Sustained attention impairment and rehabilitation

What is attention?

Attention is a basic, multidimensional cognitive ability, essential for information processing[1]. On the one hand, it is considered basic because it is essential for the correct functioning of higher-order psychological processes such as learning, by receiving, selecting and assimilating/interpreting stimuli that will later be encoded and stored in an organized manner in memory[2]. On the other hand, attention is multidimensional because it is composed of five separate levels: focused attention, sustained attention, selective attention, alternating attention and divided attention, according to the clinical model of attention by Sohlberg and Mateer. The different levels are organized in a hierarchical fashion, so that the proper functioning of the higher levels depends on the proper functioning of the lower and less complex levels[1].

Research on the development of attention has shown that, from birth to the first year of life, children’s attentional capacity is based solely on maintaining a state of alertness and orienting to sensory events, for which focused attention is responsible. During this first period, observation length varies, increasing at 8-10 weeks and decreasing between 3 to 6 months due to more efficient information processing that needs less time to process stimuli; from 7 months onwards, a greater variability in observation length is observed since the greater processing capacity allows children to process simple stimuli quickly, allowing them at the same time to process other more complex stimuli that require more time.

From the first year of life until adulthood, there will be a progressive development of attentional flexibility and the ability to control and manipulate attention, resulting in those more complex levels of attention previously mentioned[3].

What do we mean by sustained attention?

Sustained attention is the “ability to maintain a consistent behavioral response during continuous and repetitive activity” [1]. In other words, this type of attention incorporates the notion of vigilance, maintaining attention to a single stimulus for a period of time. In addition, it allows us to manipulate and process the information coming from the stimuli attended through working memory. Vigilance and working memory are the two subcomponents of sustained attention proposed by Sohlberg and Mateer[4].

An example of sustained attention from our everyday life is reading, an activity that requires a continuous response to a specific stimulus (the text), as well as the processing of information received that allows us to understand what we are reading.

Sustained attention impairment and rehabilitation

This cognitive ability is especially vulnerable to brain impairments that may arise from a neurological disease (e.g.,Alzheimer´s disease;[5,6]), acquired brain injury (e.g.,head injury;[7]), developmental disorders (e.g., autism and ADHD; [8-10]) and even psychiatric disorders (e.g., depression;[11]). Deficits result in an interruption of vigilance due to the limited ability to maintain response to a task or a fluctuating capacity resulting from attention lapses[4]. However, neuroplasticity, that is, the brain’s ability to change its structure and function, can improve or compensate for cognitive deficits as long as appropriate rehabilitation is carried out.

Until recently, rehabilitation training programs for attention disorders have been based on pencil-and-paper tasks, commonly referred to as worksheets. For sustained attention, an example of this type of exercise includes counting the number of stimuli presented in a worksheet. However, in recent years, the rise of new technologies (ICT) has given way to an increasing use of digital tools for the implementation of new and increasingly effective rehabilitation programs. In this sense, there are a variety of computerized programs whose approach is based on repetitive attention exercises of graded difficulty in order to restore the neural networks of attention [12].

Programs for training attention

One of the most widely used cognitive rehabilitation programs is Attention Process Training (APT; [1]), which, since it is based on the clinical model previously mentioned, includes tasks targeting sustained attention, selective attention, divided attention and alternating attention and uses auditory stimuli as well as pencil-and-paper exercises. Sustained attention is trained through exercises that require attending and identifying target stimuli, usually words or sequences of words, and mental math activities. For example, one of the exercises consists of tapping the table each time you hear a number that is consecutive to the previous one.

This program has proven effective in it has proven to be succesful in training attention skills, however, the search for greater ecological validity in rehabilitation has promoted the development of new programs that include exercises based on activities of daily living, and more recently, using virtual reality [e.g., 13-15]. A clear example of this progress in the design of training attention and other cognitive functions is the program NeuronUP. It is a virtual platform in which professionals have access to a wide range of games for each cognitive function, both for adults and children.

Accordingly, activities can be found for each of the types of attention mentioned above, including sustained attention, (e.g., copying the position of objects in a bookcase from a model). In addition, in its effort to improve, this platform is developing new activities for training attention in which aspects of patients’ daily lives are better reflected, with the objective of achieving training transfer to everyday functional tasks, thus allowing a successful reintegration of individuals.

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