Evaluation of Attention Process Training and Brain …antonellapavese.com/papers/attention_process_training.pdf · Evaluation of Attention Process Training and Brain Injury ... (PASAT

* The authors extend thanks to Tom Boyd, Ph.D. and Robert Kurlycheck, Ph.D. for their support of this projectand their clinical expertise in evaluating the subjects. They also thank the reviewers for their thorough editing andexcellent suggestions.Address Correspondence to: McKay Moore Sohlberg, Communication Disorders and Sciences, 5251 Universityof Oregon, Eugene, OR 97403, USA. Fax: (541) 346-2586. E-mail: [email protected] for Publication: March 30, 2000.

Journal of Clinical and Experimental Neuropsychology 1380-3395/00/2205-656$15.002000, Vol. 22, No. 5, pp. 656-676 © Swets & Zeitlinger

Evaluation of Attention Process Training and Brain InjuryEducation in Persons with Acquired Brain Injury*

McKay Moore Sohlberg1, Karen A. McLaughlin1, Antonella Pavese1, Anke Heidrich1,and Michael I. Posner1, 2

1University of Oregon, Eugene, OR, and 2Sackler Institute for Human Brain Function, Cornell MedicalCollege, New York, NY

ABSTRACT

Fourteen patients with stable acquired brain injuries exhibiting attention and working memory deficits weregiven 10 weeks of attention process training (APT) and 10 weeks of brain injury education in a cross-overdesign. Structured interviews and neuropsychological tests were used prior to rehabilitation and after bothtreatments to determine the influence of the interventions on tasks of daily life and performance onattentional networks involving vigilance, orienting, and executive function. The overall results showed thatmost patients made improvements. Some of these gains were due to practice from repetitive administrationof the tests. In addition, the type of intervention also influenced the results. The brain injury educationseemed to be most effective in improving self-reports of psychosocial function. APT influenced self-re-ports of cognitive function and had a stronger influence on performance of executive attention tasks thanwas found with the brain injury education therapy. Vigilance and orienting networks showed little specificimprovement due to therapy. However, vigilance level influenced the improvement with therapy on sometests of executive attention. We consider the implications of these results for future studies of the locus ofattentional improvement and for the design of improved interventions.

Acquired brain injuries (ABI) frequently pro-duce difficulties in attention and short termmemory. Patients with ABI report problemswith concentration, distractibility, forgetfulness,and difficulty doing more than one thing at atime (Hinkeldey & Corrigan, 1990; Mateer,Sohlberg, & Crinean, 1987). Certain aspects ofmemory are strongly related to attention (Nis-sen, 1986; Russell & D’Hollosy, 1992). Evenrelatively small decrements in an individual’sattention ability may significantly reduce thecapacity for new learning and affect academicperformance (Kinsella et al., 1997; Kinsella,1998). Attention impairments frequently accom-pany executive dysfunction (Mateer & Mapou,1996). Patient complaints and research docu-

ment problems with the allocation of attentionalresources, switching between tasks with differ-ent cognitive requirements, time-sharing pro-cessing resources and overcoming automaticresponses when faced with non-routine situa-tions (Cohen, 1993; Mateer & Mapou, 1996;Stablum, Leonardi, Mazzoldi, Umilta, & Morra,1994).

Most efforts to rehabilitate patients withclosed head injury rely on some combination ofeducation and social support, practice, and pro-cess training. Education and social support in-volves supplying individuals with relevant infor-mation about their injuries and suggesting strat-egies to help manage the consequences of thebrain damage. It also includes giving opportuni-

EVALUATION OF ATTENTION PROCESSING TRAINING 657

ties to share feelings about changes in their cir-cumstances in a supportive environment.

Practice refers to specific training on a task toimprove performance on that task. Practice maybe a deliberate part of the therapy or it might beaccomplished in the process of repeated admin-istration of tests designed to determine amountof improvement. Practice alone might improveperformance more generally if it results in trans-fer to tasks that have not been practiced.

Process training refers to a deliberate effort toemploy a therapeutic program that would im-prove a wide range of tasks involving attention.For example, several studies have reported thatAttention Process Therapy (APT) improvesmemory, learning, and some aspects of execu-tive control (Mateer & Sohlberg, 1988; Nei-mann, Ruff, & Baser, 1990; Ruff, Baser, &Johnson, 1989). Findings in a study by Sturm,Willmes, Orgass and Hartje (1997) also sup-ported attention process training. They reportedimproved performance on neuropsychologicaltests specific to the type of attention trained.They further suggested that only patients withhigher vigilance abilities respond to traininginvolving more complex components of atten-tion.

A recent study (Park, Roulx, & Towers,1999) compared performance on two neuropsy-chological tests (PASAT and ConsonantTrigrams) in patients with brain injury who re-ceived APT and in normal controls. Both groupsreceived the outcome measures twice, but thecontrols received no training. Results showedthat the performance of the experimental groupimproved on both the neuropsychological mea-surements. The control group improved on oneof the measures (PASAT) but not the other(Consonant Trigrams). The authors suggestedthat the cognitive processes involved in the con-sonant trigram are different than those stimu-lated by the training tasks in the APT, and con-cluded that the APT resulted in learning of newskills rather than improved processing.

Our study compares APT training with aneducational and support method. We used tenneuropsychological tests to clarify changes thataccompanied the interventions. We probed eachof the major attentional networks (Posner &

Petersen, 1990) together with working memory.In order to determine if the therapy improves theprospects of these patients in their normal every-day life, we also used a battery of questionnairesand structured interviews of the patients and insome cases their caregivers. Our research ques-tions were: (1) How will APT compare with ed-ucation in influencing the reports of patients andcaregivers on patient performance in naturalisticsettings? (2) Which brain networks will benefitthe most from APT and/or education? (3) Willresponses to APT and the information revealinsights about the effects of practice? (4) Willpatients’ responses to practice and/or APT differbased on their vigilance ability?

METHOD

Research DesignThis study combined features of both between andwithin subject research methodology. It employeda basic crossover design using two groups. Partici-pants were randomly assigned to groups. Thegroups were differentiated by the order of twoblocks of treatment that they received. One treat-ment block (Condition A) consisted of the cogni-tive intervention, attention process training. Theother block (Condition B) represented a placebointervention consisting of brain injury educationand supportive listening. Individuals in Group 1participated in an A-B design while individuals inGroup 2 participated in a B-A design.

During Condition A, participants received 24hours of attention process training over 10 weeksas described under Independent Variables. DuringCondition B, participants received 10 hours oftherapeutic support and education over 10 weeksthat is also detailed in the Independent Variablessection. Prior to beginning and following comple-tion of each experimental condition, all partici-pants were administered the following: (1) A neu-ropsychological attention battery; and (2) threequestionnaires to assess perceptions of daily liv-ing. Furthermore, following each block of treat-ment, each individual participated in a structuredinterview. The sequence of experimental proce-dures is summarized in Figure 1.

