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.