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Allen Cognitive Level Screen 2000

This is the fourth revision of the original screening tool (Allen, 1985; Earhart & Allen, 1990, Earhart & Allen, 1996). This revision simplifies the scoring criteria by eliminating odd-numbered scores. The even numbers are consistent with the modes assessed by the Allen Battery. The directions have been elaborated to clarify interventions in the screening process. Two versions of the screening tool exist, a regular size (called the ACLS) and a larger version (called the LACLS).

The Allen Cognitive Level Screen and the Allen Battery

The Allen Cognitive Level Screen (ACLS) is part of a body of assessment tools and references that comprise the Allen Battery. The screening tools are designed to provide an initial estimate of cognitive function. The score from the screen must be validated by further observations of performance.

The anticipated discharge environment determines the selection of further observations of performance. When the anticipated discharge setting is a stable home environment or an institution, activities of daily living (ADLs) can form the basis for further observation. ADLs use procedural memories to follow habitual routines in an environment that is not changing. The most common ADLs are analyzed in the Routine Task Inventory (chapter 7) in Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled (Allen, Earhart, and Blue, 1992) and in the methods and safety sections of Understanding the Cognitive Performance Modes (Allen, Blue, & Earhart, 1995).

When the anticipated discharge environment is the community or other changing environment, working memory must be assessed. Working memory processes new information in order to adapt to a changing environment. The most effective method of assessing working memory is with the craft projects in the Allen Battery. The Allen Diagnostic Module Instruction Manual (ADMIM) (Earhart, Allen, & Blue, 1993) provides the observations of performance for each craft project in the Battery.

The person’s best ability to function takes place in the least restrictive environment. When the environment corresponds to the person’s Allen Cognitive Level, the person can function at his/her best ability to function. Human and non-human environments can be redesigned to compensate for limitations and encourage the use of remaining abilities (Structures of the Cognitive Performance Modes, Allen & Bertrand, 1999). Caregiver education is a major part of the use of the ACL so caregivers can increase the safety of self and others. The ACLS initiates the process of advising people with a cognitive disability and their caregivers about living with the condition. When changes in ability to function occur, cases are re-opened to design a revised functional maintenance plan.

The ACLS shares the advantages and disadvantages of most screening tools. The ACLS is quick and easy to administer. Some people are frightened by tests and may refuse to cooperate. Accept the refusal graciously and try to elicit the person’s cooperation in performing an appropriate Allen Battery activity.

The ACLS screens only ACL Modes 3.0 through 5.8. At Levels 1 and 2 people do not work with objects, and Level 6 is concerned with attention to symbolic cues. The ACLS is designed to access the middle of the ACL range where the most important questions about ability to function occur.

The ACLS Kit Includes:

3-3/4" x 4-3/4" punched leather rectangle, 1 Instruction Manual, 1 blunt sewing needle, 1 hank of waxed linen thread, 2 Perma-Lok lacing needles, and 1 hank of leather lacing

Set up the ACLS

The kit is prepared ahead of time using the assembly instructions described below. Refer to the diagram A (same as original).