In this design, each participant serves as a sepa-rate controlled single subject experiment. Addi-tionally, the ability to compare performance on theprobes for the seven participants in Group 1 withthe seven participants in Group 2 after each treat-

658 MCKAY MOORE SOHLBERG ET AL.

ment block provides a between group analysis.Comparing performance on probes of cognitivefunctioning and daily living abilities after eachblock of intervention reveals differences betweenthe attention process training and the supportivecounseling plus brain injury education.

ParticipantsTwo groups consisting of 7 individuals with ac-quired brain injury were formed. Participants werereferred by local service providers working withthis population who had been given informationabout the study. The following subject selectioncriteria were utilized: (1) Between 18-60 years ofage; (2) Acquired brain injury diagnosed at thetime of injury with evidence on imaging studies;(3) Greater than one year post injury; (4) Absencefrom preinjury of any neurologic, psychiatric his-tory, or learning disability; (5) Significant otheravailable to take measures of everyday function;(6) Attention deficits determined via neuropsycho-logical evaluation and subjective report from par-ticipant and/or significant other.

Demographic and injury related participant dataare summarized in Table 1. The mean age of par-ticipants for Group One was 33.1 years (range 20to 43 years) compared to a mean age of 38.1 years(range 19-50) for Group Two. Time post injuryranged from 1 to 22 years (mean 7.5 years) inGroup One and 1 to 2.8 years (mean 1.6 years) inGroup Two. All but one participant in each groupsuffered closed head injuries. The mean years ofeducation for Group One was 11 years (range 9-16years). For Group Two, the mean years of educa-tion was 12 (range 10-20 years). Both participantswith technical training completed high school andwere counted as having 13 years of education. Inspite of random assignment, Group Two performedsuperiorly on the neuropsychological tests com-pared to Group One.

All of the participants were Caucasian with theexception of one participant in Group One whowas Hispanic. All participants spoke English as afirst language. Two individuals in each group weretaking antidepressant medications during the timeof the study. Two participants in Group One andone participant in Group Two were abusing alco-hol or drugs at the time of injury. Length of sub-stance use for all of these individuals was underfive years. All participants and their significantothers denied alcohol or drug use at the time of thestudy. Two participants in each group were sched-uled to undergo litigation related to their injuries,although none of the cases were active during thetime of the study.

Experimental Materials

Independent VariablesCondition A: The Attention Process Training pro-gram (APT) (Park, Proulx, & Towers, 1999;Sohlberg, Johnson, Paule, Raskin, & Mateer, 1994;Sohlberg & Mateer, 1987) is a widely used cogni-tive rehabilitation program designed to remediateattention deficits in individuals with brain injury.The APT materials consist of a group of hierarchi-cally organized tasks that exercise different com-ponents of attention commonly impaired afterbrain injury including sustained, selective, alter-nating, and divided attention. The program tasksplace increasing demands on complex attentionalcontrol and working memory systems. Examplesof exercises include auditory attention tapes suchas listening for descending number sequences, al-phabetizing words in an orally presented sentence,detecting targets with the presence of distracternoise or complex semantic categorization tasksrequiring switching sets. A number of tasks com-bine auditory and visual activities. The trainingtasks were different than the neuropsychologicaltests, however, it is hypothesized that they utilizesimilar attentional circuits.

Participants received 24 hours of attention pro-cess training. Therapy was administered in threeone-hour sessions each week over a total of tenweeks. Each participant was assigned a therapistwho administered the attention process trainingprogram at a university speech and hearing clinic.Clinicians were either one of two certified speech/language pathologists familiar with the APT pro-gram or one of five graduate students completingtheir master’s degree in speech/language pathol-ogy. The student clinicians were closely super-vised by a certified speech/language pathologistand were chosen because they had taken a graduateneurogenic course series that included a class oncognitive rehabilitation, had a minimum of 30 su-pervised hours with adult rehabilitation clients,and had completed an instructional program forusing the APT materials. The APT tasks chosen foreach client were specific to their attentional pro-file. For example, one participant completed verybasic sustained attention tasks while another par-ticipant completed more complex sustained andalternating attention tasks.

Condition B: The therapeutic support conditionconsisted of a combination of brain injury educa-tion, supportive listening, and relaxation training.Materials were designed for this study. Partici-pants selected their own education topics from amenu of choices related to neuroanatomy and neu-ropathology after closed head injury, cognitive


Table 1. Injury and Demographic Information for each Participant.

Participant Age atinjury

Months post-injury

Etiology Site(s) oflesion

Length ofcoma/

unconscious

Educationlevel

prior to injury

1 18 12 MVA B frontal;L temporal;R temporo-parietal;diffuse Bdeepwhite matter

3.5 months High school

2 18 26 MVA Frontoparie-tal

11 days Some college

3 25 29 Anoxia Diffuse;subcortical

2 weeks Collegegraduate

4 49 15 MVA Frontal 1 day High school5 15 33 ATV Cerebellum;

brainstem3 weeks Some high

school6 14 22.5 MVA L temporo-

parietal7 months Jr. high school

7 26 17 years Motorcycle L fronto-parietal

2 months High school

8 34 14 Motorcycle R fronto-temporo-parietal

3 weeks High school

9 49 12 MVA Frontal < 1 hour High school10 23 15 years MVA/

pedestrianB frontal; Bbasal ganglia

6 weeks Technicaltraining

11 17 26 Fall Occipitalwithfrontalinvolvement

< 1 hour High school

12 34 14 Cavernoushemangiomma

L temporal N/A High school

13 42 13 Motorcycle Occipital < 1 hour Technicalschool

14 44 26 Fall Parietal-occipital

2 weeks Prof. degree

disorders common after brain injury, relationshipissues, and self advocacy and community reentry.There were written materials corresponding toeach topic that were modified to match each partic-ipant’s level of education and comprehension.Supportive listening consisted of a ‘‘check in’’period asking participants, ‘‘How are things go-ing?’’ and listening and paraphrasing responses. Ifparticipants initiated discussion of using compen-satory strategies, these behaviors were verballyreinforced, but no specific support plan was initi-ated. Relaxation training consisted of teaching pro-

gressive relaxation using basic breathing, musclerelaxation, and visualization exercises.

