Exam 2: Allen Cognitive Levels

Allen cognitive levels

-based on Claudia Allens Cognitive Disability Model

-helps identify the severity of a cognitive disability and/or functional cognition

-based on the results of the ACLS, the OT can make recc.'s for DC setting and level of assistance and supervision required

-helps the OT estimate how the client will perform in occupations based on their cognitive level

-6 levels that describe a series of actions and activities

Treatment emphasis is on _________

1) recommending compensatory strategies for persistent disabilities

2) adapting the environment to increase success in occupations

3) modifying occupations (adaptations, graded activities)

4) providing the least restrictive environment while maintaining safety

ACL Levels

Level 0 Coma

Level 1 Automatic Actions

Level 2 Postural Actions

Level 3 Manual Actions

Level 4 Goal-Directed Actions

Level 5 Exploratory Actions

Level 6 Planned Actions

Coma

level 0

Automatic actions

level 1

Postural actions

level 2

Manual actions

level 3

Goal-directed actions

level 4

Exploratory actions

level 5

Planned actions

level 6

Level 0

-individual is alive, but in a coma, or under general anesthesia

-no conscious control of mvmt is evident

Level 1

-automatic actions (reflexive)

-people coming out of coma or late stages of dementia

-individual responds to an external stimulus

-general response, like a change in heart rate, usually precedes a specific response to a noxious stimulus followed by initial stimuli, like bells, voices, pictures, and mobiles

-positioning devices are useful in reducing burden of care (hoyer)

-family members can be encouraged to make mobiles that draw attention to external environment

-able to do basic functions: eating and drinking

set-up A, contrast for feeding, check for coughing when eating/drinking bc of increased risk of aspiration (leads to pneumonia), wait 30 mins to change positions after eating, verbal cues to chew or swallow

Level 2

-postural actions

-individual controls gross body movements to sit, stand, walk, and do push/pull exercises

-adaptive equipment that protects the individual from hazardous postural movements or supports a functional position is indicated

-some agitation

set-up A, contrast for feeding, check for coughing when eating/drinking bc of increased risk of aspiration (leads to pneumonia), wait 30 mins to change positions after eating, verbal cues to chew or swallow

Level 3

-manual actions (HANDS)

-hands are used to reach for and grasp objects

-repetitive manual actions are common–the effect produced on the object/end product is not judged

-constant supervision (24 hr) is required to protect pt from harm

-decreased attention, impaired memory

-craft projects that require repetitive actions (sanding, placing small objects like mosaic tiles or stringing beads) may sustain attention

ex: folding laundry; sorting pennies, dimes, quarters (no problem-solving involved just simple repetitive action of sorting)

Level 3: Manual Actions

-Severely impaired cognition; responds to tactile cues

-Repetitive manual actions show awareness of objects, but no understanding of cause-and-effect or goal

-Short attention span (maximum 30 minutes)

-Moderate assistance required to sustain attention and complete simple tasks

-One-on-one help needed to halt preservation and prevent unsafe or unpredictable behaviors that interfere with appropriate sequencing

Level 3: Assistance

Moderate Assistance is needed when therapists re-focus attention to sustain/complete simple, repetitive actions safely.

One-to-one assistance is required to halt perseveration and to prevent unsafe, erratic, or unpredictable actions that interfere with appropriate sequencing

T or F: ACL 3 is an important level in OT because patient can start engaging in activities with their hands.

