Excerpts

Frequently Asked Questions about Attention Process Training Programs

What are the computer requirements?

There are none. The APT 1, APT 2 and Pay Attention! have audio CDs. These can be run on any computer with a CD drive or a CD player. It is not a computer based program.

Is this a new version of the APT programs?

The APT 1 and APT 2 programs were revised in 2001 to update the literature review, produce PDF files with scoresheets for each exercise, and convert former audiotapes to CDs. If you have an earlier version, you can purchase an upgrade kit to receive the audio CDs and scoresheets.

Can I preview the program before purchasing?

Unfortunately, we do not offer a preview program. However, we have a full guarantee for our products. If you order any of the APT programs and find that it does not meet your needs, just return the item to us in good condition within 30 days and we will issue a refund.

What about norms and validity?

Because the programs are primarily designed as treatment tools and not as tests, perse, the issues around validity and reliability are quite different. Each manual describes and references research that has been conducted with the materials and contains information about efficacy and client selection.

What about efficacy?

Attention training and training using compensatory aids have recently been supported in review papers as efficacious and an appropriate component of best practices in brain injury rehabilitation. The National Institutes of Health also recognized these approaches as efficacious in the position paper on rehabilitation after traumatic brain injury. (Cicerone, K.D., Dahlberg, C., Kalmar, K., Langenbahn, D.M., Malec, J., Bergquist, T.F. Felicetti, T., Giacino, J.T. Harley, J.P., Harrington, D.E., Herzog, J., Kniepp, S., Laatsch, L. & Morse, P.A. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596-1615).

The treatment activities contained in this program were developed and tested at a rehabilitation clinic which serves individuals with mild brain dysfunction mostly due to head trauma. Unlike the rehabilitation of individuals with moderate to severe head trauma, there has been very little focus on treatment issues relevant to persons with “post-concussive syndrome” sometimes termed minor brain injury. Indeed, there is significant controversy over the legitimacy of such a diagnosis. Typically, the mild brain injury population is described as those individuals who, after a blow to the head, do not suffer prolonged loss of consciousness and often demonstrate relatively rapid and complete physical recovery with few to no hard neurologic signs (e.g., no positive findings on neuroimaging studies) to account for their symptoms. The common cognitive and somatic complaints include: difficulty concentrating; difficulty organizing and remembering information; increased fatigue and irritability; headache pain; and vestibular problems. The cognitive symptoms often are not recognized by the individual until there is an attempt to resume responsibilities at home, work or school (Raskine & Mateer, 2000). Professionals and researchers who have studied and worked with this population agree that the entity of mild brain injury represents difficulties produced by an interaction of organic, psychological and environmental variables (e.g., Kay, 1990; Lezak, 1991; Raskine & Mateer, 2000).

The APT-2 is designed to address the information processing deficits observed in this population. An underlying assumption of the program is that the attention and concentration difficulties, which concern individuals with mild brain injury, are valid and amenable to treatment. Again, it is recognized that these problems are often a result of a combination of emotional and physiological changes. As described by Mateer, Sohlberg & Youngman (1990), the approach to cognitive rehabilitation inherent in the APT-2 program in combination with psychosocial support can be effective at assisting this population in resuming productive lifestyles.

These materials have been tested predominantly with individuals who have experienced mild brain trauma; however, there are a number of other etiologies for which this intervention approach may be applicable. Attention deficits have been described in persons who suffer a variety of relatively mild forms of neuropsychological impairment due to ailments such as multiple sclerosis, attention deficit disorders, chronic fatigue, chemical toxicity, and immunodeficiency syndrome. Although the central nervous system dysfunction itself may not be mild, the information processing deficits are often mild in comparison to those observed after severe traumatic brain injuries (Raskine & Mateer, 2000). One goal of publishing the APT-2 materials is to provide clinicians who serve such clients a cognitive intervention resource, albeit experimental. It is hoped that the tools contained in this program may serve as a starting point for evaluating methods to address the information processing deficits suffered by such individuals.

Although many of the aforementioned kinds of brain insults may be labeled as “mild” or “minor”, the impact of cognitive and emotional disturbances is often life altering. Relationship stresses and employment challenges are well documented (Raskine & Mateer, 2000). There is a great need for designing and evaluating cognitive and psychological interventions in order to prevent such problems as job loss and family disruption.

