improving attention and managing attentional problems(sohlberg & mateer) (2001)

359

Improving Attention and Managing Attentional Problems

Adapting Rehabilitation Techniques to Adults with ADD

M

C

KAY MOORE SOHLBERG

a

AND CATHERINE A. MATEER

b

a

Communication Disorders and Sciences, University of Oregon, Eugene, Oregon, USA

b

Department of Psychology, University of Victoria, Victoria, British Columbia, Canada

A

BSTRACT

: Research and clinical experience in the field of brain injury reha-bilitation have focused quite extensively on the need and potential to retrainattentional skills that are commonly affected by acquired brain injury. Fourapproaches to managing attention impairments that have emerged from thisliterature include attention process training, training use of strategies andenvironmental support, training use of external aids, and the provision of psy-chosocial support. Most often, several of these will be used in combination. Forexample, a therapy regimen might include attention process training empha-sizing specific components of attention (e.g., sustained attention), in conjunc-tion with training in pacing techniques, and psychosocial support, where theclient keeps behavioral logs and discusses insights gained from tracking atten-tion successes and attention lapses. Although there are as yet little data withregard to the effectiveness of these approaches in adults with developmentaldisorders of attention, there is a growing literature suggesting they may beeffective in children and adolescents with ADHD. Further investigation of theapplication of such techniques in adults with a wide variety of attention disor-ders, including developmental disorders, would be valuable.

K

EYWORDS

: Attention training; Compensatory strategies; Self-regulation;Neuroplasticity; Rehabilitation.

It is increasingly recognized that adults with a history of developmental attention dis-orders may have persisting difficulties with attention and concentration. Interven-tions for adults who have a history of such disorders have only recently begun tobe developed and evaluated. However, in the field of rehabilitation, there is quite arich literature looking at interventions for adults and children who have acquired dis-orders of attention secondary to brain injury or other neurological diseases. Indeed,together with memory impairment, problems in attention and concentration are themost commonly reported symptoms following brain damage.

1

It is hoped that someof the procedures developed for management of acquired attentional impairmentsmay be applicable for adults with a history of developmental disorders of attention

Address for correspondence: Catherine A. Mateer, Ph.D., Department of Psychology, Universityof Victoria, Victoria, British Columbia, Canada. Voice: 604-721-8590; fax: 604-721-8929.

[email protected]

360 ANNALS NEW YORK ACADEMY OF SCIENCES

such as ADHD. This chapter reviews the approaches that have been used most widelyin remediating and managing acquired attentional problems.

MODELS OF ATTENTION

Attention is usually described as a wide assortment of skills, processes, and cog-nitive states. Among the more consistent findings in individuals with brain injury aredecreased reaction time and reduced speed of information processing.

24

Patientswith acquired brain injuries report problems with concentration, distractibility, for-getfulness, and the ability to do more than one thing at a time.

5,6

These observationsare consistent with several different models of attention, most of which include func-tions related to sustaining attention over time (vigilance), capacity for holding andworking with information in mind (working memory

7

), shifting/divided attention,and screening out nontarget information (resistance to interference or freedom fromdistractibility).

8,9

Models of attention are derived from various sources, includingcognitive neuropsychology, electrophysiological studies, and patterns of psycho-metric test scores. For example, Mirskys model, described earlier in this text, isbased on a factor analysis of performance on a variety of different measures designedto sample attention-dependent skills.

10

Neuroanatomical substrates for differentcomponents of the various models of attention have also been identified.

Sohlberg and Mateer

11,12

proposed a clinical model of attention that incorporatedmany of these theoretical concepts and was based upon the symptoms of attentionaldifficulty reported or observed in individuals with traumatic brain injury. It is a mod-el that has proved quite useful in providing a theoretically grounded method to orga-nize assessment and treatment. This clinical model consists of five components ofattention and was developed based on the experimental attention literature, clinicalobservation, and patients subjective complaints (T

ABLE

1).

