attention intervention presented by: andrea ford, susie rothman & alexis seaman

Attention InterventionAttention Intervention

Presented by: Andrea Ford, Susie Presented by: Andrea Ford, Susie Rothman & Alexis SeamanRothman & Alexis Seaman

Presentation OutlinePresentation Outline

What is attention/different typesWhat is attention/different types How attention is affected after a TBIHow attention is affected after a TBI Attention InterventionsAttention Interventions::

Attention Process Training (APT)Attention Process Training (APT)

Use of Strategies & Environmental Use of Strategies & Environmental SupportsSupports

Use of External AidsUse of External Aids

Psychosocial SupportPsychosocial Support Case studyCase study

What is Attention?What is Attention?

Described as a wide assortment of skills, Described as a wide assortment of skills, processes, and cognitive statesprocesses, and cognitive states

(Sohlberg & Mateer, 2001)(Sohlberg & Mateer, 2001)

Different Types of AttentionDifferent Types of Attention

Focused AttentionFocused Attention respond to discrete visual, auditory, or tactile respond to discrete visual, auditory, or tactile

stimuli (ie: head turning to stimuli)stimuli (ie: head turning to stimuli)

Sustained AttentionSustained Attention Vigilance (over time) and working memory Vigilance (over time) and working memory

(active holding and manipulating info)(active holding and manipulating info)

Selective AttentionSelective Attention ability to ignore irrelevant or distracting stimuliability to ignore irrelevant or distracting stimuli

Alternating AttentionAlternating Attention capacity for mental flexibilitycapacity for mental flexibility

Divided AttentionDivided Attention ability to respond to multiple, simultaneous ability to respond to multiple, simultaneous

taskstasks

Individuals with Traumatic Individuals with Traumatic Brain Injuries (TBI)Brain Injuries (TBI)

Problems with concentrationProblems with concentration DistractibilityDistractibility ForgetfulnessForgetfulness Problems with ability to multitaskProblems with ability to multitask

Can lead to problems in Can lead to problems in independent living: self-care, independent living: self-care, productivity, & leisureproductivity, & leisure

Attention Process Attention Process Training (APT)Training (APT)

APTAPTBased on…Based on…

Neuropsychological TheoryNeuropsychological Theory repeated activation and stimulation of repeated activation and stimulation of

attentional systems will facilitate attentional systems will facilitate changes in cognitive capacity; changes in cognitive capacity; reflecting underlying changes in reflecting underlying changes in neuronal activityneuronal activity

Includes forms of intervention that Includes forms of intervention that arise out of traditional arise out of traditional psychotherapeutic traditions but psychotherapeutic traditions but modifies them to the needs of a person modifies them to the needs of a person with a brain injurywith a brain injury

Emphasis on repetition and structureEmphasis on repetition and structure

APTAPT

What is it?What is it? Widely used cognitive rehabilitation Widely used cognitive rehabilitation

program designed to remediate program designed to remediate attention deficitsattention deficits

For Who?For Who? People with acquired brain injuries People with acquired brain injuries

(ABI’s)(ABI’s) People with attention deficitsPeople with attention deficits

APTAPT

Key Concepts:Key Concepts: Consists of a group of hierarchically Consists of a group of hierarchically

organized tasks that exercise different organized tasks that exercise different components of attention commonly components of attention commonly impaired after brain injuryimpaired after brain injury

Focuses on:Focuses on: Sustained AttentionSustained Attention Selective AttentionSelective Attention Alternating AttentionAlternating Attention Divided AttentionDivided Attention

APT: Specific ActivitiesAPT: Specific Activities

Sustained AttentionSustained Attention Listening for target words or sequences Listening for target words or sequences

on attention tapeson attention tapes Paragraph listening comprehension Paragraph listening comprehension

exercisesexercises Alternating AttentionAlternating Attention

Listening for one type of target word or Listening for one type of target word or sequence and then switching to a sequence and then switching to a different word or sequencedifferent word or sequence

APT: Specific ActivitiesAPT: Specific Activities

Selective Selective AttentionAttention Sustained Sustained attentionattention tasks with tasks with

background distractor noise or background distractor noise or movementmovement

Visual distractor overlaysVisual distractor overlays Divided Divided AttentionAttention

