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Attention skills are an important factor in the recovery from traumatic brain injury for two reasons. First, attention disorders are seen in the majority of traumatic brain injuries. This reason involves the structure of the brain and the process of traumatic brain injuries (discussed in greater depth in "A Look Inside," The TPN Magazine, Spring 1994, Vol. IV-2).
In injuries where the head is moving rapidly and then stopped (the "acceleration-deceleration" process seen in most motor vehicle accidents and some falls), the front portion of the frontal lobes is damaged by cartilage that separates the two hemispheres of the brain in the frontal region. This area has been identified by localizationists as housing attention skills, with numerous neural connections to the brainstem. So most people who were injured in motor vehicle accidents and some people who were injured in falls can be expected to have problems with attention skills.
The second reason attention skills are so important is they are the first critical step in more complex cognitive skills, especially memory. With impaired attention skills, you may not pay attention to new information; you then have little chance of remembering it later.
Most of the clinical research in treating impaired attention skills is by Catherine A. Mateer, Ph.D. and McKay Moore Sohlberg, Ph.D. They identify five levels of attention:
Focused Attention: The ability to respond discretely to specific visual, auditory, or tactile stimuli.
Sustained Attention: The ability to maintain a consistent behavioral response during continuous or repetitive activity.
Selective Attention: The ability to maintain a cognitive set which requires activation and inhibition of responses dependent upon discrimination of stimuli.
Alternating Attention: The capacity for mental flexibility which allows for moving between tasks having different cognitive requirements.
Divided Attention: The ability to simultaneously respond to multiple tasks. (Sohlberg and Mateer, 1987)
Assessment and treatment of disorders of attention is best handled by a rehabilitation specialist who has studied this area and worked initially under supervision. These individuals can be the most objective at measuring, selectively treating and determining accuracy and progress. But in some areas of attention skills, there are activities survivors can do to supplement this treatment.
Focused attention is one of the first skills addressed as an injured individual emerges from coma. Like most cognitive skills, focused attention must be addressed from visual, auditory and touch/movement bases (see "Thoughts and Thinking," The TPN Magazine, Winter 1995, Vol. V-1). Clinicians are trained to watch for specific reactions to various types of sounds, images, touch and movement that are different from generalized reactions, reflexive behaviors, or aversive reactions commonly noted when people are emerging from a coma. These specific responses can gradually be shaped by appropriately sequenced basic instructions. This work is best done by a rehabilitation specialist or under the supervision of such an individual, who can best identify and appropriately shape responses.
Sustained attention involves repeating this focused attention over time. Many individuals find they soon begin tiring, or find it difficult to continue doing well on a task, even when there are no distractions. At its earliest levels, individuals may be able to follow an object with their eyes for a few seconds but then can't seem to continue. At higher levels, individuals may be able to listen to a lecture for about 30 minutes but can't keep their mind on information presented after that time. One of the best things survivors can do about this issue is to be aware of it. For a few, exhaustion of their sustained attention actually feels like fatigue. For most, there may be no sensation they can describe but they may notice they are making errors or having difficulty with the task. Be aware of how long you can focus on a task now and then gently work towards lengthening that time. There will be warning signals that your attention is waning. For only an additional few minutes, work towards maintaining that focus. A suggestion I've heard and liked was to frequently ask yourself "Am I here?" Although it sounds simplistic, many individuals are not thinking about what they are doing but, instead, are thinking about other issues. After a brain injury, the brain may not be able to complete one task while thinking about something else. The brain needs to be gently returned to task, sometimes repeatedly. Always do this gently; getting frustrated with yourself only gives your brain more to think about instead of helping it focus on what you're doing!
Selective attention can be a long-standing problem for survivors after brain injury. At its basic level, it means selecting one stimulus to attend to from a group or a series, like finding certain letters in a word-search or listening for your city during a weather report. At a higher level, it may be like being at a party, trying to follow the conversation you are in and to ignore another conversation taking place nearby. When you cannot select what to attend to, you are distracted, attending to whatever catches you. Tasks for this tend to be activities where you must watch or listen for a particular item (called a target) in a group of similar items. Clinicians may have special tasks to do this so they can control for the speed and frequency while they measure the accuracy and types of responses. But, many daily tasks require us to listen selectively. Listening to talk radio requires selective attention, especially if you listen for a particular word, or for repetitions of any key word you choose. I often recommend that students who have difficulty with attention listen to a recording of their textbook while they read along. But any opportunity to selectively listen can be helpful. Be aware of the speed of the speech; newscasts and traffic reports are often spoken at very high rates of speech. Also be aware of the duration of your listening, stopping before you become tired or get a headache. Initially, the room should be quiet with no distractions. Gradually though, allow visual distractions, then sound distractions that are not spoken and finally competing spoken distractions.
Visual selective attention is required any time we look for a specific object, in our environment, on a map, or in a book. I prefer the visual selective attention tasks that present items one at a time, requiring the viewer to sustain their attention for each item and then selectively react only to the target. Selective attention for listening is inherently this way; letters, words and ideas are presented sequentially and the sound lasts only briefly. But visual tasks frequently allow us to become briefly distracted and then return to the activity without much loss; besides, we have to blink!
Trying to follow a map or a maze with your eyes and not your finger does require you to keep your eyes on the page but can present a problem when you need to blink. Word searches or hidden pictures are good tasks, made more challenging when you force your eyes to do an organized search and quickly return yourself to task if you become distracted. Reading requires selective attention but also involves so many other skills such as word attack, comprehension and retention of information that it is difficult to isolate the selective attention aspect of it.
Alternating attention is the ability to quickly and without error, move from one kind of selective task to another and then back. Working on a word search, then pausing to listen for a particular freeway during a traffic report and then returning to the word search without increased error in either task is an example of alternating attention. As your skill in selectively attending to information improves, try moving between two different tasks repeatedly, watching for your brain's attempts to continue working on the prior task.
In divided attention you are dealing with two tasks simultaneously or are attending to two aspects of a task at the same time. It is often assessed through reverse digit span, trying to both retain a series of numbers and to recite them backwards. However, it is never a good idea to use a test activity as a therapy activity. I will often recommend that students who want to work on this task try to put the letters of a word into alphabetical order (e.g. the word FACE becomes A-C-E-F).
Listening to a math problem and then trying to solve it in your head (especially with some carrying or borrowing in the math process) requires retaining the information and manipulating it mentally. Try to look at a map (in which north is up) and then face a different direction and mentally convert the information for some visual divided attention. Doing two different selective attention tasks simultaneously also works on divided attention. Working a word search while you actively listen to talk radio is a more complex task than merely trying to tune out the talk radio. Now you must attend to both tasks, not try to focus on just one.
With some understanding of what these various levels of attention involve, it is possible to look for practical examples and ways to practice in daily life. In this way, when you are unable to receive direction and monitoring from a clinician trained in treating attention disorders, you can still work towards improving a skill that is so important.
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