Improving validity of the trail making test with alphabet support

Therese Händel Waggestad; Bjørn Eivind Kirsebom; Carsten Strobel; Anders Wallin; Marie Eckerström; Tormod Fladby; Jens Egeland

doi:10.3389/fpsyg.2023.1227578

Improving validity of the trail making test with alphabet support

Front Psychol. 2023 Jul 27:14:1227578. doi: 10.3389/fpsyg.2023.1227578. eCollection 2023.

Authors

Therese Händel Waggestad¹, Bjørn Eivind Kirsebom^{2

3}, Carsten Strobel⁴, Anders Wallin⁵, Marie Eckerström^{5

6}, Tormod Fladby^{7

8}, Jens Egeland^{1

9}

Affiliations

¹ Vestfold Hospital Trust, Tønsberg, Norway.
² Department of Neurology, University Hospital of North Norway, Tromsø, Norway.
³ Department of Psychology, The Arctic University of Norway, Tromsø, Norway.
⁴ Medical Department, Section of Geriatrics, Memory Clinic and Stroke Unit, Lovisenberg Diaconal Hospital, Oslo, Norway.
⁵ Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁶ Department of Psychology, University of Gothenburg, Gothenburg, Sweden.
⁷ Department of Neurology, Akershus University Hospital, Lørenskog, Norway.
⁸ Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
⁹ Department of Psychology, University of Oslo, Oslo, Norway.

Abstract

Objective: The Trail Making Test (TMT) is commonly used worldwide to evaluate cognitive decline and car driving ability. However, it has received critique for its dependence on the Latin alphabet and thus, the risk of misclassifying some participants. Alphabet support potentially increases test validity by avoiding misclassification of executive dysfunction in participants with dyslexia and those with insufficient automatization of the Latin alphabet. However, Alphabet support might render the test less sensitive to set-shifting, thus compromising the validity of the test. This study compares two versions of the TMT: with and without alphabet support.

Methods: We compared the TMT-A, TMT-B, and TMT-B:A ratios in two independent normative samples with (n = 220) and without (n = 64) alphabet support using multiple regression analysis adjusted for age and education. The sample comprised Scandinavians aged 70-84 years. Alphabet support was included by adding the Latin alphabet A-L on top of the page on the TMT-B. We hypothesized that alphabet support would not change the TMT-B:A ratio.

Results: After adjusting for age and years of education, there were no significant differences between the two samples in the TMT-A, TMT-B, or the ratio score (TMT-B:A).

Conclusion: Our results suggest that the inclusion of alphabet support does not alter TMT's ability to measure set-shifting in a sample of older Scandinavian adults.

Keywords: TMT ratio score; alphabet support; cultural fairness; dyslexia; fitness to drive; test-validity; trail making test.