Reading paragraphs for comprehension Reading paragraphs for comprehension and simultaneously scanning for a target and simultaneously scanning for a target wordword

APT: Therapy PrinciplesAPT: Therapy Principles

1.1. Use a treatment model that is grounded in Use a treatment model that is grounded in attention theoryattention theory

2.2. Use therapy activities that are Use therapy activities that are hierarchically organizedhierarchically organized

3.3. Provide sufficient repetitionProvide sufficient repetition

4.4. Treatment decisions should be based Treatment decisions should be based upon client performance dataupon client performance data

5.5. Actively facilitate generalization from the Actively facilitate generalization from the start of treatmentstart of treatment

6.6. Be flexible in adapting the therapy formatBe flexible in adapting the therapy format

APT: the activitiesAPT: the activities Not functional; resemble laboratory tasksNot functional; resemble laboratory tasks Combination of auditory and visual Combination of auditory and visual

activitiesactivities Client specific starting pointClient specific starting point Clinical rationale (refer to page 135 of Clinical rationale (refer to page 135 of

text)text) What component? What could it be grouped What component? What could it be grouped

with?with? Methods for scoring?Methods for scoring? How to alter administration procedures to How to alter administration procedures to

make it harder or to form a hierarchymake it harder or to form a hierarchy

APT: EfficacyAPT: Efficacy

3 Levels of effectiveness3 Levels of effectiveness Training task itselfTraining task itself

Demonstrated across the boardDemonstrated across the board

Psychometric tests related to the Psychometric tests related to the tasktask Mixed resultsMixed results Reported improved performance on Reported improved performance on

neuropsychological tests specific to the type of neuropsychological tests specific to the type of attention that was trainedattention that was trained

PASAT and CTTPASAT and CTT

Everyday functioningEveryday functioning

Lopez-Luengo & Vazquez Lopez-Luengo & Vazquez (2002)(2002)

ObjectiveObjective To investigate the impact of Attention process To investigate the impact of Attention process

Training on cognitive functioning in Training on cognitive functioning in schizophreniaschizophrenia

PopulationPopulation 24 clients with schizophrenia24 clients with schizophrenia

ResultsResults Contrary to expectations, neither group Contrary to expectations, neither group

improved on clinical and information processing improved on clinical and information processing measures of attention and memorymeasures of attention and memory

Patients in the trained group had a significantly Patients in the trained group had a significantly higher performance on executive functionhigher performance on executive function

APT is feasible to use in practice to remediate APT is feasible to use in practice to remediate executive function deficits in schizophreniaexecutive function deficits in schizophrenia

Heidrich, McLaughlin, Pavese, Heidrich, McLaughlin, Pavese, & Sohlberg (2000)& Sohlberg (2000)

ObjectiveObjective To determine the influence of the ATP vs. Brain To determine the influence of the ATP vs. Brain

injury education on tasks of daily life and injury education on tasks of daily life and performance on attentional networksperformance on attentional networks

PopulationPopulation Clients with stable acquired brain injuries Clients with stable acquired brain injuries

exhibiting attention and working memory deficitsexhibiting attention and working memory deficits ResultsResults

Majority improved; some gains due to practiceMajority improved; some gains due to practice BIE was most effective in improving self reports BIE was most effective in improving self reports

of psychosocial functionof psychosocial function APT influenced self reports of cognitive function; APT influenced self reports of cognitive function;

stronger influence on performance of executive stronger influence on performance of executive attention tasksattention tasks

Palmese & Raskin (2000)Palmese & Raskin (2000)

ObjectiveObjective To investigate the effects of APT-II training on To investigate the effects of APT-II training on

individuals with attentional difficultiesindividuals with attentional difficulties

PopulationPopulation 3 voluntary clients diagnosed with mild traumatic 3 voluntary clients diagnosed with mild traumatic

brain injurybrain injury

ResultsResults APT-II improved attention and performance APT-II improved attention and performance

speed in each of the three individualsspeed in each of the three individuals Any rehabilitated cognitive skills remained stable Any rehabilitated cognitive skills remained stable

in each individual in absence of the rehabilitation in each individual in absence of the rehabilitation program for at least 6 weeksprogram for at least 6 weeks

