Attention Problems

  • Introduction
  • The Components of Attention
  • Attention Skills
  • Difficulties Experienced
  • Complications
  • Things You Can do to Help Yourself
  • More Ways to Help Yourself
  • What is Happening on the Inside
  • From the Outside
  • Caring for Your Brain Environment

Introduction

Most of us understand that attention includes the ability to focus on a task or a thought, but we often don’t consider that it is also a complex thinking ability that includes many different skills.

Many different parts of the brain manage these skills. When brain injury disrupts the executive systems, there can be complicated outcomes and effects. Everyone will experience unique and distinct problems.

One of the key functions of attention is to process all aspects of incoming information from the inner and outer environment. It is attention which selects what to process and what to ignore, and is therefore an essential part of helping us to manage feelings of flooding or being overwhelmed.

When people talk about problems they have with ‘filtering,’ what they are really describing is the challenges that arise because the brain isn’t making the automatic selections it once did. 

For example, the brain should be orienting attention to the pertinent information that would support us knowing what is salient to the moment. It is the ability to maintain attention which helps us to know what to listen to and what to see. 

The ability to multi-task is part of the cognitive process that include attention processing, so we can listen to one person and monitor what other people are doing and saying close by. 

The components of attention

Everyday activities require you to use different types of attention. 

Understanding what these are and how they affect you can help you to learn and therefore notice when impairments in your attention are creating difficulties for you.

Sustained Attention

Being able to sustain attention is the foundation for all information processing.

For this reason, practising routine is vital for getting this component of your thinking to work again. The more you can learn to do by habit again, the more ‘space’ you will have in your brain for attending to interruptions, distractions, and different demands made on you.

Examples of maintained sustained attention would be watching something for a sustained period. This might be something like watching sailing boats from a beach, children or dogs playing, or driving on a motorway when you have to be conscious of unexpected changes, such as lane closures or when your exit is coming up. 

An example of having problems with sustained attention would be driving past your exit on the motorway, failing to get off a bus or train when you should, or not noticing when a child falls because you were watching something else. 

Selective Attention 

Selective attention is when you turn you focus to particular features in your environment.

For example, you may be on raised ground on a sunny day and looking at the vista around you. You may notice smoke rising from a chimney and when you switch you attention to this you are selecting where to look at the detail.

Your brain injury may mean you have problems with seeing the details. You may feel overwhelmed when there is too much going on to hone in on whatever is interesting or important to you.

An example of having problems with making selective choices about what to focus on would be having problems with reading a book or newspaper when there are other people chatting nearby, or the TV or radio are on. 

Divided Attention

Divided attention enables us to do more than one thing at a time. 

For example, you might want to bake a cake and listen to a radio show, or watch TV while you are knitting baby booties or polishing your boots.

The more you practice any skill the more habitual it becomes to you and the less attention you need to pay to doing it. This is why repetition and routine are crucial strategies to use because they are key to getting your brain to do things automatically again.

The more you can do without having to consciously pay attention, the greater capacity your brain has to manage more than one thing happening in your environment at the same time. 

The more things you can do with unconscious competence, the less things outside where you want to focus will interfere with what you are trying to achieve.

Attention skills and deficits

Introduction

We tend to think of maintaining attention as being able to focus or concentrate. However, for you to be able to focus on the details of what is happening in your immediate moment and environment, your brain needs to be doing more than just directing your thinking.

For example, before your brain injury you would automatically have undertaken attention and thinking skills so automatically and spontaneously that you wouldn’t have noticed the vast variety of skills you were using.

Because you wouldn’t normally have broken this automatic skill down to become aware of individual features of your thinking, you will lack awareness of what these are following a brain injury.

For example, if you asked an uninjured person to describe each thinking skill they used during any normal day, they would struggle to make the definitions without giving a lot of time and thought to each task they undertook. There are multiple skills being used in everything we accomplish.

Your brain injury will mean that some parts of your brain no longer ‘speak’ to other parts. This is why you struggle with communication and actions. You might not be aware this is happening to you, but having problems tells you it is happening. 

Below are some of the complex tasks undertaken by your ability to maintain attention. 

Self-regulation and planning

Being able to envisage or ‘see’ the desired outcome and being able to plan the steps towards this goal in a disciplined and ordered fashion, taking into account any possible obstacles.

Challenges: People often describe an inability to ‘see’ the desired outcome or goal. They may recognise they are at a hurdle, but be unable to consciously know or understand it needs to crossed.

It can feel as though there is no awareness of steps, although individuals may notice they are needed. This may be described as having point ‘A,’ but not having the B, C, D etc.