APT-2 Clinical Model of Attention

Focused Attention

This refers to the ability to focus on specific sensory information. Focused attention represents the most basic level of attention observed when an individual can acknowledge visual, auditory or tactile stimuli. Focused attention is most commonly disrupted in persons with decreased level of consciousness, such as those emerging from coma who gradually progress from responding only to internal stimuli to showing increasing responsiveness to stimuli in their external environment.

Sustained Attention

This refers to the ability to maintain attention during continuous and repetitive activity. It incorporates the concepts of vigilance, persistence and task consistency. At the highest level, sustained attention includes the ability of mental control or working memory incorporating the notion of holding and manipulating information in one’s head such as required doing mental math. Impairments in sustained attention may manifest as difficulty maintaining attention over time, increased fluctuation in task consistency, or increased vulnerability to the effects of fatigue.

Selective Attention

This third component refers to the ability to selectively process target information and inhibits responding to nontarget information. It is the ability to maintain a behavioral set in the presence of distractors or other competing stimuli and thus incorporates the notion of “freedom from distractibility”. Impairments in selective attention may be seen in individuals who are easily disrupted by surrounding noise or movement (external distracters) and/or who are distracted by emotional states such as worry or anxiety (internal distracters). The importance of selective attention is demonstrated by students in a classroom who must ignore noise from the playground outside in order to attend to classwork.

Alternating Attention

This component refers to the ability to shift one’s focus of attention. It is essentially the capacity for mental flexibility that allows an individual to switch attention between tasks or activities that demand different behavioral responses or cognitive sets. Impairments in alternating attention may be seen in patients who have difficulty starting up a task after they have been engaged in an alternate activity, or who continue performing according to the parameters of the previous task after they are supposed to shift to a new task. An example of the need for alternating attention may be seen in the work of a secretary who must rapidly switch between typing and answering phones.

Divided Attention

This final component refers to the ability to simultaneously respond to two or more events or stimuli. It is the capacity that allows an individual to divide his or her attention between two or more ongoing events. Deficits in this ability are evident when an individual can only process one source of information at a time. Divided attention is a critical ability for many daily tasks such as driving where an individual must simultaneously process traffic information, operate the vehicle and perhaps converse with a companion.

The above five components of attention: focused attention, sustained attention, selective attention, alternating attention and divided attention form the organizational framework for treatment tasks in the APT-2 program. This model was drawn from clinical observations of breakdowns in attention and a review of cognitive theories of attentional processing; it accounts for the range of attentional impairments seen in persons with brain dysfunction.

Principles of Treatment

Sohlberg and Mateer (1989, 2000) describe the “process specific approach” as an effective set of basic treatment principles for addressing cognitive impairments. They suggest that the principles inherent in this approach are relevant to not only remediating impaired underlying cognitive processes (as would be the goal of attention process training), but also for training individuals to effectively utilize compensatory aids (e.g., a memory notebook) and working on a target skill or behavior (e.g., a communication behavior). In the last section, several studies supporting the efficacy of attention training were reported. Many of these studies suggested that the effective outcomes were the results of improved attentional processing. In actuality, however, no one knows whether subjects experienced improved neuropsychological functioning or whether they relearned some sorts of attentional skills. Whether the cognitive rehabilitation inherent in the process specific approach leads to improved processing, improved skills, or some combination of the two is probably of more theoretical significance than functional import. As long as the client experiences improvements in attentional abilities on everyday activities, regardless of the underlying cause of improvements, efficacy of treatment has been realized.

In this section, the six basic tenets of the process specific approach are reviewed. These treatment principles form the recommended administration model for the APT-2 program.

Principle One -The importance of working from a theoretical model:

Working from a model ensures a scientific basis for the treatment hierarchies being utilized. It also promotes the systematic delivery of a therapy regime as it organizes assessment and treatment activities. The previous section in this manual included an overview of different models of attention based on scientific research in the field. A clinical model of attention was detailed based on a review of cognitive process attention models and observation of neurological patients’ attentional difficulties (Sohlberg & Mateer, 1987). This model divided attention into five components (focused, sustained, selective, alternating and divided attention) and forms the framework for the APT-2 therapy materials. Again, having a taxonomy or framework which is theoretically and clinically motivated allows the clinician to organize intervention activities to address select components of the target process area.

