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    Oxford Handbook Attn Rehab

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    Rehabilitation of Attention Functions Oxford Handbooks Online Rehabilitation of Attention Functions lan H. Robertson and Redmond G. O'Connell ‘The Oxford Handbook of Attention cited by Sabine Kasinor Flint Publication Date: Jan 2014 Subject: Psychology, Cognitive Neuroscience, Clinical Psychology (Online Publication Dato: Ape DO! 10.1088oxorshv9730 186675111.07802% 2014 (4 Abstract and Keywords The evidence for the effectiveness of rehabiltation of three types of attention—selectivty, sustained attention, and attentional switching—is reviewed. Linited but significant effects inal three domains are observed, though evidence for generalization to wider everyday lfe functions remains relatively sparse. In the case of sustained attention and also in the case of spatial selectivity, the modulating effects of arousal are shown to be important, ‘and higher level executive deficits may at times be exacerbated or even caused by lowered levels of arousal. Conversely, methods of modulating arousal may be used to improve sustained attention and executive functions ia 2 range of clinical conditions. Attentional functions are key to other cognitive domains such as attention and perception, and so the promising evidence for attentional rehabilitation may contribute to the rehabiltaton of other cognitive domains also. 8, cohabitation, xpive raining Keywardsatentin, save, sutined atone, salt Introduction _srexman is what allows one stream of information from the internal or external environment to be selected over others and therefore pervades almost any thought or action we take in our dally lives. tis itle wonder then that deficient attention, a common feature of many disorders of the brain (see Manohar, Bonnelle and Hunter (chapter 34), this volume; Vallar and Bolognini (chapter 33), this volume), can produce such profound functional impairments, With the benefitof accumulated knowledge from cognitive science, neuropsychology, and neuroimaging, itis now abundantly clear that attention isnot a simple unitary process. In addition to being able to select stimuli for preferential processing according to some attribute (selective attention), we must also be able to sustain that selectivity, particularly in conditions of monotony or repetition (sustained attention), and further, we musthave the capacity to change the selection from one feature or stream to another (attention switching) (Posner ‘and Petersen 1990; Robertson et al, 1996). Our ever-increasing understanding of how attention is instantiated in the brain s directly fueling the development of new treatment strategies that can target specific attention subsystems (Posner and Petersen 1990), The field of cognitive rehabiltation has received a boostin recent years with 2 number of computer-based training stutlies reporting promising results, For the most part these studies have addressed deficits in working memory (Jaeggi etal. 2008; Klingbery 2020). tn the present chapter we look at the Current state of play in the effort to teat deficls In attention. In so doing we adopt the three-component framework ‘of Posner and Rothbart by reviewing studies that have specifically targeted selective attention, sustained attention, ‘and attentional control or switching, There is rather strong evidence for the effectiveness of rehabiltation of classically ‘executive’ functions such as. initiation, planning, and problem solving (Von Cramon et al. 1991; Levine etal. 2000, 2007, 2011; Fish et al. 2007; Basak etal, 2008; Chen et al. 2011). However, these are not reviewed here as these cognitive abilities do not fall under the scope of ‘attentional functions’ as we define them inthis chapter. Finally, this chapter does not cover Pogo of10 Rehabilitation of Attention Functions deficits of spatial attention such as unilateral neglect and their rehabilitation (see Vallar and Bolognini (chapter 33), this volume) Rehabilitation of Attentional Selectivity ‘Some of the strongest evidence for the considerable plasticity ofthe selective attention system comes froman ‘unusual source: action video game players. In one of the fist studies in this area, Green and Bavelier (2003) showed that habitual players had significantly enhanced visual selective attention abilities on untrained tasks, which had never been practised. Furthermore, individuals who did not regulary play video games also showed ‘tong improvements in attentional selectivity when they were given extended practice, confirming that the game. playing has a causal role in enhancing attentional selectivity (Green and Bavelier 2003). importantly, the benefits Of video game playing have also been shown to transfer to complex real-world tasks such as piloting procedures {Gopher etal. 1994) Specifically, video game practice has been shown to affect fundamental mechanisms of visual attention including innipiton of return (Castel et al. 200), and the resoluvon of spatal-attentonal (Green and tavelier Z00/) and backward masking effects (Li et al. 2010). recent electrophysiological study that compared frequent video game players with controls recorded steady-state visual evoked potentials (SSVEPs) while participants rronitored for targets in a mult-stimulus display consisting of rapid sequences of alphanumeric stimuli presented at rates of £8,612 Hz in the leftright peripheral visual fields, with a central square at fixation flashing at 5.5 Hz and a letter sequence flashing at 15 Hz at an upper central location. Cued to attend to one of the peripheral or central stimulus sequences, video game players detected