APT: Strengths and APT: Strengths and WeaknessesWeaknesses

StrengthsStrengths Based on a theoretical and clinical rationaleBased on a theoretical and clinical rationale Therapy is tailored to each specific individualTherapy is tailored to each specific individual Improvements Improvements ScoringScoring

WeaknessesWeaknesses Size and set of training materialsSize and set of training materials Number of modalities addressed in trainingNumber of modalities addressed in training Duration of trainingDuration of training Activities are not functional Activities are not functional Whether gains are generalizableWhether gains are generalizable Not enough emphasis on the whole person Not enough emphasis on the whole person

APT-IIAPT-II

Use of Strategies and Use of Strategies and Environmental SupportsEnvironmental Supports

Used with any individual Used with any individual experiencing attention deficitsexperiencing attention deficits

Used later in recovery phase to Used later in recovery phase to assist in reintegrating client into their assist in reintegrating client into their home or work environmentshome or work environments

Origins of ApproachOrigins of Approach Uses the principles of Uses the principles of Behavioral Behavioral & &

NeuropsychologicalNeuropsychological traditions traditions



Self-management StrategiesSelf-management Strategies client learns to initiateclient learns to initiate

Environmental SupportsEnvironmental Supports Environment is modified to Environment is modified to

decrease attention problemsdecrease attention problems Task Management StrategiesTask Management Strategies Environmental ModificationsEnvironmental Modifications

Use ofUse of Strategies Strategies

Self-Management StrategiesSelf-Management Strategies Self-instructed routines that assist in Self-instructed routines that assist in

focusing attention on a particular taskfocusing attention on a particular task Following a brain injury, tasks that may Following a brain injury, tasks that may

have seemed automatic before require have seemed automatic before require effortful concentration noweffortful concentration now

Orienting Procedures (ie: watch Orienting Procedures (ie: watch alarm)alarm)

Pacing (ie: time of day)Pacing (ie: time of day)Key Ideas Log (ie: asking questions Key Ideas Log (ie: asking questions

in class)in class)

Use of Use of Environmental Environmental SupportsSupports::

Task Management StrategiesTask Management Strategies Learn what tasks are affected by Learn what tasks are affected by

attentionattention(ie: make a list of “difficult” and “helpful” (ie: make a list of “difficult” and “helpful”

environments)environments)

Environmental ModificationsEnvironmental Modifications Organize physical space to help Organize physical space to help

decrease the load on a client’s attention, decrease the load on a client’s attention, memory and organizational abilitiesmemory and organizational abilities

(ie: filing systems, message boards)(ie: filing systems, message boards)

Shallice & Burgess (1991)Shallice & Burgess (1991) ObjectiveObjective

To test complex functions such as planning and To test complex functions such as planning and strategy application in clients with prefrontal lesions strategy application in clients with prefrontal lesions under both environmental supports (salient tone under both environmental supports (salient tone presented at random points) and non-environmental presented at random points) and non-environmental supportssupports

PopulationPopulation 3 clients who had sustained traumatic injuries which 3 clients who had sustained traumatic injuries which

involved prefrontal structuresinvolved prefrontal structures ResultsResults

Environmental support improved the number of tasks Environmental support improved the number of tasks attempted & amount of time spent on each taskattempted & amount of time spent on each task

Clients without the environmental support were able Clients without the environmental support were able to complete the task, but were less likely to attend to to complete the task, but were less likely to attend to it spontaneouslyit spontaneously

Use of Use of StrategiesStrategies

Clinical RecommendationsClinical Recommendations time assessing client’s attention problem time assessing client’s attention problem

will will likelihood of selecting useful likelihood of selecting useful strategiesstrategies

Plan for measurementPlan for measurement Client-centredness in strategy selection Client-centredness in strategy selection

and developmentand development Remember that establishing a strategy Remember that establishing a strategy

means training someone who may have means training someone who may have difficulties with memory, learning, and difficulties with memory, learning, and organizationorganization

