The effects of attention training: the scientific evidence

In the early 90s I developed an attention training with my colleague Luciano Fasotti which we called TPM (Time Pressure Management). Before doing that I had to review the scientific literature about the effectiveness of attention training for patients with traumatic brain injury and/or stroke.

I was amazed to find out that most effectiveness studies were of poor quality (around 70%) and what was worse: the poorer the studies, the more they concluded that this kind of training was indeed effective! But...when looking at the really good studies (methodologically sound) the conclusion had to be: attention training was only moderately effective after brain injury. Furthermore, treatment effects did not generalize to the real world (in cases in which this was actually researched).

Not a very promising conclusion, don't you agree? Now, in 2010, about 16 years later, I am writing this website and I have found an excellent meta-analysis of a lot of effectiveness studies about cognitive rehabilitation. Studies about attention, memory, visuospatial, language and executive function training. You can find this article in the next link:


Meta-analysis of Cognitive Rehabilitation 2008

This article mentions roughly the same results that I saw 16 years earlier...and that's astonishing. Either I was a genius then and could already conclude things that were confirmed in the future, or... we haven't made much progress.

The article states that in (only 45) well-done studies there is a small-to-moderate effect of attention training on attention measures. Furthermore, this kind of training is very targeted and does only lead to attention improvements and no progress in memory, language or other cognitive domains. More findings: even control groups who did not receive targeted cognitive training, showed moderate signs of improvement. And last but not least: the evidence that attention training results in significant gains in daily life is lacking! The studies focused on traumatic brain injury and stroke patients, most of them within 1 year after their injury (so spontaneous recovery was very likely).

All in all: the case for attention training is, in my opinion, not that strong. The improvements are small to medium, the researched number of patients is usually very small (talking about between 10 to 30 patients per study at the most!), and improvements in daily life activities are not studied or hardly reported.


What IS attention training really?

Although there is some evidence that attention training is moderately effective after brain injury in the first year of damage, the question arises whether it is really worth the effort.

But whát is it? Attention training? In all those studies or treatment designs, it seems very nice: "training targeted on focused, divided and sustained attention". (For a discussion of what attention actually is, see my pages on attention problems and Attention: what is it?).
However, when you focus on HOW such training is being done, you'll get a sense of the true value of such training. I have to admit that most studies focusing on attention itself do NOT show much evidence of any effect. It is usually the so-called strategy training that shows some effects of the training.

Strategy training is a kind of training in which strategies or tricks are used to compensate for the attention deficits. The attention deficit itself is not solved or cured, but its negative effects are reduced. Time Pressure Management training (TPM) is such a strategy training in which patients are learned to cope with their slowed information processing. They have more troubles in taking in lots of information at a certain speed. So they learn in TPM to reduce the information intake to manageable levels. It can be as simple as watching a recorded TV documentary and stopping the DVD or video whenever the patient can not follow the information flow. Then the video can be rewinded a bit to present this information again. In TPM patients learn to pace the information. In driving a car, when it does get too much to handle, driving more slowly, is a good strategy.

Sounds trivial and simple? Well, it is. But most patients have to learn such strategies, they will not do it automatically. Now a very strange finding in our study (done in 1994, published in 2000) was, that patients trained in TPM also were better on several attention measures. We explained that as a side-effect of getting more confident in dealing with tasks where time pressure was present. No other explanation was found.

To put everything in perspective: we only used 22 traumatic brain injury patients, only 12 did TPM. Later, another PhD study of miss Winkens (in 2009) replicated the very modest results of TPM on only 18 stroke patients. Still very small numbers when evaluating a training. That's how science sometimes works.

So attention training is NOT what most people seem to think: try to concentrate harder on your task at hand. No, although important, such kind of focus is not required in strategic attention training. It learns the patient to recognize difficult parts in a daily task and then to make this task more simple for them so they can compensate for their attention deficit. When reading a book is difficult because of concentration problems, the training does NOT try to focus even more on the words. The attention training learns the patient to read with a cover paper in which a small window is cut out, so only a few lines at a time are made visible. With this compensation technique (or trick), it is much easier to keep track of the words on the page.

And immediately I hear you say: but...that's not really practical is it? No, indeed, it isn't. That's THE reason that most (attention) strategy training is not done by most patients. Strategy training is rather cumbersome, it costs extra energy and it seriously changes the task at hand. Reading a book using strategy training changes into an experience that is NOT the same as reading a book when you were healthy. There are serious side effects of strategy training which are almost never mentioned in scientific studies. Because, for scientists it doesn't matter...that the side-effects are seriously changing every day life for brain injured patients.


