Stroke & Attentional Disorders

May is Stroke Awareness Month
Time to talk about the link between Stroke and ADD/EFD

by Madelyn Griffith-Haynie, CTP, CMC, ACT, MCC, SCAC
Part of the ADD/ADHD Comorbidities series

Not all attentional deficits are genetic

As I began in Types of Attentional Deficits, attentional problems are accompanied by specific markers, regardless of origin or age of onset:

  • neuro-atypical changes in the pattern of brain waves,
  • the location of the area doing the work of attention and cognition,
  • and the neural highways and byways traveled to get the work done.

The attentional problems you will most frequently hear or read about are exhibited by individuals diagnosed with one of the ADD/ADHD varietals, usually associated with a genetic component.

Related Post: ADD/EFD Overview-101

However, NOT ALL attentional deficits are present from birth, waiting for manifestations of a genetic propensity to show up as an infant grows older – not by a long shot!

In addition to the attentional issues that accompany neuropsychiatric issues and age-related cognitive decline, a currently unknown percentage of attentional deficits are those that are the result of damage to the brain.

  • Some types of damage occur during gestation and birth (for example, the result of substances taken or falls sustained during pregnancy, or an interruption of the delivery of oxygen in the birth process);
  • Others are the result of a head injury caused by an accident or contact sports (since TBIs often involve damage to the tips of the frontal lobes or shearing of white-matter tracts associated with diagnostic AD(h)D);
  • Still others result from the absorption or ingestion of neurotoxic substances;
  • And a great many are riding the wake of damage caused by a stroke.

A Journal of Child Neurology article by Pediatric Behavioral Neurologist Kytja K. S. Voeller, MD asserts that any injury to the brain that affects the prefrontal-subcortical circuits can result in an ADD-like picture.

For the remainder of this article, I will use only “ADD,” unless I specifically wish to highlight the hyperactivity symptom, present in only some types of Attentional Deficits. Click HERE for why.

Stroke-Acquired ADD

Following a stroke, it is common that, even once the physical effects have subsided, survivors have problems with the regulation of attention, including an increase in impulsivity.

In common with individuals with TBI/ABI, stroke victims often discover that they are no longer able to concentrate for prolonged periods of time, that they find it difficult to impossible to focus on a specific task in the presence of competing information, and are otherwise easily distracted.

Short-term memory deficits aren’t unusual and a quick-silver anger or frustration response is not uncommon.

And it has been frequently reported that impaired attention contributes to poor stroke outcomes in a number of ways.

Related post: Symptoms of Attentional Struggles

How common is it?

According to several studies, slightly over 50% of stroke patients are likely to develop attentional disorders, most of which are not diagnosed.

A 2010 study by the Department of Psychology at the University of Auckland (New Zealand) found that post stroke attention deficits significant enough to negatively impact quality of life are possibly more common — although, depending upon the forms of attention assessed and the part of the brain affected, frequency is widely variable.

Often associated with ADD-like symptoms is altered brain activity in particular nerve pathways connecting the cortex (brain’s outer layer), striatum (deeper), and cerebellum (back of the neck near the top of the spinal cord), particularly in the brain’s right hemisphere.

Depending on how early in life stroke or other damage to the PFC [Pre-Fontal Cortex] occurred, it can also lead to an overall delay in cortical development seen in some children with ADD, which frequently manifests as some type of learning disability.

Voeller‘s article above particularly mentions children who have suffered strokes involving subcortical areas in the prefrontal-subcortical circuits (behind the forehead, under the wrinkly grey covering that is the cortex) – also seen as a result of head injuries common in childhood team sports like football and soccer – as being likely to manifest ADD-like behaviors.

In one study she mentions in the same article, not only did nearly half of the children develop ADD following a stroke, there was a strong correlation between lesions of the putamen and ADD symptoms. (putamen link leads to rotating 3-D locational illustration)

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Attention MUST be Paid

According to the reportage of a Randomized Controlled Trial conducted by Suzanne L. Barker-Collo, et. al., “cognitive deficits occur in more than half of stroke survivors and are more important determinants of broader outcomes than physical disability. Impaired attention is the “most prominent” stroke-related neuropsychological change, with rates of up to 46% to 92% reported in acute stroke survivors.”

