Attention problems: how serious and how can you tell?

As I've already told you brain injury can manifest itself in attention problems, memory or problem solving complaints. Here I will focus on attention problems such as problems in concentration and getting distracted too easily. But first of all I have to explain what attention is.

In psychology, there are several different views on attention and what it is supposed to be. However, in reading a lot of books or articles about attention it becomes clear that attention has to do with a conscious effort to focus and to try to maintain this focus over some time. Technically this is called focused orselective attention. In essence, it is the focused processing of óne thing only. All your energy and mental capacity is focused on one action or activity and all effort is put on trying not to distract yourself from what is important. Examples are trying to get your first serve right at tennis, or your swing at the golf court. Not only in movement (actions) is attention very important, also in mental activities like reading. When you are concentrating sufficiently, the understanding of whole sentences with complex information will go smoothly, without having to read it twice.

The other main form of attention is what is called divided attention and the difference with focused attention is that it has to do with processing more than one thing at once. It also is a conscious effortfull process but now more things have to be taken care of. And again, as with focused attention, the problem is how to maintain this divided attention over time ánd not to get distracted too much of the relevant tasks at hand. Real life examples are driving a car and in the mean time having a conversation with someone, either by phone or sitting next to you. In soccer, when countering you have to keep the ball at your feet and in the mean time you have to look as well where and when you can give the ball to another team player. That this process has to be done under time pressure and is quite difficult for many people, can be seen in most soccer games. Only the best players in the world can divide their attention perfectly.

In dividing your attention the factor 'speed of information processing' is very important. The quicker you are in processing things, the more you can do in a specific amount of time, the better your divided attention is. In fact, we cannot do many things at once, actually we can do them only sequentially. Just like the juggler who seems to be holding up several balls at once but when played slowly you can clearly see that he only can focus on one or two balls at the same time. Due to its high speed of handling balls, it seems he does them all at once. However, our capacity to really do several things at once consciously is severely limited. The only escape we have is in automating one activity as much as possible. When one activity is very much routinized, automated, thén we can do 'more at once'. Remember your first driving lessons? I'll bet you didn't talk much when trying to handle the wheel and the clutch at the same time. Only after more lessons did your handling the wheel and the clutch become more automated, and only then you could divide your attention easier between talking with your instructor and trying to stay on the road.

Finally, both selective and divided attention have to be maintained over time, sometimes for only seconds, sometimes for several minutes. This is called our sustained attention and it costs a lot of mental energy. The brain can take up as much as 20% of all oxigen intake and it burns up glucose at high rates when doing complex tasks. Only with well-trained people sustained focused attention can last 10 to 20 minutes, such as in sharp shooters who can aim and shoot perfectly for that long. Normally, in most people focused attention (concentration) only lasts several minutes. After that it is quite normal to experience attention problems. It is even worse for divided attention because this is more complex and energy consuming process.

Brain injury and its impact on focused, divided and sustained attention

Brain damage almost always affects negatively the attentional processes, resulting in attention problems. A severe decrease in attention is therefore a very reliable and sensitive sign of how your brain condition is. This can be seen very clearly in boxers who just have sustained a blow to their head. Immediately after that blow their motor coordination can suffer or their mental capacities are less than perfect. Thát is the reason why a simple attention test is taken directly after a blow to the head, with boxers but also in American football players. Attention problems quickly show up. For example, they have to count backwards in 7s starting from 101. When their brain is even slightly damaged this kind of simple divided attention task can not be done fluently or flawlessly. Such neuropsychological 'tests' are very cheap (much cheaper than a CT-scan), sensitive and easy to administer. Of course, a good neuropsychological test has to adhere to several stringent criteria, to be found in another link on this page (about Test Psychology).

For now, it is sufficient to remember that brain injury shows up in a decreased attentional performance, hence attention problems. A very important question then is: hów diminished should a performance be to conclude that there is indeed a brain injury or damage? This is a very important but also extremely difficult question, surrounded by much controversy. What is for example the line between brain injury and a temporary lessening of brain functioning?

Is it really brain injury or just normal attention problems?

Science has no real answer to this question, researchers differ in their views about this. In my humble opinion, after reading a lot of books, articles, studies ánd having seen more than 2000 patients with brain injury, the truth lies in the middle (as always). Scientifically, the line is drawn at about 15 minutes of loss of consciousness. Being unconscious for such time or longer is considered as a brain damage, with an old-fashioned term called 'contusion'. Sometimes, tissue damage can be seen on a CT- or MRI-scan, but not always. A more reliable indicator of brain injury is the loss of memory for events after this injury, the so-called Post Traumatic Amnesia (=memory loss) or PTA. When this is more than one hour you can safely assume there has been some brain damage. When it is longer than 24 hrs (including any loss of consciousness), it is even severe brain injury.

So, whenever there is a sudden drop of consciousness and associated with it very obvious attention problems, then this is not just a temporary lesser functioning of your brain, it is indicative of brain injury. Usually, immediate rest is advised and care has to be taken not to oversee a possible bleeding due to micro-damage to blood vessels in the brain. Normally, a wake-up advice every 2 hours is given, just to be sure there is no slow bleeding in the brain which can cause a coma (=loss of consciousness) and even worse, death.

Several factors influencing your attention in daily life

Of course, due to our being a dynamic biochemical body where our blood flow, blood pressure, blood glucose, oxygen intake varies from minute to minute, our attention is not stable as well. It fluctuates constantly, within certain boundaries. Within these boundaries we function more or less efficiently every day. How neuropsychology determines whether these fluctuations are within normal range is the topic of another page of this website. People interested even more in what is normal or not, should follow this link when I am going to explain more about normal attention lapses in everyday life.

For now, you'll just have to remember that there are several factors which can influence our functioning in everyday life or in neuropsychological tests. We (as neuropsychologists) call those 'normal' factors with a little irony: disturbing factors. Such factors must be kept to a minimum to be able to conclude reliably that there is some brain injury or not. The 'disturbing' factors are: fatigue, drugs, motivation, emotions, pain, sleep deprivation. Everyone knows that being too emotional normally does not help to focus perfectly on a difficult task (accept for some rare exceptions such as tennis star John McEnroe who could serve an ace whenever who got agitated). Also, having slept badly for a couple of days, seriously decreases your concentration as can be seen in a dart game. Constant pain such as chronic lower back pain, can hinder your attention as well. Being low on blood sugar levels does no good to your concentration either, as you'll notice in a squash or tennis game. All such factors result in attention problems.


To summarize: attentional processes are extremely sensitive to brain dysfunction and whenever you have sudden obvious attention problems you should be alert. Of course, factors like drugs, serious sleep deprivation, fatigue can result as well in attention problems. However, when none of these factors seems to play a role, some other processes in your brain can be the cause of your attention problems. Only when your attention problems do not go away in a couple of days, you should seriously consider a visit to a qualified neuropsychologist. Only a neuropsychologist has the tools and expertise to interpret your complaints reliably. In the pages on Tests I will explain in more detail why I make this bold statement and how a neuropsychologist can be thát sure about your brain.

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