This article was downloaded by: [Moskow State Univ Bibliote]

On: 11 February 2014, At: 18:26

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Clinical and

Experimental Neuropsychology
Publication details, including instructions for authors
and subscription information:
http://www.tandfonline.com/loi/ncen19

Effectiveness of an attentiontraining program

a

McKay Moore Sohlberg & Catherine A. Mateer

a

Good Samaritan Hospital , Puyallup, Washington

Published online: 04 Jan 2008.

To cite this article: McKay Moore Sohlberg & Catherine A. Mateer (1987) Effectiveness of
an attention-training program, Journal of Clinical and Experimental Neuropsychology, 9:2,
117-130, DOI: 10.1080/01688638708405352
To link to this article: http://dx.doi.org/10.1080/01688638708405352

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information
(the Content) contained in the publications on our platform. However, Taylor
& Francis, our agents, and our licensors make no representations or warranties
whatsoever as to the accuracy, completeness, or suitability for any purpose
of the Content. Any opinions and views expressed in this publication are the
opinions and views of the authors, and are not the views of or endorsed by
Taylor & Francis. The accuracy of the Content should not be relied upon and
should be independently verified with primary sources of information. Taylor and
Francis shall not be liable for any losses, actions, claims, proceedings, demands,
costs, expenses, damages, and other liabilities whatsoever or howsoever caused
arising directly or indirectly in connection with, in relation to or arising out of
the use of the Content.
This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly
forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions

Journal of Clinical and ExperimentalNeuropsychology

1987, VOI.9, NO. 2, pp 117-130.

0168-8634/87/0902-0117 $3.00
@ Swets & Zeitlinger

Effectiveness of an Attention-Training Program*

McKay Moore Sohlberg and Catherine A. Mateer
Good Samaritan Hospital, Puyallup, Washington

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

ABSTRACT
Attention Process Training (APT), a hierarchical, multilevel treatment program,
was designed to remediate attention deficits in brain-injured persons. The program
incorporates current theories in the experimental attention literature. Four braininjured subjects, varying widely in both etiology of injury and time post onset,
underwent intensive cognitive remediation including 5 to 10 weeks of specific
attention training. Results are displayed using a single subject multiple baseline
across behaviors design. All four subjects demonstrated significant gains in attention following the initiation of attention training. Remediation of another cognitive function (visual processing) was not associated with alterations in attention
behavior. The merits of a process-specific approach to cognitive rehabilitation are
discussed.

Deficits in attention and concentration often go unrecognized or are misdiagnosed in the assessment of cognitive function following brain injury. Disruption
of the physiological systems critical to the regulation of attention may occur as
the result of seemingly minor, as well as severe, neurological damage. Deficits
which initially present as memory impairments are often found to reflect
underlying impairments in attention. Although the severity of an attention
deficit nearly always lessens over the course of recovery, significant deficits in
attention and concentration are often present many months or even years
postinjury.
In the past, clinical models of attention have been largely restricted to the
domain of asymmetries in spatial responsiveness or neglect. The experimental
literature views attention in a somewhat broader framework, but this has not
been tied in to clinical phenomena. In this study, a broadly based view of
attention serves as the basis for the development of an attention-retraining
program. Briefly, attention is conceptualized as the capacity to focus on particular stimuli over time and to manipulate flexibly the information. Examples of
cognitive tasks which we feel are likely to reflect attentional deficits, based on
our model, include: backward digit span, serial number sets, Trails B, and
backwards spelling.

* Partial support of this project was provided by NIH-NINCDS TIDA N500505.

AuDreciation is extended to Arlene Schmield for expert preparation on the manuscript.
Send reprint requests to: C. Mateer, Ph.D., 319 South Meridian, Puyallup, Washingfon
98371, USA.
Accepted for publication March 21, 1986.

