Neuropsychology Copyright 2007 by the American Psychological Association

2007, Vol. 21, No. 2, 212–223 0894-4105/07/$12.00 DOI: 10.1037/0894-4105.21.2.212

Changes in Attention and Information-Processing Speed Following Severe

Traumatic Brain Injury: A Meta-Analytic Review
Jane L. Mathias and Patricia Wheaton
University of Adelaide

Deficits in attention are frequently reported following severe traumatic brain injury (TBI). However,
methodological differences make it difficult to reconcile inconsistencies in the research findings in order
to undertake an evidence-based assessment of attention. The current study therefore undertook a
meta-analytic review of research examining attention following severe TBI. A search of the PsycINFO
and PubMed databases spanning the years 1980 to 2005 was undertaken with 24 search terms. Detailed
inclusion and exclusion criteria were used to screen all articles, leaving 41 studies that were included in
the current meta-analysis. Weighted Cohen’s d effect sizes, percentage overlap statistics, and confidence
intervals were calculated for the different tests of attention. Fail-safe Ns were additionally calculated to
address the bias introduced by the tendency to publish significant results. Large and significant deficits
were found in specific measures of information-processing speed, attention span, focused/selective
attention, sustained attention, and supervisory attentional control following severe TBI. Finally, age,
education, and postinjury interval were not significantly related to these deficits in attention.

Keywords: attention, information-processing speed, severe traumatic brain injury, meta-analysis, review

Supplemental materials: http://dx.doi.org/10.1037/0894-4105.21.2.212.supp

Traumatic brain injuries (TBIs) are often associated with a
number of cognitive deficits, the most frequent of which are
disorders of memory and attention (Oddy, Coughlan, Tyerman, &
Jenkins, 1985). Although a large number of studies have investi-
gated deficits in attention following TBI, the findings are incon-
sistent with respect to the nature and extent of these impairments.
Moreover, there is considerable debate about whether deficits in
attention reflect a discrete cognitive deficit or whether they are the
result of a more pervasive reduction in the speed with which
information is processed (Brouwer, Ponds, Van Wolffelaar, & van
Zomeren, 1989; Brouwer, Withaar, Tant, & van Zomeren, 2002;
Ponsford & Kinsella, 1992; Rios, Perianez, & Munoz-Cespedes,
2004).
There are a number of different components of attention that can
be affected by TBI. One of the most basic of these is the ability to
orient attention, which involves spatially directing or allocating
attention to sensory information (Hills & Geldmacher, 1998).
Another aspect of attention is attention span, which refers to the
amount of information that can be processed at one time (Lezak,
Howieson, & Loring, 2004). Selective or focused attention, on the
other hand, involves an ability to selectively attend to information
Jane L. Mathias and Patricia Wheaton, School of Psychology, University
of Adelaide, Adelaide, South Australia, Australia.
Preliminary findings from this study were presented in May 2005 at the
6th World Congress of the International Brain Injury Association, Mel-
bourne, Victoria, Australia. This research was partially funded by Grant
207711 to Jane L. Mathias, Erin D. Bigler, Stephen C. Bowden, Nigel R.
Jones, and D. James Taylor from the National Health and Medical Re-
search Foundation of Australia.
Correspondence concerning this article should be addressed to Jane L.
Mathias, School of Psychology, University of Adelaide, Adelaide, South
Australia 5005, Australia. E-mail: jane.mathias@adelaide.edu.au
that is relevant to a task while ignoring irrelevant and distracting
information (van Zomeren & Brouwer, 1987, 1992). Divided at-
tention refers to the ability to simultaneously process more than
one source of information at a time (Williamson, Scott, & Adams,
1996), and sustained attention refers to an ability to continuously
maintain attentional focus under conditions of low stimulation and
over a prolonged period of time (Williamson et al., 1996). Finally,
supervisory attentional control facilitates the strategic allocation
of attentional resources in demanding situations in order to opti-
mize performance (van Zomeren & Brouwer, 1994). In addition,
reductions in information-processing speed can have pervasive
effects on cognitive functioning, including attention.
Whereas evidence for a general reduction in speed of informa-
tion processing following TBI has consistently been found (Brou-
wer et al., 1989, 2002; Felmingham, Baguley, & Green, 2004;
Ponsford & Kinsella, 1992), specific deficits in the orienting of
attention (Cremona-Meteyard, Clark, Wright, & Geffen, 1992),
focused/selective attention (Chan, 2000; Chan, Hoosain, & Lee,
2002; Mangels, Craik, Levine, Schwartz, & Stuss, 2002; Vakil,
Blachstein, & Hoofien, 1991), divided attention (Leclercq et al.,
2000; Lengenfelder, Schultheis, Al-Shihabi, Mourant, & DeLuca,
2002; Park, Moscovitch, & Robertson, 1999), sustained attention
(Chan, 2000), and supervisory attentional control (Rios, Perianez,
& Munoz-Cespedes, 2004; Spikman, van Zomeren, & Deelman,
1996) have also been reported. Yet other studies have failed to find
evidence for the existence of specific deficits (e.g. Bate, Mathias,
& Crawford, 2001a; Brouwer et al., 1989; Felmingham et al.,
2004; Ponsford & Kinsella, 1992). This causes problems for cli-
nicians when they are trying to determine which aspects of atten-
tion to assess and what measures to use when assessing the
attention of a patient who has sustained a TBI.
Inconsistencies in the research findings may, in part, reflect
methodological differences among studies with respect to the

