Attention Process Training APT-3  A Direct Attention Training Program for Persons with Acquired Brain Injury

Attention Process Training APT-3 A Direct Attention Training Program for Persons with Acquired Brain Injury

McKay Moore Sohlberg, Ph.D. and Catherine Mateer, Ph.D.

Developed by McKay Moore Sohlberg, Ph.D. and Catherine Mateer, Ph.D.the APT-3 includes an extensive range of attention exercises appropriate for people with mild to severe attention deficits due to acquired brain injuries. Target populations include adolescents, adults and veterans. Unlike the APT-1 and APT-2 programs, the APT-3 is a computer based program promoting efficient data collection and analyses and treatment planning. The Kit includes a USB drive with customized software that can be used on either a mac or PC. It includes 2 practice drives for clients. The program runs from the USB drive and does not stay on the user's computer. The manual contains a clinical overview, research evidence, discussion of therapy principles, and detailed instructions and guidelines for assessment and treatment. Also included on the Clinician Drive is PDF manual with sample scoresheets for all therapeutic activities and tasks.

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Full Description

The APT-3 program is a comprehensive, evidence-based direct attention training program aimed at improving underlying attention deficits secondary to acquired brain injury. It is an updated version of the predecessor programs (APT-1 and APT-2) with attention exercises delivered via computer. The program targets specific domains of attention commonly disrupted after an acquired brain injury including:

  • Basic Sustained Attention
  • Executive Control: Working Memory
  • Executive Control: Selective Attention
  • Executive Control: Suppression, and
  • Executive Control: Alternating Attention.

A clinician interface allows the clinician to select exercises and associated parameters in order to create individual patient/client exercise profiles that are easily modifiable as the individual progresses.

The APT-3 software facilitates standardized, efficient delivery of the discrete attention tasks and provides self reflection opportunities. Clinicians deliver this therapy in conjunction with strategy training and generalization activities.

What's included in the APT3 Kit?

  • Comprehensive administration manuals for Attention Process Training 3

Volume 1 is a 60 page manual which includes full administration instructions and guidelines for treatment planning. Appendix A includes a set of prepackaged starter programs for the clinician. There are clear descriptions of the principles and procedures for stimulation of discrete attention subcomponents and methods for encouraging transfer of improved processing to everyday functioning.

Volume 2 is a 479 page manual (PDF Format)containing Appendix B which is a complete set of score sheets for all tasks and activities. This allows clinicians to quickly review and select scoresheets when planning treatment activities and setting treatment goals.

  • 1 Clinician USB Drive to run program on any computer
  • 2 Client Practice USB Drives
  • 1 USB Hub for data transfer

What are the Hardware Requirements?

The APT-3 software is clinician friendly and designed to support busy professionals.

APT-3 will work with computers and laptops running Mac OS 10.5 or newer and Windows XP or newer. The computer or laptop will need an available USB port for connecting the APT-3 USB drive. All of the software necessary to run the tool is contained on the drive. The clinician runs the program from the drive; thus, no software needs to be installed on the computer and any computer can be used to run the therapy program.

Click here for Q&A PDF file

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Details
Item APT3
ISBN# 1-931117-58-6
Pages Volume 1, 60 pages; Volume 2,479 pages
Year 2011

Authors

McKay Moore Sohlberg, Ph.D.

Dr. Sohlberg is a Full Professor at the University of Oregon where she directs the Master's and Ph.D. training programs in Communication Disorders and Sciences. She is widely known for her pioneering work in the field of cognitive rehabilitation having authored numerous journal articles, two leading texts in the field and a number of widely used evidence-based clinical programs. Her research focuses on the development and evaluation of methods to manage acquired deficits in attention, memory, and executive functions. She is supported by a number of federal grants to develop and evaluate assistive technology for individuals with cognitive impairment. Dr. Sohlberg has been active at the national level in the development of evidence-based practice guidelines for cognitive rehabilitation.

Catherine Mateer, Ph.D.

Dr. Mateer is a board-certified clinical neuropsychologist with an extensive background in clinical assessment, clinical intervention and both basic and applied research. She has published over 75 articles and book chapters and two previous books relating to brain organization for language, memory and praxis, as well as to the assessment and management of aquired disorders of attention, memory and executive functions in children and adults.

Dr. Mateer is known internationally for her pioneering work in rehabilitation of individuals who have sustained traumatic brain injury. She received her master’s degree in Communication Disorders from the University of Wisconsin and her Ph.D. in Psychology from the University of Western Ontario. Currently, she is professor in the Department of Psychology and the Director of the Graduate Program in Clinical Psychology at the University of Victoria in British Columbia, Canada.

Contents

Volume One - Attention Process Training, APT-3

Introduction

New Features with the APT-3

Attention Training in Context

Background: Attention and the APT-3 Program

The Target Population

What Do We Mean By Attention?