Sessions were conducted one hour per week fora total of ten weeks which matched the total num-ber of weeks for the attention process training.Most sessions combined brain injury education(approximately a half hour) with supportive listen-ing (15 minutes) and relaxation training (15 min-utes). Occasionally participants wanted to spendthe entire time period discussing an educationtopic of interest or using the supportive listening asan opportunity to share current life events. These


Baseline Measures First Inter-vention

Repeat BaselineMeasures

Second Inter-vention

Repeat BaselineMeasures

NeuropsychologicalAttention Battery



• Trail Making Test• PASAT• Gordon Diagnos-

tic• COWAT• Covert Orienting• Continuous Per-

formance Task• Stroop task• Sternberg tasks

Questionnaires• BAFQ• DEX• Attention Ques-

tionnaire

AttentionProcessTraining(Condition A)

OR

P l a c e b o –s u p p o r t i v elistening andbrain injurye d u c a t i o n(Condition B)




Questionnaires• BAFQ• DEX• Attention Ques-

tionnaire

AttentionProcessTraining(Condition A)

OR

Placebo – sup-portive listen-ing and braininjury educa-t ion (Condi-tion B)




Questionnaires• BAFQ• DEX

Attention Ques-tionnaire

Fig. 1. Sequence of Experimental Procedures.Note. PASAT = Paced Serial Addition Task; COWAT = Controlled Oral Association Word Task; BAFQ = BrockAdaptive Functioning Questionnaire; DEX = Dysexecutive Questionnaire.

choices were permitted. The clinicians were thesame as those described above. All clinicians com-pleted training familiarizing them with the educa-tion and relaxation training materials and practic-ing supportive listening skills (e.g., paraphrasing).

Dependent VariablesCognitive functions were measured using scores ofstandardized questionnaires, standardized and non-standardized neuropsychological tests, and datafrom structured interviews. This section describesgeneral methods for these dependent variables.

Neuropsychological TestsThe following neuropsychological tests were ad-ministered to each participant prior to and follow-ing completion of each experimental condition: (1)Trail Making Test (Reitan & Wolfson, 1985); (2)Paced Auditory Serial Addition Task (PASAT;Gronwall, 1977); (3) Gordon Diagnostic Vigilanceand Distraction (Gordon, 1986); (4) ControlledOral Word Association Task (COWAT; Benton &Hamsher, 1989); (5) Covert Orienting Task; (6)Stroop Task (Stroop, 1935); (7) Continuous Per-formance Tasks; (8) Memory for Location Task;and (9) Memory for Letters Task.

All of the tests were selected for their ease ofadministration and their sensitivity to attention

impairments following brain injury. The first fourneuropsychological tests were administered andscored by one of two board certified neuropsy-chologists with specialties in acquired brain injuryor by a psychometrist trained and supervised byone of the two neuropsychologists. This portion ofthe battery took approximately one hour and wasadministered at the university speech and hearingclinic with a few exceptions when the test was ad-ministered at the office of one of the neuropsy-chologists. A clinical definition of attention im-pairment was adopted based upon the diagnosis ofthe neuropsychologist. Only participants whoseperformance on the attention battery resulted in adiagnosis of significant attention impairment wereincluded.

The next five neuropsychological tasks wereselected because there had been analysis of thecorresponding brain circuitry using PET scans.They sampled the complex attentional circuitryidentified in the literature including: (1) A sensoryorienting network; (2) executive attention network;(3) vigilance network; and (4) working memorynetwork (Kinsella, 1998; Posner & Peterson,1990). This testing was conducted in a cognitivelaboratory at a university and lasted about threehours. The tasks were programmed in EGIS (Os-good, 1990) and presented on a Radius 20e com-


puter monitor controlled by a Macintosh PowerPC8500. (Electrical recordings of brain activity werecollected during participant performance on thesefive neuropsychological tasks as well as on a groupof normals. Results from this analysis are reportedin a separate paper.)

A brief description of each of the neuropsycho-logical tasks is given below. (Participant perfor-mance data for all of the neuropsychological testsare available upon request.)

Trail Making TestThis tes t assesses visual conceptual andvisuomotor tracking. It includes two parts, A andB. In part A, participants are asked to draw lines toconnect consecutively numbered circles; in part B,individuals are required to connect consecutivelynumbered circles and lettered circles by alternatingbetween the two sequences. Trails B requires plan-ning and working memory, both of which are clearexecutive functions and this measure is widelyused to assess frontal lobe functions in clinicalpopulations (e.g., Hanninen et al., 1997).

The PASATThe PASAT is considered an information process-ing or attentional measure and is a sensitive indexof cognitive impairment after brain damage. Thistest consists of a randomized presentation of a se-quence of auditory digits. The patient is required toadd each new digit to the digit immediately pre-ceding it. Deary, Ebmeier, MacLeod, and Dougall(1994) examined brain activity during the PASATusing single photon emission computed tomogra-phy and found higher tracer intake in the right an-terior and left posterior cingulate areas.

Gordon Diagnostic SystemThis measure is a computerized variation of thecontinuous performance task that is used to mea-sure attention and self-control and to assess atten-tion deficit disorders (Gordon & Mettelman,1988). We used two of the three GDS tests: Thevigilance task and the distractibility task. The vigi-lance task measures the ability of an individual tofocus and maintain attention over time and in theabsence of feedback. A series of digits flash, one ata time, on an electronic display and the participantis told to press a button every time the digit 1 isfollowed by a 9. The GDS records the number ofcorrect responses, incorrect responses (commis-sions), and failure to respond to the target digit(omissions), and the average response time of cor-rect responses. In the distractibility test, the sametask is performed while irrelevant digits areflashed on either side of the column that display

the target stimuli. A third test, the delay task, re-quires the participant to inhibit responding in orderto earn points. Burg, Burright, and Donovick(1995) found that patients with TBI perform worsethan normal controls on both the vigilance and dis-tractibility tasks, but the two groups perform simi-larly on standard delay tasks.

COWATThe COWAT is a measure of fluency in word pro-duction, a skill that is impaired after frontal le-sions. This test consists of three word-naming tri-als. Patients are asked to produce as many wordsas they can beginning with a designated letter.

The Stroop TaskThe Stroop task is a measure of conflict resolutionand has been associated with activity in the ante-rior cingulate, which is a part of the executive at-tention network. The task used in our study was avariation of the Stroop test (Stroop, 1935), inwhich individuals were asked to name the inkcolor in which words were written and to ignorethe word. There were color words (RED, YEL-LOW, BLUE, and GREEN) printed in four colors– yellow, green, blue, and red – and displayedagainst a gray background. There were also 72non-color words. Participants were required toname aloud the color in which the word was writ-ten. The words could be: (a) Color-words identicalto the color name (congruent condition), (b) colorwords different from the color name (incongruentcondition), or (c) non-color words (neutral condi-tion). Two participants were excluded from thistask because they were color-blind.

Covert Orienting TaskIn this task, participants had to detect the onset ofan asterisk presented in the left or in the right vi-sual field. The display consisted of two squares,one on the left and one on the right, that subtended4.1° of visual angle at the viewing distance of 60cm. Between the two boxes, a fixation dot was dis-played and participants were asked to fixate on thedot. The cue appeared in the same position as thefixation dot and consisted of a cross, an arrowpointing to the left box, or an arrow pointing to theright box. The cue always subtended a visual angleof .9° in height and in width, at the viewing dis-tance of 60 cm.

