Allen Cognitive Level Leather Lacing Screen

Allen, C. K. (1982). Independence through activity: The practice of occupational therapy (psychiatry). American Journal of Occupational Therapy, 36(11), 731-739. doi: 10.5014/ajot.36.11.731

Allen, C. K., Austin, S.L., David, S. K., Earhart, C. A., McCraith, D. B, & Riska-Williams, L. (2007). Manual for the Allen Cognitive Level Screen-5 (ACLS-5) and Large Allen Cognitive Level Screen-5 (LACLS-5). Camarillo, CA: ACLS and LACLS Committee.

Cairns, A., Hill, C., Dark, F., McPhail, S., & Gray, M. (2013). The Large Allen Cognitive Level Screen as an indicator for medication adherence among adults accessing community mental health services. British Journal of Occupational Therapy, 76(3), 137-143. doi:10.4276/030802213X13627524435180

Cole, M. (2012). Allen's Cognitive Disabilities group. In M. B. Cole (Ed.) Group dynamics in occupational therapy: The theoretical basis and practice application of group intervention (4th ed., pp.193-216). Thorofare, NJ: Slack Incorporated.

Mayer, M. A., (1998). Analysis of information processing and cognitive disability theory. American Journal Occupational Therapy, 42(3),176-183. doi: 10.5014/ajot.42.3.176.

McCraith, D. B. (2016). ACLS-5 and LACLS-5 Test: Psychometric Properties and Use of Scores for Evidence-Based Practice. Retrieved from http://allencognitive.com/wp-content/uploads/CopyrightReportfPsychometricsACLS-5_3-21-2016.pdf

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(1), 29-32. doi:10.1016/j.psychres.2013.02.032

References

Sampling & Normative Data

Sampling: Psychiatric disorders, adults with dementia, adults who have experienced a cerebral vascular accident, adults who have sustained a traumatic brain injury (Allen, et. al., 2007).

• The LACLS-5 can be used for individuals who have visual impairments or decreased hand functioning (Allen, et. al., 2007).

Normative Data: The purpose of the assessment is to assign a level of cognitive function rather than define what is normal vs abnormal cognition. Therefore, there is not normative data.

Standard & Criterion Scores

Reliability and Validity of the Allen Cognitive Level Leather Lacing Screen

Factors that Might Bias the Assessment Results

Criterion are provided in a scoring table in Section VI of the Manual for the Allen Cognitive Level Screen-5 (ACLS-5) and Large Allen Cognitive Level Screen-5 (LACLS-5) (Allen, et. al., 2007).

• Copies will be provided at your table while you are practicing the assessment.

Standard scores are not provided for the ACLS-5 or LACLS-5 because this is a tool to help assess cognitive functioning and guide interventions. A standard score is not applicable because there is no standard for measuring cognitive functioning for these populations.

Reliability

• Inter-rater reliability in all versions of the ACLS have shown to have correlations of R=0.91 to R=0.99 (McCraith, 2016).
• Pilot studies for ACLS-5 have shown a 0.02 margin for error in inter-rater reliability (as cited in McCraith, 2016).
• Test- retest studies show that there is a low to moderate reliability using the ACLS-90 (McCraith, 2016).
• Test- retest is less reliable because cognition functions are known to vary throughout the day, as conditions progress, and over time (McCraith, 2016).

• Use of the LACLS-5 instead of the ACLS-5 may lead to an increase in scores (Allen et al., 2007)
• However, switching from the ACLS-5 to the LACLS-5 may also bias the assessment due to the client receiving instructions or demonstrations more than once (Allen et al., 2007)
• If possible, try to discern which instrument to use prior to beginning the assessment
• The fluidity of cognition is a potential biasing factor of this assessment
• This is why test-retest reliability is poor (McCraith, 2016); cognitive abilities are subject to change
• Situational factors may influence scores
• Mood
• Activities completed that day
• Familial or cultural events
• Due to the standardized nature of the ACLS-5, using nonstandardized phrases or cues may decrease its ability to be successfully used in practice

Validity

• ACL score was significantly associated (p= <.01) with the prediction of functional independence in 225 people in a mental health setting (Scanlan and Still, 2013).
• ACL scores have also been significantly associated with medication adherence (p=<.01) (Cairns, Hill, Dark, McPhail, & Gray, 2013).
• A 2010 pilot study by Okamura, Takeshita, Teramoto, Aida, and Kino found a significant association between functional cognition scores on the ACLS-5 and global cognition measured by the Mini Mental Status Exam (as cited in McCraith, 2016).