T

ABLE

1. Clinical model of attention

Component Description Assessment Tools

Focused attention Response to discrete visual, auditory, or tactile stimuli

Simple orienting and tracking measures

Sustained attention Vigilance and working memory

Continuous performance tasks, trails A, digit span, brief test of attention

Selective attention Ability to ignore irrelevant or distracting stimuli

Test d2, test of everyday attention

Alternating attention Set shifting, mental flexibility Digit symbol, letter number (WAIS-III), consonant trigrams, trails B

Divided attention Ability to respond to multiple, simultaneous tasks

Paced auditory serial addition test

361SOHLBERG & MATEER: IMPROVING ATTENTION

Focused Attention

This is the ability to respond discretely to specific visual, auditory, or tactile stim-uli. Although almost all patients recover this level of attention, it is often disruptedin the early stages of emergence from coma. The patient may initially be responsiveonly to internal stimuli (e.g., pain, temperature).

Sustained Attention

This refers to the ability to maintain a consistent behavioral response during con-tinuous and repetitive activity. It is divided into two subcomponents. One subcom-ponent incorporates the notion of

vigilance

. Disruption of vigilance would beobserved in a patient who can only focus on a task or maintain responses for a briefperiod (i.e., seconds to minutes) or who fluctuates dramatically in performance overeven brief periods (i.e., variable attention or attentional lapses). It also incorporatesthe notion of mental control or

working memory

with tasks that involve manipulatinginformation and holding it in mind.

Selective Attention

This level of attention refers to the ability to maintain a behavioral or cognitiveset in the face of distracting or competing stimuli. It thus incorporates the notion offreedom from distractibility. Individuals with deficits at this level are easily drawnoff task by extraneous, irrelevant stimuli. These can include external sights, sounds,or activities as well as internal distractions (worry or rumination). Examples of prob-lems at this level include an inability to perform therapy tasks in a stimulating envi-ronment (e.g., an open treatment area) or to prepare a meal with children playing inthe background.

Alternating Attention

This level of attention refers to the capacity for mental flexibility that allowsindividuals to shift their focus of attention and move between tasks having differentcognitive requirements, thus controlling which information will be selectively pro-cessed. Problems at this level are evident in the patient who has difficulty changingtreatment tasks once a set has been established and who needs extra cueing to pickup and initiate new task requirements. Real-life demands for this level of attentionalcontrol are frequent. Consider the student who must shift between listening to a lec-ture and taking notes, or the secretary who must continuously move between answer-ing the phone, typing, and responding to inquiries.

Divided Attention

This level involves the ability to respond simultaneously to multiple tasks or mul-tiple task demands. Two or more behavioral responses may be required, or two ormore kinds of stimuli may need to be monitored. This level of attentional capacity isrequired whenever multiple simultaneous demands must be managed. Performanceunder such conditions (e.g., driving a car while listening to the radio or holding a con-versation during meal preparation) may actually reflect either rapid and continuous


alternating attention or dependence on more unconscious automatic processing for atleast one of the tasks. Modeling divided attention as a separate component of atten-tion highlights its importance in the rehabilitation context.

ASSESSMENT OF ATTENTION

Attention abilities are usually evaluated as part of a larger cognitive or neuropsy-chological assessment. However, there is no absolute division between assessmentand treatment, and treatment itself is diagnostic, so evaluation needs to continuethroughout the intervention process.

There are a large number of standardized tests used to evaluate attention. Theseinclude a variety of continuous performance tasks, a variety of span tasks (e.g.,Digit Span), measures of processing speech and efficiency (e.g., Digit-Symbol sub-test), and tasks involving more complex mental control and working memory (e.g.,mental arithmetic, Brief Test of Attention, Paced Serial Addition Test). Multiple mea-sures of attention are required to provide information about the nature and degree ofimpairment in different domains of attention according to standardized measures(T

ABLE

1). While necessary and valuable, reliance on standardized tests is potentiallylimited or misleading as performance on such measures does not necessarily predicthow well an individual will function on real-world activities.

13,14

It is most helpfulto combine the use of standardized tests with administration of attention-orientedrating scales, structured observations, and interview in identifying attentional dif-ficulties and prioritizing treatment options.

