What SLPs Need to Know:
Treating Attention in Speech Therapy

Causes of Attention Impairment in Adults

Any brain injury or neurological disease, like a stroke or dementia, can impair attention. The nature of the deficit depends on several factors, such as the location of the brain damage. Some examples include:

• Subcortical structures: injuries to the thalamus can affect focused and sustained attention
• Right parietal lobe: can result in left neglect (reduced visual attention to the left side of space)
• Frontal lobe structures: damage to areas such as the dorsolateral prefrontal cortex can affect high-level attention processes like alternating and divided attention

Even those with “mild” brain injuries like a concussion can still present with impaired attention. “Brain fog,” which includes reduced attention, is often experienced as a side effect of chemotherapy, depression, long COVID, hormonal changes from pregnancy or menopause, and autoimmune conditions like MS or lupus.

Note: There are attention deficits present in children and adults that are not the result of a brain injury or disease. ADHD is a developmental condition characterized by executive dysfunction. This is outside the scope of this article, which focuses on the rehabilitation of acquired attention impairments.

Direct Attention Therapy

Direct therapy focuses on rebuilding attention through practice. Here are some effective methods:

Attention Process Training (APT)

Attention Process Training is a commercially-available treatment protocol that provides structured, intensive, and repeated practice. It includes tracks corresponding to each type of attention, with activities such as cancellation tasks, listening, sequencing, mental math, and card sorting. There are 3 versions of APT:

• APT I: For individuals with severe attention impairments.
• APT II: For those with less severe impairments, such as concussion.
• APT III: A comprehensive computer-based program that is an update to APT I and APT II. It emphasizes attention strategies and self–regulation. APT III also includes generalization activities to practice techniques in more natural settings.
  
  Note that the APT-3 Clinical Attention Framework does not include divided attention, instead focusing on executive control processes such as working memory and suppression.

In a randomized controlled study, participants who used the APT program reported greater improvements in work performance skills, maintaining focus, and adjusting to changes compared to the group of participants who received activity-based attention training (Landahl et al., 2021). Some researchers believe that APT could be helping patients develop attention strategies as opposed to restoring attention functions directly.

Larger and more rigorous studies are needed to determine if computer-based training generalizes beyond the training. However, a systematic review showed promising evidence that computerized cognitive training can improve attention and executive functioning in TBI survivors.

Visual Scanning

Visual scanning is an attention treatment method often used for individuals with left neglect. It involves scanning visual fields from left to right with fading cues to improve attention to the left side of space. Cues might include a colored bar or anchor on the left side of the page or numbered rows in the left margin of text to ensure each line is read. Learn more about visual scanning in this step-by-step guide.

The Visual Search treatment in the Tactus Virtual Rehab Center makes it easy to work on visual attention. Patients locate a specified symbol in a field of distractors to target sustained and selective attention. This interactive digital treatment provides repeated practice of increasing complexity based on the patient’s performance, along with immediate feedback and visual cues as needed.

PRO TIP: Try adding background noise or having a conversation during this treatment to increase the cognitive load.

Dual-Task Training

Dual-task training is another treatment approach to improve alternating or divided attention, and generally stimulate cognitive processes. Treatment can involve doing one cognitive task and one physical task simultaneously, like walking while doing a verbal fluency activity. Not only could this potentially impact neurogenesis (the formation of new neurons), but it can also improve walking speed and balance (Ali et al., 2022).

Dual-task training can also use simultaneous cognitive tasks. The INCOG 2.0 guidelines note that patients should first practice the tasks individually before combining them. This approach works best when the tasks are based on real-life needs to ensure carryover.

Strategies for Attention Rehab

Metacognitive Strategies for Attention

Metacognitive strategies are techniques that help us think about our own thinking and are a vital part of cognitive therapy. These strategies are often best for people with more mild impairments as they require a fair bit of attention to learn, remember, and use.

Metacognitive strategies specific to attention help patients to:

1. anticipate the demands on their attention,
2. monitor their concentration, and
3. change their behavior to maximize their performance.

Time Pressure Management (TPM) is a strategy-based approach, which has four rules:

1. Analyze Time Pressure: Break the task into smaller steps and figure out which steps may introduce time pressure. Think about ways you can manage it.
2. Prevent Time Pressure: Figure out if any steps can be done ahead of time, like setting up the environment.
3. Handle Time Pressure: Create an emergency plan if there’s unexpected time pressure.
4. Monitor Task Performance: Reflect on how successfully the task was completed.

Several elements of the Time Pressure Management framework have been built into the Tactus Virtual Rehab Center in 2 unique treatments: Planning Tasks and Planning Your Tasks. These executive function treatments include time estimation and pressure prediction steps built into a sequence.

External Strategies for Attention

There are two general types of external strategies for attention rehab:

1. Environmental Modifications: Simple changes like working in a quiet space or silencing notifications can boost concentration.
2. External Aids: Tools like alarms paired with checklists can reduce the cognitive demands of a task. Choosing the right external aid depends on the age, type of deficit, and lifestyle of the patient.