What is divided attention?

Divided attention is the last and highest level of attention inthe clinical model proposed by Sohlberg and Mateer¹, in which different levels of attention are organized in a hierarchical fashion; hence, divided attention isfollowed by alternating, selective, sustainedand focused attention. This level of attention allows us to attend totwo or more different tasks simultaneously, which is commonly known as multitasking. Divided attention is used when we perform—at the same time—two activities differing in cognitive demands, or when the demands are similar but the types of stimulus to attend to differs in each activity.

The clinical model of Sohlberg and Mateer¹, establishes a dependence between the levels of attention, so that the proper functioning of the higher levels depends on the functioning of the lower levels.In the post regarding alternating attention, we explained the way in which its functioning depends onselective, sustained and focused attention. Thus, to establish the subordination of divided attention functioning to the lower levels, it is sufficient to indicate the close relationship between this level of attention and alternating attention as the authors themselves do: “divided attention may reflect either rapid and continuous alternating attention or dependence on more unconscious automatic processing for at least one of the tasks”². This statement indicates that, when it comes to carrying out a divided attention task, such as, for example, sending a message with the mobile phone while walking down the street, what we are doing is alternating very quickly between the two activities, so that we can carry them out simultaneously. In addition, the authors add that the execution of one of the tasks (e.g., walking) can be automatic.

The above example shows the numerous daily situations in which we use divided attention, and although we have always been exposed to a great deal of stimuli—especially visual and auditory—with the arrival of mobile devices (mobile phones, tablets, eBooks, game consoles, etc.) the amount of information we have to process simultaneously has increased. Thus, a task such as driving a car already implied paying attention to various visual (e.g., traffic signs) and auditory (e.g., car horns) stimuli at the same time as performing typical driving actions such as accelerating, braking, steering, etc. However, talking on acell phone and driving has become very popular these days, thereby increasing the cognitive demands, which requires the integration and smooth functioning of attention at all levels.

Considering the significant role of divided attention in our daily lives, it is not surprising that the inabilityto perform several tasks simultaneously, which commonly affect people with brain injury, substantially limitsreadjustment to school and work, as well asto everyday life. Thus,neuropsychological assessment of divided attention is imperative after a brain injury.

Assessment of divided attention

Generally, when assessing attention, the most commonly used tests assess both sustained attention(e.g., BTA) and selective attention (e.g., cancellation tasks such as the d2 test). On the other hand, in rigid batteries such as the Wechsler intelligence scales, attention is assessed by the digit span subtests (sustained attention) and letter- number sequencing (alternating attention)³. The scarcity of instruments used to assess divided attention often means that problems in this area arepushed intothe background, which in turn means that complete rehabilitation is not carried out. It may be thought that by evaluating the lower levels of attention, information can be obtained about divided attention, but ideally a complete evaluation which includes all levels should be conducted, especially in cases where the main problem is attentional. To this end, the most frequently used tool for assessing divided attention is the Paced Auditory Serial Addition Test (PASAT)⁴.

The PASAT is presented using compact disk or audio cassette tape. Single digits are presented every 3 seconds and the patient’s task is to add each new digit to the one immediately prior to it; thus, if the first digit is 5 and the second is 2, the correct answer is 7, and if the next number is 8, then the correct answer will be 10 (2+8).

Rehabilitation of attention

Much like assessment, it can also be concluded that rehabilitation of the lower levels automatically leads to improvement of the higher levels, particularlywith divided attention. However, the rehabilitation of attentionmust be comprehensive, training alllevels in a hierarchical manner, so that the rehabilitation or improvement of each level serves as a “scaffold” for the intervention of the next.

As mentioned on previous occasions, the Attention Process Training (APT) is a cognitive rehabilitation program widely used in both clinical and research settings. The APT trains sustained, selective, alternating and divided attention using paper and pencil tasks and computerized tasks including auditory stimuli. The training of divided attention in particular is done using three types of activities²:

1. Reading paragraphs for comprehension and simultaneously scanning for a target word.(e.g.,the letter h).
2. Combination of auditory sustained attention tasks with activities requiring motor response to the presence of a specific stimulus (reaction-time computer task).
3. Combination of sustained attention taskswith time-monitoring tasks(requiring tracking elapsed time).

