Challenges Post ABI
- Inability to maintain focus with and without distractions
- Inability to shift and divide attention appropriately (CASLPO 2002)
According to Park and Ingles (2001), attention is defined as the “voluntary control over more automatic brain systems to be able to select and manipulate sensory and stored information briefly or for long periods of time” (pg. 201).The speed at which information is processed or decisions are made; the ability to pay attention or stay focused on a task; the ability to complete more than one task at a time; and the ability to socialize, (due to attention issues); may impact the individual’s success in rehabilitation, returning to work or school and their ability to participate in other community activities.
In an earlier meta-analysis completed by Parks and Ingles, (2001), the authors suggested that attention deficits resulting from an ABI are treatable. Sohlberg et al. (2003), in a follow-up review, noted that attention training should be used in combination with self-reflective logs, anticipation/prediction activities, and feedback and strategy training for those who sustain mild-moderate attentional dysfunction.
Goals of Treatment
- To improve all aspects of attention including sustained, alternating, selective and divided attention.
1. Dual task training (performing two or more tasks simultaneously)
2. Drill and Practice
3. Computer Assisted Technology
4. Attention Process Training (APT)
Materials and Devices
1. Visual (Videotaped short stories -abstract and concrete);
2. Computerized tasks-simple memory tasks (visual stimulation of “language” characters, computer games, THINKable program, computerized calendar vs control diary)
3. Paper and pencil tasks
4. Auditory tasks
5. Electronic Aids
Treatment of Communication and Attention Deficits
Amos (2002) completed a RCT that evaluated remediating deficits of switching attention in patients with acquired brain injury. Twenty-four patients with ABI were randomly assigned to one of three groups and compared to eight normal controls. Results suggest perseverative error and random error are separate functions when switching attention, as suggested by a neural network model. The author notes that external inhibition significantly reduced perseverative error (applying an inappropriate rule continually), while an increase in perceptual salience decreased random error (continually failing to apply an appropriate rule) on the Wisconsin Card Sorting Test
Drill and Practice
Novack et al. (1996) found no differences between a group of 61 individuals with severe ABI who received focused stimulationcompared to another group who received unstructured stimulation. Focused attention was divided into various levels, “with the lowest level involving focused and sustained attention, with more challenging tasks requiring selective attention; alternating attention and last divided attention” (Novack et al., 1996; p.55). Both groups showed improvement on the Digit Span and mental control subtests of the Wechsler Memory Scale-Revised (WMS-R). Test results also indicated that individuals performed better at the time of discharge than they did at the time of admission. Novack et al. (1996) suggested that the study results may have been affected by the individuals’ spontaneous recovery, leading to improved attentional skills.
Mindfulness Based Mediation Techniques
McMillan et al. (2002) evaluated the effectiveness of attentional control training (ACT) with a group of individuals who had sustained an ABI. The ACT program was designed to train individuals to sustain attention on a single repetitive stimulus for an extended period of time. In this study 145 individuals were randomly assigned to one of three groups: the ACT group, the physical exercise (PE) group and the control group. Those in the ACT group of received, over a 4 week period, 5 - 45 minute sessions using an ACT audiotape. Those in the PE group received the audio-tape training based on physical fitness training. The control group were not given any contact with the therapist. Study results found no significant differences on the measures of cognitive functioning or on anxiety or depression between the groups as a result of the ACT intervention. Overall study authors found no reason to recommend this training be offered to those who have attentional problems following a closed head injury (McMillan et al, 2002).
Post ABI impairments of attention are one of the most disabling consequences of severe injuries. Patients have been shown to have difficulty performing two or more tasks at the same time. Dual-task processing “requires strategic allocation of attention, task switching and synchronization” (Couillet et al., 2010p 322). In this recent RCT, Couillet et al. (2010) randomly divided 12 participants into either a non- specific cognitive (control-A phase) group or an experimental rehabilitation (treatment-B phase) group. The control group (n=6) was asked to complete computerized or paper and pencil tasks focusing on divided attention or working memory, while the experimental group participated in a training program with specific dual task training. The objective of this phase was to train the participants to perform 2 tasks concurrently. Initially they trained to perform the task independently then simultaneously. Each treatment phase ran for 6 weeks at which time the groups reversed the order of treatment. Prior to completing the dual task, all were asked to complete the single tasks until they were able to do so without difficulty. To measure changes in divided attention, the divided attention subtest of the Test Battery for Attentional Performance(TAP) was used. At the 6th week assessment period the, BA group showed significant improvement (p<0.01) in reaction times and omissions compared to the AB group.
Fasotti et al. (2000) randomly assigned 22 severe ABI patients undergoing rehabilitation to either a Time Pressure Management (TPM) training group (n=12) or to a concentration group (n=10). Patients were pre-selected for inclusion in this study if they demonstrated slowed processing speed. TPM consists of a series of cognitive strategies to compensate for reduction in processing speed. There are 3 main stages: increased self-awareness of errors and deficits, acceptance and acquisition of TPM cognitive strategies (4 steps), and strategy application and maintenance in increasingly more demanding/ distracting situations. The effects of the TPM training were evaluated on a waterbed task (WB-story task), and a Harvard Graphics (HG-computer task). The concentration-training group consisted of 4 generic suggestions (e.g., focus, don’t get distracted). The following tests were administered to both groups: Rey’s Auditory Verbal Learning Test, the Rivermead Behavioural Memory Test, an Auditory Concentration Test, the Paced Auditory Serial Addition Task (PASAT) and Visual Choice Reaction Time Task. Groups were compared at three time points, pre-training, post-training and follow-up on task performance (information from a video recording). Results indicate the levels of managing performance in both tasks (WB and HG) showed a significant increase following training.