Continuous Performance TaskIn this task, a sequence of digits was presented andparticipants were asked to pay attention to the se-quence and to press a key only after a four follow-ing an odd number. The digits were presented in


the center of the monitor using the font Times, size24 points, typeface bold. The trial started with a200 ms blank followed by a digit that was dis-played for 500 ms. The time available for the re-sponse was 800 ms after non-target trials and1,500 after target trials. The experiment consistedof 500 trials, divided in two 250-trial sessions. Thestimulus was not a four (non-four non-targets) in400 of the 500 trials, a four that followed an evendigit (four non-targets) in 50 of the trials, and afour that followed an odd number (four targets) in50 of the trials.

Memory for Locations and Memory for LettersTasks (Sternberg Tasks)The tasks included two sub-sessions, one in whichthe to-be-remembered stimuli were dot locationsand the other in which the stimuli to be remem-bered were letters. The order of the two sub-ses-sions was counterbalanced across patients and ex-perimental sessions.

In the locations task, a sequence of two or fourblack dots, displayed in different locations, waspresented. Participants had to decide whether a redprobe dot was in the same location as one of thetwo or four previously presented black dots. A 4.1°squared box was displayed in the center of themonitor. Each dot could appear in one of eightpossible locations on the imaginary circumferencewith a diameter of 9.1° of visual angle (at theviewing distance of 60 cm). The dots consisted ofblack or red circles subtending a visual angle of.8°. The edge-to-edge distance between the dotsand the central box was 1.9°.

Similarly, in the letter task, a sequence of twoor four black letters was presented in the center ofthe screen and followed by a red probe letter. Par-ticipants had to decide whether the red probe wasincluded in the previous set of two or four letters.The display consisted of a squared box, subtendinga visual angle of 4.1° at a viewing distance of 60cm. The letters appeared in the center of the boxand were displayed in Times font, size 24 points,typeface bold. The stimulus set included 10 upper-case letters (A, D, I, L, M, Q, R, W, X, Y). Twopatients were excluded from the two memory tasksbecause they were color-blind and could not distin-guish the target items from the probe item.

QuestionnairesThree different questionnaires were used to evalu-ate adaptive functioning or the impact of attentiondeficits on day-to-day living. The three measuresincluded: (1) The Attention Questionnaire (AQ;Sohlberg et al., 1994); (2) the Brock AdaptiveFunctioning Questionnaire (BAFQ; Dywan &

Segalowitz, 1996) and (3) the Dysexecutive Ques-tionnaire (DEX; Wilson, Alderman, Burgess, Ems-lie, & Evans, 1996). These three measures werechosen because they were specifically developedfor use with the brain injury population.

Each participant and a significant other was ad-ministered the three questionnaires at the begin-ning of the study and again following each experi-mental condition. Due to difficulties with reading,most of the participants were administered thequestionnaires orally to check for question com-prehension. The significant others filled out thequestionnaires independently. A brief descriptionof each of the questionnaires is provided below.

Attention QuestionnaireThis questionnaire is based on Ponsford and Kin-sella’s (1988) attention questionnaire and asks theparticipant to rate frequency of occurrence for dif-ferent attention problems. The attention problemsare related to difficulty sustaining, switching, anddividing one’s attention as well as dealing withdistractions. This measure was selected because itis based on the model of attention used in the APTprogram and it samples a wide range of attentioncomponents. It also supplies a numerical indicatorsummarizing the overall frequency of perceivedattention problems, which was helpful for compar-ing performance after the different treatment con-ditions.

Brock Adaptive Functioning QuestionnaireThis questionnaire contains 68 items that were de-veloped through clinical practice and with the helpof community volunteers who had sustained braininjuries and their families. The goal of the BAFQis to provide measures of adaptive functioning thatare difficult to quantify psychometrically. It per-mits quantitative analysis of five domains of be-havior: Planning, initiation, attention/memory,arousal/inhibition, and social monitoring. It sup-plies a significant other form and participant form.A pilot study looking at this tool suggested that afrontally generated electrophysiological responseelicited during a simple attention task was stronglypredictive of family and patient responses on theplanning and initiation scales (Dywann & Sega-lowitz, 1996). In addition, the questionnaire pro-vides an index of awareness by finding the differ-ence between significant other and self-ratings bythe participant, with a higher score on the aware-ness index indicating poorer awareness on the partof the participant.

Dysexecutive QuestionnaireThis questionnaire is a subtest of the Behavioral


Assessment of Dysexecutive Syndrome (Wilson, etal., 1996). It contains 20 questions describingproblems related to decreased attention and execu-tive control which commonly occur followingbrain injury. The respondent rates each problem ona frequency of occurrence scale. There is a self andother rating form. This questionnaire generates araw score ranging from 0 to 80 with a higher scorereflecting greater deficits in executive function.

All participants endorsed some level of diffi-culty with attention on their responses to the ques-tionnaires at the baseline measure. These subjec-tive findings were consistent with objective find-ings showing decreased attention for all partici-pants as measured by the neuropsychological tests.Formal analysis of the relationship between sub-jective and objective findings was not completedbecause the questionnaires are not standardized.

Structured InterviewsThe fourteen participants completed a one-hourinterview with one of the researchers followingeach 10-week block of treatment. Hence, each par-ticipant was interviewed twice, once following theattention process treatment and once following thebrain injury education or placebo intervention. Theparticipants were interviewed in the same clinicalsetting in which they had received their treatment.At the beginning of each interview, they were toldthat they were going to be asked to talk about theirday- to-day functioning during the past severalmonths when they had been coming to the clinicand working with their therapist. They were alsotold that the interview would be audio taped to pro-vide the researchers with a record of what had beenhelpful and what could be improved in the therapy.The tape recorder was turned on and the partici-pants were engaged in an interview that involvedasking the following four questions: (1) Have younoticed anything in your day to day life that youfeel has been affected by participating in the treat-ment here at the clinic? (2) Is there anything thatyou feel has been particularly helpful about com-ing to treatment? (3) Is there anything that hasbeen disappointing about coming to treatment? (4)If you think specifically about changes in yourthinking ability, how do you feel this treatmenthelped or did not help?

When possible, significant others were inter-viewed using the same questions to elicit their in-sights about the daily functioning of the personwith brain injury. All but two individuals partici-pated in interviews following each block of treat-ment. (Two were unable to recall having been in-volved in the treatment.) The audio taped inter-views were transcribed and the transcripts were

analyzed to develop a coding protocol that wouldfacilitate the evaluation of response patterns. Re-sults of this analysis suggested three areas inwhich individuals reported changes as a responseto therapy. These included changes in (a) everydayfunctioning; (b) psychosocial functioning; and (c)cognitive functioning. Each of these three areaswas further divided into a variety of categoriesagain derived from the content of the interviews.Examples of categories in the everyday function-ing area included improved leisure time manage-ment and improved performance in school. (Astringent definition was used for the category ofeveryday functioning as it was reserved for reportsof consistent change in a skill that influenced per-formance in work, home, school, or community.For example, in order to be coded as a change ineveryday functioning, the participant would needto report ‘‘I am now cooking dinners’’ versus ‘‘Icooked dinner last night’’.) The categories in thepsychosocial domain that were mentioned in theinterviews included improved emotional well-be-ing and confidence and understanding of issuesrelated to the brain injury. All of the categories inthe third domain, cognition, pertained to memory,attention, and executive functions. A fourth cate-gory of response codes was also developed to doc-ument reports of disappointment or concerns aboutthe intervention.