Potential obstacles will be ‘unseen’ and therefore not taken into account. For example, the lawnmower might not work, and you fail to take into account you don’t have any mechanical skills, so take it apart anyway. If it is electrical, you may not realise it is safer to unplug it. 

The usual solution would be to understand capabilities, potential problems and dangers, and to take it to a repairer. 

Understanding instructions

Being able to process verbal or written instructions, and break them down into manageable step-by-step pieces.

Challenges: The auto-pilot in the brain will believe it can still do things the same way it could before. This ‘interference’ often goes unrecognised so you may find that you go ahead with an action, believing you are doing what was asked of you, only to find that things go wrong and you don’t understand why. 

Your brain may struggle with fully understanding incoming information because it can no longer spontaneously break this information down into full understanding. The problem is, your brain probably won’t recognise this has happened so you will respond automatically but find a lot of the data has been missed when it comes to following the instructions. 

It helps if people around you are patient and break things down for you, but, at the same time you need to be able to acknowledge you now need this extra help while your brain is rewiring.

Maintaining focus

Resisting the temptation to do something else when challenges arise or the next step is not understood. Being unable to manage ‘interrupting’ thoughts about another matter and wanting to deal with this instead.

Challenges: Your brain injury may mean you don’t get the feedback via your metacognition or ‘thinking voice.’ Because of this you may not be aware of drifting from one half-finished task to another. 

You may feel that you have been busy and be unaware that you haven’t completed any activity during the day. You may not have conscious awareness that you have met a challenge and left something you were doing thinking you would go away and think about it and forget this is what you were doing. 

Keeping a list of chores and ticking them off only when they are completed will help you to remember where you got up to and what still needs to be finished. 

Difficulty with maintaining focus can also make it tough to have or follow a conversation. You may need to think about important things beforehand and write down the points you want to make. It can help if other people are patient and pause to allow you time to think.

Being attentive

Mentally following and remembering the steps that have been taken to form a narrative or thought sequence about the actions already taken.

Challenges: Let’s use the example of making a meal. There are many sequences: preparing the vegetables and other basic ingredients, holding awareness of how long each item will take to cook, working out what you need to do first so that everything is cooked together and so on.

If you have trouble sequencing and keeping you attention on the steps you have taken you might burn something or end up with something cooked before everything else is ready. 

Having a list of what you need to do, how long it will take you to do it, knowing what to start cooking at what time and using an alarm to remind you when to do the next step are all strategies you can use to keep pace with the activity you are performing. 

Ability to ignore distractions

Being able to prioritise and make rapid decisions about events external to the activity so they do not interfere with focus, for example, remembering there is an answering machine if the telephone rings.

Challenges: Sticking with and doing one thing at a time can help you manage the completion of tasks. For example, you might be making a cup of tea, coffee, or bowl of soup and need to break this activity down to achieve the steps, when, part way through you can hear the washing machine finish it’s cycle.

Afraid you will forget about the washing machine you leave the task in hand but don’t realise that by allowing yourself to be distracted, you are now likely to forget what you were already doing. 

If you have a list with doing the laundry on it, this will remind you to revisit the task during the day. Using and alarm to remind you when the wash cycle is finished so you can go to the next step of hanging it up to dry, is better than not being able to drink or eat or continue with whatever else you were doing.

Ability to control impulsivity

Wanting to do tasks in the wrong order or abandoning a project in favour of a different solution without thinking through the consequences or new challenges.

Challenges:

Switching attention

Pausing to deal with something else and being able to either understand the new task or return to the previous one. Difficulty changing topics during a conversation, needing to fully complete one subject or task and needing a break before the next one.

Challenges: Interruptions always happen in one way or another. If you discontinue one thing to attend to another, you will struggle to remember what you were doing, what stage you were up to, and to resume any action or conversation from where you left off.

You may have some awareness of examples of where this has happened to you, and be fearful of stopping something or of someone else changing the topic of conversation before you have finished. 

Pre-planning, creating a routine, using tools and lists, can all help you to improve these problem areas. The goal is to help the brain to rewire by using the same strategies repeatedly until you learn to do things by rote or habit again. 

Your brain won’t get better on its’ own; it needs you to help it.

Multi-tasking

Difficulty understanding the multiple processes of a task or being unable to switch to something else before the first task is complete. For example, turning on the washing machine and waiting for the programme to finish and not doing anything else in between.

Challenges: If you have several tasks to accomplish in a day it can be easy to become overwhelmed and to feel as though you have taken on too much.