212
 SEVERE TRAUMATIC BRAIN INJURY AND ATTENTION
aspects of attention that are examined (e.g., focused, divided
attention), the tests that are used, and the samples that are inves-
tigated. A wide variety of tests have been used to measure the
different aspects of attention, making it difficult to directly com-
pare the findings of numerous studies even when they are exam-
ining the same aspect of attention. For example, researchers have
claimed to measure speed of information processing using the
Trail Making Test (Azouvi, Jokic, Van Der Linden, Marlier, &
Bussel, 1996) and numerous reaction time tasks (Felmingham et
al., 2004; Leclercq et al., 2000; Ponsford & Kinsella, 1992; Spik-
man, Deelman, & van Zomeren, 2000), whereas focused attention
has been assessed using visual search tasks (Schmitter-Edgecombe
& Kibby, 1998), the Stroop Test (Ponsford & Kinsella, 1992), and
the Trail Making Test (Felmingham et al., 2004). Divided atten-
tion, on the other hand, has been assessed with choice reaction
time tasks (Ponsford & Kinsella, 1992), dual tasks (Leclercq et al.,
2000), and the Paced Auditory Serial Addition Test (Chan et al.,
2002), and supervisory attentional control has been assessed with
the Wisconsin Card Sorting Test (Rios et al., 2004), the Tower of
London test (Shallice, 1988), and the Six Elements Test (Chan,
2002). Not only do these studies use different measures, but they
also examine different aspects of attention, which makes it difficult
to determine whether certain types of attention are more affected
than others and whether particular measures are more sensitive to
these deficits. Moreover, it is not possible to directly compare the
magnitude of the findings derived from different measures and
different studies unless the scores are standardized.
Variability among studies with respect to the postinjury interval,
age, education level, and premorbid intellectual abilities of partic-
ipants further adds to the difficulty in reconciling disparate find-
ings. Impairments in cognitive function, for example, reportedly
resolve more rapidly in the first 6 months after an injury, and this
rate of recovery is affected by age (Williamson, Scott, & Adams,
1996), making it important to consider postinjury interval and age
when comparing the findings of different studies. In addition,
education and premorbid intelligence are thought to influence
postinjury performance (Rios et al., 2004), suggesting that these
variables should also be taken into account when evaluating the
research literature. Similarly, the use of different patient groups,
such as consecutive hospital admissions or symptomatic referrals,
can affect the likelihood of finding deficits in attention following
TBIs. Finally, sample size has an impact on whether group differ-
ences are statistically significant. Given the large variability in the
sample sizes that have been investigated and the failure by most
investigators to provide effect size calculations, which measure the
magnitude of group differences independently of sample size, it is
difficult to know whether the statistically significant or nonsignif-
icant results are partly an artifact of sample size. However, critical
reviews of the research literature rarely acknowledge the impor-
tance of this variable and are not in a position to formally evaluate
the impact of sample size, or any of the preceding variables, on the
research findings. A quantitative review of the research literature is
therefore needed to address these issues.
The current study provides a meta-analysis of research that has
examined deficits in attention following severe TBI in order to
consolidate this literature. Specifically, we sought to identify the
measures of attention that are most sensitive to deficits in attention
following severe TBI. We hypothesized that if, as has been sug-
gested (Felmingham et al., 2004; Ponsford & Kinsella, 1992),
213
reductions in speed of information processing largely account for
the deficits in attention following severe TBI, then measures that
tap processing speed should be amongst the measures with the
largest effect sizes. This study also examined the extent to which
a number of methodological variables (age, education, postinjury
interval) were related to deficits in attention following severe TBI
in order to determine whether studies that differ methodologically
could validly be combined.
Method
Literature Search and Inclusion Criteria
A comprehensive search of the PsycINFO and PubMed elec-
tronic databases from January 1980 to November 2005 was un-
dertaken in order to identify published articles that examined
attention following severe TBI. The key search terms that were
used to capture relevant articles are provided in Table A of the
supplemental material for this study. In addition, the bibliogra-
phies of these articles were examined, and manual searches of a
number of journals were completed to identify any other relevant
articles (refer to Table B of the supplemental material for further
details).
For a study to be included in the current meta-analysis, it had to
fulfill the following criteria: (a) was published in a journal; (b) was
published in English; (c) had a control group (age-, gender-, and/or
education-matched); (d) was not a case study; (e) had a TBI group
that had sustained a severe nonpenetrating injury (i.e., Glasgow
Coma Scale score ⱕ 8, loss of consciousness ⬎ 24 hr, and/or
posttraumatic amnesia ⬎ 24 hr); (f) had no participant with a
known prior history of head injury, motor, visual, or language
impairments, psychiatric illness, or substance abuse; (g) adminis-
tered tests of attention to both groups (i.e., excludes studies using
only electrophysiological measures); (h) reported the results in a
format that enabled the calculation of effect sizes (e.g., means,
standard deviations, t tests, or F ratio from a one-way analysis of
variance [ANOVA]); and (i) had participants between 16 and 65
years of age. Where age ranges for the patient or control groups
were not included, a study was deemed eligible if the mean age ⫾
one standard deviation fell within this range. When demographic
details were not reported for the control group, the study was
included if the patient group met the age criteria.
The literature search initially identified 2,971 potentially rele-
vant studies. A preliminary application of the inclusion criteria to
the information provided in the titles and abstracts of these articles
yielded a total of 105 studies. Application of the inclusion criteria
to the full-text versions of these studies revealed that 64 of these
did not meet one or more of the inclusion criteria, leaving 41
studies.
When conducting meta-analytic reviews, it is important to en-
sure that a study’s participants are independent of those used in
other studies, as the computational procedures assume that studies
are independent of one another (Hunter, Schmidt, & Jackson,
1982; Rosenthal, 1995). If the same participants contribute more
than one score to the calculation of an effect size when studies are
combined, it can distort the magnitude of this effect (Rosenthal,
1995). Thus, two publications by Bate and colleagues (Bate et al.,
2001a; Bate, Mathias, & Crawford, 2001b), which reported sepa-
rate findings for the same participants, were combined and treated
as one study. In addition, there were two publications that de-
214 MATHIAS AND WHEATON
scribed more than one study where all or most of the participants
were different (Park et al., 1999, Experiments 1 and 2; Ponsford &
Kinsella, 1992, Experiments 1 and 3). Both of these publications
were treated as two studies. In total, 41 studies were included in
the current meta-analysis (references for studies included in this
meta-analysis are marked with an asterisk in the reference list). A
total of 48 different tests of attention were used by two or more
studies.
Data Collection and Preparation
In some cases, participants were retested (e.g., longitudinal
studies measuring recovery or studies assessing the efficacy of
rehabilitation), necessitating the use of a number of criteria to
determine what scores would be included from these studies (Lip-
sey & Wilson, 2001). Specifically, where tests were administered
on more than one occasion, only data from the first session were
used (to minimize practice effects). Where a patient group was
tested twice but only compared with a control group on the second
occasion (e.g., Azouvi et al., 1996), the first set of scores for the
patient group was compared with those of the control group in
order to equate the practice effects for the two groups. Moreover,
a test was omitted from analysis if it was not adequately described
and a reference was not provided, thereby precluding determina-
tion of whether the test assessed attention or some other cognitive
function.
Some minor transformations to the published data were neces-
sary before it could be analyzed. First, where standard errors were
reported, these were converted to standard deviations in order to
calculate effect sizes. Second, the data for a number of descriptive
variables (e.g., postinjury interval, duration of posttraumatic am-
nesia, loss of consciousness) were transformed to ensure a com-
mon scale of measurement. Finally, in Experiment 1 of Park et al.
(1999), the scores for one test had been divided into three time
intervals to examine changes in performance over time. These
scores were averaged in order to calculate a single effect size for
this test. In a second experiment by Park et al. (1999), data were
reported for three blocks of trials for each of three intertrial
intervals (10, 20, and 60 s) for the Paced Auditory Serial Addition
Test in order to test a hypothesis that was specific to that study (a
total of nine scores were reported). These scores were averaged for
the present purposes.
Each test of attention was categorized into one of seven aspects
of attention in order to organize the data provided by these studies.
Consistent with common theoretical and clinical distinctions in the
attention literature, the following categories were used: informa-
tion-processing speed, orienting of attention, attention span, fo-
cused/selective attention, divided attention, sustained attention/
vigilance, and supervisory attentional control. As there were in-
consistencies among authors with respect to how the different
measures were classified, Lezak (1995) and Spreen and Strauss
(1998) were consulted in order to provide a framework for cate-
gorizing tests. This system of categorization was adopted to sim-
plify the presentation of data and is not intended to imply that there
is agreement amongst researchers about the specific aspects of
attention that are assessed by these tests or that these tests provide
pure measures of a construct.
Effect Size Calculations and Analyses
Cohen’s d effect sizes were calculated for the current meta-
analysis, following the method described by Zakzanis (2001).
Cohen’s d is not influenced by sample size and measures the
difference between two means divided by the pooled standard
deviation (Zakzanis, Leach, & Kaplan, 1999). If means and stan-
dard deviations were not provided for a study, we converted t
values and one-way F statistics to d using the formula set forth by
Zakzanis (2001). Probability values were not used to calculate
effect sizes in the current meta-analysis, as they confound the
magnitude of an effect size with sample size (Hunter et al., 1982),