Each protocol had a space for recording state-ments of changes related to treatment that was tiedto a specific behavior in a particular context. Ex-amples of recorded comments included ‘‘I noticedthat I can sit through a whole movie now’’; or ‘‘Heis initiating more conversations at the dinner ta-ble’’. These comments are summarized in the ap-pendix.

The coding instructions included reading theinterview transcript, checking any category on theprotocol that was noted in the interview, and re-cording any specific behavioral examples. Catego-ries were designed to be mutually exclusive, thus aperson would not check the ‘‘improved prospec-tive memory’’ category and the ‘‘general improve-ment in memory’’ category in response to the samecomment. Also, a category could only be markedonce to control for differences in the verbosity andopenness of the participants. Hence, even if a par-ticipant gave several examples of improved work-ing memory, this category would only be markedone time on the protocol.

To check reliability, a blind coder who was na-ive to the study and a practitioner in the commu-nity with no involvement with the participants readfive of the interviews and completed the codingsheets. The data were analyzed by looking at the


number and types of categories coded across par-ticipants in addition to looking at the narrativecomments following their attention process train-ing and their placebo treatment.

RESULTS

The results are organized in two sections. In thefirst section, we examine evidence for generalimprovements specific to the two interventions.We first use a subjective measure of improve-ment which is the number and type of changesreported during the structured interview. Be-cause this measure shows a strong dissociationbetween cognitive performance and psychoso-cial function, we then examine the relationshipbetween the self-reports of cognitive changesand an objective measure of performance, thePASAT. The PASAT was chosen because theliterature suggests it is particularly sensitive tothe effects of brain injury, it is a commonly usedinstrument with this population, and the test in-volves different functions including executivecontrol, sustained attention, and working mem-ory (Sherman, Strauss, & Spellacy, 1997).

In the second section, we attempt to identifybrain networks that appear sensitive to the ef-fects of APT. We used the results of neuropsy-chological testing that were performed by pa-tients in the pretest session, after the first inter-vention, and after the second intervention. Thesame tests were administered three times, henceany changes in performance could be the resultof practice effects. To tease out the effect of re-peated practice from the effect of intervention,we performed two different analyses. The firstanalysis looked at test performance across thethree sessions, regardless of type of interven-tion. A main effect of practice in this analysiswould be demonstrated by improved patient per-formance across sessions, regardless of the typeof intervention. The second analysis examinedthe specific effect of intervention. In this analy-sis we used difference scores between perfor-mance at the start of a particular type of inter-vention and performance after the relevant inter-vention. These improvement scores were ana-lyzed as a function of intervention (APT and

brain injury education) and order (APT first ver-sus brain injury education first). A main effectof order would indicate a difference between thetwo groups of patients. A differential improve-ment after the two interventions regardless ofpractice would suggest a significant effect ofintervention.

In these analyses, we also examine the effectof vigilance level on both practice effects andintervention effects. The purpose of examiningvigilance is to evaluate Sturm et al.’s (1997)suggestion that a high vigilance level is a pre-requisite for improvement in other cognitivedomains.

Intervention Effects on BehaviorAll members of the sample participated in inter-views at the end of each intervention, but twowere unable to recall having been involved inthe treatment, thus 12 participants contributedinterview data (as opposed to 14 participants forthe neuropsychological and questionnaire data).The interview addressed two questions. First,are there quantitative and/or qualitative differ-ences in the changes reported by participantsafter APT and after brain injury education? Sec-ond, is there a relationship between reportedchanges and cognitive improvement measuredby an objective test of cognitive performance(PASAT)?

The first question was addressed by analyzingthe number of changes reported in the interviewas a function of intervention (brain injury educa-tion and APT) and type of change (everydayfunctions,memory/attention,psychosocial func-tions). The second question was addressed bydividing the patients in two groups on the basisof the number of cognitive changes reported (2or less and more than 2) and analyzing improve-ment of PASAT scores in the two groups.

Reliability between the two coders (naivecoder and a researcher) was assessed by comput-ing point by point agreement ratios (Kazdin,1982) for the codes given to each independentstatement in the transcripts for the five randomlyselected transcripts. The ratios ranged from 73to 85 percent, indicating adequate reliability.Areas of most frequent disagreement were in thecognitive domain between prospective memory


Table 2 . Means and Standard Deviations for all Participants.

TRAIL MAKING (Time to complete in seconds)

Trails A Trails B

First Second Third First Second Third

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD

41.9 (17.9) 44.2 (28.1) 43.8 (24.6) 125.3 (78.3) 114.9 (62.9) 92.1 (34.7)

PASAT (Number correct)

Slow Trial Fast Trial


M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

26.2 (11.7) 30.4 (13.7) 33.3 (13.3) 24.1 (10.7) 26.9 (11.0) 30.0 (12.5)

Note. PASAT = Paced Auditory Serial Addition Task.

GORDON DIAGNOSTIC SYSTEM (Number correct)

Vigilance Task Distraction Task


M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

26.1 (7.2) 26.8 (6.5) 27.9 (3.2) 16.7 (10.8) 22.0 (10.3) 21.6 (10.4)

COWAT (Total Scores)

First Second Third

M (SD) M (SD) M (SD)

26.1 9.6 28.0 9.6 30.0 12.4

Note. COWAT = Controlled Oral Word Association Task.

and working memory, and in the psychosocialdomain between improved awareness and im-proved sense of well-being.

Number and Types of Changes as a Functionof InterventionThis analysis revealed a significant effect of in-tervention, F(1, 10) = 5.00, MSE = .37, p < .05,indicating that the number of changes reportedafter APT was greater than the number ofchanges reported after brain injury education(.91 and .58, respectively). The effect of type ofchange was significant, F(2, 20) = 19.35, MSE =

9.42, p < .0001, indicating that a greater numberof changes were reported in memory and atten-tion (1.59) than in psychosocial functions (.59);the smallest number of changes was reported ineveryday functions (.05). The type of change Xintervention interaction was also significant,F(2, 20) = 10.16, MSE = 9.42, p < .001. Al-though the distributions of reported changes arenot likely to be normal, the interaction is largeenough to support parametric analyses. Morechanges were reported in the memory/attentioncategory after APT than after brain injury edu-cation, whereas more psychosocial changes


0.0

0.5

1.0

1.5

2.0

2.5

3.0

Everyday Functions Attention/Memory Psychosocial Functions

Category of Reported Change

Brain Education

APT

Av

era

ge

#o

fC

ha

ng

es

Fig. 2. Number of changes reported in the structured interview as a function of category (everyday functions,memory/attention, and psychosocial functions) and treatment (APT and Brain Education). The barsindicate one standard error.

were reported after brain injury education thanafter APT (see Fig. 2). This result is particularlyinteresting, because it suggests that APT is spe-cifically associated with perceived changes incognitive functions rather than psychosocialvariables, whereas the opposite seems to be truefor the brain injury education intervention.

