Pay Attention!!

Attention and Attention Process Training in Brain Injury

 Course Objectives

• Participants will understand and define 2 types of attention

• Participants will list specific behaviors/symptoms of
attention deficits related to brain injury
• Participants will understand the role of APT in improving
attention following brain injury
• Participants will list strategies and generalization activities
to train attention across therapy.
 What is attention?

• The ability to direct, focus and sustain interests to stimuli

under varying task and environmental conditions and includes
the ability to control attention.
• Behavioral and cognitive process of selectively concentrating
on a discrete aspect of information, whether deemed
subjective or objective, while ignoring other perceivable
information
• The allocation of limited processing resources.
 Attention Deficits in Brain Injury

• Cognitive deficits occur in more than half of stroke survivors, with

impaired attention being the “most prominent” change. (Barker-
Colloo et al., 2009)
• Sustained attention 2 months after stroke predicts functional
recovery in 2 years. (Robertson et al (1997)
• Attention is also correlated to boarder outcomes including physical,
mental health etc.
• In mild TBI attention disturbances include slower processing,
sustained attention and working memory
 Types and Models of Attention

Cognitive processing models- based on information from observations of unimpaired individuals

and describe how we process information.
i.e. Mirsky et al (1995)- 4 distinct components based on a factor analysis of performance on a range of attention tests and
included--focus-execute, sustain, encode and shift

Neuroanatomic model of attention(Posner & Rothbart, 2006) -- 3 distinct networks- alternating

(vigilance), orienting (selecting information) and executive control

Sohlberg and Mateer (2001) -clinical model of attention- divided attention into 5 components
focused, sustained, selective, alternating attention and divided attention.
 Types of Attention
Focused attention basic response to external or internal stimuli.
- auditory, visual, tactile, or cognitive.
Sustained attention  maintained response to a stimulus presented continuously. It includes:
- vigilance (the continual response over time)
- working memory – the mental control necessary to hold and manipulate information.
Selective attention  ability to select and attend to a chosen stimulus in the presence of competing
internal or external stimuli.
Alternating attention  ability to control attentional allocations in order to switch between dissimilar
cognitive tasks.
Divided attention  ability to simultaneously produce competing responses to multiple cognitive
inputs.
 Intensity & Selectivity

Intensity = processes responsible for attending over a given period of

time

Selectivity= components responsible for choosing among multiple or

competing stimuli.
 Assessing Attention

 Attention disorders are common in TBI

 Can interfere with rehabilitation
 Important for other cognitive domains
 How do we assess this?
 Behavioral observations
 Importance of obtaining a thorough history
 Subjective report
 Objective testing
 Behavioral Observations

 Report by OT & PT
 Difficulty following directions/instructions
 Distractible
 Unable to focus for long periods of time
 Poor memory
 Unable to hold a conversation
 Difficulty with problem solving
 Difficulty finishing tasks
 Impulsive
 Clinical Interview

Patient report
Caregiver report
Developmental history
 Learning disorders
 ADHD
Psychiatric history
 Anxiety
 Depression
 Obsessive-Compulsive Disorder
 Neuropsychological Testing

Attention & Concentration

 Digit Span subtest from the WAIS-III, WMS-III, WAIS-IV
 Spatial Span subtest from the WMS-III
 Spatial Addition subtest from the WMS-IV
 Digit Symbol subtest from WAIS-III
 Coding subtest from the WAIS-IV
 Continuous Performance Test
 Paced Auditory Serial Addition Task
 Stroop Color and Word Test
 Digit Vigilance Test
 Consonant Trigrams
 Rating Forms

 Behavior Rating Inventory of Executive Function - Adult Version

 Moss Attention Rating Scale
 Conners' Adult ADHD Rating Scales
 Wender-Utah Rating S
 Mood/Psychiatric Inventories
 Built-in validity measures capturing attention
 Observations of Attention Deficits

Sustained – Short attention spans, or good attention/accuracy at first that decreases over
time. Lose concentration over time.
Working memory: Decreased recall of short term information (i.e., multistep directions)

Selective - Most common in individuals who are easily disrupted by external distractions
but also internal distractions (i.e., anxiety, worry). Unable to attend in distracting
environment.