such that a p ⬍ .05 may overestimate an effect size in a large
sample and a nonsignificant result that is assigned a p ⬎ .05 will
systematically underestimate the size of an effect in a small sample
(Rosenthal, 1995). The different tests of attention were not equally
represented across studies; therefore, the use of p values in the
calculation of effect sizes may have disproportionately disadvan-
taged infrequently used tests, particularly where small samples
were used.
Effect sizes were calculated in a multistage process. The first
stage involved calculating effect sizes for each score of every test
that was used by a study. If a study provided multiple scores for a
test, and these were to be combined for the purposes of this
meta-analysis, an average effect size for that test was calculated.
The effect sizes obtained from different studies were then averaged
to evaluate the combined findings. As the reliability of an effect
size is affected by the size of the sample from which it is derived,
it is important to weight effect sizes before they are combined
(Lipsey & Wilson, 2001). Whereas weighting by sample size is
one option, Hedges and Olkin (1985) have established that the
inverse variance (i.e., the inverse of the squared standard error)
provides the best weight because it provides a better measure of
the precision of an effect size (i.e., larger standard errors are
associated with less precise effect sizes). An overall weighted
mean effect size for a test was therefore calculated by weighting
each of the effect sizes from individual studies by the inverse of its
variance and then averaging them (dw). All effect sizes were
calculated in such a way that a positive Cohen’s dw indicated that
patients with severe TBI were more impaired on tests of attention
than participants who had not suffered a TBI. According to Co-
hen’s criteria (Cohen, 1977, 1992), a small effect was defined as
d ⱖ .2, a moderate effect as d ⱖ .5, and a large effect as d ⱖ .8.
To put this into perspective, a medium effect size of .5 indicates
that the means of the two groups differ by half of a standard
deviation.
A percentage overlap (%OL) score was also calculated in order
to provide a measure of the extent to which the scores from the two
groups overlap. The %OL is inversely related to the effect size and
was calculated using the table provided by Zakzanis et al. (1999).
An effect size of zero (d ⫽ 0) is associated with 100% overlap in
the scores of the two groups, whereas an effect size of 4.0 is
associated with only 2.3% overlap in scores, indicating that the
groups perform very differently on that measure. Confidence in-
tervals for the effect sizes were additionally calculated using the
method described by Lipsey and Wilson (2001) to determine
statistical significance. If the confidence interval for an effect size
does not span zero, the true population effect size differs signifi-
 SEVERE TRAUMATIC BRAIN INJURY AND ATTENTION
cantly from zero, indicating that there is a significant difference
between the performance of the TBI and control groups on that
test.
One criticism of meta-analytic studies is that there may be a bias
toward publishing studies with significant findings, which would
mean that an analysis of published research does not include
nonsignificant findings that have not been published (referred to as
the file-drawer problem), thereby inflating the resulting effect sizes
(Rosenthal, 1995). In order to address this problem, we calculated
a fail-safe N (Nfs) for each effect size using the procedure de-
scribed by Lipsey and Wilson (2001). This statistic provides an
estimate of the number of unpublished studies with nonsignificant
findings that would be needed to call the current findings into
question, enabling the reader to evaluate the likely impact of the
file-drawer problem (Zakzanis et al., 1999). The larger the Nfs
statistic, the more confident we can be of the current findings.
The original versions of tests were often modified for use in a
study. One difficulty that occurs when tests and their adaptations
are treated separately is that the effect size for a measure may be
based on only one study. The purpose of a meta-analysis, however,
is to analyze data derived from multiple studies (Zakzanis et al.,
1999). Thus, where a test and an adaptation of it were deemed to
be similar, they were grouped together and labeled using a com-
mon term, (e.g., number and letter cancellation tasks were labeled
“cancellation tests”). This reduced the number of tests under
consideration to 23.
An additional issue that warrants consideration is whether there
are methodological differences among studies that may affect the
findings and, therefore, the effect sizes derived from these studies.
One solution is to treat these methodological differences as mod-
erator variables that may contribute to variations in the results
found by different researchers (Hunter et al., 1982; Zakzanis et al.,
1999). As meta-analyses necessarily involve combining the results
of studies that differ methodologically, moderator analyses enable
an evaluation of whether it is valid to combine the results of these
studies (Sharpe, 1997). Between-studies variation in age, educa-
tion, and postinjury interval, therefore, were examined in order to
determine whether these variables influenced the magnitude of the
group differences in attention. Estimated premorbid IQ was not
examined for this purpose, as there is increasing evidence to
suggest that measures of premorbid IQ may be affected by severe
TBI (Freeman, Godfrey, Harris, & Partridge, 2001; Mathias, Bow-
den, & Bigler, in press; Morris, Wilson, Dunn, & Teasdale, 2005;
Riley & Simmonds, 2003). In order to analyze these moderator
variables, it was necessary to calculate a mean age, educational
level, and postinjury interval for each study. For age and educa-
tion, this was done by averaging the data from the TBI and control
groups for that study (e.g., MTBI⫹control age). We assessed the
relationship among these moderator variables and the mean effect
size for the studies that reported these data. All 41 studies provided
information relating to participants’ age, 29 provided educational
data, 32 provided postinjury intervals, and 22 studies provided
details for all three moderator variables. Pearson correlation coef-
ficients (rs) were calculated to examine the relationship between
these three moderator variables and effect sizes.
Although correlations are frequently used in the analysis of
moderator variables, Steel and Kammeyer-Mueller (2002) have
demonstrated that a weighted least squares (WLS) multiple regres-
sion (using the inverse of the sampling error variance to weight the
215
multiple regression) is less affected by the problems of heterosce-
dasticity (i.e., where the distribution of sample sizes is skewed)
and multicollinearity (i.e, where predictor variables are correlated
with one another) than are bivariate correlations and other methods
of analyzing moderator variables. A WLS multiple regression was
therefore also conducted to analyze the effects of these three
moderator variables. Standard errors and confidence intervals for
the results of the WLS multiple regression were adjusted according
to the method outlined by Hedges and Cooper (1994). This regres-
sion analysis was performed on the data from the 22 studies that
provided details for all three moderator variables.
Data Interpretation
Weighted mean effect sizes (standard deviation, minimum,
maximum) for the seven categories of attention and for each
individual test of attention were calculated, as were Nfs, %OL, and
confidence intervals (CIs). The conclusions drawn from this study
are based on the combined interpretation of these different statis-
tics. From a neuropsychological perspective, a clinician would be
more confident that a severe TBI has impacted on attention when
there are large group differences (Cohen’s dw) and, consequently,
there is limited overlap in the performance of the two groups
(%OL). Clinicians would also be more confident in using a mea-
sure to assess the attentional deficits of a person who had sustained
a severe TBI if the CI did not span zero (i.e., effect size is
significant) and it was unlikely that unpublished findings could
draw the current findings into question (i.e., large Nfs). For the
purpose of this meta-analysis, it was decided that in order for a
finding to be suggestive of compromised performance following a
severe TBI, it must meet the following three criteria: (a) have a
large effect size (i.e., d ⱖ .8) and, consequently, a limited degree
of overlap in the scores obtained by severe TBI and control
participants, (b) have a confidence interval that did not span zero
(N.B., CIs are affected by N and variance), and (c) have an Nfs
score that was large enough to make it unlikely that there were that
number of unpublished studies with nonsignificant findings in
existence. As different tests were used with varying frequency, it
was decided that the Nfs should at least be greater than the number
of published studies that had used a particular test (i.e., Nstudies).
Results
Participants
Data from a total of 1,651 participants from 41 studies contrib-
uted to the current meta-analysis, comprising 823 severe TBI
patients (71% male, 29% female) and 828 control participants
(68% male, 32% female). Demographic details for individual
studies are summarized in Table C of the supplemental material for
this article. Although 7% of studies reported recruiting a selected
sample of TBI patients (i.e., patients complaining of attentional
problems), most did not report this information (93%). As Table 1
shows, fewer than half of the studies reported estimates of pre-
morbid IQ for the TBI and control groups (NTBI ⫽ 7, Ncontrol ⫽ 10)
or specific injury severity data for the TBI patients (i.e., Glasgow
Coma Scale, duration of posttraumatic amnesia, loss of conscious-
ness; Ns ⫽ 11 to 19). Moreover, only 32 studies (78%) reported
the postinjury interval. When the ages, educational levels, and
premorbid IQ estimates for those studies that provided this infor-
216 MATHIAS AND WHEATON
Table 1
Demographic Details for the Traumatic Brain Injury (TBI) and Control Groups and Injury Data for the TBI Group
TBI
N N
Variable (studies) M SD
N 41 20.1 10.8
Age (years) 41 31.6
Education (years) 29 12.8
Estimated premorbid IQ 7 101.2
GCS score 14
PTA (duration in days) 19 42.4 30.2
LOC (duration in hours) 11 863.3 1,373.7
Time since injury (days) 32 1,178.0 1,151.7
Note. GCS ⫽ Glasgow Coma Scale; PTA ⫽ posttraumatic amnesia; LOC ⫽ loss of consciousness.
mation were compared, the TBI and control groups did not differ
significantly, suggesting that these groups were well matched on
these variables.
Measures of Attention
The weighted effect sizes (dw) for the individual measures of
attention (mean, standard deviation, minimum, maximum, 95%
CIs, Nfs, %OL), broadly grouped by category of attention and rank
ordered by effect size, are provided in Table 2 (refer to Table C in
the supplemental material for specific study details). Only effect
sizes for tests that were used by two or more studies are reported
here because effect sizes that are based on a single study are not
thought to provide a reliable measure of group differences
(Rosenthal, 1995). This reduced the number of studies that were
included in this part of the meta-analysis to 37. Measures of the
orienting of visual attention were only used by one study and,