The report goes on to say that:

  • Impaired attention can reduce cognitive productivity that is necessary for learning motor skills, even when other cognitive functions are intact.
  • Distractibility and impaired attention are also associated with post-stroke balance and functional impairment […] including both physical and social outcomes.
  • Attention deficits are linked to greater functional impairment and falls in community-dwelling stroke survivors.

Let’s Focus on “Attention”

A simple definition of attention is the ability to selectively concentrate on one aspect of your inner or outer environment, ignoring others. It is currently thought to be modulated by two separate regions of the brain.

  • The prefrontal cortex [PFC] (directly behind the forehead) processes what I refer to as “intentional attending” — concentration, if you will.
  • The parietal cortex (directly behind the ears) is activated whenever an outside stimulus “intrudes,” a response thought to be developed to make sure you pay attention to anything that might indicate that you could be in danger.

Science has learned that these two brain regions allow us to sustain concentration (or not) when particular neurons produce specific types of electrical pulses – slower for the deliberate, intentional cognition of the prefrontal region, faster for the automatic processing of the parietal region.

The researchers in a study of 110 patients who were being treated for stroke at London’s Charing Cross Hospital, say that the type of attention disorder was dependent on which brain region (of several) was affected by the stroke.

For example, patients who had strokes that affected the:

  • Front of the brain – experienced difficulty filtering out distraction
  • Back of the brain – had difficulty following instructions
  • Center of the brain – showed a reduction in alertness.

Dr. Paul Bentley of the department of medicine at Imperial College London told Medical News Today:

“Since these 3 types of attention are controlled by different brain chemicals – dopamine, acetylcholine and adrenaline, these results indicate that patients could be treated with a medicine type appropriate to the brain part damaged.”

Drugs designed to regulate the release of these neurotransmitters are already available for other neurological disorders, and could be explored for the treatment of area-specific attentional disorders in stroke patients.

How the control of Executive Functions is believed to work

The appropriate functioning of the brain circuits in the prefrontal cortex in particular requires a great deal of dopamine and noradrenaline stimulation. Any interruption or reduction in the “delivery system” of these two neurotransmitters will likely lead to an under-functioning regulation of attention and behavior that is extremely similar to diagnostic ADD.

What’s the big deal about PFC under-functioning?

The PFC is the master conductor that keeps what are known as the executive functions making beautiful music, facilitating what is referred to as the supervisory attentional system that makes cognitive control possible.

Executive Functions include a great many of the cognitive abilities that most adults take for granted as products of intelligence, education and maturity — items like reasoning and problem solving, planning, concentration, mental flexibility, and controlling short-term behavior to achieve long-term goals.

Executive functions develop gradually and can be adversely affected by a variety of events like the ones listed above. They can also be assisted, repaired and rebuilt.

What helps?

Training in problem solving with stroke patients who exhibit EFDs uses techniques that are similar to ADD Coaching protocols: breaking down complex problems into manageable steps based on a problem-solving model.

According to a publication in Neurology India, Cognitive Rehabilitation in Stroke: Therapy and Techniques [Vol. 50, (Suppl. 1), Dec, 2002, pp. S102-S108], patients were encouraged to define the problem, formulate goals, generate alternatives, make decisions and verify solutions. Improvement in intelligence subtests and planning ability was demonstrated in a group of patients with stroke and/or traumatic brain injury.
(Von Cramen DY, Mathes-von Cramen, Mai N : Problem solving deficits in brain injured patients. A therapeutic approach. Neuropsychol Rehabil 1991; 1 : 45-64.)

Other interventions to treat inattention consist of exercises designed to improve attentional focus and processing speed using stimulus-response paradigms. Paper and pencil tasks as well as computer assisted reaction training have demonstrated beneficial effects on attention.
(Keith DC, Cynthia D, Kathleen K et al : Evidence-Based Cognitive Rehabilitation: Recommendation for Clinical Practice. Arch Phys Med Rehabil 2000; 81 : 1596-1615.)