The unmentioned side-effects of cognitive strategy training

Side-effects in daily life of cognitive strategy training are roughly:
1. taking much more time than normal
Most normal daily tasks take much more time when doing them using a strategy. When normally reading a book, this might take say 5 to 6 hours (when it is a small book of about 120 pages). Using a strategy to compensate for your concentration deficit, like reading with a liner or with a window-page so that only a few lines are visible, it can take several days to read this book. Because you are much slower and you will become much more easily fatigued so you have to include much more pauses than normally. Most brain injured patients I have spoken to, finally give up such kind of reading experiences or revert to much smaller and simpler books.

2. costing much more energy than normal
Although strategies can be helpful and effective it is rarely mentioned that using such strategies requires a lot of concentration and therefore energy (and determination). That seems to be the main reason most brain injured patients in clinical practice do not use such strategies. Although the minority of patients starts using them whenever in rehabilitation training, as soon as they stop rehabilitation, such strategies are stopped as well. The main reason I hear is that it takes too much energy to use the strategy and its positive effects are not worth the effort.

How come these side-effects of cognitive strategy training are not mentioned in the scientific literature? Well, first of all, it is not positive news. It is commonly known that positive findings are much more published than negative findings. Furthermore, researchers usually only care for their study to be published...focus is not really on the practical (ecological) values of their study. Fortunately, the last couple of years, there is some more attention for this ecological validity of studies (i.e. how valid are training programmes for the daily lives of brain injured patients?). A third reason is that researchers normally are not the ones who counsel or follow brain injured patients during their struggles with brain damage. So actually, they really do not know much about the patients' struggles with using cognitive strategies. A fourth reason is that in the scientific literature there are almost no studies about compliance for cognitive strategies. How long and how well patients use cognitive strategies at home isn't being studied at all! So how do we proceed? Isn't there anything positive to say about cognitive strategies, for example for attention deficits?


Strategy training for attention deficits: it IS possible

Yes, attention training can have positive effects and for sure the meta-analyses in the last couple of years has proven this. Be it a small or moderate effect of attention training, but there IS an effect.

However, attention training is only worth the effort when there are several positive prognostic factors after a brain injury. On my pages about Brain Injury Recovery I have already explained the fundamental key factors that can play a role in a good recovery process.

If you are young (under 45 years), had a good condition before your brain injury (e.g., by doing regular physical exercises), have no other serious medical problems that can affect the brain, have no serious executive function problems, have a relatively small brain injury, and have a very determined mind set, THEN attention training might be something for you.

One of the best attention training programmes is...you've guessed it...Time Pressure Management training. The main idea in this training is to learn how to give yourself more time to do things in a slower pace. Planning training is one way to deal with time pressure, such as in cooking a meal. Cooking a meal can be difficult whenever you have to use 2 or more pans. TPM teaches you that there are roughly 2 phases in cooking: the first phase without any time pressure is the planning phase. This is the phase in which you do all the preparatory work: washing and cutting the vegetables, measuring and preparing all food ready to use. The second phase is where the actually cooking begins with the fire on the stove. Here, there is more time pressure but you have learned what to do in what order. By preparing yourself that well, time pressure hardly arises and no extra attention is needed for this task.

Time Pressure Management can be used in several different tasks in daily life, be it driving a car, cycling, listening to a lecture or taking minutes during a meeting. In each task, first of all, the moments of time pressure must be recognized. Taking a left turn in a car (in a right sided driving culture) for example, is a high time pressure moment in which you have to decide fairly quickly to take the turn. TPM teaches a patient to just stop at the middle of the road, then to look around and wait patiently for a good moment in which there is no traffic and there is ample time to take the turn. Sounds very simple but what most (normal) people do is rushing in and taking a turn as quickly as possible. That's not only creating a lot of stress, it is quite dangerous as well because the time taken is almost too short to check everything safely. Most car accidents happen because of too little time to respond. Whenever you have divided attention deficits, meaning you can not do two things at once, TPM teaches you to drive defensively. You'll learn to drive with a safe distance to the car in front of you. A safe distance is the distance you will need to have ample time to come to a full stop whenever some things happen. It is that simple.

The main problem with TPM is that most people normally do not want to change their habits. Furthermore, in using the TPM philosophy, things are done a bit slower but more safely (with less errors). Most brain injured patients do not want to be seen as being slower. Their lives then resemble that of older people. The truth is, they ARE slower and DO resemble aged people. What's the big deal whenever they succeed without much errors?