consequently, are not reported here.
Tests specifically targeting information-processing speed were
amongst the most commonly used measures in the studies ana-
lyzed in this meta-analysis (refer to Table 2). A variety of simple
and choice reaction time (RT) tasks were used, which revealed
significant group differences with very high Nfs values, such that
persons who had sustained a TBI performed, on average, one
standard deviation below their healthy peers. Moreover, process-
ing speed was found to be slower in response to both simple and
complex (choice) tasks. Thus, as predicted, speed of information
processing is significantly impaired following severe TBI.
Attention span was also assessed by a large number of studies
(N ⫽ 13), using a variety of tests that assessed digit, reading, word,
and letter span. Of these, only reading span (ability to retain the
last word of increasing numbers of sentences), word span (where
the stimuli are 2- or 3-syllable words), and digit span detected
sizeable and significant effects with large Nfs values (Table 2). In
contrast, the separate scores for forward and backward digit span
and letter span showed only small to medium effects. As shown in
Table 2, there were specific (e.g., reading span, digit span) mea-
sures of attention span that appeared to be more affected by severe
TBI than others (e.g., alphabet span, digits forward and backward).
Focused or selective attention was the aspect of attention that
was most commonly assessed in the research literature. There were
six different tests (Stroop, Symbol Digit, Digit Symbol, Trails,
Controls
Range (studies) M SD Range
6.0–51.0 41 20.2 9.7 6.0–44.0
23.4–55.5 37 31.0 19.5–51.6
9.5–16.2 29 13.3 10.7–16.5
86.1–112.0 10 107.6 101.1–114.0
4.7–6.6
6.0–125.0
8.25–4,937.5
59.9–4,015.0
Inhibition Task, Auditory Odd-Ball Task), yielding a total of 14
scores, that were used by two or more studies (see Table 2).
Moreover, 11 of these scores met the study criteria for differenti-
ating among samples. Specifically, the Stroop Test (speed and
accuracy scores of the Word Reading, Color Naming, and Inter-
ference subtests), the Symbol Digit Modalities Test (accuracy
scores for the oral and written versions) and the Digit Symbol Test
(accuracy score), an Inhibition Task (speed scores from the control
and interference conditions), and the Trail Making Test (speed
scores for Parts A and B, and ratio A:B) all demonstrated large and
significant effect sizes with high to very high Nfs.
Divided attention has been assessed using either an RT measure
under dual task conditions or the Paced Serial Addition Test.
Whereas the effect sizes for these measures were significant and
the Nfs statistics were high enough to suggest reasonable confi-
dence in these findings, the mean effect sizes suggest more modest
deficits in divided attention following severe TBI than were evi-
dent on other measures of attention. Moreover, even though per-
formance on these tasks is likely to be affected either directly or
indirectly by processing speed, the deficits that were evident on
these measures were smaller than those found on measures spe-
cifically designed to target information-processing speed (i.e., sim-
ple and choice RT tasks)
Sustained attention or vigilance was assessed by visual search
and cancellation tasks in a total of eight separate studies. As seen
in Table 2, both types of tests yielded large group differences,
relatively low overlap statistics, CIs that did not span zero, and
large Nfs when the scoring system was based on a combination of
speed and accuracy or speed alone.
Finally, there were no tests of supervisory attention control that
met the current study criteria for differentiating among groups
(refer to Table 2). Interestingly, commonly used tests, such as the
card sorting tests (e.g., the Wisconsin Card Sorting Test) and the
Tower of London, which purportedly assess the executive aspects
of attention, showed only small to moderate, albeit mostly signif-
icant, effect sizes.
Moderator Variables
Pearson correlation coefficients were calculated in order to
examine the relationship between variables that might be expected
to affect performance on the measures of attention, as measured by
 SEVERE TRAUMATIC BRAIN INJURY AND ATTENTION
Cohen’s d effect sizes. The age, years of education, and postinjury
time interval for participants in those studies that reported these
data were therefore correlated with the mean effect sizes for these
studies. Small and nonsignificant correlations were observed for
age (r ⫽ ⫺.19, n ⫽ 41, p ⬎ .05), education (r ⫽ .06, n ⫽ 29, p ⬎
.05), and postinjury interval (r ⫽ ⫺.22, n ⫽ 32, p ⬎ .05),
indicating that there was no relationship between these variables.
A WLS multiple regression was additionally performed on the data
from the 22 studies that reported data for all three variables. The
mean effect size for a study was the dependent variable, the three
moderator variables were the independent variables, and the in-
verse variance was used as the weighting variable. The final model
was nonsignificant ( p ⬎ .05) and accounted for only 17% of the
variance. These analyses indicate that there was no systematic
variation in performance on the different measures of attention as
a consequence of differences in these methodological variables.
Tests Used by Only One Study
Whereas meta-analytic techniques are primarily used for con-
solidating the findings of a number of studies, it is also important
to identify measures that discriminate between groups but have
only been used by one study. In doing so, lesser known but
potentially innovative measures can be identified with a view to
encouraging the collection of additional data in order to adequately
assess their usefulness. Effect sizes for measures that met the study
criteria (Cohen’s d ⱖ 0.8, CIs ⫽ 0, Nfs ⬎ Nstudies) but were based
on only one study are therefore summarized in Table 3, where it
can be seen that there were an additional 22 measures that revealed
large and significant deficits in performance following severe TBI.
Indeed, some measures had very large effects, with very small
%OL statistics (e.g., oral Symbol Digit Modalities speed and
accuracy scores, Pigache Attention Test, Short Stimulus Task,
Random Number Generation task, Visual Nonsearch Condition of
a Visual Search Task). Moreover, the large Nfs values, relative to
the number of published studies that had used these measures,
suggest that it is unlikely that these findings are merely a conse-
quence of publication bias.
Discussion
Overall, the data for this meta-analysis were obtained from 41
studies that examined the attention of 823 persons who had sus-
tained a severe TBI, together with 828 controls, using a large
number of different tests, subtests, and scoring procedures (N.B.,
tests and close variations of tests were combined). On the basis of
the available data, the TBI and control groups appeared well
matched in terms of age, education, and premorbid IQ, suggesting
that group differences in these variables were not contributing to
the study findings. However, none of the studies reported depres-
sion scores, so it is not possible to determine whether poorer affect
may have contributed to some of the deficits in attention that were
apparent. Importantly, the current meta-analysis found that while a
wide variety of tests have been used in research that has examined
attention following severe TBI, there is considerable variation in
the extent to which performance on these measures is affected by
such an injury. There are also a number of infrequently used
measures that, if supported by additional empirical evidence, may
prove valuable in the assessment of attention following severe
TBI.
217
In order for a test to be considered useful for the clinical
assessment of patients who have sustained a severe TBI, it was
determined that a test must be able to reliably distinguish between
these two groups (as indicated by large effect sizes and small
%OL). There should also be a high degree of confidence in the
accuracy with which a measure distinguishes between the two
groups (95% CIs), and the conclusions drawn from the research
literature must not be systematically biased by the tendency to
publish statistically significant findings (measured by the Nfs sta-
tistic). An analysis of the results for each of the different tests of
attention indicated 20 measures that yielded effect sizes meeting
the study criteria (i.e., d ⱖ 0.8).
When specific measures of information-processing speed were
examined (i.e., reaction time tasks), we found that severe TBI
produced clear deficits in processing speed, with responses to
simple and complex stimuli being comparably affected. This find-
ing suggests that the time taken to process even simple stimuli is
affected by a severe TBI and that the contribution of this deficit to
performance on tests of attention that purportedly assess other
aspects of attention cannot be ignored. Indeed, in examining the
amount by which the effect sizes for other measures of attention
that involve a timed component (e.g., Digit Symbol, Stroop) ex-
ceed that for information-processing speed (Cohen’s d ⬇ 1), it is
apparent that reduced processing speed may account for a large
component of these effects. The contribution of deficits in infor-
mation-processing speed therefore needs to be given careful con-
sideration when assessing any aspect of attention. However, reac-
tion time tasks are not routinely used in clinical situations because
of a reliance on computer-administered stimuli, the need for com-
mercially available programs, and the limited availability of nor-
mative data. It may therefore be necessary to rely on one of the
other simple timed measures of attention (e.g., time to complete
Trails A) to tap into these deficits.
With respect to attention span, there were one traditionally used
measure (e.g., Digit Span) and two less commonly used measures
(e.g., Reading and Word Span) that showed large group differ-
ences. All of these measures assess a person’s ability to hold
increasing amounts of information in working memory, with the
main difference between tests being the stimuli (digits or words).
In the case of the Reading Span task, participants are presented
with increasing numbers of sentences and are required to recall the
last word of each sentence (Goldenberg, Oder, Spatt, & Podreka,
1992; Schmitter-Edgecombe & Nissley, 2000). Word Span, on the
other hand, involves participants having to recall increasing se-
quences of 2- or 3-syllable words (Park et al., 1999). Although
these tests are not timed, information-processing speed is also
likely to contribute to performance on these tasks.
Focused, or selective, attention was examined in a total of 23
separate studies using 14 measures, 11 of which clearly discrimi-
nated between groups. Commonly used measures, such as the
Stroop Test, the Symbol Digit Modalities and Digit Symbol Tests,
and the Trail Making Test, all showed evidence of impaired
performance following severe TBI, with some measures from
these tests proving to be slightly better than others (e.g., the speed
and accuracy score of the Stroop Word Reading subtest being
better than the same score from the Color Naming and Interference
subtests). Moreover, there was only one test of focused attention
that was discriminating but not well known, namely, the Inhibition
Task, which involves naming a target word in the presence of a
218 MATHIAS AND WHEATON