Clinical RecommendationsClinical Recommendations Carefully assess the contextCarefully assess the context Plan for measurementPlan for measurement Include all individuals involved with the Include all individuals involved with the

client in interventionsclient in interventions Need to allow time for client to get Need to allow time for client to get

accustomed to using the supportaccustomed to using the support

Use of Use of Environmental Environmental SupportsSupports

Strengths and WeaknessesStrengths and Weaknesses

StrengthsStrengths Theoretical foundationTheoretical foundation Assists in integrating clients back into their Assists in integrating clients back into their

‘natural’ environment‘natural’ environment Client-centred and incorporates any key Client-centred and incorporates any key

individuals involved with the client in treatmentindividuals involved with the client in treatment Use of measurement to monitor clients progress Use of measurement to monitor clients progress

and make modifications if neededand make modifications if needed Cost-effectiveCost-effective


WeaknessesWeaknesses May be difficult to train clients new habits with May be difficult to train clients new habits with

attention deficits attention deficits May need assistance or reminders to use the May need assistance or reminders to use the

strategies and/or environmental supportsstrategies and/or environmental supports May not be able to carry over strategies and May not be able to carry over strategies and

environmental supports from one task to anotherenvironmental supports from one task to another

External DevicesExternal Devices

External DevicesExternal Devices

Used to assist client’s with attention deficits Used to assist client’s with attention deficits to track, organize, and respond to to track, organize, and respond to informationinformation

Populations ServedPopulations Served Has been shown to assist individuals with Has been shown to assist individuals with

and without brain injuries, of all agesand without brain injuries, of all ages

Based on…Based on… Uses the principles of Behavioral & Uses the principles of Behavioral &

Neuropsychological traditionsNeuropsychological traditions

External AidsExternal Aids

Devices that may be used:Devices that may be used: Written calendars/Day plannersWritten calendars/Day planners Written checklistsWritten checklists Electronic organizersElectronic organizers Voice activated message recordersVoice activated message recorders Task specific devicesTask specific devices

Goals of Using External AidsGoals of Using External Aids

Compensation vs. RestitutionCompensation vs. Restitution

Domain-Specific vs. Generalized Domain-Specific vs. Generalized Use (context)Use (context)

Clinical RecommendationsClinical Recommendations

Conducting a Needs Assessment:Conducting a Needs Assessment: Organic Factors Organic Factors

cognitive/learning profilecognitive/learning profile physical profilephysical profile

Personal FactorsPersonal Factors Spontaneous use of compensation strategiesSpontaneous use of compensation strategies Personal preferencePersonal preference Financial resourcesFinancial resources Available supportAvailable support

Situational FactorsSituational Factors ContextContext HistoryHistory


Pre-training Activities:Pre-training Activities: Patience is needed in partnership with Patience is needed in partnership with

caregiverscaregivers Evaluate awareness of both client and Evaluate awareness of both client and

caregivers caregivers

Training Methods:Training Methods: Effective instructional techniquesEffective instructional techniques

academic skills, functional skills, academic skills, functional skills, errorless, prompting, clarityerrorless, prompting, clarity

Monitoring client’s progressMonitoring client’s progress Self-monitoring for cliniciansSelf-monitoring for clinicians

Blundon & Smits (2000)Blundon & Smits (2000) Objective:Objective:

examine the delivery of cognitive rehabilitation examine the delivery of cognitive rehabilitation services to survivors of TBI’sservices to survivors of TBI’s

Population:Population: 20 Occupational Therapists in Canada, who 20 Occupational Therapists in Canada, who

worked in either a) and adult rehabilitation worked in either a) and adult rehabilitation centre or b) sites offering services for individuals centre or b) sites offering services for individuals with head injurieswith head injuries

Results:Results: External aids effective in enhancing daily External aids effective in enhancing daily

occupational performance when:occupational performance when: Client is motivatedClient is motivated External aid is relatively easy to useExternal aid is relatively easy to use Training of external aid is explicit, addressing a Training of external aid is explicit, addressing a

specific impairmentspecific impairment

Evans, Wilson, Needham & Evans, Wilson, Needham & Brentnall (2003)Brentnall (2003)

Objective:Objective: To identify the variables that best predicts To identify the variables that best predicts

effective use of memory aids after brain effective use of memory aids after brain injuryinjury

To identify factors associated with the use of To identify factors associated with the use of memory aids in a group of people with memory aids in a group of people with acquired brain injury (Wilson & Watson, acquired brain injury (Wilson & Watson, 1996)1996)

