After years of futilely googling “brain injury treatment,” I leaned on my background of research and knowledge of ADD (attention deficit disorder) and googled “ADD treatment.” I’d never had problems with my concentration before my brain injury, but I believed that the enormous difficulty I was having paying attention to anything must be what ADD is like. The symptoms overlap. So maybe treatment for ADD could work for brain injury. But I didn’t want symptom management; I wanted permanent repair. To that end, I returned again and again to what rehab had taught me about attention. I say, “again and again,” because you can’t retain post-injury learning when you can’t concentrate.
“Attention is the behavioral and cognitive process of selectively concentrating on a discrete aspect of information, whether considered subjective or objective, while ignoring other perceivable information. . . .
A relatively new body of research, which expands upon earlier research within psychopathology, is investigating the diagnostic symptoms associated with traumatic brain injury and its effects on attention.”
https://en.wikipedia.org/wiki/Attention
Overview
We all know brain injury exists, but what does brain injury mean to you? I suspect, like for most of us, you perceive it as some sort of injury you rest up from and that happens to someone else. You don’t think about all the ways brain injury manifests and changes you.
For example, you go through life not worrying about how you pay attention in your work or at a party or reading a book—unless you have Attention Deficit Hyperactivity Disorder or something similar—until life smacks you across the head, ringing your brain. Suddenly, attention becomes über important to you and those around you because it’s gone. Its loss becomes a source of pontificating and judging from loved ones and strangers who’d rather not know about it, pretend nothing’s changed, and accuse you of making excuses when you can’t finish a task or tolerate a party.
without the ability to concentrate, it’s difficult to remember
Attention is also better understood by some psychologists than others in the brain injury field. It is astonishing to me that attention after brain injury is a relatively new field of study. Without the ability to concentrate, it’s difficult to remember, learn, write, read, problem solve, make decisions, work, do chores, shop—and socialize. I believe it’s the foundational cognition.
A Model
According to the Toronto Rehabilitation Institute and the 1994 McKay Moore Sohlberg paper Understanding Attention Impairments, there are five kinds of attention: focused, sustained, selective, alternating, and divided. (Scroll down for details.)
Wikipedia defines these as the Clinical Model of attention. I had difficulties with all five after my brain injury. Brain biofeedback restored some of them (see Solutions stage).
Fatigue and Brain Injury Effect
Before I begin, I ought to give a little background information on fatigue and brain injury. Imagine a certain task takes x amount of energy. After a brain injury, every task takes many multiple xs. Whether it’s your heart beating, breathing, eating, microwaving oatmeal, brushing teeth, opening the door, dressing, walking, navigating public transit, riding in a car as a passenger, talking, answering the phone, conversing, reading, writing, paying attention in a crowd — everything takes more energy, way more.
conscious execution of an action takes more energy than when done automatically
Automaticity
Part of the reason is that automaticity is lost. Conscious execution of an action takes more energy than when done automatically. We acquire automaticity in childhood and when learning new skills. But when the brain has to execute a skill or function whose neural pathways have been injured, it either can’t do it without treatment or transmits slower and takes more energy in order to do so. That drain is felt in the moment and oftentimes for days afterward as the brain recovers from the work it did.
That’s why priorities about when to exert which attention have to be set.
Attention Biases After Brain Injury
One pays attention to a task or person with one’s brain, but it’s done through the senses. Although this page is about attention in general, attention is mediated through each sense differently, depending on the person’s strengths and weaknesses and location of the injury. For example, one can pay attention to auditory stimuli but struggle with visual stimuli. Brain injury may disrupt your bias by damaging your dominant area. For example, if you’re biased toward visual stimuli prior to injury, but the brain injury impaired vision but not auditory perception, then after injury, you can attend to auditory stimuli easier. Understanding that this kind of radical sensory processing change has occurred and then adapting to it takes time.
Types of Attention
Selective Attention
Selective attention allows you to ignore distractions in the environment and pay attention to important information, like the person you’re listening to.
As anyone who’s sat across from me at a coffee shop while I’m facing the window knows, I get easily distracted by cute dogs passing by, people walking, cars zipping across my field of vision, and changing traffic lights. If I face indoors, then I get distracted by the noise of conversations, the servers, and the odd quirks of people eating. If I face a wall, I can focus better, but I hate facing walls. Perhaps it’s a relic of my pre-injury claustrophobia.
Regardless, if I can’t see a person’s mouth, I have a much harder time understanding them because it’s harder for me to discriminate or select between auditory stimuli. It has nothing to do with my hearing because I have excellent hearing, always have had. But as can be typical for a person with a concussion or brain injury, the injury ratcheted up my senses and damaged my filters. I hear everything: the clock ticking, cutlery dropping, plates being clanked, wrappers crinkling, people coughing, punctuations of laughter, footsteps. Those noises grab my attention like someone grabbing your coat collar. If those noises are in a theatre, they’re like gunshots to the head. If someone applauds behind me, it’s a physical sensation on my ears and back. They compete with what I’m supposed to be focusing on. And that’s just one sense. Vision, smell, and touch also became hypersensitive. If auditory and visual noise is all around me, like at a party, they challenge my selective attention and become a great sucking vacuum on my energy levels.