If you try and stick with doing one thing at a time, when you could be doing other things, you are making an inefficient use of your time. Outcomes of inefficiency may include struggling with energy because things take longer or with becoming frustrated because you don’t feel like you are getting anywhere.

If you pre-plan your day and create a routine to stick to, your brain will be able to learn what you want from it in better ways and will start to rewire to support you. 

The BEST Suite of apps will support, encourage, and help you to rewire your brain and take back control in respect of all these attention issues.

Difficulties experienced

The outcomes of a brain injury affect your attention skills to varying degrees and so, for some, it can feel that these skills are lost. Many people have significant difficulty with sticking to one thing and completing it, and will often leave a path of part-completed jobs behind them.

An example of how brain injury can affect attention is to think about an every-day skill – multi-tasking. Being able to maintain our focus allows us to resume previous thinking or tasks after needing to pause to do or think about something else – in effect, we are multi-tasking when this happens.

Difficulties with this and other attention problems can cause frustration and worry which, in turn, exacerbates the problems you are having.

Problems with attention will also affect your ability to remember things, especially if you can’t focus long enough to take in new information.

Other things you might struggle with include:

  • Difficulty listening to other people talk and keeping up with a conversation – especially if more than one other person is present or when there is background noise or distraction
  • Reading or watching anything from start to finish
  • Driving or undertaking any activity that requires multiple skills to be used

Demands on attentional capacity

Motivation

How motivated you are will automatically increase the capacity you have to maintain attention and achieve something. If you are struggling with getting started, ask yourself how much you want to do it and why?

Bring your attention to your level of interest and you might be better able to see if you need support or if you need to reprioritise tasks. 

Being told or asked to do something can be demotivating if you aren’t interested in the task or doing like doing it. It can help to try and notice or pay attention to how you feel and how this is affecting you. Only when you understand the barriers can you begin to think of alternative approaches.

Notice if you feel stressed or tired, as these can be demotivating.

Skills

The more skilled you are at something, the more likely you are to enjoy doing it or not to mind doing it. 

If you have lost a skill, practice it over and over until you get good at it again. This could be a skill that enables you to enjoy a craft or hobby again, or it could be a practical skill you need to rebuild. 

Practical skills would be something like knowing how to tie your boot or shoe laces. 

The better you get at rebuilding and using previous skills, the more space or capacity you will have to may attention to other demands.

Mental Effort

If we think of things that used to take us more mental effort to achieve before a brain injury, the chances are that you will now have to work even harder at that task. 

For example, you might not have like numbers very much, and found it hard work to sustain the mental effort to balance your bank account. You might find this impossible to since since the brain injury. 

Only by trying and being prepared to have to put in a lot of mental effort will you get back the ability you had before. 

Asking someone else to do it for you isn’t the answer because we all need to do everything we can to maintain our independence and to make sure we are carrying our share of the load and taking responsibility, however hard it is. 

Think of support as being a transitionary need to help you get back to where you were rather than as being a permanent change. The idea and goal must be to help your brain rewire.

Complications

The following can exacerbate symptoms and difficulties, especially in those who also have filtering problems:

  • Noise
  • Busy environments
  • Interruptions
  • Multiple people/subjects
  • Rapidly changing events
  • Fatigue and lack of sleep
  • Stress
  • Feeling unwell / illness
  • Illicit drug use
  • Doing something that you are not interested in
  • Side effects of medication
  • Depression
  • Anxiety
  • Poor diet
  • Filtering incoming information and processing in a timely way

Things you can do to help yourself:

  • Exercise regularly and get fresh air and daylight every day
  • Eat for nutrition
  • Use supplements to improve the brain environment
  • Get plenty of sleep and practice good sleep protocols
  • Take breaks during the day to allow your brain to process and catch-up
  • Follow a daily, weekly, and monthly routine to help build new habits
  • Try only to do one thing at a time to minimise confusion
  • Make sure you have enough light to see what you are doing
  • Do activities in a quiet place or when others are out so that you can focus
  • Turn off the TV or radio or wear earplugs so that your brain isn’t trying to do more than one thing
  • De-clutter your home and car to minimise distractions
  • Get organised and try to do at times of the day when you have the most energy, for most people, this is first thing in the morning
  • If you have a family, it can help to wear ear-plugs when you are reading or earphones when you are watching something.
  • Ask people to speak slowly and clearly and to repeat things for you when you notice you haven’t understood
  • Use the Best Suite

More ways to help yourself:

  • Face the person you are speaking with to focus your attention on the conversation
  • When talking with another person, summarise or repeat the key ideas back to them to show what you have understood
  • Remind your brain to “focus” as you are doing an activity
  • Take notes – write down things you noticed went wrong
  • Say the steps of a task out loud while you do the task – speaking to yourself help your brain to focus
  • Set aside distracting thoughts when you are trying to focus or write them down if you are worried about forgetting
  • Practice doing the things that are hard for you, in small steps. Repetition will help you ingrain tasks as habit freeing up your thinking space

A neuropsychologist or occupational therapist will be able to help, and you may find that it is best to seek a referral from your doctor if you find that:

  • You are unable to complete normal daily activities, including tasks at home, work, or during leisure time
  • You are unable or struggling with caring for yourself or your family
  • You have thoughts or feelings that affect your ability to pay attention
  • Your attention problem seems to be getting worse

What is happening on the inside

How each person understands their inner world is as unique as each brain injury. What happens to one person, and how they individually perceive their difficulties can be variable from one person to the next.

From the inside, many people are unaware of the extent of the difficulties they have with attention and are often unable to break these down or understand what is going wrong well enough to be able to make changes – changes that always take time and practice to achieve.

They may also be unaware of how other people see them and may struggle with understanding that other people can see the changes and outcomes that difficulties with attention bring. Because of this, people may struggle with handling feedback and may feel criticised rather than supported.

People often forget that many tasks are now challenging and so they set out with enthusiasm thinking they can do something only to find out they can’t. For them, it may feel as though they have forgotten how to do things. They might fail to remember or be reluctant to ask or be shown how to do something.

Many people struggle with their brain not being able to understand that it can’t do things – even when the person has worked this out themselves. This problem occurs when their habits or auto-pilot are at work, and it causes real problems, especially when someone is on their own for long periods. It can even prove to be dangerous when people automatically set off to go and do something they have always done, like have a bonfire, and yet no longer have the capacities to consider safety or dangers and to stay focused.

People may misunderstand the confusion they feel, so they may, for example, think that someone else is speaking too fast or are saying too much rather than relating this to slowed processing causing problems with staying focused. When things go wrong, they may believe this is due to being given unclear/inadequate instructions or that the people around them don’t understand or help enough. Often the impairments make it extremely difficult for people to associate their experience with the actual cause. Some people can’t remember what things were like pre brain injury – sometimes, all they know is that their brain now works differently.

When undertaking tasks, it may feel like it did before, and there may be no internal indicators lighting up the fact that things are going wrong. The inner intentions are still the same. Because of this, when things do go wrong, and people comment, people can feel judged.

From the Outside

It can be incredibly hard for family and friends to know and understand what is going on with any aspect of the array of impairments caused by brain injury and it can also take a while for them to incorporate new understandings into their behaviours. When we learn something new, we all need time to practice utilising this information, so it is essential that everyone is gentle with themselves – and each other – while this is going on.

Where there is a lack of information, in general, many people struggle with understanding and can easily misinterpret and misunderstand what they are seeing. So what you think you are seeing – might be something else entirely.

For example: 

Difficulty making plans or knowing they are needed – is often misinterpreted as laziness or selfishness

When someone needs instructions repeating – this may be interpreted as thinking someone wasn’t listening/paying attention

When someone is struggling to recognise that a topic has changed – this may become – you are obsessive or procrastinating

Brain injury ripples out and affects everyone – everyone needs to make changes, learn what they can, and do the best they can to help themselves.

Caring for your brain environment

There are many aspects of brain injury that can affect our ability to focus and maintain thinking. Other executive impairments and symptoms such as headaches, fatigue or depression can all interfere with how well we manage daily activities.

The brain relies on the health of our body to function well. A brain injury can disrupt how our biology operates and can quickly use micronutrient reserves. Depletion of our vitamin and mineral reserves makes it harder for the body to support the manufacture of neurotransmitters – the hormones that allow messages to pass across the synapses successfully.

The brain automatically rewires to restore neurological pathways broken by physical damage. Called neuroplasticity, this ability to rewire is dependent on many factors, including how severe the injury is, how early someone receives treatment, and how aggressive rehabilitation is.

Neuroplasticity is also enhanced when the brain environment is improved. This enrichment is why exercise, fresh air, daylight and nutrition are so important following a brain injury. The reduction or elimination of chemicals and recreational toxins is also crucial. The cleaner the brain environment and the healthier the body, the more significant improvements will be.

All executive functions and symptoms can improve when the effects of the ‘secondary injury.’ are addressed. You must speak to your doctor before following the ‘one, two, three plan’ suggested to support this process.