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

118

MCKAY MOORE SOHLBERG AND CATHERINE A. MATEER

There is far from universal agreement in the information-processing literature regarding the mechanisms of atsention, M a t models dattentionase based
on the human information-processingapproach first introduced by Broadbent
(1958). According to these models, attention is usually viewed as a selectivity
phenomenon by means of which target stimuli receive priority processing over
concurrent nontarget stimuli. That is, attention is considered to be the process
by which one selectively responds to a specific event and is able to inhibit
responses to simultaneous events (Johnston & Wilson, 1980).
Under the rubric of selectivity models there. appear to be two basic classes of
attention theory. The first class consistsof the early-seleetkm theories which are
based on the view that the differential processing demands awmded target and
nontarget stimuli operate at the perceptual level, Target stimuli are processed
more fully because there is perceptual suppression of nontarget stimuli (Broadbent, 1958;Johnston & Wilson, 1980; Treisman, 1969). Brain mechaaisms act to
limit the amount of sensory input that an individual must process.
The second class of selective attention theories consists of the late-selection
theories in which the differential processing accorded to target and nontarget
stimuli is conceived of as being nonperceptual in nature. According to these
models, a special attentional capacity within the organism allows for preferential processing of target stimuli over concurrent nontarget stimuli. All perceptual information enters the system, but only that which is sekcted by the special
attention mechanism reaches higher processing centers (Johnston & Wilson,
1980; Shiffrin & Schneider, 1977). Hence, the basicdifference between early- and
late-selection theories lies in their view of the processing stage at which unimportant aspects of information or stimuli are screened out. The early-selection
theories propose that certain stimuli are never processed due to perceptual
suppression of nontarget stimuli; whereas late-selection theories propose that
the unimportant information enters the system but simply is not chosen for
further processing.
A shortcoming of the selectivity models is that they often stop at the level of
signal detection or target selection. Additional processing of information tends
not to be addressed in these theories. We feel a more comprehensive view of
attention is necessary to adequately describe the attention deficits observed in
brain-injured populations.
The theoretical construct of working memory as described by Baddeley
(1974,1981) does begin to address the comprehensivenature of attention. The
Central Executive, one component of Baddeleys model, is hypothesized to
provide for temporary storage of information. The capacity for such temporary
storage allows for division of attention during information processing. Modeled
as a controller of memory, the Central Executive allows information to be held
in short-term storage while attention is temporarily shifted to other stimuli. This
model thus incorporates additional levels of information processing.
The problem with all of the current models of attention, however, is that none
adequately addresses the clinical phenomenon of attention deficits or their

ATTENTION TRAINING PROGRAM

119

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

remediation. The few treatment programs for attention which do exist tend to
be task oriented without a strong theoretical base. At best, treatment programs
address restricted components of attentional requirements. The purpose of the
current study was to develop a clinical treatment program which considered
attention to be a comprehensive and multilevel functional process.

Treatment Model
The attention treatment program outlined in this paper was based on the
experimental attention literature, clinical observation, and patients subjective
complaints. It considers attention as a multidimensional cognitive capacity.
There are five levels of attention addressed in the therapy model: Focused
Attention, Sustained Attention, Selective Attention, Alternating Attention, and
Divided Attention. Descriptions of each level of the model are provided below.
Focused Attention: The ability to respond discretely to specific visual, auditory, or tactile stimuli.
SustainedA ttention: The ability to maintain a consistent behavioral response
during continuous or repetitive activity.
Selective Attention: The ability to maintain a cognitive set which requires
activation and inhibition of responses dependent upon discrimination of
stimuli.
Alternating Attention: The capacity for mental flexibility which allows for
moving between tasks having different cognitive requirements.
Divided Attention: The ability to simultaneously respond to multiple tasks.
This paper examines the effectiveness of an attention-training program based
on the model as described. Hierarchies of treatment tasks were developed for
each of the five levels of the attention model. Therapy was conducted using tasks
and treatment materials as outlined in Attention Process Training (APT)
(Sohlberg & Mateer, 1986).
Outcome data is presented using a multiple baseline across behaviors replicated across four subjects (Hersen & Barlow, 1976). In this study, the Paced
Auditory Serial Addition Task (PASAT; Gronwall, 1977) was used to evaluate
attentional skills. This measure was chosen as the dependent variable for this
study because of its demonstrated sensitivity to postconcussional attention
deficits, its strong normative base and its inherent test-retest reliability (Gronwall, 1977; Gronwall & Wrightson, 1968). The PASAT reportedly provides an
estimate of the subjects ability to register sensory input, rapidly process the
information and respond verbally, as well as retain and use a complex set of
instructions. In terms of the attention model described herein, the PASAT
presupposes the existence of the fmt of the five levels (focusedattention) and depends
heavily on the adequacy of sustained and selective attention.
Design Considerations
A multiple baseline across cognitive areas (Hersen & Barlow, 1976) was used to
assess the effectiveness of the attention treatment program described in this