After more than 20 years of clinical practice with brain injured patients, I have learned that neuropsychotherapy - psychotherapy for brain damaged patients - can be of some help in adapting and accepting cognitive strategies. However, this is not very easy because of the brain injury. On my pages about Problem solving deficits I have explained that brain injury usually reduces the logical and critical reasoning of patients. Usually in such a way that normal psychotherapy is not really possible. It has to be adapted and given in a special form. An excellent book about this matter is the one of Pamela Klonoff: Psychotherapy after brain injury (2010).

Another kind of attention training that seems to have some positive results, especially in children, is neurofeedback training. In neurofeedback, EEG signals are used to condition the brain to improve focus or concentration. Despite a lot of skepticism about neurofeedback, a few well-done studies do show positive effects, especially in children with attention deficit disorder (ADD). Findings about the effectiveness of neurofeedback in brain injured patients are, to my knowledge, far less convincing. I have to speculate but this seems logical. Neurofeedback training is quite difficult, even for normal people. You have to focus as if you are meditating, and that is not simple. Especially not for brain injured patients who have very serious problems in self-regulation and concentration. Furthermore, they usually do not have the patience to sit still for longer training periods. Unfortunately, the marketing strategies for neurofeedback are all around, promising positive effects for almost all deficits after brain injury. Probably, because of its name 'neurofeedback' a lot of lay people do believe such kind of marketing.


Cogmed: attention training or working memory training

Finally, I would like to discuss Cogmed. A highly marketed attention training, put into the market as working memory training. It has been developed by Torkel Klingberg, a distinguished researcher and clinician in Sweden. Cogmed is a computerized training programme specifically aimed at improving and enlarging your working memory. In my page about Attention: what is it I am saying that working memory largely is the same as what scientists call attention. Actually, in their marketing for Cogmed it is stated as well that it really improves attention, especially when having ADD (Attention Deficit Disorder). Cogmed truly has several advantages as a cognitive attention training program that no other programs have. It has been scientifically evaluated many times, much more than other cognitive training programs. It is being delivered by professionals because there are certain restrictions for those who want to give this training (they must be qualified psychologists for example). It is highly focused on just working memory. Most other training programs focus on much more cognitive functions like memory, problem solving, attention. And Cogmed does not make extravagant claims.

What do I have to say on Cogmed? Well, the above mentioned positive claims are true, as far as I can tell. Furthermore, it is very positive that real science is used to evaluate this program and…the results up to this moment do support some optimism. However, as 22 years ago in 1990 when I reviewed the attention literature about the supposedly positive effects of attention training, I did not see actual daily life effects of such training. The research on Cogmed does support some evidence but…daily life effects have not been studied extensively yet. Largely, the evidence for positive effects in daily life is gathered by using questionnaires and some observations. It takes much more studies to get me convinced. For one thing: I know that the placebo effect of training usually is large (estimates are up to 60%!). For all I know patients have increased their confidence and lifted their mood and that would explain the positive attention effects of Cogmed. All I am saying is that evaluating the effects of such an attention training is very difficult to do because various alternative explanations can be put forward for the stated positive effects. However…more studies are being conducted and it will be a matter of (short) time before we know the true positive effects of Cogmed in daily life. If it is so promising as the marketing says…well then we should go for it.

Cogmed is a computerized training and its largest advantage would be that it can be done at home because it is Internet-based. You just log in from your own computer at home and do the exercises. This explanation of what Cogmed is comes directly from their website www.cogmed.com:
The Cogmed training method consists of 25, computerized training sessions, each 30-45 minutes long. Each session consists of a selection of various tasks that target the different aspects of working memory. The training is done on a computer at home, in school, or at work. The training program is five weeks long with five sessions every week. It is a rigorous program designed to improve working memory through intensive and systematic training.

So it surely takes some discipline to do this training but there is a 90% completion rate and that is very high indeed. I did some of those exercises but they are pretty basic and I got bored rather quickly. But then again, I do not have working memory problems.

The largest problem I have with Cogmed is its claim that it is really possible to improve working memory. More specifically, it states that the capacity of working memory is improved, meaning increased. This is really unheard of because most of science thought up till now that this capacity was flexible but could not be enlarged. Due to genetic and biological constraints. But now Cogmed states that with ‘systematic and intensive training’ (25 sessions, each session 30-45 minutes) this capacity can be increased. Although I do know that our brain can increase or change its wiring in a couple of minutes and days, this working memory capacity increase sounds too good to be true. What really is interesting is why it does NOT work for every patient. Because that’s also what Cogmed says and the studies have shown: working memory capacity does not increase in everyone. Why not? All brains can be flexible, all brains are in essence the same.