There are a number of rating scales and questionnaires that can help organize cli-nicians observations and questions about attention functioning. Responses can thenhelp identify directions for therapy. For example, the Attention Questionnaire(AQ),

15

based on Ponsford and Kinsellas attention questionnaire,

16

asks clients torate the frequency of occurrence of different kinds of attentional problems. A copyof this questionnaire is provided in Appendix A. The examiner derives a numericalindicator summarizing the overall frequency of the clients perceived attention prob-lems. Another useful rating scale is the Brock Adaptive Functioning Questionnaire(BAFQ).

17

The BAFQ contains 68 questions that were developed through clinicalpractice and with the help of community volunteers who had sustained brain injuries,as well as their families. It asks subjects to rate degree of difficulty with specificfunctions in five different behavioral domains, including planning, initiation, atten-tion/memory, arousal/inhibition, and social monitoring. It has a self and a significantother form to assist in evaluating the clients level of awareness. Questionnaires canbe very helpful in understanding the clients perceptions of functioning. This is par-ticularly useful in prioritizing treatment goals as a questionnaire may reveal what ismost bothersome to a client and/or significant other.

Structured interviews can provide additional information that may not berevealed in questionnaire data and can suggest the most important contexts for obser-vation in the assessment stage. Information from structured interview can also bevery instrumental in charting progress in treatment. Sohlberg, McLaughlin, Pavese,Heidrich, and Posner

18

recently completed a study looking at changes in attentionfunctioning following attention intervention. Qualitative data from the structured


interviews were the most revealing source of change in abilities. For example, therewere subjects who showed no change on questionnaire data, but when they wereasked structured questions such as what kinds of changes have you experiencedsince coming to the clinic? they were able to provide specific, relevant examples.Transcripts from the structured interviews showed that only after attention treatmentdid subjects report changes in real-world activities that related to attention (e.g., Ican drive and listen to music, I remember phone numbers better). Such changeswere not evident on questionnaire data because the particular everyday functionsthat were meaningful to the client were not always explicit on the rating sheets. Forexample, a client did not relate reduced sustained attention to not being able toread for very long. Asking clients to describe specific tasks that were difficult oreasy provided critical information.

Finally, observation of behavior is another valuable and functionally relevantassessment tool. For example, the clinician should take note of how the clientresponds to natural distractions in the environment and how well he/she appears totrack verbal interactions. Observations outside of the formal testing session may beparticularly useful.

While it is important to consider the complexities of attention, it is also importantnot to consider it as an isolated cognitive function. Attention is a somewhat fragilecognitive ability that can be affected by physical variables such as fatigue and/orpain, as well as by emotional variables such as anxiety and/or depression. In orderto adequately address problems in a clients attentional functioning, the clinicianwill need to consider potentially important physical, social, behavioral, and emo-tional variables.

MANAGEMENT OF ATTENTION PROBLEMS

Five approaches to address difficulties in attention are described in this section.Most often a clinician will implement some combination of these approaches eithersimultaneously or at different times in the recovery process.

12

These are summarizedin T

ABLE

2 and discussed in detail below:

T

ABLE

2. Management of attention problems

Approach Procedures Outcome

Environmental modifications

Reduce distraction, facilitate organization

Improved context for cognitive processing

Attention training Cognitive exercises, generalization training

Improved processing efficiency, increased self-awareness

Self-regulatory strategies

Orienting, pacing, key ideas log

Increased sense of self-control, personal empowerment

External aids Develop use of lists, calendars, organizers

Reduced reliance on internal attention and memory systems

Psychosocial support Education, relaxation training, psychotherapy

Decreased anxiety and depression, increased self-esteem


Environmental Modifications/Supports Attention Process Training

Self-Regulatory Strategies

Use of External Aids Psychosocial Support.

Environmental Modifications/Supports

The addition of environmental supports can be very effective in managing atten-tion difficulties. Careful assessment of the environment should be part of any cogni-tive management plan. Consideration of how to set up the environment to minimizethe effects of an attention deficit can result in significant improvement in function-ing. During the interview process, the clinician will learn what tasks are affected bythe attention disorder. Together, the clinician and client can generate strategies todeal with these issues.

A common example of an attention problem is difficulty attending in distractingenvironments. The clinician and client might make a list of difficult and helpfulenvironments. This could result in a list of restaurants that are noisy or busy andthose that are quiet and stores that are overstimulating (typically in malls) andthose that are more manageable (often, smaller stores). The client can be remindedthat, when possible, he/she should choose the more facilitating environment. Otherstrategies include reducing or eliminating distractions by turning off the televisionor stereo or shutting a door when completing a task that requires concentration.

