How To Assess Attention: 3 Evidence-Based Options

Attention deficits are common after an acquired brain injury. In fact, most patients with aphasia also have an attention deficit (Varkanitsa et al, 2023).

But it can be hard to differentiate attention from other cognitive deficits.

To help you do this, this article explains how to assess attention, including:

• How to identify the different types of attention
• Evidence-based attention assessments (with links!)

Let’s get started!

The Different Types Of Attention

Attention is the ability to focus on the information you want to focus on while tuning out the rest.

Sohlberg and Mateer (2001) proposed the following types of attention:

1. Focused attention
2. Sustained attention
3. Selective attention
4. Alternating attention
5. Divided attention

Focused and sustained attention impairments are usually caused by damage to midbrain structures or the right hemisphere.

While selective, alternating, and divided attention impairments are often caused by damage to the frontal lobes or areas of the brain that the frontal lobes depend on for information (Cicerone et al, 2022).

1. Focused Attention

Focused attention is the ability to focus on sensations. These include both internal sensations (feeling hungry) and external sensations (sounds in the environment).

A focused attention deficit may look like a patient coming out of a coma who can’t pay attention to the sensations they’re experiencing.

2. Sustained Attention

Sustained attention is the ability to pay attention to one task over a period of time. For example, being able to finish an ADL such as cooking a meal in a non-distracting environment.

Deficits in sustained attention look like a short attention span, worsening attention over time, and difficulty with working memory.

3. Selective Attention

Selective attention is the ability to pay attention to a chosen task in the presence of distractions. 

Patients with selective attention deficits can’t maintain attention when distractions are present. For example, they can’t focus on cooking a meal after the phone rings.

4. Alternating Attention

Alternating attention is the ability to switch focus between different cognitive tasks. For example, when a parent switches between making a meal and helping their child clean up a spill.

Patients with alternating attention deficits have difficulty switching between two tasks. For example, they lose their place in a book after being asked a question.

5. Divided Attention

Divide attention is the ability to multitask. This means doing two tasks simultaneously while maintaining a certain level of accuracy.

Patients with a divided attention deficit will perform poorly while doing two tasks. For example, they’ll have difficulty answering questions and cooking a meal at the same time.

How To Assess Attention

There are several attention assessments on the market, including The Test of Everyday Attention and subtests of the Wechsler Adult Intelligence Scale.

Some will give you specific results about attention. While others will give you general information that would be hard to differentiate from other cognitive deficits—but can still give useful results for choosing goals and measuring progress over time.

We’ll cover 3 evidence-based attention assessments that are free or more affordable: The Trail Making Test, The Attention Process Training Test, and The Cognitive Failures Questionnaire (Cicerone et al, 2022).

1. Trail Making Test 

The Trail Making Test is a free assessment that can give you information about sustained, alternating, and divided attention, as well as some aspects of executive functioning.

The Trail Making Test is a timed, visuospatial sequencing test. Your patient will need to be able to use a pencil to complete it.

You’ll essentially ask your patient to connect the dots on 4 worksheets:

1. Trail A Sample: Practice connecting numbered circles in sequential order
2. Trail A Test: Connect numbered circles in a sequential order
3. Trail B Sample: Practice connecting numbers and letters in alternating order
4. Trail B Test: Connect numbers and letters in alternating order

Trail Making Test Part A: Sample

Say to your patient:

• Here are some numbers (Point to the number box).
• Start at number 1 (point) then draw a line from 1 to 2 (pointing), 2 to 3 (pointing), 3 to 4, and so on, in order, until you reach the end (point to the circle marked ‘end’).
• Start here (point to number 1) and draw your line as fast as you can.
• Ok, begin.

(Center-TBI, n.d.)

Trail Making Test Part A: Test

Say to your patient:

• On this page are the numbers 1 to 25.
• You’ll do this task the same way. Start at 1 (point to number 1) then draw a line from 1 to 2 (pointing), 2 to 3 (pointing), 3 to 4, and so on in order until you reach the end (point to the circle marked ‘End’).
• Work as fast as you can.
• Ok, begin!

