High School Training

Journal of Clinical and Experimental Neuropsychology 1380-3395/00/2205-656$15.00

****, ***. **, **. *, pp. 656-676 Swets & Zeitlinger

Evaluation of Attention Process Training and Brain Injury

Education in Persons with Acquired Brain Injury*

McKay Moore Sohlberg1, Karen A. McLaughlin1, Antonella Pavese1, Anke Heidrich1,

and Michael I. Posner1, 2

1

University of Oregon, Eugene, OR, and 2Sackler Institute for Human Brain Function, Cornell Medical

College, New York, NY

ABSTRACT

Fourteen patients with stable acquired brain injuries exhibiting attention and working memory de cits were

given 10 weeks of attention process training (APT) and 10 weeks of brain injury education in a cross-over

design. Structured interviews and neuropsychological tests were used prior to rehabilitation and after both

treatments to determine the in uence of the interventions on tasks of daily life and performance on

attentional networks involving vigilance, orienting, and executive function. The overall results showed that

most patients made improvements. Some of these gains were due to practice from repetitive administration

of the tests. In addition, the type of intervention also in uenced the results. The brain injury education

seemed to be most effective in improving self-reports of psychosocial function. APT in uenced self-re-

ports of cognitive function and had a stronger in uence on performance of executive attention tasks than

was found with the brain injury education therapy. Vigilance and orienting networks showed little speci c

improvement due to therapy. However, vigilance level in uenced the improvement with therapy on some

tests of executive attention. We consider the implications of these results for future studies of the locus of

attentional improvement and for the design of improved interventions.

Acquired brain injuries (ABI) frequently pro- ment problems with the allocation of attentional

duce dif culties in attention and short term resources, switching between tasks with differ-

memory. Patients with ABI report problems ent cognitive requirements, time-sharing pro-

with concentration, distractibility, forgetfulness, cessing resources and overcoming automatic

and dif culty doing more than one thing at a responses when faced with non-routine situa-

time (Hinkeldey & Corrigan, 1990; Mateer, tions (Cohen, 1993; Mateer & Mapou, 1996;

Sohlberg, & Crinean, 1987). Certain aspects of Stablum, Leonardi, Mazzoldi, Umilta, & Morra,

memory are strongly related to attention (Nis- 1994).

sen, 1986; Russell & D Hollosy, 1992). Even Most efforts to rehabilitate patients with

relatively small decrements in an individual s closed head injury rely on some combination of

attention ability may signi cantly reduce the education and social support, practice, and pro-

capacity for new learning and affect academic cess training. Education and social support in-

performance (Kinsella et al., 1997; Kinsella, volves supplying individuals with relevant infor-

1998). Attention impairments frequently accom- mation about their injuries and suggesting strat-

pany executive dysfunction (Mateer & Mapou, egies to help manage the consequences of the

1996). Patient complaints and research docu- brain damage. It also includes giving opportuni-

The authors extend thanks to Tom Boyd, Ph.D. and Robert Kurlycheck, Ph.D. for their support of this project

and their clinical expertise in evaluating the subjects. They also thank the reviewers for their thorough editing and

excellent suggestions.

Address Correspondence to: McKay Moore Sohlberg, Communication Disorders and Sciences, 5251 University

of Oregon, Eugene, OR 97403, USA. Fax: 541-***-****. E-mail: *****@******.*******.***

Accepted for Publication: March 30, 2000.

657

EVALUATION OF ATTENTION PROCESSING TRAINING

ties to share feelings about changes in their cir- Petersen, 1990) together with working memory.

cumstances in a supportive environment. In order to determine if the therapy improves the

Practice refers to speci c training on a task to prospects of these patients in their normal every-

improve performance on that task. Practice may day life, we also used a battery of questionnaires

be a deliberate part of the therapy or it might be and structured interviews of the patients and in

accomplished in the process of repeated admin- some cases their caregivers. Our research ques-

istration of tests designed to determine amount tions were: (1) How will APT compare with ed-

of improvement. Practice alone might improve ucation in in uencing the reports of patients and

performance more generally if it results in trans- caregivers on patient performance in naturalistic

fer to tasks that have not been practiced. settings? (2) Which brain networks will bene t

