Attention

Introduction to Attention

William James (1890/1950) defined attention as the mind taking possession, in a clear and vivid form, of one out of several possible objects or trains of thought. The core of attention is focalization and concentration of consciousness, which necessitates the withdrawal from certain stimuli to deal effectively with others.

Rationale for Studying Attention

Attention is a foundational cognitive process. When attention is disrupted, it manifests as discourse problems, impacts communication, and can significantly affect various areas of language.

Clinical Model of Attention

Sohlberg and Mateer (1987, 2001, 2010) proposed a clinical model consisting of five components:

  1. Focused attention

  2. Sustained attention (includes vigilance and executive control)

  3. Selective attention

  4. Alternating attention

  5. Divided attention

Neurophysiology of Attention

Research by Peterson & Postner (2012) and Vossel, Geng, & Fink (2014) identifies two primary networks:

  • Dorsal/posterior attention system: Responsible for basic orientation to sensory stimuli and alerting/warning.

  • Ventral/anterior attention system: Manages selective attention (monitoring for targets), conflict resolution (suppressing dominant responses, such as in the Stroop Test), and sustained attention.

Levels of Attention in Daily Tasks

Tasks require varying levels of attention based on complexity:

  • Low Demand: Reading a book or talking on the phone.

  • High Demand (Selective/Divided): Reading a book with the T.V. on or talking on the phone while children ask questions.

  • Alternating: Reading a book, switching to a breaking news story on T.V., and then returning to the book.

Assessment of Attention

Comprehensive assessment involves multiple modalities to identify real-world impairments:

  • Initial Interviews: Interviews with clients and families guide the assessment and generate hypotheses about specific cognitive impairments.

  • Rating Scales and Questionnaires: Used to gauge daily functioning.

  • Observations: Conducted to see how behavior manifests in structured and unstructured settings.

Standardized Assessment Tools

  • Test of Everyday Attention (Robertson, et al., 1996): Evaluates sustained, selective, and switching attention, plus auditory-verbal working memory.

  • Trail Making Test (Reitan & Wolfson, 1995): Assesses visual attention and task switching via Part A (11 to 22 to 33…) and Part B (11 to AA to 22 to BB…).

  • Wechsler Adult Intelligence Scale IV (WAIS-IV, Wechsler, 1997a): Includes subtests like Symbol Search (selective attention) and Letter-Number Sequencing (sustained/divided attention).

  • Computerized/Specific Tests: Stroop Test (conflict resolution), Continuous Performance Test (CPT), and the Attention Network Test (ANT).

Attention Treatment: Direct Attention Training (DAT)

Sohlberg et al. (1994) developed Direct Attention Training (restitutive), which uses repetitive drills to improve neurocognitive capacity:

  • Sustained Attention: Activities like listening comprehension.

  • Selective Attention: Sustained tasks performed with background distractors.

  • Alternating Attention: Switching between tasks, such as adding +2+2 and subtracting −3-3 from a target number.

  • Divided Attention: Multi-tasking, such as reading a paragraph while counting the instances of a specific word.

  • Program Focus: The Attention Process Training (APT-3) is a standard program for persons with acquired brain injury.

Self-Management and Environmental Strategies

  • Orienting Procedures: Training clients to self-monitor by asking: "What am I doing?", "What was I doing before?", and "What is next?".

  • Pacing: Breaking tasks into intervals or scheduling demanding tasks for times of day when the client has the highest energy.

  • Environmental Support: Modifying the physical environment to reduce cognitive load (e.g., using filing systems, reducing clutter, or using "do-not-disturb" signs).

Clinical Applications and Summary

Attention interventions are applied to several conditions, including Right Hemisphere Disorder (visual neglect), Dementia, Traumatic Brain Injury (TBI), and Aphasia. Effective treatment combines direct training, self-management, and environmental modifications.