Interpretation of the Allen Cognitive Leather Lacing Screen

Procedures & Protocols to Administer the Assessment

• Screen scores will be assigned from the table provided in the ACLS-5 manual
• These can serve as an estimate for the individual's cognitive level and mode. You can find this in Cole (2012) on page 203.
• Mode provides the behavioral description of the score.
• Document the screening tool that was used and the score obtained.
• This information will allow therapists to perform additional assessments to confirm this estimate.
• Once a mode is determined, this information is integrated with the person factors that are unique to the client to establish goals and an intervention plan.

(Allen et. al., 2007)

• The ACLS-5 and LACLS-5 "offer a performance context to view a person's available cognitive abilities as they are applied to the activity demands of three leather-lacing tasks of increasing complexity" (Allen et al., 2007, p. 8)
• The ACLS-5 and LACLS-5 are highly standardized, with exact phrases and cues (written in blue) the therapist must use while giving the assessment (Allen et al., 2007).
• The administration portion of the ACLS-5 Manual is provided for you on Blackboard. While you may use this for this course, you cannot save it for future use due to copyright laws. Instead, your facility must purchase the instrument and manual.

Setup

Administration

Running Stitch: Task 1

This task corresponds with scores 3.0- 3.4. If the client does not reach for the lace, this is considered "less than 3.0" (Allen et al., 2007).

Goal: "Person completes 3 correct running stitches in consecutive holes" (Allen et al., 2007, p. 22).

• Introduce self and leather-lacing tool
• Demonstrate a correct stitch and give leather to client
• Allow client time to complete 3 stitches
• If they complete them correctly--> Continue to 2nd task
• If they need encouragement or assurance--> Provide the standard cues (written in blue)
• If they make errors or do not try--> Provide a 2nd demonstration

(Allen et al., 2007)

Introduction to the Assessment

Whipstitch: Task 2

• Administrator (that's you!)
• Practice, practice, practice!
• Holding the leather correctly
• Stitches
• Giving verbal instructions and cues
• Environment
• Minimal distractions
• Good lighting
• Sit so that you can see their stitches and facial expressions
• Tools
• Thread the needles and secure the laces for each of the 3 types of stitches
• Complete 3 of each type of stitch
• Client
• Establish rapport and introduce the screen
• Look for potential barriers
• Determine whether to use the ACLS-5 or the LACLS-5

This task corresponds with scores 3.4-4.4 (Allen et al., 2007).

Goal: "Person completes 3 correct whipstiches in consecutive holes including recognizing and correcting the cross-in-back error and the twisted lace error" (Allen et al., 2007, p. 24).

• Demonstrate a correct stitch and give leather to client
• Allow client time to complete 3 stitches
• If they complete them correctly--> Continue to Insert Problem Solving Whipstich Errors (prompts written in blue)
• If they make an error--> Allow them to problem solve to correct the error,

prompting them if necessary (prompts written in blue)

• If they need encouragement or assurance--> Provide the standard cues (written in blue)
• If they make errors or do not try--> Provide a 2nd demonstration
• If they cannot recognize the cross in back or twisted lace errors or their attempts to fix them are not working after 2nd demonstration -> Continue to Insert Problem Solving Whipstitch Errors (prompts written in blue)
• After client has completed 3 correct stitches and had the opportunity to correct both the cross-in-back and twisted lace errors--> Continue to the 3rd task

Single Cordovan Stitch: Task 3

(Allen et al., 2007)

This task corresponds with scores 4.2-5.8 (Allen et al., 2007).

Goal: "Person completes 3 correct single cordovan stitches in consecutive holes" (Allen et al., 2007, p. 28).

• Do NOT demonstrate correct stitch, simply give leather to client
• Allow client time to problem solve and complete 3 stitches
• If they complete them correctly--> End assessment
• If they need encouragement or assurance--> Provide the standard cues (written in blue)
• If they make errors--> Do not give cues or demonstration
• If client does not recognize errors or appears anxious--> Ask if they would like a hint (written in blue)
• If they say no--> Allow more time to problem solve
• If they continue to need assistance--> Offer a demonstration
• If they say yes--> Provide one of the standard cues (written in blue)
• If they still need assistance, offer a demonsration
• If they say no--> Allow more time to problem solve
• If they say yes--> Provide demonstration
• After 1st demonstration, allow client more time
• If they continue to need assistance--> Offer a 2nd demonstration
• If they say no--> End assessment
• If they say yes--> Provide 2nd demonstration
• When client has completed 3 single cordovan stitches or decided not to receive a 2nd demonstration--> Thank the client for their time and efforts

(Allen et al., 2007)

The Allen Cognitive Level Screen-5 (ACLS-5) and the Large Allen Cognitive Level Screen-5 (LACLS-5) utilize a leather-lacing task to screen the functional cognition of persons with cognitive difficulties in their everyday lives.