Other environmental modifications involve organizing a persons physical spaceto reduce the load on their attention, memory, and organizational abilities. Setting upfiling systems, message centers, bill payment systems, and organizing and labelingcupboards are all examples of environmental modifications that might assist an indi-vidual with an attention disorder.

Posting directions to others in an individuals environment may also lessen taskdemands. For example, we have had a number of clients who were greatly helped byposting various forms of do not disturb signs that would give them uninterrupted timeto work on an activity. These have been used in both home and vocational environments.

Establishing environmental supports requires planning and monitoring. Carefulassessment of the context, having a plan for measuring success or lack of success,investing the client and others in the modification, and building in time to get famil-iar with using the supports are critical to the effectiveness of this type of interven-tion. Given the individual nature of strategies and environmental supports, theresearch literature is restricted to case reports.

19,20

Attention Process Training

Most attention training programs are based on the notion that attentional abilitiescan be improved by providing opportunities for stimulating a particular aspect ofattention. The aspects of attention that are addressed vary widely between programsand depend upon the model of attention that drives a particular program. Treatmentusually involves having patients engage in a series of repetitive drills or exercises


that are designed to provide opportunities for practice on tasks with increasinglygreater attentional demands. Repeated activation and stimulation of attentional sys-tems is hypothesized to facilitate changes in cognitive capacity.

11,18,21,22

It is important to note that repetitive training of this nature does not seem to beequally beneficial in all cognitive domains. For example, there is very little evidencethat repetitive practice on recall tasks results in any significant improvement in mem-ory per se or that repetitive scanning into the left visual field improves unilateralvisual neglect.

12

However, in the domain of attention, many studies have supportedgains in attention on measures of attention or related measures of memory that weredifferent from the training materials (see Mateer & Mapou for review

9

). It has beenhypothesized that attention training tasks improve overall input to cognitive process-ing, providing a more stable and effective substrate for other cognitive abilities. Forexample, improved attention would improve input to memory systems, thereby facil-itating later retrieval of information, whereas repetitive practice at the recall stagegarners no real improvement in working of the memory system.

There are a number of commercially available attention training packages andcomputer programs motivated by the assumption that discrete components of atten-tion can be selectively rehabilitated through targeted stimulation. One example isthe Attention Process Training program (APT).

11,15,18,22

It is a widely used cogni-tive rehabilitation program designed to remediate attention deficits in individualswith brain injury. The APT materials consist of a group of hierarchically organizedtasks that exercise different components of attention commonly impaired after braininjury, including sustained, selective, alternating, and divided attention. The pro-gram tasks place increasing demands on complex attentional control and workingmemory systems.

The treatment activities in most attention training programs are usually not func-tional and tend to resemble laboratory tasks. This is because most functional activities(e.g., meal planning, vocational tasks) are complex and confound many different cog-nitive processes. Focused attention tasks permit the stimulation of discrete compo-nents of attention. Examples of attention process training exercises include auditoryattention tapes such as listening for descending number sequences, alphabetizingwords in an orally presented sentence, detecting targets with the presence of distracternoise, and complex semantic categorization tasks requiring switching sets. A numberof tasks combine auditory and visual activities. Clinicians can review available treat-ment packages and computer programs to ascertain what type of attention a particulartask addresses. The exercises listed below are from the APT program and serve asexamples.

Sustained attention:

Attention tapes that require listening for target words or sequences and press-ing a buzzer when the target is identified.

Paragraph listening comprehension exercises.

Number sequence exercises that require sequencing an auditorily presentednumber series in ascending or descending order.

Mental math activities.


Alternating attention:

Attention tapes that require listening for one type of target word or sequenceand then switching to listening to a different type of word or sequence.

Paper/pencil tasks that require alternating between generating numbers or let-ters that come before or after the presented target in a number line or alphabet.

Serial numbers activities where the respondent begins with a designated num-ber and then switches between adding and subtracting selected numbers.

Selective attention:

Any of the sustained attention tasks with background distracter noise ormovement.