Population:Population: 101 people with memory problems and their 101 people with memory problems and their

caregivers caregivers

Results:Results: Variables that best predicted use of aids were: Variables that best predicted use of aids were:

current age, time since injury, # of aids used current age, time since injury, # of aids used premorbidly, a measure of attentional premorbidly, a measure of attentional functioningfunctioning

Use of memory aids correlated with level of Use of memory aids correlated with level of independenceindependence

External aids such as calendars, wall charts, External aids such as calendars, wall charts, and notebooks were the most commonly usedand notebooks were the most commonly used

Evans, Wilson, Needham, & Evans, Wilson, Needham, & Brentnall (2003)Brentnall (2003)


StrengthsStrengths Grounded in theoretical foundationGrounded in theoretical foundation Can be used with individuals with attention, Can be used with individuals with attention,

memory and executive function deficitsmemory and executive function deficits Client-centred planning and treatmentClient-centred planning and treatment Can be very cost-effectiveCan be very cost-effective Monitoring of client’s progressMonitoring of client’s progress


WeaknessesWeaknesses May be difficult to train individuals with cognitive May be difficult to train individuals with cognitive

problems, can take a long period of timeproblems, can take a long period of time Clients may not remember to consult and use Clients may not remember to consult and use

the aidsthe aids Client may be effective with aid in therapy, but Client may be effective with aid in therapy, but

cannot transfer these strategies to new cannot transfer these strategies to new environment or settingenvironment or setting

Computerized systems shown to be very Computerized systems shown to be very effective can be very expensiveeffective can be very expensive

Psychosocial SupportPsychosocial Support


Addresses the possible reactive Addresses the possible reactive effects experienced as a result of effects experienced as a result of changes in functioning, which can changes in functioning, which can negatively affect one’s information negatively affect one’s information processing capacity and pose as processing capacity and pose as barriers to rehabilitationbarriers to rehabilitation


Kay (1992) Kay (1992) Psychosocial approaches should be used Psychosocial approaches should be used

in conjunction with cognitive rehab to in conjunction with cognitive rehab to address both organic brain damage and address both organic brain damage and psycho-emotional effects of brain injurypsycho-emotional effects of brain injury achieved through the client therapist relationshipachieved through the client therapist relationship by involving the client this: by involving the client this:

a) increases control over their situation a) increases control over their situation

b) decreases feelings of victimization/ b) decreases feelings of victimization/ discouragement discouragement


OutcomesOutcomes Decreases depressive symptoms and Decreases depressive symptoms and

anxietyanxiety Empowers clients to understand & Empowers clients to understand &

change their behaviour/circumstanceschange their behaviour/circumstances

Singer, Glang, Nixon, Cooley, Singer, Glang, Nixon, Cooley, Kerns, Williams & Powers (1994)Kerns, Williams & Powers (1994)

Family TherapyFamily Therapy Objective: Objective:

To compare two therapy groupsTo compare two therapy groups

a) Psychoeducational Groupa) Psychoeducational Group coping skills & social support for coping skills & social support for

family membersfamily members b) Informational Groupb) Informational Group

Disseminate information about illness, Disseminate information about illness, treatment, treatment and resources in treatment, treatment and resources in a supportive contexta supportive context

Population:Population: Parents of children with ABIParents of children with ABI

Results:Results: Psychoeducational Group Psychoeducational Group depressive depressive

symptoms and anxiety symptoms and anxiety Informational Group Informational Group depressive symptoms and depressive symptoms and

anxietyanxiety

Singer, Glang, Nixon, Cooley, Singer, Glang, Nixon, Cooley, Kerns, Williams & Powers (1994)Kerns, Williams & Powers (1994)


Psychoeducational therapyPsychoeducational therapy Optimal parental health facilitates & Optimal parental health facilitates &

focus on child rehabilitationfocus on child rehabilitation Coping skills used to prevent, promote Coping skills used to prevent, promote

and ameliorate parental stressand ameliorate parental stress

Informational groupInformational group Lack of coping mechanisms may Lack of coping mechanisms may

contribute to increased stress in parentscontribute to increased stress in parents