Relationship Between Perception and Perfor-manceFor each participant we computed the differencebetween the PASAT test scores from the firstand third sessions. We divided patients in twogroups, patients who reported a total of 0-2 cog-nitive changes in the structured interviews andpatients that reported more than 2 cognitivechanges. Patients who reported more than 2changes had a greater change in PASAT scoresthan patients that reported fewer than 2 changes(9.1 and 3.1, respectively). A test showed thatthis difference was significant, t(12) = –2.36, p< .05. This result indicates that perceived cogni-tive improvement in the structured interviewcorresponds to greater improvement in the

PASAT, an objective measure of cognitive func-tions.

Data from significant others were only gath-ered for eight participants. Due to the smallnumbers, these data were not analyzed. The sta-tus of six significant others changed such thatthe person did not participate in post treatmentinterviews and questionnaires. (Attrition wasdue to significant others experiencing the onsetof a medical condition, moving, or feeling toooverwhelmed to participate. Additionally, oneparticipant moved out to a more independentresidence and the significant other did not wantfurther involvement in caring for this person.)

From an ecological perspective, it is interest-ing to compare the narrative comments follow-ing each of the interventions as shown in theappendix. Only after APT did participants andtheir significant others provide any examples ofbehaviors specifically related to improved work-ing memory. Reported ‘‘disappointments’’ inthe therapy related to logistics in coming to theclinic (e.g., problems with the taxi or bus; 3 par-ticipants); wishing the therapy would continue


for longer (2 participants, one after APT and oneafter brain injury education) and frustrationsabout not working directly on ‘‘getting back towork’’ (2 participants, one after APT and oneafter brain injury education).

Effect of APT on Attentional NetworksThis section examines the effect of APT onchanges in cognitive functions mediated by dif-ferent brain networks. We consider first tasksthat either measure directly or involve compo-nents of the high-level executive attention net-work. These include the PASAT, Stroop, TrailsB, COWAT, and Working Memory tasks. Nextwe examine the orienting and vigilance net-works. In these analyses we examined the effectof practice (changes in test performance withrepeated administration), the effect of the typeof intervention, and their interaction with vigi-lance level. Our purpose was to examine (1)whether patients improve by repeating the testsand/or by undergoing cognitive training; and (2)whether patients with high and low vigilancelevels differ in their improvement due to prac-tice and/or APT.

In all the following analyses, patients weredivided into a low vigilance or a high vigilancegroup depending on their score on the vigilancetask of the Gordon Diagnostic System (GDS) inthe pretest session. High vigilance patients hada score of 29 or higher (n = 8) and low vigilancepatients had a score of 28 or lower (n = 6).

Executive Network

PASATAs described, the PASAT is a sensitive measurefor detecting changes in cognitive functions af-ter cognitive intervention. We analyzed PASATtest scores in two ANOVAs investigating theeffect of practice and the effect of type of inter-vention (APT and brain injury education). Athree-way repeated measures ANOVA analyzedthe effect of practice (first, second, and thirdsession), trial (slow and fast), and vigilancelevel (low and high). The analysis revealed asignificant effect of vigilance, F(1, 12) = 11.60,MSe = 432.20, p < .01. High-vigilance patientshad higher scores on the PASAT than low-vigi-

lance patients (35.2 and 19.6, respectively). Theeffect of trial was also significant, F(1, 12) =4.71, MSe = 30.70, p = .05. As expected, scoreswere higher in the slow trial than in the fast trial(29.90 and 27.0, respectively). Practice was sig-nificant, F(1, 12) = 12.24, MSe = 19.80, p <.0003, and significantly interacted with vigi-lance level, F(1, 12) = 5.50, p < .02. High-vigi-lance patients showed greater improvementacross sessions (30.0, 35.60, and 39.90 in thefirst, second, and third sessions, respectively)than low-vigilance patients (18.70, 19.30, and20.70 in the first, second, and third sessions,respectively).

The effect of intervention was analyzed usingimprovement scores as dependent variables. Thefour-way mixed ANOVA examined the effect ofthe between-subjects factors, order (APT firstand brain injury education first) and vigilancelevel (low and high) and the two within-subjectsfactors, intervention (APT and brain injury edu-cation) and trial. Only two effects reached sig-nificance in this analysis. Vigilance level wassignificant, F(1, 10) = 15.39, MSe = 15.22, p <.003. High-vigilance patients showed a greaterimprovement than low-vigilance patients (4.9and 1.0, respectively). More importantly, theeffect of intervention was significant, F(1, 10) =4.96, MSe = 58.80, p = .05. This effect indicatesthat improvement in PASAT scores were alwaysgreater after APT than after brain education.This effect did not interact with vigilance level,F(1, 10) < 1, indicating that both groups of pa-tients benefited more from APT than from braineducation.

These results indicated that patients improvedin PASAT performance across sessions. Moreimportantly, in each session, improvement afterAPT was greater than improvement after braininjury education, suggesting that APT had a spe-cific effect on the cognitive functions measuredby the PASAT. Performance on the PASAT de-pended on the vigilance level of the patients:Patients with a higher vigilance level had higherPASAT scores and showed a greater improve-ment across sessions. However, both groups ofpatients benefited more from APT than frombrain injury education.


1 A MANOVA computed on non-transformed scoresof the two measures gave similar results. In particular,both the order X session and the order X session Xvigilance interaction were significant in the analysisexamining the effect of intervention.

Stroop and Trails BThe Stroop task and Trails B, both dependentupon executive networks, showed a similar im-provement with practice and therefore were ana-lyzed together. In the Stroop task, we used errorinterference (errors in the congruent conditionminus errors in the incongruent condition). Per-formance in Trails B was measured as a differ-ence in time between Trails A and Trails B. Weanalyzed the data of these two tasks in the sameANOVAs. To obtain comparable measures, wetransformed both the raw scores and the im-provement scores into rank values (larger valuesindicate better performance, Whyte et al., 1997).Only 12 participants were included in theseanalyses. Two participants were color blind andcould not perform the Stroop task; one of thesetwo participants was not able to complete TrailsB.