Placement of visual distracter overlays (e.g, a plastic overhead sheet with dis-tracter lines) on top of a paper/pencil activity.

Divided attention:

Reading paragraphs simultaneously for comprehension and scanning for a tar-get word (e.g., while reading, client has to count the number of ands).

Listening to sustained attention tasks while simultaneously doing a reaction-time computer task.

Time-monitoring tasks requiring tracking elapsed time while engaging in asustained attention activity.

Therapy principles relevant to providing attention process training focus onhow to select exercises and when to stop or modify a program. The five treatmentprincples described below are recommended for effective administration of the APTprogram:

12,15

Principle One: Use a treatment model that is grounded in attention theory.

Work-ing from a theoretical model ensures a scientific basis for the treatment hierar-chies being utilized. It also promotes the systematic delivery of a therapyregimen. The clinical model described above is an example of a theoreticallymotivated treatment model.

Principle Two: Use therapy activities that are hierarchically organized.

Arrang-ing exercises in a hierarchical fashion can allow repeated stimulation andactivation of the target-underlying process. As a client progresses, the samecomponents can be stimulated at increasingly higher levels. Indeed, there issome experimental evidence suggesting that working on attention at too higha level of complexity, before basis attentional processes are established, canlead to no or even negative training effects.

22

Principle Three: Provide sufficient repetition.

Tasks need to be completed withenough intensity to stimulate improved attentional processing. If a therapyschedule does not permit sufficient repetition, enlisting caregivers to provideextra practice outside of established clinical hours or establishing a hometherapy program may be important.


Principle Four: Treatment decisions should be based upon client performancedata.

Data-based treatment allows clinicians to make informed decisionsabout when to start, stop, or modify a therapy program. For example, exami-nation of accuracy or speed may reveal that a client needs easier or morechallenging activities. Examination of error profiles may show that all errorsare at the beginning of a task (difficulty achieving a ready set, or problemswith anticipatory anxiety) or at the end of a task (difficulty with sustainedattention or fatigue). Decisions about treatment should only be made aftercareful analysis of client performance. In addition, showing a client his or herperformance on a graph can be an objective, powerful illustrator of progress.

Principle Five: Actively facilitate generalization from the start of treatment.

Cli-nicians must plan for and measure generalization from attention therapy tasksto real-world activities. This requires that clients are given opportunities toapply retrained attentional skills to everyday activities. Since the therapytasks are chosen because they target very select components of attention, it isimportant to actively facilitate generalization to real-world functional activi-ties that involve many cognitive processes. For example, if a client is workingon sustained attention tasks, he or she might develop a list of real-worldactivities (e.g., number of minutes one can attend while reading the news-paper) that should improve as sustained attention increases. The client canengage in these activities and monitor changes, and the clinician and clientcan review performance on these generalization activities as part of the ther-apy process.

Results in Individuals with Brain Injury

Attempts to measure the effects of attention training typically evaluate changesat three different levels: (1) the training task, (2) psychometric tests related to thetask, and (3) everyday functioning. Improvements following attention training at thefirst level, the training task, have been consistently demonstrated across studies.Even in subjects with severe brain injury, improvements are noted on activitiesinvolving maintenance of attention during tasks, accuracy and speed of visualsearch, and a wide range of other tasks requiring increasingly complex stimu-lus/response demands.

23,24

Results from studies that have evaluated the effects of attention training onunpracticed psychometric measures of attention in stable neurological subjects havegenerally yielded positive results.

11,22,2529

Findings in a study by Sturm

et al.

29

fur-ther supported the effectiveness of attention process training for improving discretecomponents of attention, reporting improved performance on neuropsychologicaltests specific to the type of attention that was trained.

Measurement of improvement at the level of everyday functioning is the mostimportant indicator of the success or failure of attention training. Although data arestill somewhat limited, Sivak

et al

.

30

reported improved driving performance follow-ing perceptual skills and attention training. Further, in a series of studies, Mateer andcolleagues

3133

reported improvement following attention training not only on mea-sures of attention, memory, and learning, but on levels of independent living andreturn to work.