Process training refers to a deliberate effort to the most from APT and/or education? (3) Will

employ a therapeutic program that would im- responses to APT and the information reveal

prove a wide range of tasks involving attention. insights about the effects of practice? (4) Will

For example, several studies have reported that patients responses to practice and/or APT differ

Attention Process Therapy (APT) improves based on their vigilance ability?

memory, learning, and some aspects of execu-

tive control (Mateer & Sohlberg, 1988; Nei-

mann, Ruff, & Baser, 1990; Ruff, Baser, & METHOD

Johnson, 1989). Findings in a study by Sturm,

Research Design

Willmes, Orgass and Hartje (1997) also sup-

This study combined features of both between and

ported attention process training. They reported

within subject research methodology. It employed

improved performance on neuropsychological

a basic crossover design using two groups. Partici-

tests speci c to the type of attention trained.

pants were randomly assigned to groups. The

They further suggested that only patients with groups were differentiated by the order of two

higher vigilance abilities respond to training blocks of treatment that they received. One treat-

involving more complex components of atten- ment block (Condition A) consisted of the cogni-

tive intervention, attention process training. The

tion.

other block (Condition B) represented a placebo

A recent study (Park, Roulx, & Towers,

intervention consisting of brain injury education

1999) compared performance on two neuropsy-

and supportive listening. Individuals in Group 1

chological tests (PASAT and Consonant participated in an A-B design while individuals in

Trigrams) in patients with brain injury who re- Group 2 participated in a B-A design.

ceived APT and in normal controls. Both groups During Condition A, participants received 24

received the outcome measures twice, but the hours of attention process training over 10 weeks

as described under Independent Variables. During

controls received no training. Results showed

Condition B, participants received 10 hours of

that the performance of the experimental group

therapeutic support and education over 10 weeks

improved on both the neuropsychological mea-

that is also detailed in the Independent Variables

surements. The control group improved on one section. Prior to beginning and following comple-

of the measures (PASAT) but not the other tion of each experimental condition, all partici-

(Consonant Trigrams). The authors suggested pants were administered the following: (1) A neu-

that the cognitive processes involved in the con- ropsychological attention battery; and (2) three

questionnaires to assess perceptions of daily liv-

sonant trigram are different than those stimu-

ing. Furthermore, following each block of treat-

lated by the training tasks in the APT, and con-

ment, each individual participated in a structured

cluded that the APT resulted in learning of new

interview. The sequence of experimental proce-

skills rather than improved processing. dures is summarized in Figure 1.

Our study compares APT training with an In this design, each participant serves as a sepa-

educational and support method. We used ten rate controlled single subject experiment. Addi-

tionally, the ability to compare performance on the

neuropsychological tests to clarify changes that

probes for the seven participants in Group 1 with

accompanied the interventions. We probed each

the seven participants in Group 2 after each treat-

of the major attentional networks (Posner &

658 MCKAY MOORE SOHLBERG ET AL.

Experimental Materials

ment block provides a between group analysis.

Comparing performance on probes of cognitive

Independent Variables

functioning and daily living abilities after each

Condition A: The Attention Process Training pro-

block of intervention reveals differences between

gram (APT) (Park, Proulx, & Towers, 1999;

the attention process training and the supportive

Sohlberg, Johnson, Paule, Raskin, & Mateer, 1994;

counseling plus brain injury education.

Sohlberg & Mateer, 1987) is a widely used cogni-

tive rehabilitation program designed to remediate

Participants

attention de cits in individuals with brain injury.

