Excerpts

Introduction

Attention is fundamental to cognitive performance. Broadly defined, it encompasses all of the mental processes, operations, and systems requisite for acquiring and applying information. It interacts with other cognitive functions including perception, memory and learning, organization, and reasoning. Attention is core to the integration of these systems; hence, impairments in attention can impact functioning in many different domains.

Unfortunately, attention deficits are among the most prevalent symptoms reported following acquired brain injury. A wide range of patients present with attention deficits— including people with mild to severe impairments—resulting from varying etiologies in both acute and chronic stages of recovery. Management of attention deficits is thus a frequent therapy domain for professionals providing cognitive rehabilitation. The APT-3 program is a direct attention training program, consisting of a series of exercises designed to remediate deficits in attention, and to promote self-regulation and efficient allocation of attentional resources.

New Features with the APT-3

The APT-3 is an update of the previously published APT programs. The basic therapy principles and treatment approach are the same. As with the predecessor programs, the exercises aim to improve the underlying attention deficit by reducing the deficit itself. The premise is that attentional abilities can be improved by providing structured opportunities for exercising particular domains of attention. The primary modification with the APT-3 program is the delivery of the exercises via computer. A clinician interface allows the clinician to select exercises and associated parameters in order to create individual patient exercise profiles that are easily modifiable as the patient progresses.

There are several other notable changes with the APT-3 program. First, the attention categories—or attention framework—used to organize the tasks have been updated to reflect the expanded research elucidating the different attention processes commonly disrupted following brain injury. Second, there is an emphasis on pairing the attention training with strategy instruction, and the support of self-regulation. The Task Scoresheets shown in Appendix B facilitate observation of a client's strategy use, and the actual program encourages self-reflection by having the client rate his or her level of effort and motivation after task completion.

The computerized APT-3 assists with scoring and displaying performance data, and facilitates systematic delivery of the attention training exercises. Scoresheets can be printed from the program. However, the clinical decisions involved in selecting a patient's attention tasks, modifying the attention program over time, and measuring outcomes must be made by a professional trained in cognitive rehabilitation. The section below, Implementation of APT-3, reviews considerations important for rational, clinical decision-making.

Attention Training in Context

APT-3 is not designed to be a stand-alone rehabilitation program. There are a number of different options for the clinical management of attention deficits in addition to direct attention training. Some of the most common approaches include:

§ Pharmacological management: use of medications to ameliorate attention symptoms.

§ Training the use of external aids: selection of and training the use of aids (e.g., alarms, planners, reminder systems) to help individuals compensate for attention deficits and lessen the impact on daily functioning.

§ Environmental/Task modification: setting up the environment to reduce demands on the attention system (e.g., posting reminders, organizing space and belongings, setting up functional systems such as bill-paying systems).

§ Behavioral modification: altering antecedents or consequences (e.g., reinforcing facilitative attention behavior) to reduce disruptive behavior and promote desired behavior.

There is strong research evidence supporting the efficacy of each of these approaches for certain patient profiles. Rarely will direct attention training, such as the APT-3 program, be implemented in isolation. While this manual describes the procedures for using the APT-3 program with patients who have attention deficits, it will likely be implemented in conjunction with other interventions. For example, a common cognitive rehabilitation regimen might be APT-3 plus training the patient to use a Smartphone to track calendar and “things to do”, and to implement a self-reinforcement regimen to encourage task completion when the patient is having difficulty maintaining attention.

This manual follows with a review of important background information including a description of the target population and types of attention deficits as well as an overview of the treatment evidence. The principles and procedures for conducting attention training using the APT-3 materials are described in the section on Implementation of APT-3. Appendix B contains the scoresheets with the task stimuli. These scoresheets can also be printed from the electronic program.

Background: Attention and the APT-3 Program

The Target Population

Attention deficits are well documented in individuals following traumatic brain injury (TBI). Attention deficits resulting from severe TBI usually co-occur with a host of other cognitive impairments, such as memory impairment, as well as concomitant sensory, psychological, and physical impairments that need to be considered in the rehabilitation process. In more recent years, there has been a focus on understanding the attention deficits that occur following mild traumatic brain injury (MTB). The attention disturbances commonly associated with MTB include decrements in speed of processing (particularly in dual task conditions), sustained attention, and working memory (i.e., the active monitoring and manipulation of information) (Cicerone, 2002; Zoccolotti, Matano & Deloche, 2000). Additional somatic symptoms that often occur in mtb and contribute to attention difficulties include fatigue, sleep disturbance, headache pain, and vestibular problems (Raskin & Mateer, 2000). Unfortunately, attention deficits are one of the cognitive impairments that frequently persist, and become chronic following both mild and severe brain injury.

