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OK folks, pay attention, it’s attention-after-brain-injury lesson time. Wikipedia states:
"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."
June is brain injury awareness month. 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 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 since 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. 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 references), although the attention skills required when in groups, crowds, and at parties resisted healing. Those are the ones I’ll address here because these are the ones that affect one's social life and that friends and family notice the most.
Before I begin, I ought to give a little background information on fatigue and traumatic brain injury. Imagine a certain task takes x amount of energy. After a brain injury, every task takes substantially more energy. 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, and conscious execution of an action takes more energy than when done automatically. We acquire automaticity in childhood and when learning new skills. In addition, 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.
One pays attention to a task or person with one’s brain, but it’s done through the senses. Although this post is about attention in general, attention is mediated through each sense differently, depending on the person’s strengths and weaknesses. For example, one can have little problem paying attention to auditory stimuli but a lot to visual stimuli. Brain injury may also disrupt this if one was biased toward visual stimuli prior to injury, but the brain injury impaired vision but not auditory perception and so now auditory stimuli become easier to attend to. Understanding that this kind of radical sensory processing change has occurred and then adapting to it takes time.
Selective: This attention skill allows you to ignore distractions in the environment and pay attention to important information, like the person you’re listening to.
As anyone who’s sat across from me at a coffee shop while I'm facing the window knows, I get easily distracted by cute dogs passing by, people walking, cars zipping across my field of vision, and changing traffic lights. If I face indoors, then I get distracted by the noise of conversations, the servers, and the odd quirks of people eating. If I face a wall, I can focus better, but I hate facing walls. Perhaps it's a relic of my pre-injury claustrophobia.
Regardless, if I can’t see a person’s mouth, I have a much harder time understanding them because it’s harder for me to discriminate or select between auditory stimuli. It has nothing to do with my hearing because I have excellent hearing, always have had. But as can be typical for a person with a concussion or brain injury, the injury ratcheted up my senses and damaged my filters. I hear everything: the clock ticking, cutlery dropping, plates being clanked, wrappers crinkling, people coughing, punctuations of laughter, footsteps. Those noises grab my attention like someone grabbing your coat collar. If those noises are in a theatre, they’re like gunshots to the head. If someone applauds behind me, it’s a physical sensation on my ears and back. They compete with what I’m supposed to be focusing on. And that’s just one sense. Vision, smell, and touch also became hypersensitive. If auditory and visual noise is all around me, like at a party, they challenge my selective attention and become a great sucking vacuum on my energy levels.
“People with impairments in selective attention may become easily irritated and frustrated by such extraneous noise.” (From McKay Moore Sohlberg paper.)
Grumpyface — from the Doctor Who episode "The Time of Angels," when being distracted is fatal—is a good descriptor!
Alternating: This attention skill allows a person to switch their attention easily from task to task or person to person in a group or party. Apparently, this is a high-level attention skill.
I find it takes me a moment when I have to switch my attention. When someone suddenly forces me to switch attention by popping up behind me, asking a question, demanding I switch attention instantly from what I was doing or saying, without a gentle intro hello, it slows me down more. Of course, this happens naturally when the phone rings or in parties when someone will appear from seemingly nowhere (the nowhere part is an alpha-wave open-awareness issue, where lack of open awareness leads to easy startling — see how problems start overlapping?) and want to interrupt. In my cultural background, this kind of interruption is rude but pretty commonplace here. A normal person may get a bit annoyed with the rudeness of the interruption, but a person with a brain injury will feel discombobulated and overwhelmed at the sudden need to switch attention and thus become extremely irritated.
Divided: This attention skill allows a person to pay attention to two or more things at once. Another way to look at this is multitasking.
A common divided attention scenario is driving a car and listening to the radio at once (frankly, I think "simultaneous attention" would be a better moniker). With poor divided attention skills, I can’t be a passenger in a car and listen to the radio at the same time, especially when the car starts to move at 50 or 60 kph or more, at which point the speed of sensory input overloads my brain's ability to process the input quickly enough. It's like being in an IMAX 3D movie theatre watching Star Trek and suddenly the screen in front of you goes to warp speed and Kirk is calling for Spock behind your seat and the person beside you dumps popcorn all over you, all at the same time.
I first fully understood I had a problem with divided attention when my father was talking to me while I was trying to slice bread. I couldn’t do it.
So imagine having deficits in these three attention types and being at a party—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 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 and so 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 active treatment of brain injury, like with brain biofeedback. That's the second part of brain-injury awareness—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.
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The other two kinds of attention are focused and sustained.
Focused: This is the basic attention skill where one notices objects or events and specific sensory stimuli in the environment.
Sustained: This attention skill gives one the ability to stick with an activity over time, like reading a book or writing an essay or commuting on the highway. Inconsistent performance, varying from excellent to nonexistent—like one day remembering a phone number long enough to dial it, another day not—may be problems with sustained attention.
Copyright ©2019 Shireen Anne Jeejeebhoy. May not be reprinted or reposted without permission.
References
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