In their evaluation of APT treatment effects, Sohlberg, McLaughlin, Pavese,Heidrich, and Posner

18

compared the influence of APT with another intervention(brain injury education) on tasks of daily life and on performance on attentional net-works involving vigilance, orienting, and executive function in 14 subjects withacquired brain injury. The overall results suggested that the brain injury educationwas most effective in improving self-reports of psychosocial function and facilitatedsome cognitive benefits when it followed APT. In fact, APT influenced the extent ofimprovement on self-report of cognitive function. APT training also appeared tomodify performance on some measures of executive attention and working memory.

In summary, the majority of published studies in brain-injured adults have report-ed positive findings with attention process training. There have also been severalreports of positive effects of attention training with children and adolescents whohave sustained traumatic brain injury and who demonstrate acquitted impairments inattention.

34,35

There are also reports suggesting benefit from attention training for avariety of other neurological disorders, including stroke, multiple sclerosis, andschizophrenia.

Results in Individuals with ADHD

While we are unaware of any reports of process-oriented training in adults withdevelopmental attention disorders, there are several reports of attention training hav-ing positive effects in children with developmental attention disorders. Williams

36

examined the effectiveness of attention training using materials from the APTprogram in six children (ages 813) who were diagnosed with ADHD. Results indi-cated significant improvements on the training materials as well as on untrainedmeasures of attention. A trend toward improvement was also seen on some measuresof academic efficiency. Semrud-Clikeman and colleagues

37,38

examined the efficacyof APT training coupled with training in problem solving within a school setting,with children who were identified as having problems in attention and completingwork. Children with ADHD in the treatment group were seen for 1 hour, twice week-ly, for a period of 18 weeks. The children in the treatment group demonstratedsignificant changes on measures of visual cancellation and auditory attention.The authors reported that qualitative interviews with teachers also revealed that thechildren who had undergone the treatment seemed more attentive and showedimprovement in completing tasks in class.

Although positive effects were demonstrated in these studies, it was clear that theattention training materials (e.g., APT) had been developed for adults and that manyof the tasks were not engaging for children and/or relied on skills that would not beexpected to be well developed in younger children. Kerns, Eso, and Thomson

39

developed a new set of attention training materials for younger children (Pay Atten-tion) and investigated their efficacy in two groups of seven children, ages 711years, matched for age, sex, and medication status. Children in the treatment groupperformed significantly better following treatment on a number of untrained mea-sures of attention and academic efficiency, and a marginally significant improvementin attention-impulsivity was noted by schoolteachers. Increased understanding ofhow and when attentional functions can improve is an important area for futureresearch. The literature on brain recovery mechanisms is beginning to offer possibleexplanations for how attention training might operate to improve functioning. There


are increasing numbers of reports demonstrating the plasticity of the adult centralnervous system (e.g., see ref. 40), and experience-dependent recovery processes dueto changes in synaptic connectivity

41

and advances in neuroimaging are helping toelucidate experience-dependent changes in neural functioning.

Self-Management Strategies

Self-management strategies are often used in conjunction with attention processtraining. They encompass self-instructional routines that help an individual focusattention on a task.

Orienting Procedures

Orienting procedures may be helpful for clients who have difficulty sustainingattention or screening out distractions. The goal of these procedures is to encouragethe client to consciously monitor his/her activities, thereby avoiding attentional lapses.A general orienting procedure that we frequently use is to teach clients to ask them-selves orienting questions at specified times. For example, a client may be trained toask the following three orienting questions each time his/her watch beeps on the hour:(1) what am I currently doing?; (2) what was I doing before this?; (3) what am I sup-posed to do next? If successful, this orienting routine will prevent a client from expe-riencing gaps in focusing his or her attention.

Orienting procedures may be designed for specific tasks or environments. Forexample, a driving routine can be helpful for clients who have a tendency to driveand temporarily forget where they are driving. A car memo pad is installed. The cli-ent is trained to write down three items on the pad before turning the key: (1) desti-nation, (2) estimated time of arrival, and (3) time at which it would be appropriate topull over and ask for help if feeling unsure of whereabouts.