Principle Two - Use therapy programs that are hierarchically organized:

The goal of most cognitive rehabilitation programs is to remediate an impaired cognitive process or to teach a specific skill or set of skills. Arranging exercises in a hierarchical fashion can allow repeated stimulation and activation of the target underlying process or facilitate mastery of a new skill. As soon as a client has mastered preliminary skills or experienced recovery of function at an initial level, higher level skills or continued stimulation of the process to promote further recovery can be facilitated, if tasks are hierarchically organized. Using attention process training as an example, the clinician may initially administer simple selective attention tasks for a client experiencing difficulty with this type of attentional processing. As the client progresses and is less vulnerable to distractibility, higher level selective attention tasks (e.g., use of increasingly difficult distracter CDs) may be administered to continue progress in this target subcomponent of attention.

Principle Three -The Importance of Repetition:

It is not hard to appreciate the importance of repetition of therapy exercises when one stops and considers the rather ambitious undertaking of trying to retrain a cognitive process such as attention or of teaching a cognitively impaired person a new skill. Sufficient intensity of training is critical for facilitating reorganization of cortical function or establishment of an attention skill so that it becomes automatic. If a therapy schedule does not permit lots of repetition, establishing a home therapy program or enlisting caregivers in a practice regimen outside of established clinical hours might be an important adjunct to therapy.

Principle Four - Using Data-Based Treatment:

The use of data-based treatment allows the clinician to make informed decisions about when to start, stop or modify a therapy program based on patient performance. For example, if scores on a particular attention task appear to plateau and no further progress is demonstrated, a clinician might try to develop a branch step to simplify the task in order to move the patient beyond a particularly difficult spot. Such a decision should be made based on analysis of performance data on the attention tasks. Ongoing evaluation of the utility and efficacy of a clinical treatment tool is possible when the clinician gathers data. The use of data can also be a motivating factor for many patients. Showing a patient his or her performance on a graph can be an objective, powerful illustrator of progress. The tasks in the APT-2 lend themselves well to being data based, since performance on most of them can be easily described by empirical measurements of accuracy and speed, and documentation of qualitative information such as error profiles.

Principle Five - Facilitating Generalization:

The importance of facilitating and measuring generalization and transfer of progress from clinical settings to naturalistic contexts cannot be overemphasized. A therapist has influence over a client for only a very short period in the client’s life. For therapy to be meaningful, the clinician must plan for and measure generalization. In the case of the APT-2 treatment materials, many of the tasks resemble laboratory tasks, which, in and of themselves, are not functional; hence, generalization issues are critical. The reason (in the case of attention) for selecting these types of tasks is that many functional activities such as cooking or money management confound so many cognitive processes (e.g., visuoperceptual abilities, organization, reasoning, etc.) that they do not allow targeted, repetitive stimulation or practice of the particular component of attention. As reviewed, the data support that attention processes improve given this targeted, intensive stimulation. In order to make sure improvements generalize to functional tasks, however, the clinician will need to make sure the client is given opportunities to apply retrained attentional abilities to multidimensional everyday activities such as cooking or household management or vocational tasks. The generalization program in the APT-2 materials is designed to facilitate this transfer.

In order to measure whether generalization is occurring, the clinician will want to observe performance in three areas: 1) generalization to unpracticed tasks requiring the same type of processing; 2) performance changes on standardized neuropsychological tests designed to measure and quantify functioning in the target cognitive area; and 3) generalization to everyday tasks. To probe for generalization in the first area during attention process training, the clinician may elect to evaluate generalization on alternate forms of the same attention task (e.g., administer trials of “serial numbers” that were not practiced in therapy) to see whether improvements generalize to unpracticed versions of the exact same task. In the second area, the clinician may administer (or ask the psychologist/neuropsychologist to administer) cognitive tests designed to assess attention such as the Stroop Test (Golden, 1978) or Paced Auditory Serial Addition Task (Gronwall, 1977). Of most importance is generalization at the third level, functioning in everyday contexts. Administering the APT-2 attention questionnaire, interviewing the client/other staff/significant others, and implementing the APT-2 generalization exercises can all provide information on generalization of attention training to real world activities.