Two groups consisting of 7 individuals with ac-

The APT materials consist of a group of hierarchi-

quired brain injury were formed. Participants were

cally organized tasks that exercise different com-

referred by local service providers working with

ponents of attention commonly impaired after

this population who had been given information

brain injury including sustained, selective, alter-

about the study. The following subject selection

nating, and divided attention. The program tasks

criteria were utilized: (1) Between 18-60 years of

place increasing demands on complex attentional

age; (2) Acquired brain injury diagnosed at the

control and working memory systems. Examples

time of injury with evidence on imaging studies;

of exercises include auditory attention tapes such

(3) Greater than one year post injury; (4) Absence

as listening for descending number sequences, al-

from preinjury of any neurologic, psychiatric his-

phabetizing words in an orally presented sentence,

tory, or learning disability; (5) Signi cant other

detecting targets with the presence of distracter

available to take measures of everyday function;

noise or complex semantic categorization tasks

(6) Attention de cits determined via neuropsycho-

requiring switching sets. A number of tasks com-

logical evaluation and subjective report from par-

bine auditory and visual activities. The training

ticipant and/or signi cant other.

tasks were different than the neuropsychological

Demographic and injury related participant data

tests, however, it is hypothesized that they utilize

are summarized in Table 1. The mean age of par-

similar attentional circuits.

ticipants for Group One was 33.1 years (range 20

Participants received 24 hours of attention pro-

to 43 years) compared to a mean age of 38.1 years

cess training. Therapy was administered in three

(range 19-50) for Group Two. Time post injury

one-hour sessions each week over a total of ten

ranged from 1 to 22 years (mean 7.5 years) in

weeks. Each participant was assigned a therapist

Group One and 1 to 2.8 years (mean 1.6 years) in

who administered the attention process training

Group Two. All but one participant in each group

program at a university speech and hearing clinic.

suffered closed head injuries. The mean years of

Clinicians were either one of two certi ed speech/

education for Group One was 11 years (range 9-16

language pathologists familiar with the APT pro-

years). For Group Two, the mean years of educa-

gram or one of ve graduate students completing

tion was 12 (range 10-20 years). Both participants

their master s degree in speech/language pathol-

with technical training completed high school and

ogy. The student clinicians were closely super-

were counted as having 13 years of education. In

vised by a certi ed speech/language pathologist

spite of random assignment, Group Two performed

and were chosen because they had taken a graduate

superiorly on the neuropsychological tests com-

neurogenic course series that included a class on

pared to Group One.

cognitive rehabilitation, had a minimum of 30 su-

All of the participants were Caucasian with the

pervised hours with adult rehabilitation clients,

exception of one participant in Group One who

and had completed an instructional program for

was Hispanic. All participants spoke English as a

using the APT materials. The APT tasks chosen for

rst language. Two individuals in each group were

each client were speci c to their attentional pro-

taking antidepressant medications during the time

le. For example, one participant completed very

of the study. Two participants in Group One and

basic sustained attention tasks while another par-

one participant in Group Two were abusing alco-

ticipant completed more complex sustained and

hol or drugs at the time of injury. Length of sub-

alternating attention tasks.

stance use for all of these individuals was under

Condition B: The therapeutic support condition

ve years. All participants and their signi cant

consisted of a combination of brain injury educa-

others denied alcohol or drug use at the time of the

tion, supportive listening, and relaxation training.

study. Two participants in each group were sched-

Materials were designed for this study. Partici-

uled to undergo litigation related to their injuries,

pants selected their own education topics from a

although none of the cases were active during the

menu of choices related to neuroanatomy and neu-

time of the study.

ropathology after closed head injury, cognitive

659

EVALUATION OF ATTENTION PROCESSING TRAINING

Table 1. Injury and Demographic Information for each Participant.

Participant Age at Months post- Etiology Site(s) of Length of Education

injury injury lesion coma/ level

unconscious prior to injury

1 18 12 MVA B frontal; 3.5 months High school

L temporal;

R temporo-

parietal;

diffuse B

deep

white matter

2 18 26 MVA Frontoparie- 11 days Some college

tal

3 25 29 Anoxia Diffuse; 2 weeks College

subcortical graduate

4 49 15 MVA Frontal 1 day High school

5 15 33 ATV Cerebellum; 3 weeks Some high

brainstem school

6 14 22.5 MVA L temporo- 7 months Jr. high school

parietal

7 26 17 years Motorcycle L fronto- 2 months High school

parietal

8 34 14 Motorcycle R fronto- 3 weeks High school

temporo-

parietal

9 49 12 MVA Frontal

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