Another example of a task-specific orienting procedure is reading routines. Thespecial education literature is full of research-backed strategies that can be appliedto the brain injury population. Winograd and Hare

42

review seven studies showinghow direct instruction of reading comprehension strategies can improve perfor-mance. For example, Adams, Carnine, and Gersten

43

taught fifth-grade students aneffective study-skills strategy composed of six steps: previewing headings, recitingsubheadings, asking questions, reading for detail, rereading subheadings, andrehearsing. We adapted this routine for clients with acquired brain injuries who havedifficulty with sustained attention for reading.

Pacing

Clients with attention problems often experience difficulty with fatigue or main-taining concentration over an extended period of time. It can be helpful to teach thempacing strategies. The goal of pacing is twofold. First, it is important to help clientshave a realistic expectation for productivity. Some clients feel continually frustratedas they attempt to achieve the same activity level as before their brain injury. Second,pacing allows clients to keep going for a longer period of time. Training clients toappropriately pace themselves needs to be individualized. Sometimes, it is helpful toinclude breaks at set time intervals in a particular environment. Another option is toinclude breaks based on task completion (e.g., take a break after reading 10 pages).Clients may benefit from self-monitoring fatigue or attention levels and then learning


to take a break when they begin to rate themselves with higher levels of fatigue orreduced attention.

Time of day can be a helpful aspect of pacing. Many individuals find they func-tion well in the morning, but are used up in the afternoon. It may be useful to teachpeople to complete more demanding household or vocational tasks in the morningand light activity in the latter part of the day. Setting up an appropriate pacing strat-egy obviously relies on careful assessment of when and where attention problemsinterfere. Involving the client and relevant family members, employers, or other keypersons in the design and piloting of a pacing strategy will be imperative.

Key Ideas Log

Another attention problem that interferes with day-to-day functioning is difficultyswitching between tasks (i.e., alternating attention). A common complaint is thatpeople lose their train of thought or cannot resume an activity if they are interruptedor must temporarily divert their attention. To manage this difficulty, individuals canlearn to quickly jot (or tape-record on a voice messenger) key questions or ideas thatcome to mind that need to be addressed later. This allows them to continue with aparticular task rather than going to confer with a colleague or family member onanother issue as it comes to mind and having to return to the task at hand.

Several reminders serve to increase the chance that the self-management strate-gies will be useful:

More time spent assessing the attention problem will increase the likelihoodof selecting ones that are useful. It is important to understand

how

,

when

, and

where

the attention problem is troublesome. This will require careful observa-tion and interview.

Have a plan for measurement. How will you or the client know if the strategyis working? What are the indicators of problems? What are the expectationsfor improvement?

Involve the client as much as possible in strategy selection and development.The more ownership we have over the strategies we adopt, the more likely weare to invest the time to learn to use them.

Remember that establishing a strategy usually means training someone whomay have difficulties with memory, learning, or organization to implement anew habit. Habit formation is difficult even without concomitant cognitiveproblems. Hence, clinicians should build in systematic training with adequatesupport, a reasonable expectation for it to take awhile to establish a habit, aswell as an expectation for the client needing periodic refreshers as use of thehabit wanes.

Use of External Devices

There are a number of external devices that assist individuals in tracking infor-mation and initiating planned activities. These include written calendar systems,electronic devices, reminder alarms, and checklists. Sohlberg and her colleaguesdeveloped a manual that reviews principles and procedures for selecting and training


the use of external devices to help people compensate for decreased memory andexecutive functions. This information is also relevant for individuals whose attentionproblems would be lessened by using an external aid to help them track and respondto information. Devices that would be particularly useful for individuals with atten-tion impairments include the following:

calendar systems with day planners

electronic organizers

voice-activated message recorders

task-specific devices such as pillbox reminders, key finders, and watch alarms.

Psychosocial Support

The importance of psychosocial support for managing cognitive difficulties can-not be underestimated. The connection between our emotional states and cognitivefunctioning is well established.

44

Individuals who have experienced a life-alteringchange in functioning may display reactive effects, including grief, anger, and deni-al, which impair their information processing capacity. The source of an attentionaldeficit may be organic brain damage (i.e., changes in the neural circuitry that servesour attention abilities), psychoemotional (e.g., inability to adequately process infor-mation due to overwhelming grief), or a combination of the two.