Only two effects reached significance in thesecond analysis: The main effect of treatment,F(1, 8) = 12.63, MSe = 39.50, p < .01, and treat-ment × vigilance level interaction, F(1, 8) =8.23, MSe = 39.50, p < .03. Figure 3 shows thetwo-way interaction. Patients in the high vigi-lance group did not show any difference be-tween improvement after APT and improvementafter brain education. Patients with low vigi-lance scores, however, showed a pattern similarto the PASAT analysis. Improvement wasgreater after APT than after brain education bothin the second and the third testing sessions.1

These results indicate that high-vigilance pa-tients perform better than low-vigilance patients,but that vigilance does not influence practice.However, vigilance does influence the effect ofintervention: Only patients with low vigilancescores benefit more from APT than brain educa-tion.

Working MemoryPerformance in working memory tasks are fre-quently related to executive control measures

(Smith, 1999). Accordingly, we included perfor-mance on our two working memory tasks, mem-ory for letters and memory for locations. Twoparticipants did not perform the Sternberg mem-ory tasks because they were color-blind andcould not distinguish the target items from theprobe item. In this task, performance was mea-sured as percentage of errors. Two separateanalyses were carried out on the letter task andon the location task. The dependent measure wasimprovement in the error percentage scores be-tween first and second session and between sec-ond and third session. The independent mea-sures were order (APT first and brain injury ed-ucation first), vigilance level (low and high),and session. None of the effects were significantin the letter task analysis, indicating that in thistask there was a similar improvement in the sec-ond and the third session, and no difference be-tween APT and brain injury education interven-tions.

In the location task, however, there was a sig-nificant order × session interaction, F(1, 8) =5.97, Mse = 133.36, p < .05, indicating that im-provement from the previous session wasgreater after APT than after brain education(10.8% and 3.4%, respectively).

This result indicates that APT had a specificeffect on working memory for location. Accu-racy on this task improved more after APT thanafter brain injury education in both the secondand the third sessions.1

COWATThe COWAT, also a measure of frontal func-tions, was analyzed for the effect of practice byusing a two-way mixed ANOVA that examinedthe effect of vigilance level (high and low) andpractice (first, second, and third session).COWAT scores served as the dependent mea-sure.

COWAT scores were influenced by the vigi-lance level, F(1,10) = 11.88, Mse = 172.27, p <.01. Patients with higher vigilance scores hadhigher COWAT scores than patients with lowvigilance scores (34.4 and 19.6 respectively).The effect of practice approached significance,F(2,20) = 3.47, Mse = 11.22, p= .05, indicatinga slight increase in performance across sessions


0

4

8

12

16

20

24

High Low

Vigilance Level

BIAPT

Intervention

Fig. 3. Improvement on Stroop and Trails B-A scores as a function of intervention (APT and Brain Education),order (APT-Brain Education and Brain Education-APT), and vigilance level. Improvement is measuredin score ranks. The bars indicate one standard error.

0

5

10

15

20

25

2nd session 3rd session

High Vigilance

BE-APT

APT-BE

2nd session 3rd session

Low Vigilance

-8

-6

-4

-2

0

2

4

6

8

10

12

2nd Session 3rd Session

BE-APT

APT-BE

2nd Session 3rd Session

High Vigilance Low Vigilance


(26.10, 28.0, and 30.0 for sessions one, two, andthree respectively). However, the analysis ofCOWAT improvement scores did not show anysignificant effect. In particular, improvementwas not influenced by intervention.

These results indicate a difference betweenCOWAT and other tests associated with frontalfunctions. Although participants show a slightimprovement in COWAT scores as a function ofrepeated testing, improvement was not influ-enced by intervention, F(1,10) < 1.

SummaryOverall there were improvements in perfor-mance with practice for all of these tasks exceptmemory for letters. For PASAT, Stroop, Trails,and memory for locations there were also spe-cific improvements in performance associatedwith APT that were greater than those associatedwith brain injury education. In the case ofStroop and Trails, the specific improvementwith APT was limited to low vigilance perform-ers.

Vigilance NetworkA MANOVA was carried out on three measuresof vigilance (number of hits on the Gordon Vigi-lance task, Gordon Distractibility task, and CPT)as a function of practice (first, second, and thirdsession). In this analysis, the dependent variablewas number of hits. The analysis revealed a sig-nificant effect of practice, F(6, 50) = 2.32, p <.05, indicating a progressive improvement ofperformance across sessions. Average vigilancescores were 21.70, 23.90, and 24.80 for first,second, and third session, respectively.

A second analysis was carried out on im-provement scores in the second and third ses-sions and examined the effect of order and treat-ment. None of the effects were significant. Inparticular, the effect of treatment was far fromsignificant, F(3, 10) < 1, p > .65, indicating thatintervention did not influence vigilance im-provement on these tasks.

These results show that performance on thesethree vigilance tasks improved across sessions,but improvement was similar after APT and af-ter brain education. Therefore, APT did not

seem to have any specific effect on the vigilanceperformance of patients with TBI.

Orienting NetworkThe validity effect on the covert orienting task(valid minus invalid trials) and times on theTrails A of the Trail Making Test were used asmeasures of visuo-spatial orienting abilities.Two MANOVAs carried out on these measuresdid not show any effects of practice or interven-tion. Therefore, there is no evidence in thesedata of an improvement in performance acrosssessions or of a specific benefit of APT.

QuestionnairesA multivariate analysis of the three question-naire scores (Attention questionnaire, DEX, andBROCK) showed a significant effect of practice(improvement in reports of functioning overtime), F(6, 50) = 3.36, p < .01. However, therewas not significant interaction between sessionand order, F(3, 8) < 1, p > .65, indicating thatimprovement in the response to the question-naires was not differentially influenced by thetype of intervention. (Due to attrition in the sig-nificant others, their questionnaire data were notanalyzed.)

DISCUSSION

Research QuestionsThe results of this rather small-scale study pro-vide support for differential effects of therapeu-tic strategies in the rehabilitation of patientswith acquired brain injury. All aspects of thestudy suggest that practice, whether by repeatingthe assessment tasks, or from participating in thetraining of general processes using APT, im-proves performance. In addition, teaching aboutbrain injury issues appears to improve the atti-tude of patients.

The first research question focused on com-paring the effects of attention process trainingwith brain injury education. APT seems to im-prove performance on a wide range of tasks thatinvolve executive functions and attentional con-trol. Because the tasks used in the APT were


different from the neuropsychological tests usedto assess cognitive functions, improvement onthose tests represents a generalization of learn-ing. These findings are consistent with otherevaluations of attention process training whichsuggest that associated cognitive changes are notcaused by simple nonspecific cognitive stimula-tion (e.g., Neimann, et al., 1990; Sohlberg &Mateer, 1989; Sturm, et al., 1997; Wood &Fussey, 1987).