Table 2
Weighted Effect Sizes for the Different Tests of Attention, Categorized by Category of Attention
Category of attention test N
(score)a (studies) M dw SD dw Min dw Max dw 95% CI Nfs %OL Study references

Information-processing speed
Choice reaction time (speed) 12 1.10 0.28 0.69 1.48 0.98–1.22 65 41 Felmingham et al., 2004; Ponsford & Kinsella,
1992, Exp. 1; Rugg et al., 1988; Rugg et
al., 1989; Sarno et al., 2003; Schmitter-
Edgecombe, 1996; Schmitter-Edgecombe et
al., 1992; Shum et al., 1990, 1994; Willison
& Tombaugh, 2006; Withaar & Brouwer,
2003; Zahn & Mirsky, 1999
Simple reaction time (speed) 9 1.07 0.68 0.72 2.98 0.94–1.20 47 41 Felmingham et al., 2004; Leclercq et al., 2000;
Perbal et al., 2003; Ponsford & Kinsella,
1992, Exp. 1; Sarno et al., 2003; Willison &
Tombaugh, 2006; Wilson et al., 1999;
Withaar & Brouwer, 2003; Zahn & Mirsky,
1999
Attention span
Reading span 2 1.01 0.04 0.99 1.04 0.62–1.40 9 45 Goldenberg et al., 1992; Schmitter-Edgecombe
& Nissley, 2000
Word span 2 0.81 0.29 0.61 1.02 ⫺0.02–1.64 7 53 Park et al., 1999, Exp. 1; Park et al., 1999,
Exp. 2
Digit span 6 0.80 0.42 0.08 1.25 0.52–1.08 23 53 Azouvi et al., 2004; Bate et al., 2001a, 2001b;
Leclercq et al., 2000; Rugg et al., 1993;
Schmitter-Edgecombe et al., 1992;
Schmitter-Edgecombe & Rogers, 1997
Alphabet span 2 0.57 0.37 0.39 0.91 0.03–1.11 5 62 Schmitter-Edgecombe & Rogers, 1997;
Schmitter-Edgecombe & Beglinger, 2001
Backward digit span 5 0.42 0.46 0.16 1.34 ⫺0.17–0.67 10 73 Azouvi et al., 2004; Bate et al., 2001a, 2001b;
Leclercq et al., 2000; Perbal et al., 2003;
Wilson et al., 1999
Forward digit span 5 0.25 0.14 0.07 0.39 0.00–0.50 5 79 Azouvi et al., 2004; Bate et al., 2001a, 2001b;
Leclercq et al., 2000; Perbal et al., 2003;
Wilson et al., 1999
Focused/selective attention
Stroop Word Reading (speed 4 1.45 0.38 1.20 2.05 1.15–1.75 28 30 Bate et al., 2001a, 2001b; Felmingham et al.,
and accuracy) 2004; Ponsford & Kinsella, 1992, Exp. 1;
Rios et al., 2004
Symbol Digit Modalities, 3 1.33 0.18 1.08 1.41 1.01–1.65 19 35 Bate et al., 2001a, 2001b; Ponsford &
oral (accuracy) Kinsella, 1992, Exp. 1; Schmitter-
Edgecombe & Beglinger, 2001
Symbol Digit Modalities, 3 1.31 0.09 1.23 1.40 0.99–1.63 19 35 Bate et al., 2001a, 2001b; Ponsford &
written (accuracy) Kinsella, 1992, Exp. 1; Schmitter-
Edgecombe & Beglinger, 2001
Digit Symbol (accuracy) 9 1.28 0.40 0.85 1.95 1.05–1.51 57 35 Rugg et al., 1988, 1989, 1993; Schmitter-
Edgecombe, 1996; Schmitter-Edgecombe et
al., 1992; Schmitter- Edgecombe & Rogers,
1997; Schmitter-Edgecombe & Kibby, 1998;
Schmitter-Edgecombe & Nissley, 2000;
Simpson & Schmitter-Edgecombe, 2000
Stroop Color Naming (speed 3 1.24 0.42 0.91 1.74 0.94–1.54 18 38 Bate et al., 2001a, 2001b; Ponsford &
and accuracy) Kinsella, 1992, Exp. 1; Rios et al., 2004
Inhibition Task, control 2 1.23 0.36 0.97 1.48 0.75–1.71 11 38 Ries & Marks, 2005; Simpson & Schmitter-
condition (speed) Edgecombe, 2000
Inhibition Task, interference 2 1.12 0.22 0.96 1.27 0.65–1.59 10 41 Ries & Marks, 2005; Simpson & Schmitter-
condition (speed) Edgecombe, 2000
Trail Making Test A (speed) 7 1.11 0.42 0.73 1.83 0.85–1.37 38 41 Azouvi et al., 1996; Brouwer et al., 1989;
Felmingham et al., 2004; Rios et al, 2004;
Simpson & Schmitter-Edgecombe, 2000;
Timmerman & Brouwer, 1999; Withaar &
Brouwer, 2003
Trail Making Test A:B ratio 2 1.04 1.00 0.65 2.06 0.59–1.49 9 45 Rios et al, 2004; Rugg et al., 1993
(speed)
Trail Making Test B (speed) 8 0.96 0.52 0.61 1.99 0.74–1.18 37 45 Azouvi et al., 1996; Brouwer et al., 1989;
Felmingham et al., 2004; Rios et al., 2004;
Simpson & Schmitter-Edgecombe, 2000;
Spikman et al., 2000; Timmerman &
Brouwer, 1999; Withaar & Brouwer, 2003
 SEVERE TRAUMATIC BRAIN INJURY AND ATTENTION 219