Alternating- Difficulty initiating a task after they have been engaged in a different activity.
May continue to perform activity related to the previous one. Perseverate
 Observations of Attention Deficit

Divided – Difficulty doing two tasks– i.e. eating and talking, or answering
questions while doing simple tasks (i.e. folding laundry). Almost always leads
to performance issues

Alternating – Difficulty switching between 2 activities- i.e. reading a recipe

and cooking, lose their place easily
 What can you do about it??
APT– Attention process training
• Structured program of attention training
• 5 different tracks
• Hierarchically organized

Why it works:
• Enhances performance on functional tasks
• Improve scores on neuropsychological measures of attention, executive
function and working memory
• Improves self reported attention ability.
 What is Attention Process Training (APT)

• Direct attention training approach aimed at improving underlying

attention deficits related to acquired brain injury.

• Intensively presented attention drills that stimulate impaired components

of attention can enhance the corresponding processing abilities.

• Uses structured drills and tasks for specific attention areas.

• Based on repeated activation and stimulation of a particular

subcomponent of attention, activates that areas on the brain and
strengthens the connection in the neural network ---neuroplasticity again!

• Discrete attention tasks delivered in conjunction with strategy training

and generalization activities.
 APT 1 and II

APT I: significant impairment

APT II: less severe impairments
APT III: mild to severe impariment
 Let’s prove it with research

Galibiati et al, 2009 - 65 children and adolescents with cognitive deficits following TBI
• Experimental- participants got drill oriented attention exercises (APT) and strategy training 4x week for 6
months
• Control- traditional therapy
Significant gains over control on tests of attention, adaptive functioning.

Baker-Collo, Feigin, Lawes et al 2009- Prospective randomized control trial with 1st time stroke survivors.
• APT group- 2x week training, standard care group.
• Control – standard care

APT group improved significantly in all areas of attention versus control on

primary attention outcome measure.
Serino et al., 2006- compared attention training to non specific stimulation in 9 adults with TBI
• Experimental- repetitively administered working memory tasks of holding onto number
sequences or add pairs of numbers.

• Control- Non specific attention stimulation

Attention training had benefit on improving a number of attention and executive function
subsystems and generalized to everyday life.

Sohlberg et al.,2000- Crossover design with 14 people with moderate-severe TBI.

• Experimental- APT for 24 hours over 10 weeks.

• Control- 10 hours Brain injury education, supportive listening.

Training showed improvement on neuropsychological tests for attention and memory and
more reports of improvement to daily life (via questionnaires).
Serino et al., 2006- 23 patients with moderate-severe TBI compared attention
training (APT) to non specific stimulation.

• Experimental-APT tasks

• Control- Non specific attention stimulation

Post-testing showed significant improvement on PASAT and Consonant

trigrams. No significant improvement on BDI.
.
Kim and colleagues (2009)- assessed possible changes in the attention network following direct
attention training using fMRI.
• fMRI post treatment during visual attention task and compared to healthy individuals

Patients with TBI demonstrated improved performance on all tasks and corresponding changes in
the attention network activation including a decrease in frontal lobe activity and increase in the
anterior cingulated cortex activity.

This shows us neuroplasticity of the brain! The ability to attention training to redistribute the
attention network.
 Justification of non-functional

• Functional activities like cooking, money management, navigation

tasks do not allow targeted practice of select attention processes
because they require activation of a range of processes
- organization, reasoning, visuospatial etc.

• APT addresses selected attention process and applies those

strategies/gains to functional tasks
 Concurrent Treatment

APT not stand alone some other approaches include:

• Pharmacological mgmt.

• Use of external aids (alarm, planner, reminders)

• Environmental/task modification – set un environment to

reduce attn. demands (organize space, reduce distractions)

• Attention logs – records breakdowns/successes in activities

• Metacognitive strategies- “thinking about thinking” self-

regulation, and deliberate allocation of attentional resources

 APT Therapy Principles Examined

1. Organize activities in a theoretically grounded model

2. Provide sufficient repetition

3. Use patient performance to drive therapy tasks

4. Include metacognitive strategies

5. ID and practice functional goals related to attention

 Organize activities in a
theoretically grounded model

• Move from simplest to hardest

• Basic sustained attention, complex sustained attention, selective

attention, suppression, and alternating attention
 Provide sufficient repetition

• Sufficient intensity is critical to learn

• Make skills automatic
• Minimum of 2x week for 6 weeks
• Developers clinic model  45 min 3x/week for 6-8 weeks.
At least 30 minutes of which are APT-3 tasks.
• Home practice –either with printed stimuli or practice
drives.
• 3 minutes per tasks
 Use patient performance to drive therapy

• Outcome-based treatment with ongoing evaluation

Examples: If a particular task starts to plateau,
clinician might simplify the task (fast---slow)
• Use data as a motivator- give examples/scores as a way
to show patient progress
• Review progress and goals daily
 General guidelines of patient performance:

Move to harder task if:

- >90% accuracy and effort rating of <3
- >80% accuracy in 3 / 4 trials and effort <4
- Client is bored, or observation that they don’t need to “pay attention”
Move to easier task if:
- Refusal to complete task because it is too frustrating
- <50% accuracy and effort rating >5 for 2 trials
- Effort >9 for 3 trials.
 Include metacognitive strategies

• Strategy instruction -deliberate allocation of resources

• Makes patients use their attention in a meaningful way
Can include:
 Educating patients about strengths and deficits
 Increasing awareness
 Identifying specific task completion strategies to help them
efficiently allocate resources
 Improve self monitoring and self regulation during task
 ID strategies or types of feedback that increase motivation and
effort
 Self monitoring is built in– self rate effort and motivation after
tasks
 Attention strategies
What works:
Task completion
- reauditorization
- visualization
- self talk
- eyes closed
-breathing, posture changes
- looking at screen
- timers
- checking off completed items
What works:
Increase motivation/decrease anxiety
- goal setting
- self talk (positive)
- rewards
- relaxation, breathing
-breathing, posture changes
- performance checks
- prediction of difficulty
What works:
Improve task comprehension
- repeat/paraphrase instructions
- written reminders
- demonstration
 ID and practice functional goals
related to attention

• Not specific part of APT

• Clinician managed
• Can utilize self questionnaires to determine patient selected
functional goals
• APT II questionnaire
• Pt and family report
In Practice Tips
 Therapy Dosage

Must have sufficient intensity

- different settings, tasks and constraints
- include home program when possible
- at least 30 minutes/daily
-
 Assess Error Patterns

Types of errors:
- at beginning--- difficulty establish tasks (ready-set)
- more errors over time--- loses attention
- late responses- latency or speed of processing deficits
- random errors- poor task understanding, too difficult a task,
difficulty initiating attention
 Generalization

• Record sheet for person to complete

• Strategy lists for home
• Building in natural supports
Tasks could include:
- co treat with PT
- navigation tasks
- cooking task
- reading/watching show and summarizing
 Some examples….

Sustained attention: Selective attention:

• Cooking • Cooking with noise, people
• Writing a letter • Writing a letter with TV on
• Watching a show • Watching a show with kitchen
• Typing task noise/people talking
• Stocking shelves • Typing task with people in background
• Putting away • Eating in a busy cafeteria
laundry/groceries
Alternating:
• Cooking while monitoring laundry
• Writing a letter with phone calls
• Any task with interruptions
• Banking errand with multiple tasks
• Completing list of errands
• Putting away dishes/laundry with
interruptions
Divided attention:
• Cooking with multiple items (stove
chicken, salad making, baking
brownies)
• Taking minutes/notes
• Talking while completing dishes etc.
 Case Study
 26-year-old Caucasian man
 18 years of education
 Symptoms:
 Insomnia
 Fatigue
 Progressive right arm weakness
 Bilateral lower extremity weakness ( R > L)
 Blurred vision
 Slurred speech
 Decreased concentration and memory
 Case Study - Hospital Course
 Presented to urgent care transferred to local hospital
 MRI brain w/ & w/o contrast
 MRI spinal survey
 EEG
 5-day course of IV Solu-Medrol & 5-day course of IVIG
 Evaluated by OT, PT, SLP
 Acute Comprehensive Inpatient Rehabilitation
 Significant gains in his motor and cognitive functioning
 Discharged home after one week
 Recommendations for outpatient rehabilitation &
neuropsychological evaluation
 Neuropsychological Assessment

 Seen for neuropsychological assessment one week after discharge

 Denied any concerns regarding his cognition
 Testing revealed deficits in:
 Bilateral motor speed and dexterity
 Complex psychomotor speed
 Visual perception
 Learning, recall and recognition of rote verbal material
 Considered an appropriate candidate for cognitive rehabilitation
 Referral was made to SLP
 Treatment
100

• PT & OT 80

• 21 sessions of PT 60

• 6 sessions of OT 40

20
• SLP
0
• Initial assessment
• NAB
 Case Study – SLP Assessment

30

25

20

15

10

0
 Case Study - APT

 Patient completed a total of 4 SLP sessions

 Trained on multiple attentional strategies

AND

 Daily completion of a home program using the Attention

Process Training practice drive
 Case Study - Training

 Patient reported most benefit from

internal strategies:
 Re-auditorization
 Self talk
 Closing his eyes
 Trained in the application of these
strategies in his work environment
Neuropsychological Assessment Battery –
Initial Visit & Discharge
Comparison of APT Performance
Questions?