Claudia Allen's expertise and passion for the dignity of individuals with cognitive deficits has enabled therapists to better understand this population through her establishment of the Cognitive Disabilities Model (Cole, 2012).

Retrieved from http://www.crisisprevention.com/Resources/Knowledge-Base/Cognitive-Assessment-Tools

Theoretical Application of the Assessment

Function & Dysfunction

Focus & Assumptions

Clinical Application of the Assessment

Allen's definition of function and dysfunction occurs along a continuum from the lowest cognitive level, 1, to the highest, 6. At level 1, behavior is mostly automatic, while at level 6, behavior is organized.

It is important to note that Allen did not believe that a "functional" person only operates at a Level 6. Instead, people tend to oscillate through the levels as necessary throughout the day. When one can no longer reach a higher level of cognitive ability, despite his or her best effort, that is when they are considered "dysfunctional" or "disabled."

• Claudia Allen's Cognitive Disabilities Model focuses on empowering a client to be as functional as possible (Cole, 2012).
• Cole (2012) writes, "This theory is best applied when there is a need to measure and monitor a client's problem-solving ability and safety while performing daily activities" (p. 193).

• This model assumes that "the difference in patterns of performance between the six cognitive levels are due to differences in informa- tion-processing capabilities" (Mayer, 1998, p.182).

(Allen, 1982; Cole, 2012)

Allen's Scale of Cognitive Assistance: Levels 1 - 6

(Cole, 2012, p. 199)

*Note: The ACLS-5 or LACLS-5 allows for scores of “less than 3.0” and 3.0- 5.8 (Allen et al., 2007).

Retrieved from www.allencognitivelevelscreen.org

Assessments & Interventions

Change & Motivation

• Allen's method suggests that clients should begin treatment with other clients at similar levels of cognition. Clients must be placed in appropriate groups prior to beginning OT intervention.

• In order for a client to function optimally, the OT may give advice for caregiver assistance and ways to adapt the environment for the client .

(Cole, 2012)

Assessments developed by Allen include:

• Allen Cognitive Level Screen (ACLS)
• Routine Task Inventory (RTI)
• Cognitive Performance Test (CPT)
• Allen Diagnostic Module (ADM)

(Allen et al., 2007)

Settings

• The Cognitive Disabilities Model employs adaptation of both the environment and of the task to create a "just-right challenge." Allen outlines features of the just-right challenge in the Cognitive Assistance Levels.
• For some clients, the just-right challenge helps them to improve cognitive functioning.
• For others, the Cognitive Assistance Levels help predict their discharge disposition and required level of assistance.

Interventions in this model are based on Allen's Cognitive Assistance Levels (Cole, 2012). These interventions are frequently used in therapeutic group settings where individuals are placed in groups according to the level of cognitive assistance that promotes their best performance (Cole, 2012).

• Group settings, chronic-care settings (group homes or skilled nursing facilities), inpatient or outpatient mental health settings, and dementia care facilities can use the ACLS-5 and LACLS-5 to screen cognition for a variety of populations.
• Levels 1-2 are not recommended for group therapy; Levels 3-6 may engage in group therapy with various foci.

(Cole, 2012)

Cognitive Disabilities Model

Interventions

Task Analysis

Providing Necessary Assistance

• Caregivers should be informed to first observe the client and his or her response to the environment provided for the task.
• Next, Allen suggests four ways to provide cognitive assistance:
• "Facilitate - Give sensory cues appropriate to level.
• Probe - Ask focused questions to encourage problem-solving.
• Observe - Allow client time to process cues and questions and try out new behaviors.
• Rescue - When frustration arises, correct error or do a step for the client" (Cole, 2012, p.194).

Task analysis is a critical aspect of applying the

Cognitive Disabilities Model to practice!

• Allen (1982) writes, "The therapist uses the task analysis to change the task procedure so that patients can achieve greater independence. Used in this manner, the task analysis can be applied to realistic and optimistic objectives" (p. 734).
• Thus, the amount or type of adaptations needed depend on the client's cognitive functional capacity (Cole, 2012).
• Context
• Environment
• Task
• Cues given
• Assistance required

To support optimal cognitive functioning for clients, occupational therapy can benefit by:

• "assessing the cognitive impairment
• using assistance and environmental adaptation to compensate for activity limitations
• promote routines that allow continued participation in the occupations of daily life" (Cole, 2012, p. 195).

This coincides with the Cognitive Disabilities Model.

(Cole, 2012)

(Cole, 2012)

Allen Cognitive Level Screen

Hillary Johns, Faith Smith, & Chelsey Seagren