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

120

MCKAY MOORE SOHLBERG AND CATHERINE A. MATEER

study. Previous research (Gianutsos, 1981; Gianutsos k Gianutsos, 1979; Gianutsos k Gianutsos, in press) has established the practicality of using the
single-case design to study the retraining of cognitive proo~esesin individuals.
In psychological research, the standard method of demonstrating ~ i c a n t
change involves the analysis of group statistics to determine the probability of
observed effects having occurred by chance(Bailey k Bostow, 1977). Typically,
a large number of subjects are studied for a short period of time. This approach,
however, is often not satisfactoryfor examiningthechanges in cognitiveprocesses since the statistical manipulation of group data is likely to obscure changes
in individual functioning. This is especiallytrue for populations which display
as much diversity in degree and nature of cognitive disab&ty as brabinjwed
persons. Hence, single-casedesigns are being used with increasing frequency to
study treatment effects in individuals.
The goal of the present study was to examine the relationships between the
implementationof an attention-trainingmodel and changesin attentional slcills
as measured by the PASAT. To establish a functional relationship, it was
necessary to observe changes in attention and plot improvement over time. Use
of a multiple baseline design in which simultaneouschanges in a second cognitive process area (i.e., visual processing) would be followed allowed us to
formulate the following hypotheses:
(1) An increase in PASAT scores over baseline levels will be observed
following attention training;
(2) Increases in PASAT scores followingattention training will be maintained beyond the cessation of attention treatment;
(3) Training of attention skills will not be associated with a generalized
improvement in cognitive abilities. Attention training will not, for
example, consistently result in changes on measures of visual processing;
(4) Training of other cognitive processes, for example visual processing,
will not regularly impact attentional skills.
METHODS
Subjects
The subjects were all participants at the Center for Cognitive Rehabilitation, a postacute, day treatment brain-injury program. They were randomly selected from a consecutive series of admissions to the program. Subjects varied widely in both nature of
injury and time postonset. Descriptions of demographic and neuropsychological data
are presented for each subject in Table 1.
At the time of the program entry, each subject underwent a 2-week comprehensive
cognitive and psychosocial evaluation including assessment of attention, visual processing, memory, and reasoning. Results from the testing were then used to determine which
cognitive processes should be addressed and at what level of dificulty.

121

ATTENTION TRAINING PROGRAM

Table 1
Subiect

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

Age
Sex
Education (years)
Time Post Onset
(months)
Etiology

01

02

03

04

30

29
M
12

28
M
12

25
M
11

M
13

12
Closed-Head
Injury
5 weeks
Coma Duration
7 weeks
24h
Dispatch
Preinjury Vocational Owned an auto Diesel mechanic
controller
Status
repair shop
80
82
87
VIQ
88
74
98
PIQ
82
FSIQ
77
85
Wechsler Memory Scale I
8/2
Paragraph Recall
16/10
13/13
Immediate/delayed
13/6
Design Reproduction
4/0
8/8
Immediate/delayed
6/5
Digits (F/B)
5/3
5/4
14
Aneurysm

72
Gunshot

48
Closed-Head
Injury
2 weeks
Flagman
80
88
82
8/7
7/6
6/5

Measurement
The PASAT was administered in standard fashion using a tape made in accordance with
the parameters set forth by Gronwall(l977). Subjects listened to an auditoriallypresented string of digits; they were required to add each number to the one immediately
preceding it. Each score represented the percentage of correct responses made prior to
the presentation of the next stimulus. Different norms were used for the first and later
administrations of the PASAT (Gronwall, 1977).
Each subject was tested individually. All four subjects met criteria on two recorded
pretest measures requiring repetition of 10 single digits and correct responses to 10 paced
simple addition problems. This was followed by the administration of one practice list of
10 single digits recorded at 2.4s intervals. Each full test trial consisted of 61 digits
(numbers 1 to 9 used in random order). The interstimulus interval was always 2.4 s. A
commercial tape recorder with intensity level well above threshold and adjusted to
comfortable listening level in free field conditions was used.
The measure used to assess visual processing abilities was the Spatial Relations Subtest
(SR) from the Woodcock-Johnson Psychoeducational Battery (1977). This is a test of
spatial perception and judgment which requires the subject to identify discrete spatial
components which would fit together to form the whole target figure. Scores on both the
PASAT and SR test were obtained at regular intervals over the course of 30 weeks.
Procedures
For each subject, a significant impairment in attentional skills and visual processing
ability was identified. During the evaluation stage, at least two measures of PASAT
performance were obtained. Scores achieved during this period, throughout which no
treatment took place, served as the baseline. Subsequent to the evaluation, baseline