  1. Cut a 15" length of waxed linen thread and tie a large knot in one end. Thread the other end through the sewing needle. Holding the leather rectangle with the shiny side towards you and the long side horizontal, start on the bottom of the leather about one hole to the left of the curved portion. Push the needle from back to front and come up through the next clockwise hole of the leather. Complete three running (sewing) stitches, working from left to right (clockwise). Three stitches means the needle should have gone through seven holes. The thread should exit to the front of the leather when ready to use.
  2. Cut two 30" lengths of leather lacing. Prepare one end of each lacing by cutting it at a sixty degree angle. You will notice that the brass needle has screw threads inside one end. Insert the prepared end of the lacing into the needle and "screw" the needle onto the lacing. The lacing should be attached to the needle with a bond strong enough to resist a gentle tug. Prepare the other lacing and needle in the same manner.
  3. Set up the whipstitch: Hold the leather rectangle with the shiny side towards you and with the running stitch on the bottom. The whipstitch starts at the two o’clock position (in the middle of the curve). The end of the lacing may be secured under the first stitch or left hanging free. Keep lacing flat (no twists). Pull each stitch TIGHT. After first stitch, complete three or four stitches, working left to right (clockwise). The last whipstitch should be on the straight (as opposed to the curved) portion of the leather.
  4. Set up the single cordovan stitch (Refer to the diagram B): Hold the leather rectangle with the shiny side towards you and with the running stitch on the bottom. Start the single cordovan stitch at the eleven o’clock position. Starting from the front of the leather rectangle, thread the needle and lacing through the hole. The end of the lacing may be secured under the first stitch or left hanging free. Come over the leather edge and go through the next hole, as if you were making another whipstitch. Do not tighten the stitch but leave a small loop about inch in diameter. Go through the loop from front to back with the needle and lacing leaving another small loop about inch in diameter. Be sure there are no twists in the lacing. Tighten the first loop by pulling the lacing tight from the rear of the leather. Tighten the second loop by pulling (tight) the lacing in the direction of the next hole to be used. Complete three more single cordovan stitches. Be sure the last stitch is on the straight (as opposed to the curved) portion of the leather. Be sure that the tension on all stitches is uniform, as tension of the stitch is one of the scoring measures.
  5. Check to ensure that needles and thread or lacing go through all holes easily. If necessary, the holes may be enlarged using an awl or a ballpoint pen.
  6. If desired, a pocket (made from another piece of leather or an index card) can be affixed to the back of the leather to store unused lacings while screening. Storage is recommended when persons screened demonstrate confusion about which hole to go through next while doing the running stitch. The difficulty in finding the next hole may reflect a focal perceptual deficit in imagining a line. Stitch deficits may be seen in diagnostic groups such as dementia, CVA, or traumatic brain injury. Dangling lacings further confuse these persons. When diagnosis is uncertain, leave all lacings out of the storage pocket to assist in detection of such focal deficits.

Initial Preparation to Administer the Screen:

The person administering the screen is referred to as the administrator; the person being screened is referred to as the person. Prior to administering the ACLS for the first time, the administrator should:

Practice holding the leather so the person can clearly see the demonstration. An administrator should be able to do all three stitches while standing or sitting on the person's left. Practice doing stitches while holding the leather out to the right (where it would be in front of person).
Memorize the verbal directions and then practice combining the demonstration and verbal directions. It is not necessary to be able to recite the directions from memory, but an administrator should have a clear idea of the directions, the words to say, and the next steps in the screen. The verbal directions should not deviate markedly from the instruction book, nor be elaborated upon. It is recommended that the directions for administering the screen be on your lap to refer to if one of those "total losses of memory" occurs.
Select a location for the screening that offers the best light and the fewest distractions.
Construct a brief interview that can be used to get to know the person before administration of the screen. If rapport can be established with the person, it less likely to get a refusal to try the screen.
Always start with the running stitch. Busy administrators may be tempted to skip the running stitch when person is coherent during the interview. The time saved is rarely worth what is lost. If the person does the running stitches easily, he/she gains confidence to try the harder stitches. If the person complains of visual impairments later in the screen, it may be possible to rule out bad vision based on how the running stitch was done.
Be prepared to stop the screen when an error is made and not corrected. Score the highest level achieved. An exception to stopping the screen should be made when a focal deficit in imagining a line is suspected in the running stitch. In this case, continue on to the whipstitch.
It is a good practice to have a LACLS and an extra ACLS handy on the floor by your left hand. With this preparation, when the person says, "I can’t see the holes" the LACLS can be substituted or if a needle comes off the leather lacing, the other ACLS can be substituted.

Maintenance of the Screens

Over time the leather lacing becomes worn by twisting and dirt can obscure the difference between the smooth and rough sides. The linen thread may split or fray. Replace the lacing and thread when this happens.

Pieces of leather lacing which break off inside the Perma-Lok needles can be removed by burning with a match.

A finish can be applied to the leather if desired to protect it from becoming dirty.

The kit can be disinfected with alcohol (or whatever solution your facility uses).

General Notes

Start with the small ACLS and switch to the LACLS to compensate for impairments such as vision problems, hand tremors, or hemiplegia. If the switch to the larger version occurs, avoid giving three demonstrations. A third demonstration is acceptable while administering the running stitch, but a third demonstration should be avoided in the whipstitch.

Check the person’s vision by asking "Can you see the holes?" When beginning the whipstitch, check vision again to see if the person can see the smooth/dark versus rough/light sides of the lacing. If they cannot see this difference, switch to the LACLS. Not being able to see is a frequent excuse for an inability to do a stitch.

It is permitted to hold the leather for persons who have the use of only one hand. Be careful not to rotate the leather to show the person errors on the back. Tell the person to turn it as they want. If the person is using the non-dominant hand, the person may be slow. Reassure the person that it is not a timed screen and the person can take as long as the person needs.

