Impaired sustained attention and error awareness in
traumatic brain injury: Implications for insight
Laura McAvinue1, Fiadhnait O’Keeffe1, Deirdre McMackin2,
and Ian H. Robertson1
1Trinity College Dublin, Dublin, Ireland
2Beaumont Hospital, Dublin, Ireland
The processes of error awareness and sustained attention were investigated in
18 traumatic brain injury (TBI) individuals and 16 matched control participants.
In Experiment 1, we found that: (1) in comparison to controls, TBI participants
displayed reduced sustained attention and awareness of error during the
Sustained Attention to Response Task; (2) degree of error awareness was
strongly correlated with sustained attention capacity, even with severity of injury
partialed out; and (3) that error feedback significantly reduced errors. We repli-
cated the finding of a correlation between error awareness and sustained atten-
tion capacity in Experiment 2 with a separate sample of 19 TBI participants and
20 controls. We conclude that TBI leads to impaired sustained attention and error
awareness. The finding of a significant relationship between these two deficits in
TBI suggests there may be a link between these two processes. Feedback on
error improves sustained attention performance of control and TBI participants.
INTRODUCTION
Closed head injury (CHI) is a form of traumatic brain injury (TBI) which can
result from a blow to the head or from rapid acceleration or deceleration. The
brain is damaged while the skull remains intact. While CHI can lead to wide-
spread damage in the brain, the frontal lobes and white matter of the brain
appear to be particularly sensitive to CHI (Fontaine, Azouvi, Remy, Bussel, &
Samson, 1999; Stuss & Gow, 1992). CHI has been associated with deficits in
© 2005 Psychology Press Ltd
http://www/tandf.co.uk/journals/pp/09602011.html DOI:10.1080/09602010443000119
Correspondence should be sent to Prof. Ian Robertson, Department of Psychology,
Trinity College Dublin, Dublin 2, Ireland. Tel: 003531 6082684, Fax: 003531 6712006.
Email: Ian. Robertson@tcd.ie
NEUROPSYCHOLOGICAL REHABILITATION
2005, 15 (5), 569–587

executive control. Two deficits often experienced are a reduction in the capac-
ity to sustain attention and reduced awareness.
Sustained attention is an endogenous process which people engage when
they “sustain mindful, conscious processing of stimuli whose repetitive, non-
arousing qualities would otherwise lead to habituation and distraction to other
stimuli” (Robertson, Manly, Andrade, Baddeley, & Yiend, 1997). TBI partici-
pants’ deficits in sustained attention are well documented. Vigilance tasks
require participants to detect infrequently occurring targets over long periods of
time. TBI participants have been shown to be impaired in such tasks (Whyte,
Polansky, Fleming, Coslett, & Cavallucci, 1995; Wilkins, Shallice, & McCarthy,
1987). TBI participants also have difficulty with continuous performance tasks
of sustained attention, which require the participant to maintain his/her response
(to the go targets), but to inhibit response to certain infrequently occurring
stimuli (the no-go target) (Chan, 2001; Robertson et al., 1997).
Lack of awareness is a common problem after brain injury. The well-
known condition, anosognosia, is characterised by an unawareness of deficits
that are obvious to friends, family and therapists (Bisiach, Vallar, Parani,
Papagno, & Berti, 1986). Patients often display a lack of knowledge about
their specific deficits and about the impact of their deficits on everyday life
(Flashman & McAllister, 2002). They tend to overestimate their behavioural
competencies (Prigatano et al., 1998; Sherer, Boake, Levin, Silver, Ringholz,
& High, 1998c). Impaired awareness can have a detrimental effect on out-
come after brain injury and can become a formidable barrier to rehabilitation
(Prigatano, 1999). Impaired awareness has been associated with lower voca-
tional and residential status (Trudel, Tryon, & Purdum, 1998) while accurate
self-awareness has been associated with favourable employment outcome
(Sherer, Bergloff, Levin, High, Oden, & Nick, 1998a). The potential negative
impact of impaired awareness has led to the creation of several methods of
measuring awareness of deficits. These mainly take the form of questionnaires
and interviews which are used to compare reports made by patients and sig-
nificant others. Examples include the Dysexecutive Questionnaire, the Self-
Awareness of Deficits Interview (Bogod, Mateer, & MacDonald, 2003;
Burgess & Alderman, 1996; Simmond & Fleming, 2003) and the Awareness
Questionnaire (Sherer, Bergloff, Boake, High, & Levin, 1998b). Impaired
awareness of deficits is a lack of global awareness (i.e., awareness of a gen-
eral error propensity). It can be distinguished from awareness of deficit at the
local level (i.e., the detection of a specific error at a specific time) (Prigatano
& Schachter, 1991). In contrast to an extensive literature on global awareness,
there has been little research done to investigate the effects of TBI on local
awareness. However, there is some evidence that TBI participants display
impaired awareness at the local level also. For example, in one study, TBI
patients completed everyday tasks, such as packing a child’s lunchbox
or wrapping a gift. Compared to controls, TBI patients corrected and showed
570 MCAVINUE ET AL.