Attention deficits have been identified in a number of different clinical groups with neurologic disorders. For example, several recent studies have focused on children and adults with attention deficits induced by radiation and chemotherapies for the treatment of brain cancers (Butler et al., 2008). Radiation therapy for the brain is known to cause damage to cortical white matter, and thus impair neural transmission with reduced attention processing as a result. Similarly, attention deficits have been identified as one of the most prevalent neuropsychological changes following stroke (Hochstenbach, den Otter & Mulder, 2003) with evidence indicating that attention contributes to variability in post-stroke outcomes (Robertson, Ridgeway, Greenfield & Parr, 1997). Less studied, but known to interrupt functioning, are attention deficits associated with a number of diseases and conditions such as multiple sclerosis, chronic fatigue, chemical toxicity, and immunodeficiency syndrome (Raskin & Mateer, 2000). Psychiatric conditions have also been associated with attention deficits. For example, deficits in sustained attention have been documented in people with schizophrenia and a variety of thought disorders (Mirsky, Yardley, Jones, Walsh & Kendler, 1995).

Attention deficits are also well documented for a number of developmental conditions including Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), Fetal Alcohol Syndrome (FAS), and Learning Disability (LD). Research has attempted to identify profiles of attention deficits that are predominant in each disorder as well as to distinguish between deficits likely to occur with acquired versus developmental conditions. For example, Anderson and colleagues used a continuous performance paradigm to look at profiles of children with either developmental or acquired conditions (Anderson, Anderson & Anderson, 2006). This study found that children diagnosed with ADHD exhibited global and severe attention impairments. In contrast, children who had experienced moderate TBI displayed mild attention difficulties associated with selective and sustained attention. Predicting specific attention profiles based on diagnosis remains speculative, however, and requires clinicians to consider attention as a multidimensional domain that can be differentially impaired in patients who have the same diagnosis.

Questions and Answers

about the

New APT-3 Attention Process Training Program

How is this different than APT-1 and APT-2?

The primary modification with the APT-3 program is the delivery of the exercises via computer. A clinician interface allows the clinician to select exercises and associated parameters in order to create individual patient exercise profiles that are easily modifiable as the patient progresses. The computerized APT-3 assists with scoring and displaying performance data and facilitates systematic delivery of the attention training exercises. There is also is an emphasis on pairing the attention training with strategy instruction and the support of self-regulation.

Is this program for persons with mild, moderate or severe brain injury?

There are over 100 tasks with parameters that can be modified to increase or decrease the parameters including the number of stimuli and the speed. The program is designed to be used with a wide range of people including those who have severe attention deficits to those with concussion symptoms.

Does the APT-3 use the same hierarchy of attention as the APT-1 and Apt-2?

The attention framework used to organize the tasks has been updated to reflect the expanded attention research and includes tasks targeting: Basic Sustained Attention as well as Executive Control Processes related to Working Memory, Selective Attention, Suppression and Alternating Attention

Should I still use the APT-Test with the APT-3 program?

The APT-Test is not a normed psychometric test but an indicator of what types of attention may be targeted. This measure may be useful but the APT-3 manual details a number of standardized attention tests as well as rating scales that can provide a good indication of what attention areas to work on and offer an outcome measure.

Is there a research basis for the APT-3 Program?

The literature base is the research evaluating the efficacy of direct attention training. A summary of the research is provided in the manual.

What age range can I use the APT-3 with ?

It was designed for adolescents and adults.

How long and how often should the APT sessions be?

One of the key therapy principles underlying direct attention training is provision of sufficient intensity of exercise. For patients who are able, based on the current research, and our own clinical work using APT-3 with people who have had brain injuries, we suggest APT-3 training sessions for a minimum of 40 minutes, three times a week. This includes time to work on strategies along with the direct attention exercises. The manual describes options for home practice.

Does the APT-3 have norms?

No. The tasks by themselves are not functional. Improvement should be measured by reeadministration of standardized unpracticed attention tests and by changes on functional activities requiring the target attention. A process for goal attainment scaling is outlined in the manual.

Who do I contact if I have trouble running it on my computer?

If you have general questions or need to return an APT-3 USB drive, please call Lash and Associates at 919-556-0300.   If you are experiencing technical issues with the APT-3 USB drive, please contact Personal Technologies at 800-716-9695 or support@personaltechnologies.com

Can you use this program on multiple computers or run it on a network?

The program always runs from the USB drive, so you never have to install anything.   Thus, you can use your APT-3 USB drive on any computer running Windows XP and higher or Mac OS 10.5 and higher.   The files on the USB should not be copied from the USB drive, and the software is encrypted so that it will only run from the USB drive.

Is there a training demo I can watch to preview the program?

We are working on it.