“People with impairments in selective attention may become easily irritated and frustrated by such extraneous noise.”
McKay Moore Sohlberg paper, https://studylib.net/doc/7675348/understanding-attention-impairments
Grumpyface — from the Doctor Who episode “The Time of Angels,” when being distracted is fatal—is a good descriptor!
Alternating Attention
Alternating attention allows you to switch your attention easily from task to task or person to person in a group or party. Apparently, this is a high-level attention skill.
I find it takes me a moment when I have to switch my attention. When someone suddenly forces me to switch attention by popping up behind me, asking a question, demanding I switch attention instantly from what I was doing or saying, without a gentle intro hello, it slows me down more. Of course, this happens naturally when the phone rings or in parties when someone will appear from seemingly nowhere and interrupts (the nowhere part is an alpha-wave open-awareness issue, where lack of open awareness leads to easy startling — see how problems start overlapping?).. In my cultural background, this kind of interruption is rude but pretty commonplace in North America. A normal person may get a bit annoyed with the rudeness of the interruption, but a person with a brain injury will feel discombobulated and overwhelmed at the sudden need to switch attention and thus become extremely irritated.
Divided Attention
Divided attention allows you to pay attention to two or more things at once. Another way to look at this is multitasking.
A common divided attention scenario is driving a car and listening to the radio at once (frankly, I think “simultaneous attention” would be a better moniker). With poor divided attention skills, I can’t be a passenger in a car and listen to the radio at the same time, especially when the car starts to move at 50 or 60 kph or more, at which point the speed of sensory input overloads my brain’s ability to process the input quickly enough. It’s like being in an IMAX 3D movie theatre watching Star Trek and suddenly the screen in front of you goes to warp speed and Kirk is calling for Spock behind your seat and the person beside you dumps popcorn all over you, all at the same time.
I first fully understood I had a problem with divided attention when my father was talking to me while I was trying to slice bread. I couldn’t do it.
Focused Attention
Focused attention is the basic attention skill where you notice objects or events and specific sensory stimuli in the environment.
Think of it as when you notice a bird singing or the smell of French Toast frying.
When this skill is damaged, you may first be able only to attend to internal states, such as hunger or thirst. Then gradually or sporadically notice the room is bright because the sun is up in a cloudless sky.
Sustained Attention
Sustained attention gives you the ability to stick with an activity over time, like reading a book or writing an essay or commuting on the highway.
Inconsistent performance, varying from excellent to nonexistent—like one day remembering a phone number long enough to dial it, another day not—may be problems with sustained attention. Some days you’ll perform a task very well; other times you’ll make lots of mistakes. And still other days, you won’t be able to do a previously easy task at all. Also, becoming tired leads to being unable to sustain your attention. Your focus wanders or you become blank, with nary a thought in your head.
Discussion
Imagine having deficits in one or more of these attention types and being at a party or in a crowd—an event full of distractions by its very nature — with every sound cranked up to airplane engine level in your ears, with every visual like flashing beacons screaming “Watch me! Watch me!” and the smells of food and perfumes and shampoos shoving themselves up your nose, all demanding attention. Add to that people naturally placing demands on weak or nonexistent divided, alternating, and selective attention just by trying to converse with you or you trying to mingle.
Brain-injury awareness is about becoming mindful of what it’s like living with brain injury and learning to not insist your injured friend or family member should show up to parties or attend a talk or meeting with many people because that’s what they used to do pre-injury and if they don’t, it’s proof they’re using “excuses” or don’t care.
Awareness would hopefully lead to more people exhibiting the compassionate, human response: to understand these issues and then to listen to and accommodate the one with the brain injury when they say: “I’d rather see you over coffee, in a quiet place, one-on-one, where I can be myself, not Grumpyface, and when I won’t have to spend days recovering just because I chose to socialize.”
The alternative is to be unaccepting, to abandon your loved one with the brain injury. Or your client if you’re working with them on how to socialize while conserving functionality and energy.
The ultimate answer to these injured attention skills is to repair them through objective diagnostic tests that inform active treatment of brain injury, like with brain biofeedback. That’s the third stage of healing brain injury—to learn that such treatments exist and then to help your friend, family member, or client afford and attend them. Because a healed brain injury is better than managing an unhealed injury.
References
Sohlberg, McKay Moore. (1994). Understanding Attention Impairments. Communication Skill Builders. Inc 602-323-7500
Thompson, M., Thompson, L., Reid-Chung, A., and Thompson, J. (2013). Managing Traumatic Brain Injury: Appropriate Assessment and a Rationale for Using Neurofeedback and Biofeedback to Enhance Recovery in Postconcussion Syndrome. Biofeedback: Winter 2013, Vol. 41, No. 4, pp. 158-173.
Thompson, M., Thompson, L., and Reid-Chung, A. (2015). Treating Postconcussion Syndrome with LORETA Z-Score Neurofeedback and Heart Rate Variability Biofeedback: Neuroanatomical/Neurophysiological Rationale, Methods, and Case Examples. Biofeedback: Spring 2015, Vol. 43, No. 1, pp. 15-26