Table 2 (continued)
Category of attention test N
(score)a (studies) M dw SD dw Min dw Max dw 95% CI Nfs %OL Study references

Stroop Interference (speed 4 0.87 0.39 0.79 1.58 0.65–1.09 16 48 Bate et al., 2001a, 2001b; Felmingham et al.,
and accuracy) 2004; Ponsford & Kinsella, 1992, Exp. 1;
Rios et al., 2004
Stroop Interference (speed) 2 0.36 0.22 0.10 0.41 ⫺0.02–0.74 3 73 Marsh & Knight, 1991; Spikman et al., 2000
Stroop Interference (error) 2 0.33 0.25 0.27 0.62 ⫺0.09–0.75 2 79 Marsh & Knight, 1991; Ponsford & Kinsella,
1992, Exp. 1
Auditory Odd-Ball Task 2 0.01 0.69 ⫺0.43 0.54 ⫺0.46–0.48 0 100 Rugg et al., 1988, 1993
(accuracy)
Divided attention
Reaction time dual task 3 0.70 0.32 0.46 1.04 0.47–0.93 10 57 Schmitter-Edgecombe & Nissley, 2000;
(speed) Spikman et al., 2000; Withaar & Brouwer,
2003
Paced Auditory Serial 5 0.60 0.30 0.28 1.09 0.45–0.75 14 62 Bate et al., 2001a, 2001b; Park et al., 1999,
Addition Test (accuracy) Exp. 1, Exp. 2; Ponsford & Kinsella, 1992,
Exp. 1; Spikman et al., 2000
Sustained attention/vigilance
Cancellation task (speed and 2 1.99 0.09 1.93 2.05 1.73–2.25 19 19 Geldmacher & Hills, 1997; Hills &
accuracy) Geldmacher, 1998
Visual search (speed) 2 1.78 0.74 1.46 2.51 1.59–1.97 17 23 Heinze et al., 1992; Schmitter-Edgecombe &
Kibby, 1998
Cancellation task (speed) 4 1.10 0.54 0.88 2.06 0.86–1.34 21 41 Hills & Geldmacher, 1998; Mattson et al.,
1994; Ponsford & Kinsella, 1992, Exp. 1;
Simpson & Schmitter-Edgecombe, 2000
Cancellation task (accuracy) 4 0.66 0.50 0.25 1.18 0.38–0.94 12 57 Bate et al., 2001a, 2001b; Mattson et al.,
1994; Ponsford & Kinsella, 1992, Exp. 1;
Simpson & Schmitter-Edgecombe, 2000
Supervisory attentional
control
Card-sorting tests (error) 6 0.76 0.39 0.25 1.40 0.54–0.98 22 53 Marsh & Knight, 1991; Rios et al., 2004;
Rugg et al., 1989; Schmitter-Edgecombe,
1996; Schmitter-Edgecombe & Kibby, 1998;
Simpson & Schmitter-Edgecombe, 2000
Card-sorting tests (accuracy) 6 0.60 0.52 ⫺0.07 1.38 0.37–0.83 17 62 Goldenberg et al., 1992; Marsh & Knight,
1991; Rios et al, 2004; Schmitter-
Edgecombe, 1996; Schmitter-Edgecombe &
Kibby, 1998; Simpson & Schmitter-
Edgecombe, 2000
Tower of London (speed) 2 0.37 0.72 0.09 1.12 0.07–0.67 3 73 Ponsford & Kinsella, 1992, Exp. 3; Spikman
et al., 2000
Tower of London (accuracy) 2 0.18 0.69 ⫺0.10 0.88 ⫺0.16–0.52 1 85 Ponsford & Kinsella, 1992, Exp. 3; Spikman
et al., 2000

