R The Specificity of Attention Retraining in E P Traumatic Brain Injury O R T Louise Penkman Catherine A. Mateer Attentional deficits are a very common complaint following that attention training tasks and intensity of treatment do vary traumatic brain injury (TBI). Concentration problems, together widely across studies. In addition, an emphasis on training of with poor memory, are reported to be among the most common attention skills is often only one component of a more post concussive cognitive complaints (Binder, 1986). It has been comprehensive rehabilitation program. The program may also suggested that many apparent failures of memory are due to include awareness training and/or psychotherapeutic support to attention dysfunction and that this problem contributes assist the individual in dealing with the emotional consequences substantially to difficulty with reintegration into independent of sustaining a brain injury and coping with changes in living and vocational settings (Sohlberg & Mateer, 1989). Brooks functioning. Therefore, it remains unclear whether attention and McKinlay (1987) reported that attentional impairment predicts training per se is beneficial (Goransen, 1997). return to work after head injury. For example, Palmese and Raskin (2000) administered attention There has been considerable clinical and research interest in training to three adults with mild traumatic brain injury. Following the potential for improving attention skills. Attention interventions their treatment, the three adults participated in six to seven typically involve administration of a series of cognitive exercises sessions of brain injury education and a focus on the application that place increasingly greater demands on the attention system. of cognitive abilities. This condition was considered to be a no- Research in this area has produced somewhat mixed results. treatment control. However, all three of the participants showed While many studies have provided support for the efficacy of some change after both the attention training condition and the attention training, (Sohlberg & Mateer, 1987; Neimann, Ruff & no-treatment control condition. It is difficult to ascertain if the Baser, 1990; Gray & Robertson, 1989; Gray, Robertson, Pentland differences in performance on neuropsychological tasks noted & Anderson, 1992; Sturm, Willmes, Orgass & Hartje, 1997; after the no-treatment control were due to carry-over effects of Cicerone et al., 2000; Sohlberg, McLaughlin, Pavese, Heidrich & the attention training or to non-specific change related to both Posner, 2000; Palmese & Raskin, 2000), other authors have found conditions because there was no counter-balancing for order. more equivocal results (Gauggel & Neimann, 1996; Park, Proulx Similarly, other studies have included a psychotherapeutic & Towers, 1999; Malec, Jones, Rao & Stubbs, 1984; Gansler & element as part of the intervention but have not evaluated its McCaffrey, 1991; Ponsford & Kinsella, 1988). impact on outcome (Park, Proulx, & Towers, 1999; Middleton et Park and Ingles (2001) conducted a meta-analysis of 30 studies al., 1991). that evaluated the efficacy of attention interventions. They In a large meta-analysis, Carney and colleagues (1999) reported concluded that retraining attention only produces a small, non- no treatment effect when cognitive rehabilitation was compared statistically significant improvement on outcome measures. with another form of treatment. They stated the need to test the However, their study sample included studies evaluating differential effects of general stimulation versus cognitive interventions for individuals with stroke and surgical lesions in rehabilitation. Similarly, Wilson (1993) has suggested asking addition to traumatic brain injury. Differential response for these questions that tease out the effects of particular rehabilitation groups to rehabilitative interventions may have impacted their procedures as they are applied to particular patient groups. results. The patients represented in their meta-analysis had A few studies do attempt to provide data relevant to this primarily severe injuries so their findings cannot be generalized issue. Ruff and colleagues (1989) conducted a randomized group to individuals with injuries of mild to moderate severity. The design study aimed at separating specific treatment effects from nature and duration of the interventions evaluated were highly those of stimulation and social support. In their study two groups variable. Outcome measures were also highly variable and were of 20 subjects received different treatments. Their control group analyzed in aggregate and this may also have contributed to the received sessions focusing on psychosocial adjustment, leisure, negative findings. In