If they make an error, keep timing but point and say, “No, where do you want to go from here?” You’ll stop timing after 100 seconds.

Score by keeping track of how long they took and how many errors they made.

(Center-TBI, n.d.)

Trail Making Test Part B: Sample

Say to your patient:

• Here are some numbers and letters. Start at 1 (point) then draw a line from 1 to A (point), from A to 2 (point), from 2 to B (point), from B to 3 (point), from 3 to C, and so on in order until you reach the end (point).
• Remember to alternate the numbers and letters: first a number, then a letter, then a number, then a letter, and so on.
• Draw your lines as fast as you can.
• Start here (Point to 1).
• Ok, go!

(Center-TBI, n.d.)

Trail Making Test Part B: Test

Say to your patient: 

• Here are some numbers and letters. Connect them in the same way. Start here (point to 1) and draw a line from 1 to A (pointing to each number and letter), A to 2, 2 to B, B to 3, 3 to C, and so on in order until you reach the end (point to the circle marked ‘End’).
• Remember to alternate numbers and letters. Start with a number, then a letter, then a number, then a letter, and so on. Go in order from each circle. Draw your lines as fast as you can.
• Begin here (point).
• Ready, go!

If they make an error, keep timing but point and say, “No, where do you want to go from here?” Stop timing after 300 seconds.

Score by keeping track of how long they took and how many errors they made.

(Center-TBI, n.d.)

2. Attention Process Training Test

The Attention Process Training Test (APT-Test) was developed by Sohlberg and Mateer.

While it’s part of the Attention Process Training program, you can purchase the test separately for around $75.

The APT-Test measures simple sustained attention, complex sustained attention, selective attention, alternating attention, and divided attention.

The results help you determine if and what types of attention impairment a patient has, if they need attention training, and at what level.

A pro tip from our reader Karen is to document the APT Test as a screening tool, as it’s not psychometrically normed.

3. Cognitive Failures Questionnaire

The Cognitive Failures Questionnaire (CFQ) is a free, self-report measure that assesses how often a patient fails on everyday cognition tasks due to attention or memory deficits.

The CFQ is practical not only because it’s quick and free, but because the scores are also associated with real-world results, like the risk of car and work accidents (Goodhew et al, 2024).

Goodhew and Edwards developed the Cognitive Failures Questionnaire 2.0 which attempts to make up for some of the shortcomings of the original test. Scroll down to Appendix B in their article for the questionnaire.

More Resources

References

• American Speech-Language-Hearing Association. (n.d.). Right hemisphere Disorder [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Right-Hemisphere-Disorder/
• Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Broadbent, D.E., Cooper, P.F., FitzGerald, P., & Parkes, K.R.  (1982). The Cognitive Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical Psychology, 21, 1-16.
• Center-TBI. (n.d.). Trail Making Test (TMT). [PDF]. https://www.center-tbi.eu/files/approved-translations/English/ENGLISH_TMT.pdf
• Cicerone, K. D., Dams-O’Connor, K., Eberle, R., Fraas, M., Ganci, K., Langenbahn, D., Shapiro-Rosenbaum, A., Tate, R. L., Trexler, L. E., & American Congress Of Rehabilitation Medicine. (2022). ACRM Cognitive Rehabilitation Manual & Textbook Second Edition: Translating evidence-based recommendations into practice.
• Goodhew, S. C., & Edwards, M. (2024). The Cognitive Failures Questionnaire 2.0. Personality and Individual Differences, 218, 112472. https://doi.org/10.1016/j.paid.2023.112472
• Varkanitsa, M., Godecke, E., & Kiran, S. (2023). How Much Attention Do We Pay to Attention Deficits in Poststroke Aphasia? Stroke, 54(1), 55–66. https://doi.org/10.1161/STROKEAHA.122.037936