Use a combination of:Use a combination of: actively involving parents in developing actively involving parents in developing

their coping skills their coping skills

&& Supportive education groups on Supportive education groups on

implications of Traumatic Brain Injuriesimplications of Traumatic Brain Injuries Incorporate the client’s natural environment Incorporate the client’s natural environment

in practicing coping skillsin practicing coping skills More research requiredMore research required

Glang, Todis, Cooley, Wells & Glang, Todis, Cooley, Wells & Voss (1997)Voss (1997)

Social Re-integrationSocial Re-integration Objective:Objective:

to develop, evaluate, & implement interventions to develop, evaluate, & implement interventions to prevent social isolationto prevent social isolation

Population: Population: Children with ABI (in a school setting)Children with ABI (in a school setting)

Interruptions in cognitive processes Interruptions in cognitive processes ↓↓

social networks dissolve social networks dissolve ↓↓

social isolationsocial isolation ↓↓

↓ ↓ social support social support ↓↓

depression, anxiety, dependency, depression, anxiety, dependency, self- self-

esteemesteem


Results: Results: Initially Initially social contact outside the classroom social contact outside the classroom Initially Initially social validation/inclusion with peers social validation/inclusion with peers Clients likely to initiate contact with peersClients likely to initiate contact with peers


Strengths/WeaknessesStrengths/Weaknesses

Strengths:Strengths: Clients became happier and displayed Clients became happier and displayed

depressive symptoms and anxietydepressive symptoms and anxiety Interdisciplinary team effortInterdisciplinary team effort

Weaknesses:Weaknesses: Social contact Social contact when facilitator removed when facilitator removed Importance of friendships as social support Importance of friendships as social support

dependent on family/cultural viewsdependent on family/cultural views


More research required in this areaMore research required in this area

Ensure consideration of client and family Ensure consideration of client and family goals in determining focus of social supportgoals in determining focus of social support

Intervention should take place in natural Intervention should take place in natural social setting to include social contactssocial setting to include social contacts

Greater focus on active development of Greater focus on active development of social skills- not passive recipientsocial skills- not passive recipient

MB was hit by a moving vehicle and fell and MB was hit by a moving vehicle and fell and

injured his lower back and head. A magnetic injured his lower back and head. A magnetic resonance imaging (MRI) scan 2 years post injury resonance imaging (MRI) scan 2 years post injury revealed damage to the right frontal region. MB has revealed damage to the right frontal region. MB has had three jobs since his accident. His employers had three jobs since his accident. His employers have noticed that MB’s work repeatedly includes have noticed that MB’s work repeatedly includes significant errors. He is unable to appropriately significant errors. He is unable to appropriately assess and prioritize tasks, and he cannot identify assess and prioritize tasks, and he cannot identify and resolve problems in a timely fashion. MB has and resolve problems in a timely fashion. MB has trouble organizing, summarizing and trouble organizing, summarizing and communicating effectively.communicating effectively.

MB has become socially isolated from MB has become socially isolated from family and friends. His wife feels this may be due to family and friends. His wife feels this may be due to his decreased ability to communicate as he is easily his decreased ability to communicate as he is easily distracted by external stimuli and cannot interact distracted by external stimuli and cannot interact continuously for lengthy periods of time. Finally, continuously for lengthy periods of time. Finally, she is becoming frustrated and burnt out due to she is becoming frustrated and burnt out due to MB’s decreased participation in their marriage and MB’s decreased participation in their marriage and household duties which is resulting in the need for household duties which is resulting in the need for her to take on a more parental role within their her to take on a more parental role within their marriage. marriage.

In Summary…In Summary… Recognize the importance of identifying the Recognize the importance of identifying the

appropriate attentional deficit appropriate attentional deficit Ensuring interventions are specific to each Ensuring interventions are specific to each

individual and contextindividual and context PhysicalPhysical Social Social TransferabilityTransferability

Approaches should be used in combination Approaches should be used in combination dynamic process dynamic process

More research is required for all More research is required for all populations; not limited to TBIpopulations; not limited to TBI

attention intervention presented by: andrea ford, susie rothman & alexis seaman

Documents

attention tapesparagraph

attention deficitsfor

brain injuryfocuses

brain injuryemphasis

different word

target words

target wordapt

type of target word