Can Disabilities Resulting from Attention Impairments be Effectively Treated?

1. Can Disabilities Resulting from Attention Impairments be Effectively Treated? McKay Moore Sohlberg, Ph.D. University of Oregon Teaching Research

2. Evidence-based medicine (EBM)(Rubenfield, 2001; Tonelli, 2001; Ylvisaker et al., 2002) We must remember: • Evidence only affects practice if it changes beliefs • RCT is one type of evidence; risky to place it at the pinnacle • Evidence necessarily includes practitioner/client beliefs and values & system resources

3. Is a hierarchy of evidence sensible for evaluating disability? • Class I: prospective randomized controlled trials • Class II: prospective cohort studies, retrospective case controlled studies, clinical series with controls • Class III: clinical series without controls, single subject methodology • Single observational studies and unsystematic clinical observations

4. Attention Impairments Changes in... • Speed of processing • Vigilance & maintenance of attention • Freedom from distractibility • Shifting attention • Working memory (“working attention”) (Brooks & McKinlay, 1987; Mateer & Mapou, 1996; Cicerone, 2002)

5. Six Intervention Approaches • Direct training of attention processes • Specific skills training • Training of metacognitive strategies • Training use of external aids • Environmental modification/task accommodation • Collaboration-focused programs

6. Disability resulting from attention impairment includes • Changes in what you do by yourself or with others • Changes in simple and/or complex activities • Changes in what you can do in a uniform environment and what you do do in your environment. (www3.who.int/icf/icftemplate.cfm)

7. The evidence • Studies evaluating direct process training are predominantly Class II • Studies evaluating metacognitive strategy training are predominantly Class III • Studies evaluating specific skills training and use of external aids are mostly single observational studies • There are no studies examining accommodations & collaboration

8. Direct Training of Attention • Repeated stimulation of attentional systems via hierarchical attention exercises • Attention divided into components that are targeted discretely (e.g., Sohlberg, McLaughlin et al., 2000)

9. Challenges in Measuring Reduction in Disability • Most studies focus on impairment-based indices which do not translate to meaningful improvement • Disability related markers are subject to floor/ceiling effects, lack of reliability, and questionable validity • But…there’s enough evidence to keep trying

10. Disability Markers Reveal Mixed Results... • Improvements via anecdotal reports (Cicerone, 2002; Sohlberg & Mateer, 1987) • Mixed reports of improvements on standardized rating scales and self report(Cicerone, 2002; Novack et al., 1996; Sohlberg et al., 2000) • Improvements via coded structured interviews (Sohlberg et al., 2000) • No improvement via direct observation (Ponsford & Kinsella, 1988)

11. driving (e.g., Kewman et al., 1985) academic skills(e.g., Glang, Singer, Cooley & Tish, 1992) vocational tasks(e.g., von Cramon & Mathes-von Cramon, 1994). Treatment aimed at assisting individuals to learn or relearn skills of functional importance to them Training of Specific Skills

12. Specific skills training uses theoretically-based instructional methods that... • clearly define the relevant skills and subskills • carefully select training examples • build in methods for systematic corrections • provide sufficient practice (Sohlberg & Mateer, 2001)

13. Evidence of the effects of specific skills training is the improvement on the target task

14. Metacognitive Strategy Training • Emphasize behavioral methods to train specific attention skills • Help individuals achieve internalization of strategies for controlling and monitoring attention

15. Metacognitive Strategy Training Specific to Rehabilitation of Attention • Self instructional statements to use when attention drifts (Webster & Scott, 1983) • Time Pressure Management (Fasotti et al., 2000) • Cognitive Rehabilitation Program (Butler & Copeland, 2002)

16. Impairment-level Changes All three studies reported improvements on standardized tests measuring speed of processing, memory, and/or complex attention

17. Disability-related change from Metacognitive Strategy Training • Improved performance on functional task(Webster & Scott, 1983; Wilson & Robertson, 1992) • Improvements in reading concentration, sexual function and vocational functioning via self report(Webster & Scott, 1983) • Improved use of time management steps(Fasotti et al., 2000)

18. Training External Aids • Effective in managing difficulties in memory and executive functions (Kim, Burke, Dowds et al., 1999) and also attention? • Examples include written/computerized reminder systems, task aids (phone dialers, pill reminders, message logs etc.)

