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Introduction

According to Brown (2012), Allen Cognitive Levels (ACL) consider metacognitive demands of CBT for assessment and intervention guidelines. If individuals obtain an ACL score of either 3 or 4, determined by completing different stitching patterns, then CBT models and understandable cognitive strategies would be beneficial for these individuals. Specifically, these individuals learn best using concrete, repetitive, situation-specific strategies (Brown, 2012). Penny, Mueser, and North (1995) found that social competence in clients with schizophrenia can be closely related to ACL. ACL uses crafts to not only assess patients but also can be used for craft activities to use during therapy, consequently, increasing quality of life.

Theory

The Person-Environment-Occupation (PEO) model examines the interaction among three elements: person, environment, and occupation; and the effects of these relationships on an individual’s occupational performance.  The person (P) component refers to the individual, his/her interests and level of functioning. The environment (E) element considers cultural, socioeconomic, institutional, physical, and social contexts. Finally, the occupation (O) component refers to meaningful tasks and activities.  Performance is optimal when a good fit is achieved among all components (Scaffa & Reitz, 2014). Using Cognitive Adaptation Training (CAT) to address cognitive issues and adapt the environment to facilitate client independence with activities of daily (ADLs), all elements of the PEO model are addressed.

Evidence

A study conducted by Scanlan and Still (2015) randomized 116 individuals with schizophrenia or schizoaffective disorder into one of four treatments. The four treatments included Cognitive Behavioral Therapy for psychosis (CBTp), Cognitive Adaptation Training (CAT), training including both CBTp and CAT (Mcog), and lastly, treatment as usual (TAU). Main results using the Multnomah Community Ability Scale (MCAS) measuring community integration skills as well as auditory hallucinations (AHS) were positively impacted and had better outcomes among participants who received CAT compared to those who did not receive CAT. Overall, participants who participated in CAT, demonstrated improvements in functional performance and modest improvements in symptoms associated with schizophrenia (Scanlan, & Still 2015).

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness. Fitzroy was referred to an occupational therapist at The Fountain House to address his issues with completing his morning routine, such as hygiene and dressing. The occupational therapist met with Fitzroy to conduct the Allen’s Cognitive Levels assessment to determine his level of cognitive function. Through interview and assessment, the therapist identified that he currently scored a 3.8 level, therefore,  requires 46% cognitive assistance and 10% physical assistance with fine motor tasks. The occupational therapist determined Fitzroy’s level of cognition prevents him from being able to follow more than 3 step sequences, however, he is able to learn new routines. Consequently, Fitzroy requires 24 hour supervision to get supplies and has less social interaction with peers due to a lack of hygiene. Following the assessment, the occupational therapist determined Fitzroy would benefit from cognitive adaptation training (CAT) to increase his independence in his activities of daily living.

Intervention Plan

Problem Statement

Fitzroy demonstrates an inability to appropriately complete activities of daily living during his morning routine, due to a decrease in cognitive function.

Long Term Goals

1. Fitzroy will score a 4.0 on Allen’s Cognitive Level to increase independence in ADLs within 8 weeks.
2. Fitzroy will be able to follow a 4 step sequence for brushing teeth with moderate verbal cues to increase independence in ADLs within 8 weeks.
3. Fitzroy will be able to choose appropriate clothing independently to increase independence in ADLs within 8 weeks.

Short Term Goals

1. Fitzroy will be able to follow a 4 step sequence for brushing teeth with the use of visual cues to increase independence in ADLs within 4 weeks.
2. Fitzroy will be able to make corrections when presented with inappropriate clothing selections with moderate verbal cues to increase independence in ADLs within 4 weeks.

Intervention Format

Individual session

Setting

Fitzroy will meet with the occupational therapist for individual sessions at the Fountain House for 45 minutes 3 times a week for 8 weeks.

Supplies

None

Agenda

• Meet with Fitzroy and determine level of orientation (X3) (5 min)
• Educate caregiver on appropriate amount of cues and supervision (10 min)
• Educate Fitzroy on the use of environmental adaptation (checklist)  (10 min)
• Complete teeth brushing utilizing checklist (15 min)
• Debrief (5 min)

Documentation

S: Client caregiver stated, “He never brushes his teeth the right way.  He always misses a step and gets frustrated with me when I correct him.”

O: Client participated in a 45 minute individual OT session with emphasis on cognitive adaptation training for morning activities of daily living. Fitzroy was oriented X3 to person, place and situation. Caregiver was trained on the use of 24 hour supervision and appropriate cues during activities.  Fitzroy engaged in a teeth brushing activity with the use of a checklist on the bathroom mirror. Fitzroy was able to follow 6 out of 8 steps using the checklist on the mirror, with maximal verbal cues for redirection.

A: Caregiver was receptive and demonstrated understanding after education of appropriate supervision and cueing, showing adequate support for the client. Client’s need for maximal verbal cues for redirection to use the checklist as a guide demonstrates a lack of cognitive attention and a level of high distractibility. Fitzroy’s ability to remain calm during the session demonstrates the effectiveness of the checklist to decrease frustration during cognitively taxing activities.

P:  OT treatment indicated 3x per week for 45 minutes for 8 weeks. Continue with cognitive adaptation training including caregiver to increase cognitive function and independence in ADLs.

References

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

Brown, C. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: AOTA Press. ISBN-13: 978-1-56900-331-2

Scaffa, M. E., & Reitz, S. M. (Eds.). (2014). Occupational therapy in community-based practice settings. 2nd ed. Philadelphia, PA: F.A. Davis Company.

Scanlan, J. N., & Still, M. (2015). Cognitive adaptation training demonstrated benefits for individuals living with schizophrenia in terms of community functioning and impact of auditory hallucinations. Australian Occupational Therapy Journal, 62(5), 367-368.

Penny, N. H., Mueser, K. T., & North, C. T. (1995). The Allen Cognitive Level test and social competence in adult psychiatric patients. American Journal of Occupational Therapy, 49, 420–427.