6

Week 13: Allen Cognitive Levels

Introduction

The Allen Cognitive Levels scale or ACL Scale was developed through systematic observation and documentation of predictable patterns of performance of adults in inpatient mental health settings as they engaged in activities of daily living (ADLs), instrumental activities of daily living (IADLs) and leisure activities (Allen & Blue, 1998). Cognitive levels reflect sets of underlying cognitive processes that affect functional performance such as motor actions and verbal behaviors observed as an individual engages in an occupation (Austin, 2009). —The six cognitive levels are titled with prominent, observable, voluntary motor actions associated with the level (Allen, Earhart, & Blue, 1992). The levels are a hierarchy of increasingly complex abilities, with the fewest and simplest available cognitive capacities and functional abilities described by cognitive level 1-“comatose” and the most complex by cognitive level 6- “premeditated activities, no supervision required.” Intervention focuses on providing activities in which the individual can succeed, with the goal of creating an environment that allows the individual the least restrictions while maintaining safety.

Theory

The person, environment, and occupation model (PEO) looks at the interaction of all three systems. Following the PEO model, occupational performance is enhanced when the person and environment system are interacting cohesively (Strong et al., 1999). Increasing function as a whole depends on all three system; therefore, it is important to ensure all three systems are connecting in an efficient way (Strong et al., 1999). After assessing patients using Allen’s Cognitive Levels, we can adapt the environment to meet their individual level of function in order to perform occupations. PEO seeks to find a good fit between the individual, current level of functioning, and desired occupation and can follow the individual along the continuum of care and improvement.

Evidence

A published study by Scanlan and Still (2013), with persons in a mental health setting found a significant association between functional cognition measured and and level of independence. ACLS is supported by 50 years of theory development, clinical expertise, and existing published research as well as current research being conducted or in the process of being published nationally and internationally. —A small pilot study found that persons in a group using the CDM improved on the ACL but did not improve on other measures when compared to a control group (Raweh & Katz, 2008). In addition, both the national and international academic, clinical, and research OT community consider use of the 5th version of the ACLS and the supporting theory and research to be “best practice” (Allen & Blue, 1998).

Case Study

Sam is an 18-year-old boy who is diagnosed with autism spectrum disorder. He lives at home with mom, dad, and sister. Sam was referred to occupational therapy because his parents would like him to be more independent. Sam is having difficulties completing the appropriate sequence of toileting, often forgetting the appropriate steps. He needs constant verbal and visual cues during toileting to ensure he finishes each step, in the correct order. He will forget to flush the toilet, fasten his pants and wash his hands. The occupational therapist completed the Allen cognitive levels assessment and Sam scored a 3.6.

Intervention Plan

Problem Statement: Client has difficulty completing his morning routine due to a decrease in sequencing skills.

Long term goals

1-  Client will use a visual schedule to complete post toilet hygiene and safety with supervision by discharge.

2- Caregiver will demonstrate the ability to generalize the use of appropriate short, concise commands to use on an unfamiliar task with client by discharge.

Short term goals

1- Client will be able to state the last task needed to complete post toilet hygiene and safety with two verbal cues in 2 weeks.

2- Client will be able to wash hands after toileting with one visual cue and one verbal cues in 2 weeks.

3- Caregiver will be able to demonstrate appropriate short, concise commands to assist client in toileting in 1 week.

Intervention format

• Individual

Setting

• Home

Supplies

• Toileting supplies
  • Toilet paper, hand soap, hand towel
• Visual cues
  • Construction paper (bright colors)

Agenda & description

• Recap from last session with Sam and his mom about using visual cues in the bathroom (10 mins)
  • Last session the OT introduced visual cues to Sam and his mom and how they can implement it around the house
• Implement using the visual cues with Sam and his mom in the bathroom (25 mins)
  • The visual cues are simple, one word commands around his bathroom in specific places reminding him to finish toileting and hygiene routine.
  • There are 5 visual cues:

1. Flush toilet
2. Pull up pants
3. Fasten pants
4. Wash hands
5. Dry hands

• Training with Sam’s mom on appropriate use of verbal cues  (10 mins)

Documentation

S-  Client’s mom expressed excitement about learning new techniques about giving commands to help Sam so that he can participate more in adls.

O-  Client completed 45 minutes OT session in which we worked on post toilet hygiene and safety with the use of visual and verbal cues. He was able to complete 2 out of 5 steps utilizing visual cues and 3 verbal cues. Client required supervision for all tasks. Further training was provided to client’s mom in  appropriate use of verbal cues, she effectively provided 2 of the 3 cues.

A- The fact that Sam was only able to complete 2 out of the 5 steps demonstrates poor sequencing skills and poor memory recall which causes safety concerns during ADL completion. Because he required multiple cues, it is imperative that his mom is trained in giving short, concise commands.  Client will benefit from sessions focused on ADL completion and safety under supervision.

P- Client will continue with OT services 2x/week for 6 weeks to increase his sequencing skills in order to increase his independence with toileting.

References

Allen, C. K. & Blue, T. (1998). Cognitive disabilities model: How to make clinical judgements. In N. Katz (ed.), Cognitive rehabilitation: Models for intervention in occupational therapy. Bethesda, MD: American Occupational Therapy Association.

Allen, C.K., Earhart, C.A., & Blue, T. (1995) Understanding Cognitive Performance Modes Ormond Beach FL: Allen Conferences

Allen, C. K., Earhart, C. A., & Blue, T. (1992). Occupational therapy treatment goals for the physically and cognitively disabled. Bethesda, MD: American Occupational Therapy Association.

Austin, S. A. (2009). Hierarchies of abilities and activity demands in the Allen Diagnostic Module 2nd Ed.: A validity study (Unpublished doctoral dissertation.). University of Illinois, Chicago.

—Brown, C., Stoffel, V.C., & Munoz, J.P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia, PA: F. A. Davis Company. ISBN-10: 0-8036-1704-6

—Raweh, D. V, & Katz, N. (1999). Treatment Effectiveness of Allen’s Cognitive Disabilities Model with Adult Schizophrenic Outpatients. Occupational Therapy in Mental Health, 14(4), 65–77. http://doi.org/10.1300/J004v14n04

Scanlan, J. N. & Still, M. (2013). Functional profile of mental health consumers assessed by occupational therapists: Level of independence and associations with functional cognition. Psychiatry Research, 208, 29-32.

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the person-environment-occupation model: A practical tool. Canadian Journal of Occupational Therapy, 66(3), 122-133.