Attention Intervention

1. Attention Intervention February 1, 2004 OCT 1172 Amanda Garnett, Zahra Jamal & Brenda Dorey

2. Outline Interventions Remedial Approach APT Compensatory Approach Occupation-Specific Approach Efficacy of Attention Interventions Recommendations for Clinical Practice

3. Why is Attention Intervention Important? Attention affects many aspects of everyday life Attention problems may cause one to be unable to: Carry on a conversation Cook a meal Driving a car Maintain employment

4. Introduction Several different options for managing attention impairments Just as no two people are alike, no two brain injuries are alike Appropriate treatment and rehabilitation will vary from individual to individual Programs and treatments change as a person's needs change It is important to recognize that "more therapy" does not make a person "better", but that "appropriate" therapy may (Brain Injury Association of America, 2004)

5. Intervention Approaches Remedial � Direct Training of Attention Processes Compensatory � Self-Management Strategies and Environmental Supports Skill/Occupation Specific Training Psychosocial Support External Devices

6. Remedial Approach

7. Remedial Approach Description: Also known as the Restorative Approach Goal is rehabilitation and improvement of attention deficits Treatment usually involves having patients engage in a series of repetitive drills or exercises that are designed to provide opportunities for practice on tasks with increasing attention demands Essentially trying to �fix� the damage that has resulted from brain injuryEssentially trying to �fix� the damage that has resulted from brain injury

8. Remedial Approach (cont�d) Theory: Based on neuropsychological theory Centred on the premise that repetitive practice of a specific component of attention will lead to improved attention and cognitive functioning (Sohlberg & Mateer, 2001; Park, 1999) Hypothesized that the repeated activation and stimulation will promote recovery of damaged neural circuits which will lead to improved function in the impaired attention process

9. Remedial Approach (cont�d) Several commercially available attention training packages and computer programs We will focus on the Attention Process Training Program

10. Attention Process Training (APT) Widely used! Developed by a neuropsychologist and speech pathologist (Mateer and Sohlberg) For use with inpatients or outpatients who have mild to severe attention deficits due to brain injury side note � these are listed in order of increasing complexity) side note � these are listed in order of increasing complexity)

11. APT (cont�d) Based on the Clinical Model of Attention Contains hierarchically organized auditory and visual tasks designed to improve discrete levels of attention: Sustained Attention Selective Attention Alternating Attention Divided Attention

12. APT (cont�d) Treatment Activities: Cognitive exercises within APT are not functional Activities tend to be more like a laboratory tasks in order to isolate components of attention In comparison, everyday tasks are complex and involve different levels of attention

13. APT (cont�d) Specific � Purpose is to isolate and improve/ restore specific components of attention Repetitive � Treatment programs usually involved patients engaging in a series of repetitive exercises to stimulate attentional systems Hierarchical - Exercises are designed to provide opportunities for practice on tasks with increasing attention demands

14. APT Exercises Sustained Attention: Listen for target words on audio tapes and press a buzzer when the target is identified Paragraph-listening comprehension exercises

15. APT Exercises (cont�d) Selective Attention: Use of some form of distraction (noise or movement) in the background during any of the sustained attention tasks Use of visual distracter overtop a paper-and-pencil activity (e.g. plastic overhead sheet with distracter lines) Vigilance � maintenance of attention over time during continuous activity Working memory � actively holding and manipulating information Vigilance � maintenance of attention over time during continuous activity Working memory � actively holding and manipulating information

16. APT Exercises (cont�d) Alternating Attention: Listening for one type of target word or sequence on attention tapes, and then switching to listening for a different type of word or sequence Begins with a designated number and then switches between adding and subtracting selected numbers

17. APT Exercises (cont�d) Divided Attention: Read a paragraph for comprehension while scanning for a target word (e.g. while reading client has to count the number of �ands�) Complete a sustained attention task while performing a reaction time computer task at the same time Important for daily tasks such as driving where individual must process traffic info, operate vehicle, and perhaps converse with a companion. Important for daily tasks such as driving where individual must process traffic info, operate vehicle, and perhaps converse with a companion.

18. APT Exercises (cont�d) Instructions: Begin reading the words as they appear and then switch to reading the size of print when the instructor says change Example: BIG little LITTLE BIG big LITTLE

19. APT-II Modeled after APT reflecting more recent advances in understanding of attention disorders Incorporates the trend in the field of cognitive rehabilitation to plan for, facilitate, and measure generalization of treatment to everyday life For individuals with mild attention deficits

20. Administering a Remedial Program Use a treatment model that is grounded in attention Use therapy activities that are hierarchically organized Provide sufficient repetition Treatment decision should be based upon client performance data Actively facilitate generalization from the start of treatment Be flexible in adapting the therapy format

21. Compensatory Approach

22. Compensatory Approach Description: Also called Adaptive Approach Requires the use of intact cognitive abilities to �compensate� for attention deficits Involves collaborating with clients to develop strategies to aid the completion of functional activities of daily life Include self-management strategies and environmental supports

23. Compensatory Approach Theory: Based on behavioural theory Incorporates the use of behavioural strategies Centred on modifying environment or teaching individual strategies - not modifying the individual

24. Self-Management Strategies Techniques a person uses to help them stay focused �self-instructional routines� (Solhberg & Mateer, 2000) Strategies are considered to be a key element of the compensatory approach Strategies are highly individualized and should be developed with the client based on their current level of function and their awareness of their attention difficulties

