What Is the CTMT-2? The Comprehensive Trail-Making Test Explained

The CTMT-2, or Comprehensive Trail-Making Test–Second Edition, is an individually administered neuropsychological test in which the examinee connects sequences of numbers and letters as quickly as possible across five timed tasks called "trails," or drawn paths. Published by PRO-ED in 2020 and authored by psychologist Cecil R. Reynolds, it is used with people ages 8 through 79 to assess attention, concentration, resistance to distraction, and "cognitive flexibility," the ability to shift between mental rules or categories. It is a performance test given one-on-one by a trained professional, and it measures specific brain-related abilities rather than general intelligence, so it does not produce an IQ score. This article explains what the CTMT-2 measures, how its five trails work, how scores are reported, what the research shows, and how it relates to IQ testing.

The CTMT-2 belongs to the family of trail-making tasks, one of the oldest and most widely used formats in neuropsychological testing. According to a 2017 review in the Journal of the International Neuropsychological Society, the Trail Making Test ranks among the most extensively used cognitive measures in the world. The original Trail Making Test asks the examinee to connect scattered circles in order, first numbers only, then alternating numbers and letters. Reynolds published the first Comprehensive Trail-Making Test through PRO-ED in 2002 as an expanded, standardized version with more trails, more varied task demands, and national norms. The second edition arrived in 2020.

The publisher describes performance on the trails as heavily influenced by four overlapping abilities. In the research literature these fall under the umbrella of "executive functions," the control processes that let us direct attention and adjust behavior. According to a widely cited review by developmental cognitive neuroscientist Adele Diamond, the core executive functions are inhibition, working memory, and cognitive flexibility, which is also called set shifting.

• Attention and concentration: staying focused on the search for the next correct circle without losing the sequence.

• Resistance to distraction: ignoring irrelevant marks and decoy circles that appear on some trails.

• Psychomotor speed: how quickly the hand and eye work together, since every trail is scored by completion time.

• Set shifting: flexibly switching between rules, such as moving between different types of stimuli within a single trail.

Because these abilities depend on healthy brain function, PRO-ED lists the evaluation and diagnosis of brain injury and other central nervous system compromise as the test's primary use. The publisher also cites detection of frontal lobe deficits, problems with visual search and sequencing, and monitoring recovery from concussion and other traumatic brain injuries.

The basic task never changes: draw a line connecting a series of stimuli in a specified order as quickly as possible. What changes from trail to trail is the difficulty. The publisher reports that the five trails use numbers expressed as numerals or in word form, plus letters, and that the number of distractor items varies across trails.

The first trail is the simplest. In a study of older adults published in the journal Geriatrics, researchers describe Trail 1 as connecting the numbers 1 through 25, each printed in a plain black circle, in ascending order. Later trails raise the demands by adding distractor circles and by mixing stimulus types, which forces the examinee to hold a rule in mind while resisting interference. The same study notes that the line paths in the Comprehensive Trail-Making Test are more complex and varied than in the original Trail Making Test, so the test draws more heavily on executive control.

The five trails are grouped into two clusters that mirror two core executive functions:

• Trails 1 through 3 (Inhibitory Control): these trails emphasize focused attention and the ability to suppress responses to distractors, the same general ability tapped by measures like the Stroop test.

• Trails 4 and 5 (Set Shifting): these trails emphasize flexibly switching between stimulus categories, a hallmark executive demand.

Administration is individual and brief. PRO-ED lists a testing time of 5 to 15 minutes, with manual scoring. The test is classified at qualification level B, meaning purchasers need graduate training in assessment or an equivalent credential. The publisher's list of intended users includes neuropsychologists, clinical and school psychologists, occupational therapists, speech-language professionals, and physical therapists.

The raw score for each trail is simply the time in seconds needed to complete it. Raw times are converted to "T scores," standard scores with a mean of 50 and a standard deviation of 10, based on the normative sample. The publisher reports that the second edition was normed on 1,904 people from 38 states, with the sample built to reflect 2017 United States Census data for ages 8 through 79.

The individual trail scores can be pooled into three composite indexes:

• Inhibitory Control Index: combines Trails 1 through 3; internal consistency reliability of .89, per the manual.

• Set-Shifting Index: combines Trails 4 and 5; internal consistency reliability of .79.

• Total Composite Index: combines all five trails; internal consistency reliability of .92.

The two narrower indexes are new to the second edition. PRO-ED states that they were added to help clinicians and researchers pin down the source of a low score, since a slow overall time could reflect weak inhibitory control, weak set shifting, generally slow psychomotor speed, or some combination. As with any brief timed test, a single administration carries measurement error, so careful examiners interpret scores alongside history, observation, and other test results rather than in isolation.

