RESEARCH PAPER

Children’s Color Trail Test for Objective Assessment of Attention in

Children with Attention Deficit Hyperactivity Disorder: A Diagnostic
Accuracy Study
MONICA JUNEJA1, HARPREET MEHAR2, SMITHA SAIRAM1, NEHA VERMA2, RAHUL JAIN1 AND DEVENDRA MISHRA1
From 1Department of Pediatrics; and 2Child Development Center; Lok Nayak Hospital, Maulana Azad Medical College, New
Delhi, India.

Correspondence to: Dr Devendra Objective: To compare the Children’s Color Trail Test scores in children with and without
Mishra, Professor, Department of Attention Deficit Hyperactivity Disorder to assess its diagnostic performance in assessing
Pediatrics, Maulana Azad Medical attention-deficit. Methods: 50 children with Attention Deficit Hyperactivity Disorder
(diagnosed as per Diagnostic and Statistical Manual, 5th edition) and 50 age- and sex-
College, New Delhi 110 002, India.
matched children underwent Test 1 and Test 2 of the Children’s Color Trail Test. A Receiver
[email protected] Operating Characteristics curve was constructed for the diagnostic accuracy of Children’s
Received: January 03, 2019; Color Trail Test in Attention Deficit Hyperactivity Disorder. Results: The Receiver Operating
Initial review: March 09, 2019; Characteristics curve showed a score ≤32 for Children’s Color Trail Test 1 [AUC: 0.8 (0.71 to
Accepted: September 30, 2019. 0.87); P<0.001] and score ≤40 for Children’s Color Trail Test 2 [AUC: 0.85 (0.77 to 0.92);
P<0.001] as the best cut-off for diagnosing Attention Deficit Hyperactivity Disorder.
Conclusion: Children’s Color Trail Test is a promising tool for diagnosing attention deficit,
and could be used in settings where parent or teacher reports are not available.
Keywords: Attention deficit disorders, Diagnosis, Neurodevelopmental disorders.

T
he diagnosis of Attention deficit hyperactivity of the brain including visual attention, psychomotor
disorder (ADHD) is typically based on the speed, sequencing and cognitive flexibility [7]. Although,
reports of the caregivers, family members and it was initially developed for use in patients with Human
teachers. The criteria laid down in the immuno-deficiency virus (HIV) and traumatic brain
Diagnostic and Statistical Manual for Mental Disorders, injury, previous studies have shown that it can
5th edition (DSM-5) is considered the gold standard for differentiate children with attention deficits, and may be
its diagnosis [1]. In clinical settings, interview schedules helpful in monitoring their course [8]. This study
like Conner’s Parent Rating Scale (CPRS) and Conner’s intended to assess the diagnostic performance of CCTT
Teacher Rating Scales (CTRS) [2] are often used to elicit in assessing attention deficit in children with ADHD, and
the symptomology, as they provide an objective score, also study the correlation of CCTT with Conner’s rating
which can be used for assessing response to therapy [3,4]. scales.
Although widely accepted, the assessment based on
METHODS
caregivers/teachers report has many shortcomings. At
times, the information may be inaccurate. The diagnosis Following approval from the Institutional Ethics
becomes difficult when caregivers and/or teachers are not Committee, this study was carried out from June, 2014 to
available, or if their reports are contradictory to each May, 2016 in the pediatric outpatient department (OPD)
other. There is a need for instruments that can directly and Child development center of Maulana Azad Medical
assess attention and/ or level of hyperactivity in a child. College, New Delhi. A sample of convenience of 100
children aged 8-15 years (50 with ADHD and 50 without
Few computer-based tests, commonly referred to as
ADHD) were enrolled after obtaining informed consent
Continuous performance tests (CPTs) have been
from one of the parents, and assent from the participants.
developed to objectively assess the attention level of a
child; however, their cost is prohibitive [5]. Children’s Consecutive children presenting with features
Color Trail Test (CCTT) is a simple neuropsychological suggestive of ADHD (e.g., lack of concentration in the
test that consists of circled numbers 1-15 placed classroom, poor school performance, lack of interest in
randomly on a paper, which have to be sequenced by a studies, motor hyperactivity, forgetfulness, poor listening
performer [6]. It objectively assesses executive functions responses) were assessed for inclusion. ADHD was