25. Self-Management Strategies (cont�d) Orienting Procedures: Conscious, deliberate monitoring of activities to maintain focus Intense concentration required for activities that may once have been automatic Pacing: Learn to pace oneself throughout the day to avoid overexertion and become overtired Allows clients to be more productive and continue being productive for longer periods of time

26. Self-Management Strategies (cont�d) Key Ideas Log: Help with higher levels of attention function, such as alternating attention Keep a log of questions and ideas to be addressed later, therefore stay focused on the task at hand

27. Environmental Supports Task Management Strategies: Specific strategies to help cope with tasks that are affected by attention deficits Environmental Modifications: Changes that can be made in the physical environment

28. Examples of Compensatory Strategies As students we all employ compensatory strategies for maintaining attention on a daily basis What are some of these strategies? Highlighting (colour-coding) Earplugs Turn of TV/radio Write notes to yourself

29. Examples of Compensatory Strategies (cont�d) From a Toronto Rehab Institute handout entitled, �Maximizing Your Attention� Ask people to slow down their speech or repeat information Read out loud Plan daily activities the night before Schedule more exhaustive activities at most energetic times of the day Take regular relaxation breaks Highlight important details When losing focus, get up and walk around

30. Occupation Specific Approach

31. Occupation Specific Approach Description: Referred to as �specific skills training� in the literature Aim of this intervention is to help clients re-learn skills that are of functional importance to them Intervention thus focuses on developing specific and practical skills which involve attention

32. Occupation Specific Approach (cont�d) Generally used with higher functioning or clients who are more aware Not as well researched as remedial approach In a meta-analysis on attention rehabilitation 26 remedial vs. 4 specific skills (Park & Ingles, 2001)

33. Occupational Specific Approach (cont�d) Intervention involves: Identifying occupation or skill of importance Identifying clearly the relevant skills and sub- skills involved in occupation Selecting training examples Building in methods for systematic corrections Allowing for sufficient practice

34. Occupation Specific Approach (cont�d) Theory: Based upon behavioural and neuropsychological principles Hypothesized that individuals with brain injury will compensate by using unaffected neural processes Believed that individuals with brain injury learn to perform the skill differently then non-brain injured individuals

35. Occupation Specific Approach (cont�d) Examples: Administrative Assistant Driving a car Cooking a meal

36. Efficacy In order to determine the efficacy of an intervention approach, the client must be able to generalize to activities in their everyday lives

37. Efficacy of APT The results for the efficacy of APT and APT-II have been mixed The addition for tools for generalization in APT-II has helped to improve the potential benefits realized with this intervention

38. Efficacy of APT (cont�d) Some researchers have not supported the benefits of APT For example, Park, Proulx and Towers (1999) found that although the treatment group did improve after training, the improvement was not significantly greater than the improvement of the control group

39. Efficacy of APT (cont�d) Park & Ingles (2001) also found that direct retraining techniques (such as those used in APT) did not improve attentional function Other studies have found improvements in attentional function for those with mild brain injuries however the participants in the studies used for the meta-analysis had suffered from severe brain injurieshowever the participants in the studies used for the meta-analysis had suffered from severe brain injuries

40. Efficacy of APT (cont�d) Palmese & Raskin (2000) followed the interventions of 3 patients who had suffered a mild brain injury The results showed that all 3 patients significantly improved after rehabilitation involving the use of APT-II

41. Efficacy of Compensatory Approach Engelberts et al. (2002) found a compensatory approach to more effectively improve self-ratings of neuropsychological outcomes and quality of life than remedial approaches On other measures, significant differences were not found

42. Efficacy of Compensatory Approach (cont�d) Compensatory techniques have been shown to be useful in memory, however, have been less studied in terms of attention Thought that compensatory approaches decreases the need for generalization because the strategies will naturally be applied in real life settings Awareness, or lack of awareness, of one�s attention deficits may greatly influence the outcome of interventions

43. Efficacy of Occupation Specific Training A study conducted by Kewman et al. (1985) found a significant difference between individuals trained on a driving simulator when compared to individuals exposed to the simulator when tested on the road In a meta-analysis, Park & Ingles (2001) found that studies using skills-specific training showed significant improvements in attention where as improvements in direct attention training studies were found to be not significant

44. Efficacy of Occupation Specific Training (cont�d) However not a large amount of research has been done on occupation specific training What about generalizability of training beyond the specific occupation?

45. Problems with the Research There are a number of problems with literature reviewing the effectiveness of attention interventions Highly focused on remedial approaches Severity of brain injury Various types of outcome measures utilized in studies Research on interventions not reflective of use in clinical practice

46. Attention Intervention in Practice Which intervention approach would you use? Most therapists do not utilize just one form of intervention but rather a combination Combination of interventions allows treatment to be individualized and dynamic No absolute division exists between assessment and intervention, both are done continuously during treatment process

47. Attention Intervention in Practice (cont�d) Factors to consider when conducting an attention intervention: Mood Medication Awareness Personal Characteristics Social Support Education: Brain Injury (for individual & family) Motivation

48. Attention Intervention in Practice (cont�d) Future Recommendations: Conduct research reflecting how attention interventions are used in practice APT and brain injury education (Sohlberg, McLaughlin, Pavese, Heidrich, & Posner, 2000) Reflective control groups Develop interventions that are comprehensive in nature

49. Take Home Messages Attention is crucial to everyday functioning In practice, attention interventions are used in combination Interventions need to be individualized and dynamic (keyword: client-centred) Don�t forget the person behind the deficit!

50. Questions