If you are left-handed, you must administer the screen with your right hand. If the person with a possible cognitive disability is left-handed, the screen is still administered with the right hand.

Throughout the screen, you may offer words of encouragement: "Take your time; you are doing fine; I appreciate your efforts". Be careful not to give cues on how to do the stitch.

Preparation for Administering the ACLS

Before administering the ACLS, verify that ACLS only has three running stitches (six holes) which exit on the smooth side, four whipstitches, and four single cordovan stitches. Remove any excess stitches.

Begin by establishing rapport with the person to be screened. A good way to develop rapport is with an interview that establishes the person’s functional history. One of the best questions is to ask the person to describe a recent typical day. Show the leather lacing samples to the person and explain why you are doing the assessment.

"Have you ever done anything like this before?"

If yes, find out how much and how long ago. On occasion, a person may be encountered who has done a lot of lacing. The ACLS may not be testing new problem solving abilities, and the ACLS score may be higher than the person’s ability to function.

"Can you see the holes?" If no, change to the LACLS.

Running Stitch:

"I am interested in seeing how you follow directions and concentrate. I will show you how to do a stitch now, so watch carefully what I do." The administrator holds the leather with running stitch at top edge so that it is facing both the administrator and the person. Hold the leather in front of the person so that both sides of the leather can be seen. "Take the needle and push it down through the next hole and pull the thread through the hole. Push the needle up through the next hole. Pull the needle through the hole and tighten it. Don't skip any holes. Now you do it."

Hand the leather and the needle to the person. These verbal directions and demonstrations can be repeated once if the person cannot complete the stitch on the first attempt. If the person stops before going through six holes, urge them to continue. If the person cannot complete the stitch after the second demonstration, thank them for participating and end the screening.

If the person has trouble seeing the holes, try to anticipate the need for changing to the LACLS before giving the second demonstration. If you have to change to the LACLS, a third demonstration may be given.

If errors are corrected or no errors are made, proceed to demonstrate the whipstitch.

Interventions for errors – Running Stitch

1. "Is yours like mine?" "No." Go to step 3. If spontaneous fixing occurs, no further intervention may be required.

3. "How is it different?" Points to or names error. Go to step 5. Keep quiet if the person starts to fix it spontaneously.

5. "Can you fix it?" Attempts to fix by removing error and starting over.

2. "Yes" or no response to question of "Is yours like mine?" "You have a mistake. Can you find it? Show me where it is."

4. Does not identify error. "Your mistake is right here," while pointing to the error. "I want you to make yours look just like mine."

6. No attempt or an ineffective attempt to fix. "Would you like me to show you again?" Take out the error and start the demonstration over. Repeat the demonstration one time., If you think impairments (hand or vision) could explain the person’s difficulties, change to the LACLS now.

Whipstitch:

If the person is able to complete the running stitch, the administrator goes on to the whipstitch. The whipstitch verbal directions and demonstration can be repeated once if the person cannot complete the stitch on the first attempt.

"See how the leather lacing has a dark, smooth side and a light, rough side." Check the person’s vision by looking at the person’s face and obtaining an acknowledgment to be sure that the person sees the two sides of the lacing. If they cannot see the two sides, switch to the LACLS.  "Always keep the smooth, dark side up as you do each stitch, being careful not to twist the lacing. Now I will show you another stitch. Watch me carefully. Take the lacing and bring it around to the front, over the edge of the leather. Push the needle through the hole and tighten it. Be sure the lacing isn't twisted. Don't skip any holes. Now you do 3 stitches."  If the person stops after one stitch ask the person to do at least 3 stitches by asking, "Can you do two more?"

Two errors that are part of the rating criteria do not always occur: the cross in the back and twists in the lacing. When the problems do not occur, the errors should be introduced. If, however, the cross and/or twist do occur spontaneously, it is not necessary to repeat this/these problems. The instructions for introducing either of these problems are as follows: "I’m going to make a mistake to see if you can correct it." The administrator takes the ACLS and holds it to the left side to shield it from the person. On the backside of the ACLS, push the needle through the loop, trapping the lacing underneath the loop. This forms a cross in back of the ACLS. Hand the ACLS back to the person.  "Can you show me my mistake?" "Can you fix it?"

If the person can point out and correct the cross error, demonstrate the twist. The administrator takes the ACLS and introduces a twist in the last stitch. Make the twist clearly visible. Hand the ACLS back to the person."I have made another mistake." "Can you show me my mistake?" "Can you fix it?"