19. Disability-based Outcome Measures(Wright, Rogers et al., 2001) • Questionnaires where participants rated ease of use for different pocket computers • Interviews about preferences, problems and device usefulness • Frequency of use data (actual use as recorded on computer)

20. Training protocols reporting successful implementation incorporate: • Needs assessment leading to individualized aid • Collaboration with caregiver • Systematic instruction • Monitoring of implementation (Donaghy & Williams, 1998; Sohlberg, Todis, & Glang, 1998; Wright et al., 2001)

21. Accommodations/Environmental Modification Possible modifications: • Task instructions • Task expectations • Supports for task completion • Physical environment

22. For example…classroom accommodations specific for attention difficulties: • Take breaks • Clear clutter • Use earplugs or headset during seatwork • Seat away from noises • Post expectations on cue cards (Thompson & Kerns, 1999)

23. Collaboration Approaches • Forming partnerships with clients and careproviders as a primary intervention • Use positive, highly contextualized everyday routines by forming aliances with “everyday people” who act as coaches (Ylvisaker & Feeney, 1998) • Teach everyday people to observe and analyze data on issues of concern (Sohlberg et al., 2001)

24. Detailed Case Descriptions Source of evidence for reduction in disability associated with implementation of: • Accommodations • Collaborative Approaches

25. It is difficult to design studies with unequivocal disability-level outcomes because of... • The heterogeneity inherent in the ABI population; • the strengths and limitations unique to each setting and practitioner ; and • the range of opinions regarding what constitutes meaningful change.

26. Bottom line? There is not sufficient evidence to recommend any one type of intervention for any particular client profile or setting There is evidence that different types of attention interventions can reduce disabilities in a variety of people with attention impairments from ABI

27. Standardized rating scales or self report measures that can be quantified Attention Rating and Monitoring Scale (ARMS) allows rating frequency of attention symptoms using five point scale (Cicerone, 2002) Attention Questionnaire allows rating frequency of occurence for attentional breakdowns in different types of attention (Sohlberg et al., 2000) Disability Markers

28. Direct observation of performance Measuring performance on attention dependent tasks such as driving (e.g., Kewman et al., 1985) or academic skills (e.g., Butler & Copeland, 2002; Glang, Singer, Cooley & Tish, 1992; Wilson & Robertson, 1992) Measuring performance on use of steps in metacognitive strategy (e.g., Fasotti et al., 2000) Frequency of use of external aid (Wright et al., 2001) Disability Markers

29. Structured interview Use of ethnographic reporting where clients' responses to questions about possible changes in functioning are analyzed and changes are coded (e.g., Sohlberg et al., 2000) Disability Markers

30. Self or caregiver report Report of improvement concurrent with therapy; such as improved functioning with use of an external aid (e.g., Donaghy and Williams, 1998; Wright et al., 2002) or a detailed case report describing changes following family collaboration meetings (e.g., Sohlberg et al., 2001) Disability Markers

31. Anecdotal reports Experimenter description of differences in global functioning such as employment and independent living pre- and post-treatment (e.g., Cicerone, 2002) Disability Markers

32. Standardized rating scales or self report measures that can be quantified Direct observation of performance Structured interview Self or caregiver report Anecdotal reports Disability Markers

33. If Talking to Clinicians... • Know intervention options (direct attention process training, specific skills training, metacognitive strategy training etc.) • Scrutinize the evidence (does the case description have application to your client?) • Develop disability related outcome measures (goal attainment scaling…if this treatment were successful, how would you know?) • Implement and monitor--evaluate your new evidence

34. If Talking to Researchers… We need to develop disability related markers that are • Feasible and practical • Reliable and valid • Meaningful to client and/or careproviders

35. Ideas for developing disability measurement paradigms... • Functional assessment (Lucyshin, Albin, & Nixon, 1997) • Interpretive research methods (e.g., Communication Profiling System; Simmons-Mackie & Daminco, 1996) • Goal attainment scaling (Sohlberg et al., in progress)

36. References • Brooks, D. N., & McKinlay, W. (1987). Return to work within the first seven years of severe head injury. Brain Injury, 1, 5-15.  • Butler, R.W., & Copeland, D.R. (2002). Attentional processes and their remediation inchildren treated for cancer: A literature review and the devleopment of a therapeutic approach. Journal of International Neuropsychological Society, 8, 115-124. • Cicerone, K.D., (2002). Remediation of ‘working attention’ in mild traumatic brain injury. Brain Injury, 16(3), 185-195. • Cicerone, K..D., Dahlberg, C., Kamar, K., Langenbahn, d.M., Malec, J.f., et al. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine & Rehabilitation, 81, 316-321. • Cicerone, K.D., & Giacino, J.T. (1992). Remediation of executive function deficits after traumatic brain injury. Neurorehabilitation, 2, 73-83. • Donaghy, S., & Williams, W. (1998). A new protocol for training severely impaired patients in the usage of memory journals. Brain Injury, 12(12), 1061-1070.