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

122

MCKAY MOORE SOHLBERG AND CATHERINE A. MATEER

period, training in attention was initiated using the attention treatment model as described in this paper. Once subjects met individuallydetermined criterion levels for the
specific treatment tasks in each of the five levels of the attention-training model,
remediation of visual processing skiiis was initiated. To control for an order effect, the
above sequence was reversed for one subject (M), who received training in visual
processing prior to attention training.
At least eight measures of performance on the PASAT and SR were taken with a
minimum of two measuresduring each of the treatment phases (before, during, and after
attention training). The subjects received between seven and nine individual cognitive
retraining sessions per week which focused specificallyon attention, visual processing,
or memory, according to the treatment phase (see Figure 1). Each subjectreceived4to 8
weeks of attention training, the length of training determined by the severityofattention
deficit. Within that period, goals were set which provided maximal achievement within
each of the components of the attention-training program. In addition to cognitive
remediation each subject received concurrent intervention in the areas of daily living,
prevocational, and psychosocial skills.
Treatment tasks were developed for each of the five levels of attention. Tasks were
arranged in hierarchies of difficulty based on both the complexity of the tasks and
processing speed requirements. It is important to recognize that at every lcvd of the
treatment model, success can be impaired by a slowed rate of procesing or latency of
response. A variety of computer programs, commercially available attention tasks and
original treatment materials were adapted for use in each of the five levels of the attention
model. A list of treatment tasks can be found in Appendix 1.

RESULTS
Research findings for each of the four subjects are displayed using a multiple
baseline across cognitive areas. Data for each subject are presented in a pair of
vertically oriented graphs. The ordinate on the top graph represents PASAT
z-scores used to measure changes in attention ability. Large intersubjectvariability prompted use of z-scores (as opposed to raw scores) in order to facilitate
comparisons. The ordinate on the bottom graph representsrawscores on the SR
used to measure changes in visual processing. The abscissa on both graphs
corresponds to both weeks of treatment (lower scale) and the treatment phase
(upper scale). Scores t o the left of the heavy striped line represent the pretreatment baseline measures.

Subject 01
Data for subject 01 (Figure 1) revealed a stable baseline for PASAT scores. Over
the first 2 weeks during which no cognitive treatment had been provided, there
was n o change in PASAT scores. Following the initiation of attention training,
PASAT scores increased from a z-score of -8 to -1.4. This represents a
dramatic increase in attention abilities as measured by the PASAT following
specific attention training. Following cessation of attention training (during
visual processing and memory training), scores remained at or above -2.2 and

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

A'ITENTION TRAINING PROGRAM

123

WEE KS
Figure 1. Results of attention training in Subject 01 using a multiple baseline across
cognitive areas (attention,visual processing and memory).
showed a continuing gradual improvement. The baseline condition for the SR
scores extended through the attention-training period since specificremediation
in visual processing did not begin until the 12th week. During the baseline
condition, there was a gradual improvement in SR scores in the absence of
specific visual processing training. There is some suggestion, however, that SR
scores may have been leveling off during this period. Following the initiation of
specific visual processing training, SR scores increased significantly. With subsequent initiation of memory training, absolute SR scores decreased, yet remained above baseline.
At the time of program entry, this subject had been living with relatives
during the 7 months since his discharge from the hospital. He was exhibiting
profound cognitive problems and required 24-h supervision. The family had
begun proceeding for psychiatric hospitalization due to a suicide attempt and
unmanageable cognitive and behavioral disorders. He subsequently received 8
months of intensive cognitive training including 10 weeks of attention training.
Following discharge, the subject began living independently in an apartment
and obtained a paid half-time position as a food service worker. To date he has

124

MCKAY MOORE SOHLBERG AND CATHERINEA. MATEER

maintained independent living status and been gainfully employed for 12

months.

