Can Disabilities Resulting from Attention Impairments be Effectively Treated

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Can Disabilities Resulting from Attention
Impairments be Effectively Treated?

• McKay Moore Sohlberg, Ph.D.
• University of Oregon
• Teaching Research

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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

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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

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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)

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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

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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)

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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

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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)

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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
• Buttheres enough evidence to keep trying

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Disability Markers RevealMixed 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)

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Training of Specific Skills

• Treatment aimed at assisting individuals to learn
  or relearn skills of functional importance to
  them

• 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).

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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)

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Evidence of the effects of specific skills
training is the improvement on the target task
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Metacognitive Strategy Training

• Emphasize behavioral methods to train specific
  attention skills
• Help individuals achieve internalization of
  strategies for controlling and monitoring
  attention

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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)

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Impairment-level Changes

• All three studies reported improvements on
  standardized tests measuring speed of processing,
  memory, and/or complex attention.

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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)

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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.)

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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)

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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)

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Accommodations/Environmental Modification

• Possible modifications
• Task instructions
• Task expectations
• Supports for task completion
• Physical environment

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For exampleclassroom 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)

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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)

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Detailed Case Descriptions

• Source of evidence for reduction in disability
  associated with implementation of
• Accommodations
• Collaborative Approaches

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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.

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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

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Disability Markers

• 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)

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Disability Markers

• 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)

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Disability Markers

• 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)

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Disability Markers

• 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)

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Disability Markers

• Anecdotal reports

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

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Disability Markers

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

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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 scalingif this treatment were
  successful, how would you know?)
• Implement and monitor--evaluate your new evidence

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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

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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)

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References

• available at
• www.think-and-link.org