Cognitive Rehabilitation Strategies
In an earlier study Sohlberg et al. (2000) found that those who were assigned to the Attention Process Training group (APT) (n=7), showed improved performance on cognitive function and executive attention tasks compared to those in the brain education therapy group (n=7). Results of the Paced Auditory Serial Addition Task (PASAT) found those with higher PASAT scores were related to higher levels of vigilance. Improvement in PASAT scores was greater after APT than with brain education, suggesting participants benefited more from APT than from the brain education program. Similar results were also found when looking at the scores of the Controlled Oral Word Association Task(COWAT- a measure of frontal function). Those with higher vigilance scores had higher COWAT scores. Self-reports of those receiving only brain “education” indicated an improvement in psychosocial function.
Computer Assisted Technology for Attention
Thomas-Stonell et al. (1994) studied 12 patients (6 treatment, 6 control) who participated in individualized, 8-week period of a computer-based program called TEACHware for remediating cognitive-communication skills (i.e. attention, memory/word-retrieval, comprehension of abstract language, organization and reasoning/problem solving skills). The remediation modules of the TEACHware program were primarily in a game format with 3 levels of difficulty. In an effort to assist with generalization to real-life situations the subjects in the remediation group had a SLP, OT or teacher present and available to them at all times. Performance improved on both the screening module and standardized assessment measures within the remediation group.
In an early study, Gray et al. (1992) randomized a group of individuals with an ABI who reported having difficulty with concentration (which affected their reading and/or their ability to follow conversations) to either a treatment group or a control group. Stratification of severity was based on the Paced Auditory Serial Addition Task (PASAT). Those in the treatment groups were given fourteen 75 minute training sessions with these session lasting 3 to 9 weeks. The package consisted of 4 types of programmes: Reaction Time Training, Rapid Number Comparison, Digit Symbol Transfer, Alternating Stroop Program and Divided Attentional Tasks. The control group received approximately 12.7 hours of recreational computing delivered over 3-9 weeks. Controls were excluded from externally paced tasks, sort or masked displays. Participants were tested prior to treatment, immediately afterward and again 6 months later. Pretesting showed no differences between the groups. Initial post testing indicated scores on the Wechsler Adult Intelligence Scale-Revised (WAIS-R) picture completion and the PASAT Information Processing Rate (IPR) improved significantly for the treatment group (p=0.031; p=0.023 respectively). The in relation to their psychological well being, those in the treatment group, the IPR scores improved significantly during the intervention phase (p=0.004) and over the 6th month follow-up phase (p=0.001). For the control group, IPRs did not improve during training, but did improve 6 months later (p-0.034).
Ruff & Bergquist(1994) evaluated the effect of computer-assisted rehabilitation using the THINKable computer program, a multi-media system that focuses on memory and attention retraining. All 15 participants were randomly assigned to one of two treatment groups: Group A received attention training first, followed by the memory training and Group B received training in the reverse order. Due to the small number recruited, the groups were analyzed as a pre-post comparison design. The THINKable system provides photo-like images using digitized real spec and is designed to accept touch screen responses or input using a mouse. Psychometric testing revealed modest but significant gains made for some memory and attention measures in each of the groups.
Calendar to Improve Orientation
In a randomized controlled trial, Watanabe et al. (1998) examined whether use of a calendar would enhance orientation following an acquired brain injury. Results indicated that the presence of a calendar did not enhance performance on a temporal orientation test (date and time). It is difficult to judge the outcome of this study as no scores were reported for either the control or treatment group, and it is not clear whether post-traumatic amnesia, and/or severity of injury had an impact on performance.
The reader is encouraged to review the aforementioned studies within Table 7.1 at the end of this module for further details.
There is Level 2 evidence from a study conducted by Novack et al. (1996) suggesting specific structured training programs are not effective in improving attention post ABI.
Results from several studies indicate there is Level 2 evidence that dual task training has a positive effect on divided attention and is effective on speed of processing (Couillet et al., 2010; Fasotti et al., 2009)
There is Level 1b evidence suggesting Attention Process Training (APT) improves cognitive function (Sohlberg et al., 2000).
Based on the results of an earlier study conducted by Ruff & Bergquist, (1994), there is Level 2 evidence supporting the use of computer assisted technology to enhance concentration and attention post ABI.
Although TEACHware is no longer available, based on this one RCT, there is Level 2 evidence that this computer-based program designed to remediate cognitive-communication skills, improved cognitive and communication outcomes in individuals with ABI (Thomas-Stonell et al., 1994).
Based on the results of a study conducted by Watanabe et al. (1998), there is Level 2 evidence suggesting the use of a calendar did not improve patients’ orientation to time and date.
Despite the success of APT training in improving cognitive functioning there is still evidence suggestingstructured training programs are not effective in improving attention post ABI. More research needs to be conducted.
Dual task training assists individuals to deal with dual-task situations rapidly and accurately.
Dual task training on speed of processing is effective.
Computer-based interventions that integrate learning, metacognitive and other validated strategies developed for the individual may be considered as an adjunct to clinician-guided treatment for the remediation of attention deficits after ABI.
Of note, despite the availability and demand for computer-assisted technology, to date it has only been found to enhance concentration and attention for those with a mild to moderate ABI. More research is needed investigating its effectiveness with those who sustain severe ABI.
In an isolated RCT regarding the presence of a calendar and temporal orientation, a positive effect was not found in improving an individual’s orientation to time and date.