Note. N ⫽ number of studies contributing to the effect size; dw ⫽ weighted effect size; min ⫽ minimum effect size; max ⫽ maximum effect size; Nfs ⫽
fail-safe N; %OL ⫽ percent overlap between traumatic brain injury and control groups; CI ⫽ confidence interval.
a
Although a number of studies measured the orienting of attention, no measure was used by more than one study, necessitating the exclusion of these data
for this analysis.

distractor word, with or without interference (Ries & Marks, 2005;
Simpson & Schmitter-Edgecombe, 2000). In contrast, neither the
speed nor the accuracy scores of the commonly used Stroop
Interference subtest, which involves naming the ink color (e.g.,
blue) in which a color word (e.g., red) is printed, proved to be as
discriminating as a score that combined speed and accuracy on this
same subtest. Moreover, the Stroop Interference subtest was not as
discriminating as the Stroop Word Reading or Color Naming
subtests. This finding is somewhat counterintuitive as the Interfer-
ence task is more likely to draw on selective attention than are
simpler tasks, such as Color Naming or Word Reading. It is
possible that the latter two measures proved better because they
tapped the speed-of-processing deficits that are also apparent after
severe TBI (Bate et al., 2001b; Felmingham et al., 2004; Ponsford
& Kinsella, 1992; Rios et al., 2004). In fact, all of the 11 measures
of focused/selective attention described above reflect either the
time taken to complete a task (e.g., Trails A and B speed) or the
number of correct responses given under time-limited conditions
(e.g., Symbol Digit Modalities Test accuracy); therefore, it is
highly likely that reduced processing speed contributed to the
impaired performance of the TBI group on many of these mea-
sures.
Although the most commonly used measures of divided atten-
tion did not prove very discriminating, when measures that had
only been investigated by one study were additionally considered,
it became apparent that there are a number of measures that may
prove useful if further empirical evidence replicates these findings.
These measures assess dual task performance in a variety of
conditions, ranging from a simulated driving situation (Withaar &
Brouwer, 2003) to Posner’s Covert Orienting of Attention Test
220 MATHIAS AND WHEATON

Table 3
Weighted Effect Sizes for the Different Tests of Attention Used by Only One Study, Where Cohen’s d Was ⬎ 0.8
N M Cohen’s
Category of attention test (score) (studies) dw 95% CI Nfs %OL Study reference

Focused attention/selective attention

Symbol Digit Modalities, oral (speed and accuracy) 1 2.71 1.52–3.90 13 9 Ponsford & Kinsella, 1992, Exp. 1
Pigache Attention Test (error) 1 2.31 1.65–2.97 11 13 Keller et al., 1995
TEA Map Search (speed and accuracy) 1 1.25 0.74–1.76 5 35 Bate et al., 2001a, 2001b
TEA Telephone Search (speed and accuracy) 1 1.18 0.67–1.69 5 38 Bate et al., 2001a, 2001b
Go–no-go task (Go accuracy) 1 0.87 0.22–1.52 3 48 Rugg et al., 1989
Divided attention
Tracking dual task (speed and accuracy) 1 1.49 1.05–1.93 6 29 Withaar & Brouwer, 2003
Random number generation dual task (speed) 1 1.32 0.83–1.81 6 35 Leclercq et al, 2000
Tone monitoring dual task (speed) 1 1.14 0.73–1.54 5 41 Schmitter-Edgecombe, 1996
Phenome detection dual task (error) 1 1.04 0.54–1.54 4 45 Bate et al., 2001a, 2001b
COAT valid cue dual task (speed) 1 1.03 0.74–1.32 4 45 Bate et al., 2001a, 2001b
COAT neutral cue dual task (speed) 1 0.97 0.68–1.25 4 45 Bate et al., 2001a, 2001b
COAT invalid cue dual task (speed) 1 0.83 0.54–1.11 3 53 Bate et al., 2001a, 2001b
Paced Auditory Serial Addition Test (error) 1 0.83 0.35–1.31 3 53 Ponsford & Kinsella, 1992, Exp. 1
Sustained attention/vigilance
Visual Nonsearch (speed) 1 1.73 1.51–1.95 8 25 Schmitter-Edgecombe & Kibby, 1998
Visual Search (accuracy) 1 1.67 1.13–2.21 7 25 Schmitter-Edgecombe & Kibby, 1998
Supervisory attentional control
Short Stimulus Task shifting cost (speed) 1 2.02 1.12–2.92 9 19 Stablum et al., 1994
Random number generation (speed) 1 1.84 1.10–2.58 8 23 Leclercq et al., 2000
Random-number generation (error) 1 1.43 0.50–2.36 6 32 Azouvi et al., 1996
Tower of London (speed and accuracy) 1 1.00 0.48–1.52 4 45 Goldenberg et al., 1992
Orienting of attention
COAT valid cue (speed) 1 1.03 0.21–1.35 4 45 Bate et al., 2001a, 2001b
COAT neutral cue (speed) 1 0.92 0.57–1.27 4 48 Bate et al., 2001a, 2001b
COAT invalid cue (speed) 1 0.84 0.55–1.12 3 53 Bate et al., 2001a, 2001b

Note. N ⫽ number of studies contributing to the effect size; dw ⫽ weighted effect size; Nfs ⫽ fail-safe N for effect size; %OL ⫽ percent overlap between
traumatic brain injury and control groups; CI ⫽ confidence interval; TEA ⫽ Test of Everyday Attention; COAT ⫽ Covert Orienting of Attention Test.