addition, the exclusion criteria described in activities of daily living, coping skills and health. The experimental this meta-analysis were somewhat unclear and excluded frequently group received computerized training in attention, memory, spatial cited studies in this area (e.g., Sohlberg & Mateer, 1987). integration, and problem solving. Both groups received 50 minutes A significant problem with this body of literature is the fact of group psychotherapy at the beginning of each day. At post- Louise Penkman, PhD., Alberta Children’s Hospital, Oncology Pro- test, both groups improved significantly on neuropsychological gram, 1820 Richmond Road, S. W., Calgary, Alberta, T2T 5C7 and measures in all areas except for spatial integration. The relative Catherine A. Mateer, Department of Psychology, University of Victoria, efficacy of the two treatments was not demonstrated but statistical Victoria, British Columbia, Canada. trends in the data suggested that the experimental group made Spring 2004 - The Journal of Cognitive Rehabilitation 13 R E P O R T larger gains in almost all areas. Their data suggest that the enriched further support for the efficacy of APT in improving attentional environment characteristic of the therapeutic milieu yields some functioning. The data also strongly suggest that non-specific or benefits, even in the absence of targeted, neuropsychologically psychosocial interventions that are often part of a rehabilitation based training. Their data also suggest that specific training may program do exert an effect and should not be ignored in studies have some benefit above and beyond what is provided by a examining the efficacy of cognitive rehabilitation or attention supportive therapeutic situation but this conclusion is tentative. retraining techniques. The primary goal of the current study was An additional difficulty with this study is the fact that all to determine if there is a specific effect for the administration of participants received psychotherapy and the impact of this attention training above and beyond a supportive, compensatory intervention on outcome was not considered. In a later paper, and adjustment-focused approach. Ruff and Niemann (1990) reported on the impact of cognitive A secondary goal of this study was to determine if remediation versus psychosocial day treatment on emotional and neurophysiological correlates of attention change after attention psychosocial variables. They predicted an increase in affective retraining, implicating the occurrence of underlying neuronal distress after participation in cognitive remediation and a decrease recovery/change. The P300 and N200 event related potentials after participation in the day program. Using the design described (ERPs) were recorded because of their association with cognitive above, they found that their hypotheses were not supported. processes. The P300 is considered a neurophysiologic index of Both groups demonstrated a reduction in symptoms of attention capacity in humans (Deacon-Elliott, Campbell, Suffield psychosocial distress. These findings underscore the importance & Proulx, 1987; Polich, 1998; Picton, 1992). The N200 is associated of considering separately the impact of cognitive rehabilitation with evaluation of stimulus information required for response and psychosocial interventions in outcome studies. selection (Gevins & Cutillo, 1971). The P300 has been shown to In a study focused specifically on attention training, Sohlberg, be both reduced in amplitude and delayed in latency in the TBI McLaughlin, Pavese, Heidrich and Posner (2000) compared population (Heinze, Munte, Gobiet, Niemann & Ruff, 1992; Attention Process Training (APT) (Sohlberg & Mateer, 1987) Papincolau, Levin, Eisenberg, Moore, Goethe & High, 1984; with a placebo condition of brain injury education using a within Campbell, Deacon-Elliot & Proulx, 1986; Rugg et al., 1988; Keren, and between groups design. Fourteen individuals with brain Ben-Dror, Stern, Goldberg & Groswasser, 1998). injury were divided into two groups and received 24 hours of Researchers have begun to employ these measures to evalu- individually administered APT over 10 weeks and 10 hours of ate brain changes following participation in attention retraining brain injury education over 10 weeks in counterbalanced order. with individuals with TBI. Baribeau, Ethier & Braun (1989) as- Dependent measures were administered at pre-test and after each sessed auditory ERPs as neurophysiological indices of selective experimental condition. Outcome measures included attention before and after an intensive, computer-dispensed cog- neuropsychological tests sensitive to attention dysfunction, nitive rehabilitation program. They utilized 21 individuals with cognitive marker tasks (tasks that have