Effective management of cognitive impairments requires a clinician to be skilledat providing psychosocial support as well as neurocognitive intervention. Approach-es to psychosocial support include supported listening, education, relaxation train-ing, psychotherapy, and grief therapy. Decreased attention ability may be the resultof an interaction between neurological impairment and psychosocial factors, andindividuals can become paralyzed by even very subtle symptoms. Kay

44

discussespossible dysfunctional scenarios arising from a persons shaken sense of self aftera brain injury. He describes problems due to the fear of going crazy and condi-tioned anxiety responses about ones performance. Similar phenomena can be seenin individuals with developmental disorders of attention as well. Kay acknowledgedthe importance of neuropsychological rehabilitation such as attention process train-ing as well as psychosocial therapies including stress management, family systemstherapy, and psychotherapy. It is important to acknowledge the interaction betweenneurological dysfunction and psychoemotional difficulties when designing a reme-diation program. Therapists need to link psychosocial treatment to changes in neu-ropsychological functioning.

In recent years, the benefits of self-efficacy and personal empowerment havebegun to be realized within the realm of cognitive rehabilitation. Therapists havegradually moved away from traditional medical models, where the therapist is theexpert and prescribes the treatment, toward a therapy process where they partnerwith clients and together determine what activities and goals would be most help-ful.

45

Such partnering helps the individual take control of his/her situation andreduces feelings of victimization and discouragement. Behavioral logs and facilitat-ed self-observation are one method used to empower individuals to make changes.Sohlberg

20

describes how patients with mild brain injuries benefit from assistance in


tracking their successes and their concerns, and discussing the observations theymake with the therapist. Helping clients track the contexts where their attention pro-cesses break down, as well as situations where attention is functioning well, oftenleads to a perception that attention is improving. It may be that people inadvertentlydo things to improve their functioning due to increased self-monitoring. Alternative-ly, people may feel more in control when they are assisted to pay attention to theirown functioning during their day-to-day life.

46

The effectiveness of psychosocial support is illustrated in a recent study compar-ing the effects of psychosocial support and attention process training on persons withacquired brain injury.

18

While the attention process training was associated withgreater improvement on neuropsychological test performance, as well as morerobust patient perceptions of improved attention functioning on a day-to-day basis,the power of the psychosocial support was unanticipated. Some improvement in cog-nitive functioning was noted following the psychosocial treatment, which consistedof brain injury education and supported listening. The authors suggest that someindividuals may have been significantly depressed, and the information about theirbrain injury combined with the supportive listening lessened the depression or anx-iety symptoms that had been one cause of reduced attention abilities. Another expla-nation may be that supplying individuals with information about the nature of theirdisabilities helps them engage in behaviors that compensate for difficulties. While itis commonly seen simply as a research method to determine whether the interventionreally worked, it may be wise to embrace therapies that produce and build upon a so-called placebo effect and thereby empower individuals to understand and modifytheir circumstances.

SUMMARY

Research and clinical experience in the field of brain injury rehabilitation havefocused quite extensively on the need and potential to retrain attentional skills thatare commonly affected by acquired brain injury. Four approaches to managing atten-tion impairments that have emerged from this literature include attention processtraining, training use of strategies and environmental support, training use of exter-nal aids, and the provision of psychosocial support. Most often, several of these willbe used in combination. For example, a therapy regimen might include attention pro-cess training working on specific components of attention (e.g., sustained attention)in conjunction with training in pacing techniques and psychosocial support wherethe client keeps behavioral logs and discusses insights gained from tracking attentionsuccesses and attention lapses. Although there is as yet little data with regard to theeffectiveness of these approaches in adults with developmental disorders of atten-tion, there is a growing literature suggesting they may be effective in children andadolescents with ADHD. Further investigation of the application of such techniquesin adults with a wide variety of attention disorders, including developmental disor-ders, would be valuable.


ACKNOWLEDGMENTS

Portions of this chapter were adapted or taken directly from: S

OHLBERG

, M.M. &C.A. M

ATEER

. 2001.

Cognitive Rehabilitation: An Integrated NeuropsychologicalApproach

, Guilford Press, New York.

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improving attention and managing attentional problems(sohlberg & mateer) (2001)

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