The APT, like the NeuronUP platform (where multiple exercises are available to train different cognitive functions) is included inthe intervention programs that target deficits directly, which is known as restoration of function. However, other procedures can be performed in a neuropsychological intervention and these will be employed according toeach patient’s clinical characteristics and needs.

Such procedures or types of intervention are not exclusive, in fact, in most cases they should be used in combination to ensure the best recovery of the patient.

• Functional compensation/adaptation: after a brain injury, and especially in adults, it may not be possible to restore the damaged function, so other less deteriorated or intact functions are trained to compensate for clients’ deficits.
• Environmental modifications: most of these involve adapting clients’ environment to improvecognitive functioning. Reducing distraction is an example of an environmental modification for managing attention problems.
• External aids: whencognitive functions cannot be recovered, patients are provided with tools or devices to allow them to carry out activities of daily living as asubstitution for the damaged function. An example is the use of tape recorders in class to assist students with attention deficits.
• Intervention within the family: cognitive, behavioral and emotional problems of brain-injured patients can be overwhelming for their family members and/or caregivers, so the provision of psycho-education and psychological support is vital. On the other hand, they play an active and essential role in rehabilitation by providing information regarding intervention outcomes outside of formal therapy sessions or carrying out rehabilitation activities at home.
• Behavioral and emotional interventions: behavioral and emotional disturbances may be the result of organic changes caused by an injury or are the patient’s emotional reaction to the deficits experienced following an injury. It is important not to neglect the emotional aspect as it is closely related to cognitive functioning. For example, depressive symptoms may worsen attention problems.

Within behavioral and emotional intervention, motivational interviewing deserves special attention, since it is a great methodfortherehabilitation and compensation of cognitive deficitsfor various reasons:

• Increasesrehabilitation adherence.
• Guaranteespatients will exert maximum effort on tasks and obtain better results.
• Allows the inclusion of tasks outside of the rehabilitation sessionsas part of the intervention program.
• Once the intervention is over, the patient can follow the guidelines if required.

To increase patient motivation, it is useful to follow a few guidelines, including the following:

• Establish a bond with patients from the start, making them feel comfortable and above all, building trust, so that they can express their doubts and emotions.
• Be honest and don’t offer false hope. Match patients’ expectations with rehabilitation goals that can be accomplished.
• At the beginning of the treatment, explain in detail what it will consist of, how long it will last, and the commitment required from them as patients and you as therapist.
• Set clear and specific short and long-term goals so that patients can evaluate the results they are achieving on their own.
• Before each session, explain the purpose of the tasks to be performed, so that carrying them out can be meaningful to patients.
• Give patients the opportunity to suggest ideas and even make small decisions, for example, in choosing the sequence of exercises planned for the session. Thus, patients will feel that they are an active part of rehabilitation.

To conclude, it should benoted that after implementing a neuropsychological rehabilitation program, it is advisable to monitor the patient by assessing his/her cognitive, emotional and behavioral functioning and the influence the deficits have on their quality of life. This last aspect is particularly relevant, as achieving improvedquality of life is the ultimate goal of any intervention.

References

1. Sohlberg MM, Mateer CA. Effectivenessofanattention-training program. JournalofClinical and Experimental Neuropsychology. 1987;9(2):117–30.
2. Sohlberg MM, Mateer CA. ImprovingAttention and ManagingAttentionalProblems. Annalsofthe New York AcademyofSciences. 2006;931(1):359–75.
3. Amador J.A. Escala de inteligencia de Wechsler para adultos-IV (WAIS-IV).2013.
4. Sherman E.M, Strauss E, Spellacy F. Validityofthe Paced Auditory Serial Addition Test (PASAT) in adultsreferredforneuropsychologicalassessment after head injury. ClinNeuropsych. 1997;11(1):34-45.