Principle Six - The ultimate measures of success are changes in community functioning:

This principle serves as a reminder that the ultimate measures of success of cognitive rehabilitation are changes in an individual’s ability to manage work, daily living or leisure time activities rather than improvements in therapy exercises or test scores. A therapist implementing an attention training program needs to be aware of issues relevant to community functioning such as barriers to vocational success or independent living. The therapist may be able to provide valuable information to the client and other service providers about attentional abilities which may influence vocational and avocational goals. Conversely, attention to global areas of functioning such as independent living issues may influence the course of the attention training program.

List of APT-2

SUSTAINED ATTENTION ACTIVITIES

• Attention CDs (Series A, B, & C)
• Paragraph Listening Exercise
• Alphabetized Sentence Exercise
• Reverse Sentence Exercise
• Progressive Sentence Exercise
• Number Sequence Ascending
• Number Sequence Descending
• Number Sequence Reverse
• Number Sequence Every Other
• Mental Math Activity

ALTERNATING ATTENTION ACTIVITIES

• Attention CDs (Series D)
• Alternating Alphabet Exercise
• Serial Numbers Activity
• Sentence Change Exercise
• Number Change Exercise

SELECTIVE ATTENTION ACTIVITIES

• Attention CDs (Series E, F, & G)
• Sustained Attention Activities with Distracter Noise
• Sustained Attention Activities with Distracter Movement

DIVIDED ATTENTION ACTIVITIES

• Attention CDs with Simultaneous Task
• Read and Scan Task
• Time Monitoring Task

APT-2

Generalization Program

The attention process training tasks described in the current program are designed to stimulate and provide intensive practice with discrete subtypes of attentional processing (e.g., alternating attention). Although many of the tasks resemble laboratory or experimental activities and have no inherent functional value by themselves, they are selected for their ability to target the distinct types of attention that are commonly disrupted after brain injury. Implementing attention training while actively planning for and facilitating generalization to real world contexts has been shown to have beneficial effects as measured by functional outcomes such as “return to gainful employment” (e.g., Mateer, Sohlberg & Youngman, 1990). Improvements in attentional processing that extend across a wide number of tasks have not been shown to occur simply by repetitive administration of real world tasks such as cooking (Sohlberg & Mateer, 1989).

The APT-2 program relies on the following three tenets to promote generalization.

1. Generalization should be planned from the onset of the initial evaluation.

2. In order to effectively plan for generalization, the clinician must observe or gather reliable data on client functioning in real world contexts.

3. Therapy outcomes for attention training need to include measurements based on client functioning in naturalistic settings.

APPENDIX A

Stimuli for Clinical Tasks

• Sentence Stimuli--4 Word
• Sentence Stimuli--5 Word
• Sentence Stimuli--6 Word
• Number Mental Control Stimuli--4 Numbers/1-30
• Number Mental Control Stimuli--4 Numbers/1-100
• Number Mental Control Stimuli--5 Numbers/1-100
• Mental Math Stimuli
• Alternating Alphabet Stimuli
• Serial Numbers--2 Step
• Serial Numbers--3 Step
• Math Calculation Sheets--Adding & Carrying
• Math Calculation Sheets--Subtracting By Borrowing
• Math Calculation Sheets--Adding Larger Numbers
• Semantic Categories--Set A, Set B, Set C (Blank)
• Semantic Categories--Set A, Set B, Set C (Answers Filled In)
• Read And Scan Articles--#-8 (Blank)
• Read And Scan Articles--#1-8 (Targets Circled)

Appendix B

Scoresheets/Protocols for Clinical Tasks and Generalization Activities

• Attention CD Scoresheet
• Paragraph Listening Scoresheet
• Paragraph Listening Answer Blank
• Sustained Attention Scoresheet
• Alternating Attention Scoresheet
• Selective Attention Scoresheet
• Divided Attention CD Scoresheet
• Read and Scan Scoresheet
• Time Monitoring Task Scoresheet
• Sustained Attention Generalization Sheet
• Alternating Attention Generalization Sheet
• Selective Attention Generalization Sheet
• Divided Attention Generalization Sheet
• Attention Lapse Log/Attention Success Log
• Attention Questionnaire