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

Subject 02

PASAT scores remained within .5 z-score standard deviation during the baseline condition (Figure 2). An increase in scores was noted following the
initiation of attention training. After withdrawal of attention training, scores
remained stable throughout visual processingand memory treatment phases (18
weeks). Scores on the SR task remained stable throughout the visual-process
baseline period, despite provision of attention training. SR scares improved
over the course of visual process training and remained high throughout the
next cognitive process treatment phase.
This subject presented a particular challenge because of the long length of
time postinjury. Upon program entry, he displayed moderate overall cognitive
deficits, but exhibited marked impairments of initiation and executivefunctions
due to extensive frontal-lobe involvement. He had been living with his parents

VISUAL PROC

MEMORY
TRAINING

I
I

H
flA
A
(I)

N -1

c
4

I
I

I
I

-4

u, -E

I
I

I
I
(

.-

50

Ji0

45

40

.
I

35

30

I
I

0
P
v)

I
I

I
d

10

15

20

2s

30

3s

WEEKS
Figure 2. Results of attention training in Subject 02 using a multiple baseline across
cognitive areas (attention,visual processing and memory).

125

ATTENTION TRAINING PROGRAM

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

during the 7 years since his injury. Despite the long period of time since injury,
he made steady gains in many aspects of the cognitive program. Several perseverative and ritualistic behaviors, however, proved quite refractory to intervention. He received 10 weeks of specific attention training at the beginning of the
program, achieving and maintaining normal range PASAT scores. Near the end
of his program, he was involved in a successful transitional independent living
trial, completed a work station experience in food preparation and was exploring several vocational retraining options. To the disappointment of staff,
however, his parents terminated his program involvement prior to completion.

Subject 03
This subject's PASAT scores were stable and just within normal limits during
the pretreatment phase (Figure 3). Following attention training, scores increased and stabilized within the mid-range of normal expectations. SR scores
also demonstrated remarkable stability not only prior to initiation of visual
process training but over the period during which attention training was

2 l R A C F I INF

-4

v)

-6

a
a

MEMORY
TRAlNlNQ

VISUAL PROC
TRA INlNG

ATTENTION

I
-

-8

I
0

-.0

a
v)

35
30
2
I

10

I
15

20

WEEKS
Figure 3. Results of attention training in Subject 03 using a multiple baseline across
cognitive areas (attention,visual processing and memory).

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

126

MCKAY MOORE SOHLBERG AN11 CATHERINE A. MATEER

proving effective in altering PASAT scores. SR scores only showed improvement during the period of intensive visual process training. Posttreatment SR
data points gathered during the memory training phase regressed to pretreatment baseline levels.
At the time of program entry and during the initial 2 months of program
participation, this subject resided in a full-care nursing facility. He required maximal
assist for ambulation and many self-care activities, and demonstrated moderate
generalized cognitive deficits. Attention training was not begun until 1 month
after program entry, but he achieved normal range PASAT scores during the
next month of specific attention treatment. During the program he moved from
the nursing home to an independent apartment. Following program completion
he returned to his former place of employment in a lesser capacity as a warehouseman for a magazine distribution company. He has been self supporting
for 8 months at the time of this report.
Subject 04
To control for a possible order effect, the attention-training and visual-processtraining periods were reversed in subject 04 (Figure 4). He received training in

0,
a

AT TENT ION
TRAINING

BASELlNE
I
1
I

-2

v) -6

50

.H

4s

-*.6

35

v)

30

0
P

'

b'

40

V I S U A L PROC
T RA I N I N G

251

10

I
15

I
2c

25

WEEKS
Figure4. Results of attention training in Subject 04 using a multiple baseline (reversal)
across cognitive areas (attention and visual processing).