If the person starts to correct the twist by taking the stitch out, stop the person. Ask "Can you do it without taking the lacing out of the hole?"

Interventions for Errors - Whipstitch

As soon as a mistake is made, prompt to determine if the person can correct the error. The person should not continue to do more stitches with an error in a previous stitch.

The following prompts and interventions can be used:

1. "Is yours like mine?" "No." Go to step 3. If spontaneous fixing occurs, no further intervention may be required.

3. "How is it different?" Points to or names error. Go to step 5. Keep quiet if the person starts to fix it spontaneously.

5. "Can you fix it?" Attempts to fix by removing error and starting over.

2. "Yes" or no response to question of "Is yours like mine?" "You have a mistake. Can you find it? Show me where it is." If the error is on the back, wait to see if the person can locate the error spontaneously. If you are holding the leather for the person, do not turn it over to show the person the error on the back until the person asks you to do so.

4. Does not identify error. "Your mistake is right here," while pointing to the error. "I want you to make yours look just like mine."

6. No attempt or an ineffective attempt to fix. "Would you like me to show you again?" Take out the error and start the demonstration over. Repeat the demonstration one time. If you think impairments (hand or vision) could explain the person’s difficulties, change to the LACLS now. Do not provide a third demonstration with the LACLS

A whipstitch cross and twist cannot be scored if visual impairments or language comprehension are alternative explanations for being unable to do this part of the screen. Scores of 4-0 to 4.4 can be confounded by these factors. When in doubt, continue the screen by going on to the single cordovan stitch. If the person scores 4.2 or 4.4 on the whipstitch, proceed to the single cordovan stitch. If the person scores 4.0 or lower, stop the screen. When there is a discrepancy between the whipstitch and single cordovan stitch, score the highest score.

Single Cordovan Stitch:

The task difficulty jumps from an ACL 4.4 demand to an ACL 5.8 demand when the single cordovan is introduced. The jump occurs as an outcome of creating an opportunity to observe learning without a demonstration.

Hand the leather to the person and point to this stitch. "Can you do this stitch by yourself?" An immediate response of panic, frustration, or a refusal to try to figure out how to do the stitch is an indication that the problem is too hard for the individual. Offer assistance by asking if the person would like a demonstration. Anytime that the person looks lost, frustrated, or in danger of quitting, offer a demonstration. Only two demonstrations can be scored. Provide verbal and demonstrated directions simultaneously:

"Would you like to be shown how?" If so, continue: "Watch me carefully. Bring the needle to the front of the leather. Push the needle through the next hole towards the back of the leather. Don't pull the lacing tight but leave a small loop in it. Bring the lacing to the front of the leather. This time put the needle through the loop you have made. Keep the needle to the left of the lacing. (Show the insertion of the needle) Pull the lacing through the loop towards the back of the leather. Tighten the lacing from the back hole, then tighten the long lacing end. Make sure the lacing isn't twisted. Now you do 3 stitches."

The administrator’s response to the person’s comments should be as non-directive as possible. If the person asks if he/she is doing it right, say "What do you think?" or "Is yours like mine?" or "Keep trying"- If the person says "that's not right", say "Can you fix it?" or "Can you show me what is wrong?"

When a demonstration has not been provided and after a few minutes of attempting to do the stitch, a verbal cue may be provided: "Would you like some help?" If so, give a verbal cue with one piece of information such as "You have the first part right" or "Go from front to back". If that does not help, try pointing out the error. Allow time for the person to try to figure it out. This is not a timed screen. If the verbal cue does not improve performance, offer a demonstration.

Offer a second demonstration when the same mistake is made over and over again or when no improvement in performance is observed. No more that 2 demonstrations can be scored. A few people may insist on a third demonstration, which may be provided but the third demonstration is not scored.

Make sure that the person does 3 stitches. Some people get lucky and do 2 stitches but have not really learned how to do the stitch.

Allen' Cognitive Levels Screen Scoring Guidelines, 2000

Running Stitch

3.0 Grasps leather or pushes it away. May not attempt to grasp the lacing or may grasp the leather lacing when handed to the person and moves leather lacing in a random manner.

3.2 Pushes needle through at least one hole, which can be the wrong location. May skip holes.

3.4 Completes at least 3 running stitches with no more than two demonstrations. Does not skip holes.

Whipstitch

3.6 Does at least one whipstitch in the correct location; no skipped holes.

3.8 Does not recognize twist, cross errors in back when cued. Does recognize running stitch error, but is unconcerned about error. May continue until out of space. May say, "Am I done?"

