Rehabilitation of attention and executive function impairments

Abstract

Disturbances of executive functions, including the executive control of attention, are recognized as among the most common, persistent, and debilitating consequences of traumatic brain injury (TBI) [1-6]. This chapter focuses on the application of empirically supported strategies for managing impairments of higher level attention and executive functions following TBI. We recognize that the clinical neuropsychology and cognitive rehabilitation literatures have typically considered attention and executive functions in relative isolation. However, there is considerable overlap and interdependence in the structure and function of higher-level aspects of attention and executive functions. Throughout the chapter, we use the term "attention-executive functions" to refer to executive functions (e.g., anticipating consequences, planning and organizing, initiating and sus- taining activities) as well as skills associated with the executive control of attention (also referred to as supervisory, complex, or higher-level attention). Skills associated with executive control of attention include the abil- ity to sustain attention in the face of distractions (selective attention), switch focus or mental sets (alternating attention), or manipulate and control information held online (working memory). The processes involving attention-executive functions are distributed throughout the frontal regions and connect with other frontal, posterior, and subcortical areas to exert executive (i.e., top-down) control over lower level, more modular, or automatic functions [7, 8]. The frontal lobes and interconnecting circuits are particularly vulnerable to focal and diffuse damage in TBI, which accounts for the frequency of deficits involving attention-executive functions in this population. Given the overlap in the structure and function of attention- executive processes, interventions targeting these processes are also inti- mately related. The chapter begins with a review of attention-executive functions. We also provide a brief overview of recent empirically driven models of frontal lobe functioning, particularly as these frameworks relate to the concep- tualization and remediation of attention-executive deficits following TBI. Next, we describe the nature of attention-executive functioning impair- ments and illustrate how associated impairments can manifest in individu- als' everyday lives. This is followed by a review of interventions for attention-executive functioning, including empirical evidence that has culminated in recommendations for clinical practice. The remainder of the chapter is devoted to describing the application of metacognitive training, a class of interventions that have demonstrated empirical evidence of efficacy in ameliorating attention-executive impairments [9-12]. Based on our clinical experiences and judgments, we will emphasize key compo- nents of the described therapies with the intent of providing a greater understanding of the theory and application of metacognitive strategy training in the context of brain injury rehabilitation.