37. References • Glang, A., Singer, G., Cooley,E., & Tish, N. (1992). Tailoring direct instruction techniques for use with elementary students with brain injury. Journal of Head Trauma Rehabilitation, 7(4), 93-108. • Kewman, D.G., Seigerman, C., Kinter, H., Chu, S., Henson, D., & Redder, C. (1985). Simulation training of psychomotor skills: Teaching the brain injured to drive. Rehabilitation Psychology, 30, 11-27. • Kim, H.J., Burke, D.T., Dowds, M.D., & Georege, J. (1999). Utility of a microcomputer as an external memory aid for a memory impaired head injury patient during in-patient rehabilitation, Brain Injury, 13(2), 147-150. • Mateer, C.A. Sohlberg, M.M. & Crinean, J. (1987). Perceptions of memory functions in individuals with closed head injury. Journal of Head Trauma Rehabilitation, 2, 79-84. • Mateer, C.A. & Mapou, R.L. (1996). Understanding, evaluating, and managing attention disorders after traumatic brain injury. Journal of Head Trauma Rehabilitation, 11(2), 1-16.

38. References • Novack, T.A., Caldwell, S.G., Duke, L., Bergquist, T.F., & Gage, R.J. (1996). Focused versus unstructured intervention for attention deficits after traumatic brain injury. Jouranl of Head Trauma Rehabilitation 11(3), 52-60. • Park, N.W., Ingles, J.L. (2001). Effectiveness of attention rehabilitation after acquired brain injury: A meta-analysis. Neuropsychology, 15(2), 199-210. • Ponsford, J.L., & Kinsella, G. (1988). Evaluation of a remedial programme for attentional deficits following closed head injury. Journal of Clinical and Experimental Neuropsychology, 10, 693-708. • Robey, R. (2001). CEU part III: Evidence-based practice. ASHA Special Interest Division 2 Newsletter, 11(1), 10-15. • Rubenfield, G.D. (2001). Understanding why we agree on the evidence but disagree on the medicine. Respiratory Care, 46(12), 1442-1449. • Sohlberg, M. (in press) Evidence-based practice. ASHA Special Interest Division 2 Newsletter.

39. References • Sohlberg, M.M. & Mateer, C.A. (2001) Cognitive Rehabilitation: An Integrated Neuropsychological Approach. New York: Guilford Publication. • Sohlberg, M.M., Avery, J., Kennedy, M., Yorkston, K., Coelho, C., Turkstra, L., & Ylvisaker, M. (unpublished manuscript) Development of evidence-based practice guidelines for attention process training. • Sohlberg, M.M., McLaughlin, K.A., Todis, B., Larsen, J., & Glang, A. (2001). What does it take to collaborate with families affected by brain injury? A preliminary model. Journal of Head Trauma Rehabilitation, 16, 498-511. • Sohlberg, M.M., McLaughlin, K.A., Pavese, A., Heidrich, A. & Posner, M. (2001). Evaluation of attention process training and brain injury education in persons with acquired brain injury. Journal of Clinical and Experimental Neuropsychology. 22(5): 656-676. • Sohlberg, M.M., Todis, B., Glang, A. (1998). SCEMA: A team-based approach to serving secondary students with executive dysfunction following brain injury. Aphasiology, 12(12), 1047-1092.

40. References • Sohlberg, M.M., & Mateer, C.A. (1987). Effectivenss of an attention-training program. Journal of Clinical and Experimental Neuropsychology. 9(2). 117-130. • Thompson, J.B., & Kerns, K. A. (1999). Mild traumatic brain injury in children. In S. A. Raskin & C.A. Mateer (Eds.), Neuropsychological management of mild traumatic brain injury (pp 233-251). New York: Oxford University Press. • Tonelli, M.R. (2001). The limits ofevidence-based medicine. Respiratory Care, 46(12), 1435-1441. • Von Cramon, D.Y. &Matthes-von Cramon, G. (1994) Back to work with a chronic dysexecutive syndrome? A case report. Neuropsychological Rehabilitation, 5, 69-74. • Webster, J.S., & Scott, R.R. (1983). The effects of self-instructional training on attentional deficits following head injury. Clinical Neuropsychology, 5, 69-74.

41. References • Wilson,C. & Robertson, I. (1992). A home-based intervention for attention slips during reading following head injury: A single case study. Neuropsychological Rehabilitation, 2(3), 193-205. • Wright, P., Rogers, N., Hall, C., Wilson, B., Evans, J., Emslie, H., & Bartram, C. (2001). Comparison of pocket-compputer memory aids for people with brain injury. Brain Injury, 15(9), 787-800. • Ylvisaker, M., Coelho, C., Kennedy, M., Sohlberg, M.M., Turkstra, L. Avery, J., & Yorkston, K. (2002). Reflections on evidence-based practice and rational clinical decision making. Journal of Medical Speech-Language Pathology, 10(2). • Ylvisaker, M. & Feeney, T.(1998). Collaborative brain injury intervention: Positive everyday routines. San Diego: Singular Publishing Group.