The strongest evidence base for trail-making tasks concerns traumatic brain injury. For the second edition, the publisher reports diagnostic accuracy studies in which the Total Composite Index alone distinguished people with a history of traumatic brain injury from people without one, even in samples tested after rehabilitation, with sensitivity of .73, specificity of .71, and an area under the receiver operating characteristic curve of .82. In plain language, the index correctly flagged about 73 percent of the injured group and correctly cleared about 71 percent of the uninjured group.

Independent research on the first edition points the same direction. A 2008 study in Archives of Clinical Neuropsychology compared 30 adolescents with moderate to severe traumatic brain injury to 30 matched healthy controls and found that the injured group scored roughly two standard deviations below the control mean on every one of the five trails and on the composite index, with good classification accuracy overall. Researchers have also extended the test beyond injury populations. The Geriatrics study cited earlier used the Comprehensive Trail-Making Test to characterize cognitive slowing in older patients with mild cognitive impairment.

The second edition manual adds validity data linking CTMT-2 performance to Wechsler intelligence scale indexes and to injury severity as measured by the Glasgow Coma Scale, according to the publisher. Those correlations are informative for clinicians, but they do not make the CTMT-2 an intelligence test, which brings us to a distinction worth spelling out.

An IQ test samples a broad range of reasoning, knowledge, memory, and speed abilities and summarizes them as a full-scale score on the familiar mean-100, standard-deviation-15 scale. The CTMT-2 does something narrower and more targeted. It measures how quickly and flexibly a person can execute a visual sequencing task, reports results as T scores rather than IQ scores, and exists mainly to detect and monitor brain-based impairment. A person can have a high IQ and still show a clinically low CTMT-2 score after a concussion, and that gap is exactly what the test is designed to reveal. Neuropsychologists often administer both kinds of measures in a full evaluation because each answers a different question.

If your question is about general cognitive ability rather than neurological status, a well-normed IQ test is the right tool. The Reasoning and Intelligence Online Test, developed by RIOT IQ with psychometrician Dr. Russell T. Warne, measures adult general intelligence through 15 subtests across six cognitive indices: verbal reasoning, fluid reasoning, spatial ability, working memory, processing speed, and reaction time. It takes about 52 minutes and reports scores on the standard mean-100, standard-deviation-15 scale for adults 18 and older. It does not replace an individually administered diagnostic evaluation like the CTMT-2, and no online test can diagnose a brain injury. For a rigorous picture of your own cognitive strengths, you can take the RIOT IQ test online.

No. It is a neuropsychological measure of attention, inhibitory control, set shifting, and psychomotor speed. It reports T scores, and it is used chiefly to evaluate brain injury and related impairment, so it does not yield an IQ score.

PRO-ED lists an age range of 8 years 0 months through 79 years 11 months, with norms reflecting 2017 U.S. Census data across that span.

The publisher lists a testing time of 5 to 15 minutes. It is administered individually and scored by hand.

It is a level B instrument, so it is sold to professionals with graduate-level assessment training, such as psychologists, neuropsychologists, occupational therapists, and speech-language professionals.

Each trail and composite is reported as a T score with a mean of 50 and a standard deviation of 10, so scores near 50 are average for the person's age group.

The classic Trail Making Test has two parts and no single national norming study behind its many versions. The CTMT-2 uses five trails with graded difficulty and distractors, adds Inhibitory Control and Set-Shifting indexes, and was normed on 1,904 people matched to U.S. Census data.

1. PRO-ED. (2020). CTMT2: Comprehensive Trail-Making Test–Second Edition, Complete Kit. proedinc.com

2. Bednorz, A., & Religa, D. (2023). Utility of the Comprehensive Trail Making Test in the assessment of mild cognitive impairment in older patients. Geriatrics, 8(6), 108. pmc.ncbi.nlm.nih.gov

3. Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135-168. pmc.ncbi.nlm.nih.gov

4. Casaletto, K. B., & Heaton, R. K. (2017). Neuropsychological assessment: Past and future. Journal of the International Neuropsychological Society, 23(9-10), 778-790. pmc.ncbi.nlm.nih.gov

5. Armstrong, C. M., Allen, D. N., Donohue, B., & Mayfield, J. (2008). Sensitivity of the Comprehensive Trail Making Test to traumatic brain injury in adolescents. Archives of Clinical Neuropsychology, 23(3), 351-358. pubmed.ncbi.nlm.nih.gov

Photo by Tamarcus Brown, via Wikimedia Commons (CC0)