INDIAN PEDIATRICS 1025 VOLUME 56__DECEMBER 15, 2019

JUNEJA, et al. COLOR TRAILTEST FOR ADHD

diagnosed by a developmental pediatrician using the reported. Correlation between CCTT scores and CPRS
DSM-V criteria, after interviewing the child and the and CTRS subscale scores was evaluated using correlation
parents. CPRS and CTRS were administered, and scores coefficient (r).
on various sub-scales (inattention, hyperactivity, learning
RESULTS
problems, executive-functioning, aggression and peer-
relationship) were obtained [2]. IQ assessment was done The study population consisted of 100 boys (50 in each
using the Binet Kamat Test [9]. Age- and sex-matched group), with median (IQR) age of 9 (8,12) years. The
controls were enrolled from the pediatric OPD. Children parental educational status and other socio-demographic
with Intelligence Quotient (IQ) <70, neurological variables in both groups are shown in Web Table I. Of the
disorders likely to affect upper limb motor performance or 50 children with ADHD, 39 had combined, 10 had
compliance with directions for the test, and those who had predominantly inattentive, and one had predominantly
received any treatment for behavioral problems/ADHD hyperactive type of ADHD.
were excluded.
Controls had significantly higher mean scores on
Children’s Color Trails Test (CCTT) was administered CCTT 1 [41.7 (7.84) vs 29.5 (10.74), P<0.001] and
to all the subjects by a blinded clinical psychologist. This CCTT2 scores [45.1 (10.17) vs 29.5 (9.99), P<0.001] as
test has two parts – Part 1 (CCTT1) is a page with circled compared to children with ADHD. The ROC analysis
numbers 1-15 placed randomly on a paper (even numbers showed that CCTT1 has an AUC of 0.8 (95% CI, 0.71 to
printed in yellow circles and odd in pink circles). The child 0.87) and CCTT2 has an AUC of 0.85 (95% CI, 0.77 to
has to rapidly connect numbers in sequence using a pencil. 0.92, P<0.001) for diagnosing ADHD. A score ≤32 for
In part 2 (CCTT2) of the test, numbers from 2–15 are CCCT1 and ≤40 for CCTT2 were the best cut-off values
presented twice, as both pink and yellow circles. The child for diagnosis (Fig. 1). The sensitivity (95% CI) and
has to rapidly connect the numbered circles in sequence, specificity (95% CI) for a DSM-5 ADHD diagnosis was 74
alternating between pink and yellow circles. CCTT takes (59.7-85.4) and 74 (59.7-85.4) for a CCTT-I score ≤32,
15-20 minutes for administration. The examiner records and 84 (70.9-92.8) and 72 (57.5-83.8) for a CCTT-2 score
the time taken to complete each trail and errors committed, ≤40.
to arrive at the score of each part [6].
Table I shows the correlation of the two CCTT tests
Statistical analysis: SPSS version 20.0 was used. Receiver with CPRS and CTRS scores. All Connors scores
Operating Characteristics (ROC) analysis was done and correlated negatively with CCTT-1 and CCTT-2 scores,
Area under curve (AUC) determined as the measure of with correlation-coefficients (r) in the range of –0.44 to
diagnostic performance of the test. The best cut-offs on –0.59 (P<0.001), except for Parent-learning problems
CCTT 1 and CCTT 2 for diagnosis of ADHD was subscale, which had r= –0.38 with CCTT-1. CCTT-1 and
ascertained and the sensitivity, specificity, positive CCTT-2 correlated significantly with each other (r=0.637,
predictive value and negative predictive values were P<0.001).

FIG. 1 ROC curves for diagnostic performance of (a) CCTT1 and (b) CCTT2 against DSM-5 diagnosis of ADHD.

INDIAN PEDIATRICS 1026 VOLUME 56__DECEMBER 15, 2019

JUNEJA, et al. COLOR TRAILTEST FOR ADHD

WHAT THIS STUDY ADDS?

• Children’s Color Trail Test is a promising tool in the diagnostic armamentarium for attention deficit, especially
in settings where reliable reports from parents or teachers are not feasible.

TABLE I CORRELATION OF CHILDREN COLOR TRAILS TEST demonstrated that CCTT scores differ significantly
SCORES WITH CONNERS RATING SCALE SCORES IN between ADHD group receiving medications, ADHD-
CHILDREN WITH ATTENTION-DEFICIT HYPERACTIVITY drug free group and normal children. This study also
DISORDER (N=50) showed good test-retest reliability of CCTT. Seo, et al.
Subscale scores (CRS) Correlation coefficient* [11] showed that CCTT has good correlation with
CCTT1 CCTT2 Comprehensive attention test (CAT) in children with
ADHD. A few studies have used CCTT as a tool to
Parent Scale evaluate improvement in children with ADHD, with a
Inattention -.498 -.524 demonstrable change after intervention [12,13].
Hyperactivity -.556 -.596
Learning problems -.383 -.579 Studies have attempted to derive normative values of
CCTT in different populations. It has been noted that
Executive functioning -.535 -.534
CCTT scores is influenced by socio-demographic
Aggression -.448 -.487
variables like age, sex, socio-economic status and
Peer relationship -.458 -.581
ethnicity [14-16].
Teacher Scale
Inattention -.537 -.476 The major limitations of this study are the small
Hyperactivity -.540 -.578 sample size and convenience sampling. Children with
Learning/ Executive functioning -.531 -.513 predominantly hyperactive type were under-represented
Aggression -.477 -.478
in this study, making it impossible to compare the
performance amongst different sub-types of ADHD.
Peer Relationship -.517 -.513
Further, it would have been ideal to test the tool in a
CRS, Connors Rating Scale; CCTT, Children’s Color Trail Test I and II; community sample or undiagnosed children with
*All P<0.001 for correlation between Conners subscale scores and the
CCTT scores.
behavioral issues.
The good diagnostic accuracy of the CCTT in this
DISCUSSION study suggests that its role in evaluation of children with
ADHD needs to be further explored. If substantiated, it
In this study, CCTT showed good performance against can prove to be a useful tool in the management of
DSM-5 criteria for diagnosing ADHD, with a sensitivity ADHD. Further studies may also explore its use to assess
and specificity of >72%, at cut-off score of ≤32 and ≤40 response to intervention (drugs and/or behavioral
for CCTT I and CCTT II, respectively. CCTT also therapy). Studies with larger number of children in each
showed significant correlation with various sub-scale age-group would be helpful in providing age-specific
scores of Connor’s parent and teacher rating scales. As norms for Indian children.
CCTT is a broad screener for executive functions, it
correlated well with learning problems and executive Contributors: MJ,RJ,DM,SS: study planning; SS,HM,NV;
participant assessment and evaluation; HM,DM,RJ,MJ:
functioning sub-scales, in addition to the inattention
statistical analysis; HM,DM: manuscript writing. All authors
subscale. The correlation with hyperactivity and made important intellectual contribution to study planning, data
aggression sub-scale can be explained by the fact that in analysis, and manuscript writing. All authors approved the final
most children with ADHD these behaviors often co-exist manuscript.
with inattention. Funding: None; Competing interest: None stated.
There are few studies on CCTT in children with REFERENCES
attention problems. William, et al. [7] compared the time
1. American Psychiatric Association. Diagnostic and
taken to complete the test in children with mild Statistical Manual of Mental Disorders, 5th ed. Arlington:
neurological disorders, learning disability, ADHD and American Psychiatric Publishing; 2013.
controls. Children with ADHD took maximum time to 2. Conners CK. Clinical use of rating scales in diagnosis and
complete the test followed by those with mild treatment of attention-deficit/ hyperactivity disorder.
neurological disorder [7]. A Korean study [10] also Pediatr Clin North Am. 1999;46:857-70.