targets with greater speed and accuracy than non-players. These benefits seemed to be achieved in two ways: (a) an increased suppression of SSVEP amplitudes to unattended peripheral sequences in the context of equivalent SSVEPS to attended-to streams in the two groups; (b) greater P3 amplitudes by the video garre group to targets in the alphanumeric strearrs. The authors suggest that the hehavinural improvements in altentinnal selartvily that many shidias have now demonctrated are attrtutable in part to better inhibition of irelevant information and also more effective perceptual decision-making processes. Comparable ERP effects on inhibition of irrelevant stimuli and enhanced processing of targets folowing attention training in healthy participants were obtained by Melara and colleagues (Melara etal. 2002). A likely reason that action video games are so effective is that they are specifically designed to be entertaining and immersive, while their fast pace, increasing diffculty, and unpredictability place substantial demands on attentional control. Many {games also include the element of adaptive training, with difficulty altering in ine with performance, a crucial element of the success of other types of cognitive training including working merrory taining (Klingherg 2010). ‘There have been fewer studies of selective attention training with individuals suffering from brain lesions or disease, but those studies which have been carried out have been broadly consistent with studies of healthy participants using commercial video games. Sturm and his colleagues in Aachen, Germany (Sturm et al, 1997), developed computerized training programmes which targeted either alerinessisustained attention or selective/divided attention, using a progressive shaping procedure wihere tasks became more challenging as performance improved (adaptive training). Patients with vascular lesions and associated attentional impairments showed training-specifc (14 one-hour sessions) improvements on untrained tasks, with the selective/divided altention training programmes improving only on selective attention measures and not on the sustained attention/viglance measures, and vice versa. Similarly specific improvement in test-measured attention performance has been found in patients with multiple sclerosis (Piohmann et al. 1998) trained for 12 hours on Computerized attention training progranmes aimed at cifferent attentional functions, with selectivity showing improvements following selective attention training, Age-related selective attention deficits have also been successfully improved using progressive training in maintaining attention to stimull in the face of auditory or visual distractors (Mozolic etal, 2011). ‘A more general computerized attention training which addressed a range of different attention functions but which included a selectivity component also yielded specific improvements in attention in a group of 29 traumatic brain injured patients (Niemann etal, 1990) and other studies have shown similarly promising results with this patient ‘group (€.9. Ruff etal. 1994). General attentional training programmes have also shown promising effects following stroke (Barker-Collo et al. 2009). A systematic review of the Iterature by the Cochrane group, however, concluded that while there was evidence of the effectiveness of attentional taining, there was insufficient evidence of Poge2ot10 Rehabilitation of Attention Functions generalizabilty to reabife function (Lincoln et al. 2008). Training on tasks that are more ecologically valid may be one way of achieving greater transfer to real-life function. For example, an early single case study with a patient suffering from severe distractibity following @ traumatic brain injury showed significant increases in the ammount of text he could read by practising at home reading against distracting verbal auditory stimull—this behavioural goal was important for this person's college studies (Wilson and Robertson 1992). We recently completed a study with traumatic brain injured patients with sel reported dificuttes in attending against background noise and conversations could be trained to improve their selective attention to, and consequent memory for, spoken material, by applying a behavioural shaping method similar to that devised by Wilson and Robertson (1992) (Dundon et al. in preparation). Patients listened to spoken text in one ear, against intially low volume competing text inthe other. Gradually the volume of the competing text was increased. After training, patients showed better memory for the target text. Furthermore, patients with the ‘greatest amount of pre-training self-reported dlstractiblty and associated stress showed the greatest improvements in memory post-training. The trained group also showed evidence of generalized attentional selectivity improvements on an untrained oddball auditory attention task: the trained group showed a specific inereace in the amplitude of the ERP P3b response to targets, without any change in the ERP P3a response (see Fig, 36.) In summary, there is clear evidence that taining in selective attention can improve attentional selectivity in both healthy and brain-impaired individuals, though the evidence for the generalization ofthese effects to reabife function is stl lacking, in the main. The mechanisms by which selective attention taining operates are not clear, except that both inhibitory and selective processes appear to be upregulated, down to quite low levels of perceptual processing (e.g. inhibiton of return and backward masking). A key ingredient ofthe training methods that have proved successful s the use of adaptive training, namely