lines between consecutive numbers.

• Trail Making Condition 3 (letter sequencing): Quickly connecting lines between sequential letters.

• Trail Making Conditions 2 & 3 Combined: Time taken across number and letter trials.

• Trail Making Condition 5 - Motor Speed: Tracing a dotted line as quickly as possible.

•  If there is a low score on the D-KEFS: Trails Condition 4 – Number-Letter Switching you must look at the contrast scores which compare the previous conditions to the Switching condition to interpret the findings accurately.

•  The Number – Letter Switching Condition does not load on other measures of Shifting Attention based on TWU factor analytic studies.

Reporting the Qualitative Behaviors

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Executive Functions Qualitative Behaviors


Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level

Set Loss Errors D-KEFS Trail Making Test 15

Trail Making Test Interpretation Example 1

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Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level

Visual Shifting of Attention D-KEFS: Trails Condition 4 – Number-Letter Switching: (4)

• Trail Making Condition 1 (visual scanning): Quickly connecting lines between consecutive numbers.

(10)

• Trail Making Condition 2 (number Sequencing): Quickly connecting lines between consecutive numbers.

(4)


(7)


(6)


(10)

Low score on Condition 4 is due to poor number sequencing skills.




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Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level



(4)


(10)


(10)


(10)


(7)

Low score on Condition 4 is due to poor visual scanning and mild motor speed weakness.


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Expected Level

Below Expected

Level

Slightly Below

Expected Level

At Expected

Level

Slightly Above

Expected Level

Above Expected

Level

Well Above

Expected Level



(10)


(4)


(5)


(4)


(10)

Low score on Condition 4 is due to poor sequential processing for both numbers and letters.

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References

Delis, D. Kaplan, E., and Kramer, J. H. (2001). Delis-Kaplan Executive Function System Examiner’s Manual. San Antonio, Texas.