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

ATTENTION TRAINING PROGRAM

127

visual processing prior to remediation of attention. Extremely poor scores

characterized SR performance in the 3-week pretreatment period. Although
dramatic improvements in SR scores were seen during the visual-processtraining period, a slow but fairly steady decline was seen over the next 20 weeks.
At the last testing, scores remained significantly above baseline levels, but were
not judged to be stable. Scores on the PASAT did rise during the course of
visual-process training in the absence of specific attention training, but leveled
off over the 10 weeks at more than 3 standard deviations below expectations. In
the period during and after attention training, PASAT scores showed improvement.
This subject, who was 4 years postinjury, had been living with his family and
had participated unsuccessfully in several pain management programs prior to
participation in the cognitive retraining program. He began attention training
only after the baseline period and 10 weeks of very successful visual process
training. The subject moved to independent living status during the program
and 6 months following discharge he obtained employment as a printer.
DISCUSSION
In the subjects who presented with mild to moderate attention deficits (02 and
03), indicated by PASAT scores within 2 SD of the mean, attention skills
increased to within normal limits. The subjects with severe attention impairments (0 1 and 04), whose PASAT scores were greater than 3 SD below the mean,
achieved scores within the mildly impaired range following attention training.
Improvements in attention in all cases remained above baseline levels following
cessation of specific attention training for periods as long as 8 months, which
was the longest period of measurement. These results demonstrate the potential
for improvement of attention deficits in brain-injured persons given specific
attention training. They also support the general effectiveness of the attentiontraining model outlined in this study. We are as yet unable, however, to identify
the relative contribution of individual components of the training program. We
do not know, for example, whether it is critical to work on tasks within each of
the five levels of our proposed hierarchy of attention. Nevertheless, the dramatic
and sustained improvements in attention observed in ail four subjects lend
strong support for the provision of comprehensive attention training.
Models of cognitive rehabilitation generally fall into one of three major
categories. These include the Functional Adaptation approach, the General
Stimulation approach and the Process Specific approach. The Functional
Adaptation approach facilitates functioning in a particular naturalistic living or
work environment. This is commonly accomplished via task analysis followed
by development of environmental manipulations or compensatory strategies.
Problems arise,however, when the narrownessof focusand restnctedgeneralility
of this model limit the potential extent of recovery. The General Stimulation

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

128

MCKAY MOORE SOHLBERG AND CATHERINE A. MATEER

approach facilitates recovery through use of tasks which encourage cognitive

processing at any level. The lack of theoretical orientation and poor accountability restrict the effectiveness of this model. A Process Specific approach
to remediation, however, assumes the ability to differentially impact distinct
cognitive areas. Treatment is oriented toward targeted remediation of deficits in specific cognitive areas.
Results in this study support the use of a process-specific approach to cognitive rehabilitation. The data suggest that, although there may be some impact
on attentional skills following any focused cognitive treatment (i.e., visual
processing), more significant improvements are made following specific attention training. In subject 04,gains in attention are evidenced during the baseline
condition during which there was visual processing training but no specific
remediation of attention. However, these gains appear to level off, and more
dramatic increases are seen following specific attention training. In subjects 02
and 03, analogous results were found relative to visual processing ability. SR
scores remained stable during the period of attention training, despite improved
PASAT scores, and increased only after initiation of visual-process training.
This double dissociation provides powerful support for independent improvements in specificcognitive areas. The clinical implication is that therapy directed toward remediation of underlying deficit processes should be encouraged.
A major problem inherent in many reports of cognitive treatment outcomes is
the confounding of results by the training of assessment tools. The same task
which is being used to assess an underlying behavior is used as the primary
treatment task. In order to support a claim for having improved an underlying
cognitive process, the change in criterion task (dependent variable) must not
merely reflect practice effects or task familiarity. In this study, tasks and
materials used in remediation of attention were developed in such a way that
they simulated the general attentional requirements of the PASAT, but did not
replicate the specific procedures. Therefore, observed changes in performance
on the PASAT can be attributed to changes in attentional processing ability and
not merely alterations in task performance.
We recognize that test scores on tasks such as the PASAT are not necessarily
correlated with functional skills. Prior to program entry, none of the four
subjects were living independently or gainfully employed. The clinical goals for
each of the four subjectsin this study included independent living (01,02,03, and
04) and sheltered employment (01 and 02) or competitive employment (03 and
04). In each case, vocational and independent living goals were achieved following 5 to 8 months in the program. Although we cannot attribute these
outcomes solely to cognitive training, observed functional gains correlated in
time with improvements in cognitive performance.
Although we feel the multiple baseline across behaviors design was useful for
examining individual response to treatment, several problems with application
of this design were encountered. This methodology requires repeated measurement of discrete, quantifiable behaviors. Currently, the best assessment of