increasing the dificult level of the selective attention challenge in ine with progression in performance, a method which has also been used successfully with working merrory training (see Klingberg 2010). Click to view anger Figure 36.1 ERPs derives from a 2-stimulus oddball tsk. The overal ining group demonstrated no traning related change in the F3a component but a postaining increasein the P3D component By contrast, the contol group (receiving no intvening raining between est and retest) id not show rable ‘change nether the PB or P3a components With respect to the second set of attentional functions (sustained attention and attention switching), however, the range of approaches has been more varied, and hence the theoretical basis for them requires some elaboration. Rehabilitation of sustained Attention/Alertness Human beings find it surprisingly dificult to deploy the top-down aspects enhancing selectivity to unchanging, of LUnchallenging repeutive suru and responses for extended periods of Une. This already fragile ability wo sustain {goak-directed attention is very sensitive to disorders and damage to the brain, and can be a major source of impairmentin everyday life in conditions such as traumatic brain injury (Robertson et al, 1997a), attention-deficit hyperactivity disorder (ADHD) (Belgrove etal. 2005a, 2005), and tavopathy-related neuradegeneration (O'Keeffe {et al. 2007). tis also interesting to note that the ability to sustain attention is an important factor in determining recovery of motor and other functions folowing stroke (Ben-Yishay et al. 1968; Blanc-Garin 1994). Motor recovery following right hemisphere stroke over a two-year period was significantly predicted by measures of sustained attention taken two months after right hemisphere stroke (Robertson et al. 19976). This is perhaps not surprising in Pogo ot10 Rehabilitation of Attention Functions light ofthe fact that learning any skil typically requires many hundreds, even thousands, of tials, whichis particularly true for the re-learning underpinning recovery folowing brain damage. As mentioned above, attention is the capacity to allocate processing resources selectively to particular stimul or classes of stimuli, and as Blake etal. (Blake et al. 2006) showed, this is a critical element.in experience-dependent plasticity. If plastic reorganization requires attention to mediate the effects of rehabiliative experience. then the capacity to deploy attention over relatively long periods to relatively unchanging and monotonous stirull is likely to be a strong predictor of successful recovery. This sustained component of attention has tended to be neglected in the iterature but recent research is pointing to new avenues towards its enhancement. Imaging studies have indicated that this type of attention is controlled by a rightlateralized cortical network, including the anterior cingulate gyrus, the right dorsolateral prefrontal cortex, and the inferior parietal lobule, which regulates activity within subcortical arousal structures (Robertson and Garavan 2004). Posner and Petersen (Posner and Petersen 1990) identified the midbrain locus coeruleus (LC) as the critical arousal hub supporting the alert state by increasing perceptual signal-to-noise ratios via the neurotvansmitter noradrenaline. The influence of the locus coeruleus system in humans was demonstrated by Smith and Nutt (Smith and Nutt 1996), who reported that suppressing the release of noradrenaline through clonidine administration resulted in the zerts of attentional lapses that are characteristic of diminished vigilant attention. Pharrracological studies have found similarly close links between noradrenergic function and vigilant attention (Coull 1995). More recenly, our group has demonstrated a specific linkage in humans between noradrenaline activity and performance on a viglant attention task in healthy adults who differ in a genotype that codes for an enzyme (doparrine &-hydroxylase) controling the availabilty of noradrenaline in the brain, individuals whose genotype was associated with relatively low noradrenergic availabilty showed signiicanty increased errors of commission (Greene et al, 2009) and we showed similar results in children diagnosed with ADHD (Beligrove et al. 2006). [Anyone who has worked in a rehabilitation hospital will be farnilar withthe difference between the responses of rmany individuals—those who have suffered a stroke for instance—first thing in the morning, versus in the early afternoon. Even in those of us who have not suffered an adverse neurological event but who have had to catch an early roming fight or two, itis not uncommon to find that our arousal levels can be so low at certain times of the {day that cognitive function becomes severely compromised. Yerkes and Dodson famously studied the effects of, diferent degrees of arousal (by varying the degree of shock) on the abilty of mice to learn discriminations between the luminance of two compartments (Yerkes and Dodson 1908). They found that where ightness levels, were easily discriminated, the mice performed better at high levels of arousal, whereas dificult light discriminations were best leamed at low levels of arousal. On the basis of these experiments, they formulated the Yerkes-Dodson law. This law proposed that any task will have an optimal level of arousal below and beyond which performance will decline; they hypothesized this optimal level is ower in challenging tasks than in routine tasks. Similarly, Broadbent (Broadbent 1971) showed that while stress can improve performance on routine, non-derranding tasks, the sare level af

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