4.0 Does recognize twists or the cross in back as an error when pointed out. Does not attempt to correct twist or cross errors. Corrects running stitch errors on back when pointed out.

4.2 Corrects twists by redoing the last stitch. Does not untwist while lacing is still in the hole. Corrects errors in cross in back.

4.4 Can untwist at least one whipstitch without pulling it out. Stops after 3 stitches.

Single Cordovan Stitch

5.8 Completes 3 single cordovan stitches without a demonstration or a verbal cue by examining the sample stitches and using trial and error.

5.6 Completes 3 single cordovan stitches without a demonstration but requires a cue (verbal or pointing to location of error) to do the stitch correctly.

5.4 One (but only one) demonstration is given. Corrects errors in directionality, tangled lacing, or tightening in sequence without a second demonstration by altering actions two or more times.

The following scores are after Second Demonstration is Given:

5.2 Corrects errors in directionality, tangled lacing, or tightening in sequence with a second demonstration. The loops are tightened in sequence; the tension may be a little loose but no other errors remain.

5.0 Corrects errors in directionality, tangled lacing, or tightening in sequence but cannot replicate solutions. A little improvement or alteration occurs with a second demonstration but errors remain.

4.8 Lacing is not tightened in sequence (hole then loop), just pulls on needle, may or may not recognize error. Little to no improvement is noted with first or second demonstration.

4.6 Right/left orientation of lacing and needle are incorrect when going through the loop. Little to no improvement is noted with first or second demonstration.

4.4 Goes from front to back through the hole (like the whipstitch) but inserts needle through loop from the back as if it were one step. (Lacing is under loop but does not wrap around it.) Or, directionality goes front to back through the hole but back to front through the loop or vice versa. Does not benefit from first and second demonstration.

4.2 Repeats the whipstitch or does the whipstitch followed by an attempt to do a second unrelated step. Does not benefit from first and second demonstration.

References

Allen, C.K. (1987). Occupational Therapy: Measuring the severity of mental disorders. Hospital and Community Psychiatry, 38, 140-142

Allen, C.K. (1987) Eleanor Clarke Slagle lectureship – 1987: Activity: Occupational therapy’s treatment method. American Journal of Occupational Therapy, 41, 563-575.

Allen, C.K. & Allen, R.R. (1987). Cognitive disabilities: Measuring the social consequences of mental disorders. Journal of Clinical Psychiatry, 48, 185-191.

Allen, C. & Bertrand, J. Structures of the Cognitive Performance Modes (1999) Ormond Beach FL: Allen Conferences, Inc

Allen, C., Blue, T., & Earhart, C. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled, Rockville, MD: American Occupational Therapy Association.

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

Averbuch, S. & Katz, N. (1998). Assessment of perceptual cognitive performance: A comparison of psychiatric and brain injured adult patients. Occupational Therapy in Mental Health, 8, 57-71.

Bertrand, J. Best Ability to Function (2000) Ormond Beach FL: Allen Conferences, Inc

Cognition and Occupation in Rehabilitation. (1998) Ed by Katz, N. Rockville, MD: American Occupational Therapy Association.

Earhart, C, Allen, C., & Blue, T., (1993) Allen Diagnostic Module Instruction Manual Colchester, CT: S&S Worldwide, Inc.

Heiman, N.E., Allen, C.K., & Yerxa, E.J. (1989). The routine task inventory: a tool for describing the functional behavior of the cognitively disabled. Occupational Therapy Practice, 1, 67-74.

International Classification of Impairments, Disabilities, and Handicaps (1999) Geneva, Switzerland: World Health Organization.

Katz, N., Gilda, N. & Peretz, C. (1988). Cross cultural application of occupational therapy assessments: Human occupation with psychiatric inpatients and controls in Israel. Occupational Therapy in Mental Health, 8, 7-30.

Landsman, L.T., & Katz, N. (1988). Concrete to formal thinking: Comparison of psychiatric outpatients and a normal group. Occupational Therapy in Mental Health, 8, 73-94.

Mayer, M.A. (1988). Analysis of information processing and cognitive disability theory. American Journal of Occupational Therapy, 42, 176-183.

 

 

Copyright 2001 Allen Conferences, Inc.
Last modified: March 17, 2000