Attention Theories

APT-3 Clinical Attention Framework

Basic Sustained Attention

Executive Control: Working Memory

Executive Control: Selective Attention

Executive Control: Suppression

Executive Control: Alternating Attention

What Does the Research Say?

A Review of Selected Studies Published After the Practice Guidelines

But Does it Generalize?

What Types of Metacognitive Strategies Have Been Paired with APT?

Why Would APT Work?

Implementation of APT-3

APT-3 Therapy Principles

Principle One: Organize Therapy Activities Using a Theoretically Grounded Model

Principle Two: Provide Sufficient Repetition

Principle Three: Use Patient Performance Data to Direct Therapy

Principle Four: Include Metacognitive Strategy Training

Principle Five: Identify and Practice Functional Goals Related to Attention

The Assessment Process

Initial Assessment

Evaluating Metacognition

Measuring Treatment Progress

Goal Attainment Scaling

Treatment Components

Designing Clients' APT-3 Programs

Selecting Starter APT-3 Training Tasks

Selecting Strategies

Selecting Goals and/or Generalization Activities

Administration of APT-3 Tasks

Treatment Dosage

Treatment Pacing

Metacognitive Strategy Training

Documenting Performance

Program Modification and General Decision Rules

General Criteria to Move to a Harder Task

General Criteria to Move to an Easier Task

Facilitating Generalization

Measuring Outcomes

Pre-/Post-Treatment Measures

On-Going Measures

Using the Computer Program

Client Example

References

Appendix A: Prepackaged Starter Programs

Volume Two - Attention Process Training, APT-3

Appendix B - Task Scoresheets

Attention Training in Context

Attention Domain: Basic Sustained Tasks

Listening for 1 Number

Listening for 1 Letter in a Word

Listening for 1 Noise

Listening for 1 Animal Sound

Listening for 2 Numbers

Listening for 2 Letters in a Word

Listening for 2 Noises

Listening for 2 Animal Sounds

Listening for 2 Numbers Ascending

Listening for 2 Numbers Descending

Matching Digital & Analog

Watching for Multiples of 3 (Easy #1-30)

Watching for Multiples of 3 (Hard #1-99)

Number Comparisons (Easy)

Number Comparisons (Hard)

Remembering Clock Times

Matching Season and Month Words

Matching Abstract Shapes (2-back)

Remembering Clock Times (2-back)

Matching Animals (2-back)

Matching Faces and Emotion Words

Section II - Executive Control Selective Attention Tasks

Listening for 1 Number

Listening for 1 Letter in a Word

Listening for 1 Noise

Listening for 1 Animal

Sound

Listening for 2 Numbers

Listening for 2 Letters in a Word

Listening for 2 NoisesListening for 2 Animal Sounds

Listening for 2 Numbers Ascending

Listening for 2 Numbers Descending

Matching Digital & Analog Clocks

Watching for Multiples of 3 (Easy #1-30)

Watching for Multiples of 3 (Hard #1-99)

Number Comparisons (Easy))

Number Comparisons (Hard))

Remembering Clock Times)

Matching Season and Month Words)

Matching Abstract Shapes (2-back)

Remembering Clock Times (2-back))

Matching Animals (2-back))

Matching Faces and Emotion Words)

Section III. Executive Control Working Memory Tasks

2-Step Serial Number Calculations)

3-Step Serial Numbers Calculations)

3-Number Sequences (0-30)

4-Number Sequences (0-30)

4-Number Sequences (0-100)

5-Number Sequences (0-100)

4-Word Sentences

5-Word Sentences

6-Word Sentences

Section III. Attention Domain: Executive Suppression

Happy—Sad

Falling-Rising

High-Low

Loud—Soft

Adult – Child

Fast-Slow

One—Two Voices

Serious—Silly

Left—Right

Above—Below

Big—Small

Solid—Hollow

Numbers—Digits

Circle—Triangle—Square

Word Shapes

High—Mid—Low

Left—Right—Center

North—South—East—West

Left—Right—Top—Bottom

Word Directions

Section IV. Executive Control Alternating Tasks

Happy—Sad

Falling—Rising

High—Low

Loud—Soft

Adult—Child

Fast—Slow

One—Two

Serious—Silly

Left—Right

Above—Below

Big—Small

Solid—Hollow

Circle—Triangle—Square

Word Shapes

High—Mid—Low

Left—Right—Center

North—South—East—West

Left—Right—Top—Bottom

Word Directions

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.

It is clear that attention is vulnerable to disruption from a wide range of acquired and developmental conditions. The APT-3, like the original APT-1 and APT-2 materials, was developed and used with adolescents and adults with acquired brain injury including TBI, anoxia, and disease processes such as brain tumor. As reviewed, there have been efficacy studies evaluating direct attention training in other populations, but given the sparse intervention research, it is important that clinicians establish and monitor treatment outcomes for each patient recognizing the program was developed for people with acquired brain injury.
 

 

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?

Yes View a demon at http://www.vimeo.com/6627052 .

 

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