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 reportCaregiver reportDevelopmental history Learning disorders ADHDPsychiatric 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:

• Cooking

• Writing a letter

• Watching a show

• Typing task

• Stocking shelves

• Putting away laundry/groceries

Selective attention:

• Cooking with noise, people

• Writing a letter with TV on

• Watching a show with kitchen noise/people talking

• Typing task with people in background

• Eating in a busy cafeteria

Divided attention:

• Cooking with multiple items (stove chicken, salad making, baking brownies)

• Taking minutes/notes

• Talking while completing dishes etc.

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

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

• PT & OT• 21 sessions of PT

• 6 sessions of OT • SLP

• Initial assessment • NAB

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Case Study – SLP Assessment

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Case Study - APT

Patient completed a total of 4 SLP sessions Trained on multiple attentional strategies

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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?