Subtances & Pharmaceuticals

Medical science is still investigating the attention regulation mechanisms of the parietal region and the putamin, hoping to be able to develop new drugs to counteract underfunctioning and damage to those areas.

The prefrontal cortex, however, has been studied fairly extensively, and there are already a number of drugs and other substances known to have a up-regulating effect on that particular area of the brain, in addition to others.

During challenging mental activities, central nervous stimulants [“psychostimulants”] increase neuro-chemical activity in the PFC and attention-related areas of the parietal cortex, areas that have long been shown to be underactive in ADD brains.

The most effective stimulants are ADD medications like methylphenidate (ex., Ritalin, Concerta) and dexedrine (ex., Adderall, Vyvanse), Schedule II medications available by prescription only.

However, there are non-pharmaceutical substances that have a stimulant effect on the same areas, with varying degrees of effectiveness and duration: caffeine, tea, nicotine, pseudoephedrine, or the initial effects of alcohol, for example — as well as cocaine and other illicit “recreational drugs” taken to produce a feeling of energetic euphoria.

Some scientists believe that many drug abusers are unconsciously attempting to “self-medicate,”  possibly the reason that addiction statistics are so high in [untreated] attentionally impaired populations.

Rehabilitation Programs

One broad attention rehabilitation program validated in neurological samples is APT – Attention Process Training.

APT is a multilevel treatment protocol, including sustained, selective, alternating, and divided attention. It is usually administered, in successive levels, by specialty-trained neuropsychologists, occupational therapists, speech/language therapists, and other rehabilitation specialists.

Although there is still no significant research on APT after a stroke, it has been examined in a number of small TBI samples, and is the basis of rehabilitation packages for mild deficits.

Several reports indicate APT also improves other cognitive areas after TBI, like memory, for example, linking attention training to improved real-world outcomes like returning to work and independent living.

In a meta-analysis (combining study results) of 359 individuals who had suffered a traumatic brain injury, Park and Ingles found attention improved significantly after specific skills training in prepost studies. The positive findings for attention in studied trials indicate that APT would be a valuable intervention for patients experiencing attention deficits following a stroke.

Computer Games and Programs

Dr. Paul Bentley of the department of medicine at Imperial College London told Medical News Today:

“Computer games similar to the one used [in the London’s Charing Cross Hospital study] have been developed which can act as ‘brain training’ aids, and which can be tailor-made to each patient so as to rehabilitate them specifically for the [types of attentional] deficits they exhibit.

These findings suggest a new strategy by which stroke treatments can be personalized depending on information gained from patients’ brain scans.”

In a future article, I will examine some of the particular evidence-based computer games and programs that are known to be particularly effective for the improvement of attentional regulation, so STAY TUNED.

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About Madelyn Griffith-Haynie, MCC, SCAC
Award-winning ADD Coach Training Field founder; ADD Coaching field co-founder; [life] Coaching pioneer -- Neurodiversity Advocate, Coach, Mentor & Poster Girl -- Multi-Certified -- 25 years working with EFD [Executive Functioning disorders] and struggles in hundreds of people from all walks of life. I developed and delivered the world's first ADD-specific coach training curriculum: multi-year, brain-based, and ICF Certification tracked. In addition to my expertise in ADD/EF Systems Development Coaching, I am known for training and mentoring globally well-informed ADD Coach LEADERS with the vision to innovate, many of the most visible, knowledgeable and successful ADD Coaches in the field today (several of whom now deliver highly visible ADD coach trainings themselves). For almost a decade, I personally sponsored and facilitated seven monthly, virtual and global, no-charge support and information groups The ADD Hours™ - including The ADD Expert Speakers Series, hosting well-known ADD Professionals who were generous with their information and expertise, joining me in my belief that "It takes a village to educate a world." I am committed to being a thorn in the side of ADD-ignorance in service of changing the way neurodiversity is thought about and treated - seeing "a world that works for everyone" in my lifetime. Get in touch when you're ready to have a life that works BECAUSE of who you are, building on strengths to step off that frustrating treadmill "when 'wanting to' just doesn't get it DONE!"

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