(COAT; Bate et al., 2001a). Once again, the contribution of
deficits in information-processing speed to performance on these
measures must also be considered, as performance is frequently
measured directly in terms of speed (e.g., the COAT) or accuracy
under time-limited conditions (e.g., the Paced Auditory Serial
Addition Test; Gronwall, 1977).
Following severe TBI, patients also appear to experience con-
siderable problems in sustaining focused attention over a period of
time when they are assessed on tasks that require them to search
for a visual target that is embedded amongst other stimuli (e.g.,
visual search tasks, letter and number cancellation tasks). Notably,
whereas visual search and cancellation tasks are described as
measuring sustained attention by Lezak (1995), both tasks are
performed under time-limited conditions and are, therefore, also
likely to be affected by reductions in information-processing
speed.
Deficits in the executive aspects of attention (supervisory atten-
tional control), on the other hand, were not apparent on any of the
measures that were used by two or more studies (i.e., card-sorting
tests, Tower of London) but were evident on four measures (ob-
tained from three tests) that were used by only one study. Specif-
ically, there were large and significant differences on a task that
required participants to make one of two responses (motor or
auditory) depending on the stimulus (Short Stimulus Task shifting
cost), a random number generation task in which participants were
required to generate numbers without repeating sequences (speed,
accuracy scores), and a score that combined the speed and accu-
racy with which participants completed the Tower of London.
Notably, neither the speed nor the accuracy with which the Tower
of London test was performed discriminated between the TBI and
control groups in the two studies that used these scores. Other
card-sorting tests that have often been used to tap into this aspect
of attention, such as the Wisconsin Card Sorting Test, also proved
less successful in discriminating between samples, although mod-
erate group differences were still apparent.
Finally, the orienting of visual attention, which involves the
allocation of visual attention in space (Bate et al., 2001a), has not
been widely examined in severe TBI samples. Consequently, there
were no COAT measures that had been used by more than one
study. When those measures that had only been examined by one
study but revealed large effect sizes were additionally considered,
it was apparent that there are a number of simple COAT measures
that may prove useful for measuring this aspect of attention,
namely RTs to valid, neutral, and invalid cues (Bate et al., 2001a).
As with the previous measures, the contribution of information-
processing speed to performance needs to be considered, as these
are timed measures.
With respect to participant characteristics that may act to mod-
erate the impact of TBI on attention, the data indicated that age,
education, and postinjury interval did not significantly contribute
to the variability in effect sizes, suggesting that it is acceptable to
combine the results of studies that differ on these methodological
variables. However, these findings should be viewed with caution,
as the data on which these analyses were based were less than
 SEVERE TRAUMATIC BRAIN INJURY AND ATTENTION
optimal. First, not all studies provided the requisite data, thereby
reducing the sample size for this analysis. Second, and probably
more importantly, mean effect sizes were calculated for each study
for these analyses. Thus, the effect sizes for all of the individual
measures that were used by a given study were averaged. If a study
yielded both small and large effect sizes for different measures,
these were combined to calculate a mean effect size, which was
then correlated with the moderator variables. A more useful anal-
ysis would involve analyzing each measure separately by corre-
lating the effect sizes from all of the studies that used a particular
measure with the age, education, and postinjury interval data for
those studies. However, this was not possible as the maximum
number of studies that used any given measure was 12. When
those studies that did not provide data for the moderator variables
were excluded, the sample size was reduced to an unacceptably
low number. Thus, the current moderator analysis was necessarily
limited.
Other limitations to this study include those that are generally
associated with meta-analytic procedures. Specifically, it is possi-
ble that there were unpublished studies with nonsignificant find-
ings (possibly due to small sample sizes) or articles published in
other languages that may have been excluded from the current
analyses. While there is no obvious solution to this problem, the
calculation of fail-safe statistics assists the reader in evaluating the
degree of confidence that can be placed in the current findings. In
addition, it is possible that the search terms were not exhaustive
and that some relevant articles failed to be identified. Although a
relatively large number of terms were used, electronic searches
only identify matches on the basis of words contained in the title,
abstract, or keyword listings. Manual searches of journals indexes
and bibliographies were therefore undertaken to reduce the likeli-
hood of missing relevant studies.
Finally, it should be noted that a number of studies that were
included within the current review used sophisticated experimental
designs to investigate the specific nature of the deficits in attention
following TBI. In particular, Ries and Marks (2005); Schmitter-
Edgecombe and Kibby (1998); and Simpson and Schmitter-Edge-
combe (2000) used a variety of experimental conditions in order to
isolate some of the cognitive processes that contribute to attention,
including speed of information processing. To this end, these
researchers examined interaction effects and within-group planned
comparisons, in addition to the simple group effects (TBI vs.
controls) that were the subject of the current meta-analysis. Inter-
action effects result from the relationship between two or more
independent variables and a dependent variable and are not reduc-
ible to a standardized difference between two groups (Tilley,
1996). Thus, it was not possible to include effect sizes to summa-
rize the results of these complex experimental designs in the
current meta-analysis. Instead, only the results of simple group
comparisons on the control tasks were presented for present pur-
poses. This research is, however, important as it provides a more
detailed and experimentally controlled examination of attention
and may eventually lead to the development of better tests of
attention for use in clinical practice.
In addition, whereas a meta-analysis is ultimately limited by the
quality of the data that it is provided by the primary research, it
also provides an opportunity to specify some of the information
that is needed by the scientific community in order to adequately
critique the findings of a study, either qualitatively or quantita-
221
tively. These requirements are essential to the evaluation of an
individual study and to the integration of findings in the form of a
meta-analysis and, if consistently provided, will raise the quality of
the research in this field with minimal additional data. Specifically,
research into deficits in attention (or other cognitive functions)
following TBI needs to provide the following information: (a)
details of the age, educational level, injury severity (Glasgow
Coma Scale, loss of consciousness, and/or posttraumatic amnesia),
postinjury interval, affective state (e.g., depression), and source of
participants (e.g., consecutive hospital admissions, symptomatic
referrals for neuropsychological assessment), and the numbers
involved in litigation; (b) means, standard deviations, and effect
sizes for both significant and nonsignificant findings; and (c) clear
descriptions of the study measures (or a test reference) and any
modifications that have been made to the test. Many studies do not
currently provide all of this information.
In conclusion, following a severe TBI, patients appear to exhibit
a range of attentional deficits that are broadly subsumed under the
categories of information-processing speed, attention span, selec-
tive/focused attention, sustained attention, and supervisory atten-
tion control. Moreover, performance deficits of one standard de-
viation or more below scores of their healthy peers are apparent on
a range of commonly used measures, including visual search tasks,
cancellation tasks (e.g. the Ruff 2 and 7 Test, letter and word
cancellation tests), the Stroop Test (Word Reading, Color Naming,
and Interference subtests), the Symbol Digit Modalities Test (oral
and written versions), the Digit Symbol Test, and the Trail Making
Test (Part A). However, the fact that many of these tests yield
scores that reflect the time taken to complete a task or the number
of correct responses within a fixed time interval suggests that the
contribution of reduced processing speed to performance on tests
of attention must be given careful consideration. Finally, although
there is some suggestion that differences in patient variables (e.g.,
age, education, postinjury interval) do not significantly contribute
to the extent of these deficits, this finding should be viewed with
caution, as it was not possible to analyze the moderating influence
of these variables on specific measures.
References
*References marked with an asterisk are included in the meta-analysis.
*Azouvi, P., Couillet, J., Leclercq, M., Martin, Y. Asloun, S., & Rous-
seaux, M. (2004). Divided attention and mental effort after severe
traumatic brain injury. Neuropsychologia, 42, 1260 –1268.
*Azouvi, P., Jokic, C., Van Der Linden, M., Marlier, N., & Bussel, B.
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Received March 15, 2006
Revision received November 6, 2006
Accepted November 20, 2006 䡲