What is this Working memory capacity really? I have tried to explain this already on my page about Memory Problems. It is nowadays in the scientific world assumed to be the front-stage of the real memory consolidation process. Actually, when looking into the concept and reading lots of literature about working memory I cannot but notice that most researchers are either bad philosophers with a poor ability to clearly define a concept or…working memory is nothing more than ‘executive attention’. In this case, I still prefer the cognitive model of the Miller and Cohen group (Todd Braver, Jonathan Gray, Carter) about the prefrontal cortex and their parsimonious concept of ‘cognitive control’. With this concept terminology like behavioral inhibition, working memory and selective attention are all sides of the same coin. What’s more important: this cognitive control model is much more based on a connectionist philosophy of how our brain works. Recent research trends do focus much more on network models of the brain, see the excellent book by Olaf Sporns (networks of the brain, 2011). Now, to my point. In seeing the working memory concept in this Cognitive Control light, it is nothing more nor nothing less than the ability to reverberate things just long enough to work on them (hence the term ‘working’ memory). This repeating or holding essential elements of processing is a true prefrontal ability. It is largely determined by the biology of a brain, its genetic make-up and probably by how fit your brain is. Taking into account circadian rhythms, hormonal influences and your arousal levels. And the true question is: can this capacity to hold something long enough for adequate processing really be increased. If so, does that really happen with only 25 sessions of 30 to 45 minutes of dull computer training games?

Unfortunately, no one knows the answer yet. We do know however, that our brain is indeed highly flexible. For example, weeks of meditation does indeed changes the brain, as does any kind of attention training. Regions develop more connections, thereby increasing their volume. Every training does that, by the way. So it COULD be possible. We also know that we cán learn to focus better in several tasks, specifically after targeted attention training. And that it indeed takes only weeks to show such increased focusing effects. Due to everyday intensive training. We have seen this all kind of sports, especially in pistol shooting. Pistol shooting requires very high levels of concentration and I have done it myself. It is indeed possible to train intensively your concentration in such a way that you really become better in pistol shooting. So…ONLY after intensive attention training the brain gets rewired. Just as probably is the case in neurofeedback training. However, the COGMED training is much more focused and very rigidly set up to incorporate the best classical and operant conditioning techniques. That’s also why it is so dull in its exercises. That’s probably also the reason you will need a coach that calls you every week, to stimulate you to keep going on. Only then, it is theoretically possible that your brain will be rewired and there is indeed an increase in this capacity of holding a bit longer specific information for processing.


In summary

Although I am truly sceptical about the claim that attention training is possible, there are positive indications that a new attention training form called COGMED can be of value. However, although it seems theoretically possible that our ‘working memory capacity’ or our attention can be expanded a bit, it still remains to be seen if this truly leads to improvements in daily life tasks. We will wait and see. It is truly exciting though.



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How you can train your kids in improving their attentional skills:

How we can learn ourselves how to focus with very practical exercises:

Thé most wonderful book about human consciousness and how it evolves out of our brain is this one from Damasio. Sometimes difficult to read but surely a brain teaser and fascinating!:

From quite another perspective: trying NOT to focus even improves your skills more. Research has shown for decades that automatic processing is much more reliable than controlled (conscious or attentional) processing. In this book it is argued quite convincingly that letting go and NOT interfering on a conscious (attentional) level improves your actions and skills:

Some encouraging news about coping with ADHD:

Clearly written book about our limited attentional capacities and hope about improving it, backed by scientific studies:

Nicely illustrated and in plain language explained how our brain has several attentional systems and how they are used less when we learn new things:

A really well-written more academic but introductory book about all neuropsychological aspects of attention. For students as well as clinical professionals:

The excellent integrative framework of Cowan about attention and working memory:

The book that summarizes all theorizing about working memory:

For the really die-hards here comes a rather formally written book but extensively covering all aspects of attention also in patients with brain injury:

For the even more die-hards comes a book that extensively discusses all research about the interaction between attention and action. Again, more formally written to indicate serious science:

A very recent book just about the topics I have discussed here: selectivity and control of attention. However, a bit pricy and very scientific indeed with heavily focuses on visual attention research. Furthermore, most researchers are not clinicians but more scientists. Nevertheless, if you are interested in very current theories about attentional control this 2012 book is worth reading:

Fans of one of the best neuroscientists today Michael Posner should read this recently updated work with many well-known neuroscientists. However, this as well is quite scientific and formally written stuff:

This book is for the real die-hards because it is highly complex and in a language from network theory. However, it shows the new way of thinking about how the brain actually works. The old box models of the brain are truly medieval compared to this book:

For those who rather like to see a holistic approach to therapy for brain injured patients this book is a real treat: