「軌跡標示測驗平板版」的信、效度研究暨本土常模建置

Reliability and Validity of Tablet-Based Trail Making Test and Establishment of Normative Data

軌跡標示測驗（Trail Making Test）能評估個體高層次的認知執行功能及基本認知能力，廣泛用於健康樣本、腦損傷及組件功能缺陷之患者。然在測驗工具使用上多以人工閱卷，以致有計分相對耗時費力之劣勢。在臺灣亦尚無以數位化平板電腦操作之軌跡標示測驗，實為研究缺口，發展中文版平板操作軌跡標示測驗暨本土常模建置有其必要性。本研究發展一套電子數位化版本，即「軌跡標示測驗平板版」（Tablet-Based Trail Making Test, TB-TMT）。本測驗涵蓋五個情境：情境一視覺掃描、情境二簡單圖形數字序列、情境三選擇圖形數字序列、情境四轉換圖形數字序列、情境五動作速度，藉由情境間的分數轉換，可得四項指標：視覺掃描時間、動作時間、抑制情境時間、轉換情境時間。依北、中、南、東，採分層隨機取樣1,046位健康研究參與者，年齡介於8至29歲，進行信效度檢驗。結果顯示，TB-TMT再測信度具有可接受的穩定性。各指標成分能代表其特性，具有適當的內部相關性。效度考驗中，以彩色路徑描繪測驗、西蒙作業、塔測驗、反應時間作業、中文版執行功能指標為效標，發現TB-TMT具有良好之效標關聯效度。總結而言，TB-TMT具有良好的信度與效度，深具實務應用價值，適用於未來學術研究、教學實務，以及檢視臨床功能的良好工具，以提供有效之參考依據。

The Trail Making Test (TMT) is widely used to evaluate higher-order executive cognitive functions and basic cognitive abilities. This test is suitable for both healthy individuals and patients with brain injuries or specific functional impairments. The TMT consists of a visual cancellation task and a series of exercises requiring the sequential connection of numbered and lettered circles. It evaluates several aspects of executive functioning, such as visual scanning, motor speed, inhibition, and switching. In clinical neuropsychology, the TMT is an effective measure for distinguishing the cognitive performance of healthy individuals from that of patients. Its ease of administration, practicality, and sensitivity make it a valuable tool for diagnosing cognitive disorders and neurological injuries. Overall, the TMT is a crucial instrument for evaluating executive function.
In recent years, researchers worldwide have utilized the TMT to establish local normative data. Most studies have focused on adults, particularly middle-aged and older individuals (Indorewalla et al., 2022; Magnusdottir et al., 2021; Siciliano et al., 2019; St-Hilaire et al., 2018) as well as seniors (Fröhlich et al., 2024). However, research providing local normative data for school-aged children, middle school students, high school students, and younger adults remains scarce. Additionally, most of these studies have sample sizes ranging from approximately 200 to 1000 participants. In Taiwan, Kuo and Hua (2015) translated and adapted the Color Trails Test (CTT), originally developed by D’Elia et al. (1996), into a Chinese-language version. This adaptation applied TMT principles to establish normative data for Taiwan’s middle-aged and older populations. Their data were derived from a study conducted on healthy adults aged over 50 years. While this research provided a valuable foundation for neuropsychological assessments of executive and frontal lobe function, it did not include data from diverse age groups. Furthermore, the study employed a paper-based format, which is both time-consuming and labor-intensive, and included only two subtests, limiting its scope for assessing cognitive and basic abilities.
In Taiwan, a significant research gap exists due to the lack of a digital version of the TMT designed for tablet administration. Therefore, developing a Chinese-language TMT for tablet use is essential to establish local normative data. This study introduced the Tablet-Based TMT (TB-TMT), a digital adaptation of the TMT, comprising five conditions. Condition 1, Visual Scanning evaluates visual scanning and attention through a quick and focused task. Condition 2, Simple Symbol Number Sequencing requires participants to sequentially connect numbers in a visual-motion task. This condition assesses basic numerical processing, visual scanning, attention, and motion. Condition 3, Selective Symbol Number Sequencing involves sequencing symbol-number pairs in a visual-motion task. This condition provides a foundational measure of the ability to alternate between symbols and numbers. Condition 4, Switching Symbol Number Sequencing is a core component of the TMT. Test takers must alternate between connecting symbols and numbers in a specific sequence. This condition evaluates higherorder abilities, such as multitasking, simultaneous processing, and divided attention, serving as a key measure of cognitive flexibility within executive functioning. Condition 5, Motor Speed assesses the foundational aspects of cognitive flexibility by measuring motor reaction times. Individuals with motor function disorders involving the central nervous system or related areas may demonstrate poorer line-drawing performance, leading to lower scores across most conditions, particularly in Condition 4.
Through calculations based on scores for the different conditions, we derived four indicators. The first indicator—Visual Scanning Time, reflected in Condition 1—measures performance in visual scanning and attention, with shorter times indicating better performance. The second indicator—Motion Time, derived from Condition 5—examines reaction performance, where shorter times indicate better reaction performance. The third indicator, Inhibition Time, is obtained as follows: (Condition 2 + Condition 3)/2−(Condition 1 + Condition 5)/2. Shorter times represent stronger inhibition skills. The fourth indicator, Switching Time, is obtained as follows: Condition 4−(Condition 2 + Condition 3)/2. Shorter times reflect higher switching skills.
This study included 1,046 participants aged 8–29 years, divided into four age groups: primary school students in Grades 3–6, middle school students, high school students, and college students (including graduate and postgraduate levels). To ensure the sample's structural features were representative of the population, stratified random sampling was conducted based on variables such as age, region, and gender. This approach aimed to evaluate the reliability and validity of the TB-TMT and establish normative data. The study was approved by the Research Ethics Committee of Taiwan Normal University. All participants were informed of the research procedures and provided written informed consent before participation. Upon completing the test, participants received a small gift as a token of appreciation.
This study employed practical cognitive tasks and self-report behavior assessment scales—including the CTT, Simon Task (SmT), Tower Task (TwT), Reaction Time Task (RTT), and Chinese Executive Function Index (CEFI)—to evaluate the criterion-related validity of the TB-TMT. A reliability analysis was conducted to assess test–retest reliability, and internal correlation analysis was performed to examine the relationships among the indicators derived from the TB-TMT. To further evaluate criterion validity, established tools with proven reliability and validity—such as the CTT, SmT, TwT, RTT, and CEFI—were utilized. The results demonstrated that the test–retest reliability of the TB-TMT ranged from .40 to .55, indicating acceptable stability. Additionally, each indicator effectively reflected its intended construct and exhibited appropriate internal correlations. Correlation coefficients ranging from .17 to .38, obtained using the CTT, SmT, TwT, RTT, and CEFI as validity criteria, confirmed that the TB-TMT possesses satisfactory criterion-related validity.
The TB-TMT developed in this study represents Taiwan’s first digital adaptation of the Trail Making Test (TMT). It offers several unique contributions, including its emphasis on diverse participant demographics, its innovative digital test format, and its advanced methodology for analyzing test results.
First, unlike previous studies that primarily focused on adults and seniors (Fröhlich et al., 2024; Indorewalla et al., 2022; Magnusdottir et al., 2021; Siciliano et al., 2019; St-Hilaire et al., 2018), the present study includes school-aged children, middle school students, high school students, and adults. By establishing local normative data, this study provides a valuable resource for professionals, educators, parents, and researchers seeking to assess and understand executive functioning.
Second, regarding the test format, most existing TMTs used to assess executive function are paper-based (Delis et al., 2001; Nasreddine et al., 2005; Reitan & Wolfson, 1985), and no tablet-based digital TMT had been developed prior to this study. The tablet-based test developed in this study is a standardized digital tool designed to establish local normative data. It overcomes the limitations of manual scoring with an enhanced design that incorporates non-text identification. This feature eliminates textrelated constraints during testing and allows participants to complete the test within 15 minutes.
Third, the test evaluates individuals' executive function and higher-level cognitive abilities. Upon completion, the raw data are transmitted to a report analysis system, which compares the participants' results against the established local normative data. The system then generates detailed feedback and comments on the participants' performance and response abilities, as well as tailored recommendations for training to enhance their cognitive skills and improve future performance.
The TB-TMT is Taiwan's first tablet-based digital version of the TMT. It is designed to assess executive function indicators and basic cognitive abilities in healthy individuals aged 8–29 years, spanning school-aged children to adults. This digital test offers convenient administration and overcomes the limitations of manual scoring. Compared to self-report scales, the TB-TMT provides a more objective evaluation of an individual’s executive function. It effectively gathers data on executive function indicators such as inhibition and switching time, as well as basic cognitive skills, including visual scanning time and motor speed. Furthermore, the standardized testing procedure of the TB-TMT ensures consistent scoring and integrates automated report generation. The TB-TMT establishes representative local normative data in Taiwan, providing a solid foundation for interpreting test results.
This study developed the TB-TMT as a comprehensive digital system for evaluating and analyzing executive function. The TB-TMT is suitable for preliminary screening of executive function and can be applied in various settings. It provides valuable insights for teaching practices, supports academic research on cognitive function, and facilitates the assessment of clinical functions. Its utility extends to schools, research institutions, and clinical environments, making it a valuable resource for both research and practical applications. In summary, the TB-TMT demonstrates strong reliability and validity, making it a highly practical tool for future academic research, educational practices, and clinical evaluations.