Attention Process Training APT-2 for Persons with Mild Cognitive Dysfunction
by McKay Moore Sohlberg, Ph.D., Lori Johnson, Laurie Paule, Sarah Raskin, and Catherine Mateer
The APT2 programme is for adolescents, adults and veterans with mild cognitive impairments and attention disorders due to acquired brain injury. The APT2 programme uses audio CDs for therapy tasks and PDF files for score sheets
This programme is for treating impairments in attentional processing in persons with relatively mild cognitive disturbance, such as post-concussion syndrome.
Activities address difficulties with sustained attention, slowed speed of information processing, distractability, shifting attention between multiple tasks, and paying attention to more than one source of information at a time.
What is APT-2 ?
A library of auditory attention CDs and hierarchically organised attention exercises grouped according to specific types of attention disorders
Generalisation programme with suggested activities, record logs, and data collection protocols to facilitate generalisation from the clinic to real world settings
Who can use it?
Neuropsychologists, speech and language therapists, occupational therapists, cognitive remediation specialists, and special education teachers.
What’s in the manual?
The APT-2 manual explains how to administer the attention training programme and methods for scoring and analysing client performance. All clinical and generalisation tasks contain data collection graphs and charts, detailed task descriptions, and suggestions for increasing or decreasing task difficulty level.
216 page manual with 5 tabs in a 3-ring binder
46 activity sheets and forms
6 audio CDs
4 response clickers and stopwatch
CD with PDF files scoresheets.
All packaged in a sturdy handy carrying case.
Extra sets of CDs are available separately
Background on attention and the APT-2 clinical programme
Models of attention
APT-2 clinical model of attention
Treatment of attention deficits
Assessment of attention deficits
APT-2 Clinical programme
Principles of treatment
Analysis of patient performance
Sample therapy regimen
List of APT-2 clinical task descriptions
Sustained attention task descriptions and sample scoresheets
Alternating attention task descriptions and sample scoresheets
Selective attention task descriptions and sample scoresheets
Divided attention task descriptions and sample scoresheets
APT-2 Generalisation programme
Procedures for promoting generalisation
Designing generalisation activities
Generalisation activities for sustained attention
Generalisation activities for alternating attention
Generalisation activities for selective attention
Generalisation activities for divided attention
Stimuli for clinical tasks
Scoresheets/protocols for clinical tasks and generalization activities
Auditory CD Stimuli
Frequently Asked Questions about Attention Process Training Programmes
What are the computer requirements?
There are none. The APT 1, APT 2 and Pay Attention! have audio CDs. These can be run on any computer with a CD drive or a CD player. It is not a computer based programme.
Is this a new version of the APT programs?
The APT 1 and APT 2 programmes were revised in 2001 to update the literature review, produce PDF files with scoresheets for each exercise, and convert former audiotapes to CDs. If you have an earlier version, you can purchase an upgrade kit to receive the audio CDs and scoresheets.
What about norms and validity?
Because the programmes are primarily designed as treatment tools and not as tests, the issues around validity and reliability are quite different. Each manual describes and references research that has been conducted with the materials and contains information about efficacy and client selection.
What about efficacy?
Attention training and training using compensatory aids have recently been supported in review papers as efficacious and an appropriate component of best practices in brain injury rehabilitation. The National Institutes of Health also recognised these approaches as efficacious in the position paper on rehabilitation after traumatic brain injury. (Cicerone, K.D., Dahlberg, C., Kalmar, K., Langenbahn, D.M., Malec, J., Bergquist, T.F. Felicetti, T., Giacino, J.T. Harley, J.P., Harrington, D.E., Herzog, J., Kniepp, S., Laatsch, L. & Morse, P.A. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596-1615).