Subjective patient report from structured in-terviews also suggests a positive effect of APTon executive control and working memory. Pa-tients reported more changes in cognitive func-tion following APT and more changes in psy-chosocial functioning following the brain injuryeducation. Those who reported more cognitivechanges also had greater improvements on thePASAT.

The second question was to explore whichbrain networks would benefit the most from in-tervention. The improvement due to APT in ourstudy appears to be confined to tasks that drawon executive function and is not present in tasksinvolving mainly vigilance or mainly orientingtoward sensory signals. Again, this is consistentwith other reports showing effects of attentionprocess training. Similar to our study, Park et al.(1999) reported improvements on a workingmemory task, consonant trigrams, which wasspecific to attention process training. It is notknown in that study whether improvements onthe PASAT for the head injury group who re-ceived APT were due to practice, APT, or acombination of the two since the normal controlgroup who were given the PASAT twice withoutany intervention showed a practice effect on se-rial administration of the PASAT.

In a separate study of our same patients(Pavese, Heidrich, Sohlberg, McLaughlin, &Posner, 1999), we found clear evidence of im-pairment in the ability to control stimulus inputin the Stroop task. Normal participants showeda difference between neutral and color word tri-als over electrodes that appear to involve ante-rior cingulate activation. This was missing in thepatient population. Additional comparisons be-tween patients and normals indicated difficultyin communicating information between brain

areas. We speculate that the repetitive trainingin APT might help to restore some of these con-trol mechanisms.

The third and fourth research questions fo-cused on the role of practice and the role of pa-tient vigilance levels. We found interesting dif-ferences in test practice and intervention effectsin high- and low-vigilance patients extendingSturm et al.’s (1997) findings. The significantfinding in this study was that for low-vigilanceparticipants, APT resulted in improvedattentional skills, which generalized to measuresthat were different from the training tasks. Thestudy also showed that for the more demandingattentional (or working memory) activity re-quired by the PASAT, the treatment effect wasalso apparent for less impaired (high vigilance)participants.

An important clinical implication of thisstudy is the encouragement to use structuredinterview to ascertain how attention is employedin day-to-day life. Although the indices pro-vided by the standardized questionnaires andneuropsychological tests gave a quantitativemarker for the level of impact on daily life pro-duced by the attention deficits, they did not pro-vide specific information on the nature of theimpact. This information was only revealedthrough the interview. For example, a number ofparticipants showed no response to treatment asmeasured by the questionnaires, but when inter-viewed spontaneously gave examples such as ‘‘Ican watch a whole movie’’, ‘‘I can drive andlisten to the radio’’, and ‘‘I can remember phonenumbers’’. Perhaps due to the concrete nature oftheir thinking, the participants did not notechanges unless they were asked about a specificactivity with relevance to their lives.

The fundamental shortcoming of the com-monly employed questionnaires, checklists, andrating scales is that they do not produce authen-tic data; rather, they give an indication of differ-ent individuals’ perceptions of functioning. Analternative assessment paradigm that offers amodel for ecological measurement of real worldfunctioning is the functional assessment modelused in special education to assess children whoare displaying severe behavioral problems(Lucyshin, Albin, & Nixon, 1997; O’Neill, Hor-


ner, Albin, Storey, & Sprague, 1990). Thismodel allows individuals and caregivers to gen-erate and test hypotheses about the contexts sur-rounding problem behaviors. Another relevantassessment model is the Communication Profil-ing System, which uses interpretive researchmethods to evaluate the impact of a communica-tion impairment (i.e., the communication handi-cap) on an individual’s daily life (Simmons-Mackie & Damico, 1996). Cognitive rehabilita-tion may benefit from exploration of such mea-surement paradigms.

In addition to encouraging the use of struc-tured interview in the assessment of attention,this study supports Kinsella’s (1998) call forimprovement of formal measures of attention.Participants performed differently on the variousattention tests. Kinsella (1998) notes the diffi-culty of using neuropsychological measures thatare multifactorial and calls for standardizedmeasures to evaluate discrete components ofattention. She further calls for more analyses ofthe relationship between psychological tests andtheoretical constructs of attention in order toimprove assessment.

Future StudiesKnowledge gained from this study helps set thestage for future inquiries. One important area ofconsideration for future investigations concernsthe formation of participant groups. Larger num-bers of participants, the use of a control group,and matching participants would strengthen thestudy. A control group that receives serial mea-surements without any treatment would enhanceexperimental control. Furthermore, in our study,the two groups were not matched for importantdemographics such as education and may haveresponded differentially to the treatment. Addi-tionally, follow up measures would strengthenour understanding of intervention effects. Werecognize that the complexity of this populationincluding the difficulties in identifying matchedcontrols and the required length of time to studyintervention effects creates challenges for mak-ing these improvements in methodology.

Future studies would further benefit fromusing clinicians who were blind to the study de-sign and participant group assignment. Although

every effort was made to follow the objectiveexperimental protocol, the current study mayhave introduced an experimental bias effect byhaving the authors provide some of the interven-tion. Ultimately, replication of findings will bethe test of cognitive treatment effects.

This study encourages looking at specific pa-tient profiles in order to predict who may bemost responsive to practice and/or attentiontraining. Further investigation of whether vigi-lance levels affect responsiveness to interven-tion is warranted. Investigation of other vari-ables such as IQ and educational backgroundmay also be enlightening.

The current study employed an existing reha-bilitation program that is loosely based on a the-oretical attention hierarchy and used selectedneuropsychological tests and cognitive markertasks to measure different aspects of attention.An advantage of this approach was that wecould look at a wide range of possible effects.The disadvantage of this approach, however, isthat there may have been enhanced treatmenteffects if the materials and assessments weregenerated from the same theoretical framework.Having completed this initial broad study ofpossible attention training effects, future investi-gations might benefit from closer linkage be-tween the rehabilitation materials and the as-sessment tools. For example, a series of separatestudies that evaluate training of discrete atten-tion networks might be revealing.

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APPENDIX

Examples of changes perceived to be related to treatment given during structured interviewsComments following attention process training from participant interviews:

• I can remember phone numbers better (4 individuals).• I can watch a whole movie.• I read more (2 individuals).• School is a lot easier because I can read better and pay attention more.• I check my memory log more often.• When I type up the poems I have written, I don’t have to look back at the page for each word.• I remember my appointments better.• I am less rigid and ritualized about everything and I don’t have to do stuff in the same way, like

when I clean the barn I can insert different steps and don’t double check everything.

Comments following attention process training from significant other interviews:• She can hold on to a conversation better.• She remembers more of her appointments on her own.• Her reading is better.• He is reading more.

Comments following placebo intervention from participant interviews:• I check my day-timer and e-mail more often.• I check my calendar.• I know more where I am going when I leave my place.• I remember my appointments.• I remember to put appointments in my book.• Getting up in the morning feels easier.

Comments following placebo intervention from significant other interviews:• He remembers where he was sitting.

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