INDIAN PEDIATRICS 1027 VOLUME 56__DECEMBER 15, 2019

JUNEJA, et al. COLOR TRAILTEST FOR ADHD

3. Venkata J, Panicker A. Prevalence of attention deficit 11. Seo JM, Kim HW, Yeo JY, Byun EH, Chung S. Executive
hyperactivity disorder in primary school children. Indian J function in attention-deficit/hyperactivity disorder:
Psychiatry. 2013;55:161-4. Relationship of comprehensive attention, stoop color-
4. Juneja M, Sairam S, Jain R. Attention deficit hyperactivity word, children’s color trails, and Wisconsin card sorting
disorder in adolescent school children. Indian Pediatr. tests. J Korean Neuropsychiatr Assoc. 2012;51:59-69.
2014;51:151-2. 12. Kim JK. The effects of a home-based sensorimotor
5. Berger I, Slobodin O, Cassuto H. Usefulness and validity program on executive and motor functions in children with
of continuous performance tests in the diagnosis of ADHD: A case series. J Phys Ther Sci. 2018;30:1138-40.
attention-deficit hyperactivity disorder children. Arch Clin 13. Kim SH, Han DH, Lee YS, Kim BN, Cheong JH, Han SH.
Neuropsychol. 2017;32:81-93. Baduk (the Game of Go) Improved cognitive function and
6. Llorente AM, Williams J, Satz P, D’Elia LF, eds. brain activity in children with attention deficit hyperactivity
Children’s Color Trails Test – Professional Manual. Lutz: disorder. Psychiatry Investig. 2014;11:143-51.
Psychological Assessment Recourses; 2003. 14. Konstantopoulos K, Vogazianos V, Thodi C, Nikopoulou-
7. Williams J, Ricket VI, Hogan J, Light R. Children’s color Smyrni P. A normative study of the Children’s color trails
trails. Arch Clin Neuropsychol. 1995;10:211-23. test (CCTT) in the Cypriot population. Child
8. Llorente AM, Voigt RG, Williams J, Frailey JK, Satz P, Neuropsychol. 2015;21:751-8.
D’Elia LF. Children’s Color trails test 1 and 2: Test-retest 15. Fasfous AF, Puente AE, Pe´rez-Marfil MN, Cruz-Quintana
reliability and factorial validity. Clin Neuropsychol. F, Peralta-Ramirez I, Pe´rez-Garcý´a M. Is the Color trails
2009;23:645-60. culture free? Arch Clin Neuropsychol. 2013;28:743-9.
9. Kamat V. Measuring Intelligence of Indian Children. 16. Arango-Lasprilla JC, Riverab D, Ramos-Usugac D,
Bombay: Oxford University Press; 1967. Vergara-Moraguesd E, Montero-L´opeze E, et al. Trail
10. Koo H-J, Shin M-S. A standardization study of Children’s Making Test: Normative data for the Latin American
color trails test (CCTT). Journal of Korean Academy of Spanish-speaking pediatric population. Neuro
Child and Adolescent Psychiatry. 2008;19:28-37. Rehabilitation. 2017;41:627-37.

INDIAN PEDIATRICS 1028 VOLUME 56__DECEMBER 15, 2019

JUNEJA, et al. COLOR TRAILTEST FOR ADHD

WEB TABLE I SOCIODEMOGRAPHIC CHARACTERISTICS OF

CHILDREN WITH ATTENTION DEFICIT
HYPERACTIVITY DISORDER AND CONTROLS
(N=100)
Characteristic ADHD Group, Control Group,
n (%) n (%)
Maternal education
Illiterate 1 (2) 2 (4)
Primary 2 (4) 2 (4)
Senior secondary 20 (40) 27 (54)
Higher education 27 (54) 19 (38)
Paternal education
Illiterate 1 (2) 0 (0)
Primary 1 (2) 4 (8)
Senior secondary 14 (28) 28 (56)
Higher education 34 (68) 18 (36)
Child’s school Grade
3rd 15 (30) 15 (30)
4 th 13 (26) 13 (26)
5 th 7 (14) 7 (14)
6 th 1 (2) 1 (2)
7 th 7 (14) 7 (14)
8 th 3 (6) 3 (6)
9 th 1 (2) 1 (2)
Age, y
8 16 (32) 15 (30)
9 13 (26) 14 (28)
10 6 (12) 6 (12)
11 2 (4) 2 (4)
12 5 (10) 5 (10)
13 4 (8) 4 (8)
14 3 (6) 3 (6)
15 1 (2) 1 (2)
50 children in each group; ADHD: Attention Deficit Hyperactivity
Disorder.

INDIAN PEDIATRICS VOLUME 56__DECEMBER 15, 2019