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

ATTENTION TRAINING PROGRAM

129

cognitive behavior is through the use of neuropsychological tests. However,

repeated test administration introduces problems related to practice effects. We
attempted to deal with this problem by assessing performance more infrequently than is the case in most single-subject treatment designs and by using the
established norms for first and later PASAT administrations. Additional data
points in all phases of the study would have allowed more convincing evidence
relative to performance trends.
In summary, results of this study confirm each of the four hypotheses regarding process-specific cognitive retraining. PASAT scores improved over baseline levels following attention training and remained significantly above initial
performance throughout the period of postattention training measurement.
Training of and improvement in attention skills was not routinely associated
with improvements in visual processing abilities. Similarly, training of visual
processing did not regularly impact PASAT performance. These results were
interpreted as support for a process specific model of cognitive rehabilitation.
REFERENCES
Baddeley, A. (1981). The concept of working memory: A view of its current state and
probable future development. Cognition, 10. 17-23.
Baddeley, A. D., &Hitch, G. (1974). Working memory. In G. Bower (Ed.), Thepsychology of learning and motivation (Vol. 8). (pp. 47-85). New York: Academic Press.
Bailey, J. & Bostow, D. (1977). Research methoak in applied behavior analysis. Florida:
Authors.
Broadbent, D. E. (1958). Perception and communication. London: Pergamon Press.
Gianutsos, R. (1981). Training the short- and long-term verbal recall of a postencephalitic amnesic. Journal of Clinical Neuropsychology. 3, 143-153.
Gianutsos, R. & Gianutsos, J. (1979). Rehabilitating the verbal recall of brain-injured
patients by mneumonic training: An experimental demonstration using single-case
methodology. Journalof Clinical Neuropsychology, 1, 117-135.
Gianutsos, R., & Gianutsos, J. (in press). Single-case experimental approaches to the
assessment of interventions in rehabilitation psychology. In B. Caplan (Ed.), Handbook of contemporary rehabilitation psychology. Springfield, IL: Charles Thomas.
Gronwall, D. (1977). Paced auditory serial addition task: A measure of recovery from
concussion. Perceptual and Motor Skills, 44, 367-373.
Gronwall, E. & Wrightson, P. (1968). Memory and information processing capacity after
closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 31, 299-306.
Hersen, M., & Barlow, D. (1976). Single case experimentaldesigns: Strategiesfor studying
behavior change. New York: Pergamon Press.
Johnston. W. & Wilson, J. (1980). Perceptual processing of nontargets in an attention
task. Memory and Cognition, 8, 372-377.
Shiffrin, R., & Schneider, W. (1977). Controlled and automatic human information
processing: 11. Perceptual learning, automatic attending, and a general theory. Psychological Review, 84, 127-190.

130

MCKAY MOORE SOHLBERG AND CATHERINE A. MATEER

Sohlberg, M. M., & Mateer, C. (1986). Attention Process Training (APT). Puyallup:
Center for Cognitive Rehabilitation.
Treisman, A. (1969). Strategies and models of selective attention. PsychologicalReview,
74.282-299.
Woodcock, R., & Johnson, B. (1977). WoodcockJohnson Psychoeducational Battery.
Boston: Teaching Resources Corporation.

APPENDIX I

Downloaded by [Moskow State Univ Bibliote] at 18:26 11 February 2014

Treatment Tasks Used in Attentioo-Training

Focused Attention
REACT (reaction time computer programs published by Life Science Associates)
Attention Tape 1 (detection of auditorially presented number targets; developed by
Sohlberg and Mateer, 1986)
Sustained Attention
Attention Tapes 2-8 (auditorially presented strings of stimuli with response requirements
of increasing difficulty; Sohlberg and Mateer, 1986)
Serial Numbers (number manipulation exercises, Sohlberg and Mateer, 1986)
Timesense (time estimation computer program published by Soft Tools)
Selective Attention
Attention Tapes 9-16 (auditorially presented strings of stimuli recorded in background
noise; Sohlberg and Mateer, 1986)
Visual Reaction Stimulus Discrimination 1 (computer program requiring inhibition of
responses; published by Psychological Software Services)
Auditory Reaction Stimulus Discrimination (computer program requiring inhibition of
responses published by Psychological Software Services)
Peg Board Exercises Using Noise Tape (visuomotor task with distractor)
Construx With Distractor Tape (visuomotor task with distractor)
AlternatingAttention
Addition/Subtraction Flexibility, BeforeIAfter, Odd/Even Number Flexibility (Sohlberg and Mateer, 1986)
Simultaneous Sequencing Exercises (Sohlberg and Mateer, 1986)
Set Dependent Activity I and I1 (Sohlberg and Mateer, 1986).
Divided Attention
Simultaneous Multiple Attention (computer program by Soft Tools)
Multilevel Card Sort (Sohlberg and Mateer, 1986)
React Plus Attention Tape (dual task, one requiring response to auditory information and
another requiring response to visual information)
Note: Materials referred to Sohlberg and Mateer (1986) are available as part of APT
(Attention Process Training).