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
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.
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.
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.
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
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.
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