The treatment activities contained in this programme were developed and tested at a rehabilitation clinic which serves individuals with mild brain dysfunction mostly due to head trauma. Unlike the rehabilitation of individuals with moderate to severe head trauma, there has been very little focus on treatment issues relevant to persons with “post-concussive syndrome” sometimes termed minor brain injury. Indeed, there is significant controversy over the legitimacy of such a diagnosis. Typically, the mild brain injury population is described as those individuals who, after a blow to the head, do not suffer prolonged loss of consciousness and often demonstrate relatively rapid and complete physical recovery with few to no hard neurologic signs (e.g., no positive findings on neuroimaging studies) to account for their symptoms. The common cognitive and somatic complaints include: difficulty concentrating; difficulty organising and remembering information; increased fatigue and irritability; headache pain; and vestibular problems. The cognitive symptoms often are not recognised by the individual until there is an attempt to resume responsibilities at home, work or school (Raskine & Mateer, 2000). Professionals and researchers who have studied and worked with this population agree that the entity of mild brain injury represents difficulties produced by an interaction of organic, psychological and environmental variables (e.g., Kay, 1990; Lezak, 1991; Raskine & Mateer, 2000).
The APT-2 is designed to address the information processing deficits observed in this population. An underlying assumption of the programme is that the attention and concentration difficulties, which concern individuals with mild brain injury, are valid and amenable to treatment. Again, it is recognised that these problems are often a result of a combination of emotional and physiological changes. As described by Mateer, Sohlberg & Youngman (1990), the approach to cognitive rehabilitation inherent in the APT-2 programme in combination with psychosocial support can be effective at assisting this population in resuming productive lifestyles.
These materials have been tested predominantly with individuals who have experienced mild brain trauma; however, there are a number of other etiologies for which this intervention approach may be applicable. Attention deficits have been described in persons who suffer a variety of relatively mild forms of neuropsychological impairment due to ailments such as multiple sclerosis, attention deficit disorders, chronic fatigue, chemical toxicity, and immunodeficiency syndrome. Although the central nervous system dysfunction itself may not be mild, the information processing deficits are often mild in comparison to those observed after severe traumatic brain injuries (Raskine & Mateer, 2000). One goal of publishing the APT-2 materials is to provide clinicians who serve such clients a cognitive intervention resource, albeit experimental. It is hoped that the tools contained in this program may serve as a starting point for evaluating methods to address the information processing deficits suffered by such individuals.
Although many of the aforementioned kinds of brain insults may be labeled as “mild” or “minor”, the impact of cognitive and emotional disturbances is often life altering. Relationship stresses and employment challenges are well documented (Raskine & Mateer, 2000). There is a great need for designing and evaluating cognitive and psychological interventions in order to prevent such problems as job loss and family disruption.
APT-2 Clinical Model of Attention
This refers to the ability to focus on specific sensory information. Focused attention represents the most basic level of attention observed when an individual can acknowledge visual, auditory or tactile stimuli. Focused attention is most commonly disrupted in persons with decreased level of consciousness, such as those emerging from coma who gradually progress from responding only to internal stimuli to showing increasing responsiveness to stimuli in their external environment.
This refers to the ability to maintain attention during continuous and repetitive activity. It incorporates the concepts of vigilance, persistence and task consistency. At the highest level, sustained attention includes the ability of mental control or working memory incorporating the notion of holding and manipulating information in one’s head such as required doing mental math. Impairments in sustained attention may manifest as difficulty maintaining attention over time, increased fluctuation in task consistency, or increased vulnerability to the effects of fatigue.
This third component refers to the ability to selectively process target information and inhibits responding to nontarget information. It is the ability to maintain a behavioral set in the presence of distractors or other competing stimuli and thus incorporates the notion of “freedom from distractibility”. Impairments in selective attention may be seen in individuals who are easily disrupted by surrounding noise or movement (external distracters) and/or who are distracted by emotional states such as worry or anxiety (internal distracters). The importance of selective attention is demonstrated by students in a classroom who must ignore noise from the playground outside in order to attend to classwork.
This component refers to the ability to shift one’s focus of attention. It is essentially the capacity for mental flexibility that allows an individual to switch attention between tasks or activities that demand different behavioural responses or cognitive sets. Impairments in alternating attention may be seen in patients who have difficulty starting up a task after they have been engaged in an alternate activity, or who continue performing according to the parameters of the previous task after they are supposed to shift to a new task. An example of the need for alternating attention may be seen in the work of a secretary who must rapidly switch between typing and answering phones.