true

Level 3 - OT activities

activities with repeated actions

Level 3 - Safety: requires assistance to

remove hazardous objects

Level 3 - Supervision required

24 hour care

Level 3 - ADL: requires assistance to

initiate, set up, prompt actions

Level 3: Attention

30 minutes maximum

Level 3.0

grasping objects

24 hr care

pays attention to: handling material objects

motor behavior: grasps, holds, throws objects

communication behavior: uses nouns and verbs; names a few objects

duration/time: holds a few seconds; slows

Level 3.2

distinguishing objets

close supervision

pays attention to: moving objects back and forth

motor behavior: uses associated actions on objects; random placement of objects

communication behavior: uses short phrases; names objects, locations

duration/time: stops, starts action on command

Level 3.4

sustaining actions on objects

close supervision

pays attention to: repeating a manual action

motor behavior: repeats familiar actions; places object in a row

communication behavior: talks at others; names actions

duration/time: 1-5 minutes

Level 3.6

noting effects of actions on objects

close supervision

pays attention to: immediate effects of actions on objects

motor behavior: repeats demonstrated effects; places objects on perimeter

communication behavior: names shapes; waits for a minute; message of vital need

duration/time: up to 30 minutes

3.6

cause and effect

can categorize with repetition

cause and effect

3.6

Level 3.8

using all objects

close supervision

pays attention to: effects of actions on activity

motor behavior: covers space, uses all objects; sequences familiar actions

communication behavior: recognizes activity only when done

duration/time: up to time when all objects are used

Level 4

-goal-directed actions

-actions are goal-directed to complete a familiar activity

-routine ADLs can be done independently

-independent in self-care (set-up A, checklists)

-daily check-ins

-assistance required to solve any problems presented by changes in the environment and to protect from unseen hazards

-simple projects with lines to trace, cut, or color are preferred

-striking visual cues like primary colors and familiar shapes (hearts, strawberries) are matched according to a sample project

ex: brushing teeth, grooming, showering

Level 4: Familiar activity

-Moderate cognitive impairment; focus on tangible cues

-Understands visible cause-and-effect but struggles with new problems

-No independent new learning or inventive motor actions

-Recognizes errors only if clearly visible; may ask for help

-Good attention span for up to one hour

-Needs minimum assistance for set-up and safety

-Requires specific training for new activities, with no generalization of skills to other contexts

Level 4 assistance

Minimum Assistance is needed when therapists set up goal-directed activities with tangibleresults

Help is needed to correct repeated mistakes, to check for compliance with established safety procedures, and to solve problems presented by unexpected hazards

Level 4 - OT activities

activities with several steps

Level 4 - ADL: requires assistance to

provide materials in familiar locations

Level 4 - Safety: requires assistance to

solve new problems

Level 4 - Supervision required

live alone with daily check-ins

Level 4: Attention

1 hour

Level 4.0

sequencing familiar steps

close supervision

pays attention to: activity to be done, objects within arms length in front

motor behavior: sequences familiar actions to complete routine activities

communication behavior: asks for next step; no problem recognition

duration/time: length of activity; disoriented to date

independent in self care

4.0

Level 4.2

differentiating features of objects

close supervision

pays attention to: features of objects that match: shape, color, length

motor behavior: matches one striking feature at a time

communication behavior: identifies features, problems; asks for help, date

duration/time: 1 hour increments; one activity

discharge to community

4.2

(live with family, requires supervision)

Level 4.4

completing a goal

close supervision

pays attention to: pairs of striking features within 36"

motor behavior: matches pairs of striking features; copies samples

communication behavior: asks for exact supplies, demos; follows social rules

duration/time: routines, oriented to day/date

Level 4.6

personalizing activity

daily check-ins

pays attention to: supplies; ppl within view

motor behavior: scans for information; varies amount, pressure, depth

communication behavior: asks for past supplies, comments on deviations

duration/time: change in routine; two concurrent schedules

live alone

4.6

Level 4.8

rote learning new activity

daily check-ins

pays attention to: sequences of new steps; all striking features of objects

motor behavior: rotates objects when done for close inspection

communication behavior: asks for verification; follows lists

duration/time: routine within a concurrent schedule

Level 5

-exploratory actions

-new actions are learned by doing an activity

-trial and error and new learning

-weekly check-ins

-intonation in speech

-hazards are not anticipated and supervision in using dangerous or expensive equipment is advised

-aesthetic judgments about less striking visual cues are made but with difficulty (don't need as many striking visual cues)

Level 5: Learning new activity

-Mild global cognitive impairment

-Learning through trial-and-error

-Poor judgment and impulsiveness

-Decisions influenced by personal preferences or social standards

-Able to imitate and recognize new learning during activities

Level 5 assistance

Standby Assistance is needed when therapists adapt a new activity for safe and effective performance because errors and a need for safety precautions are not always anticipated

Persons may also need memory and planning aids to effectively function at a desired standard.

Level 5 - OT Activities

concrete activities

Level 5 - ADL: requires assistance to

identify hazards

Level 5 - Safety: requires assistance to

issue warnings

Level 5 - Supervision required

live alone with weekly check-ins

Level 5: Attention

weeks

Level 5.0

comparing and changing new variations in new activities

weekly check-ins

pays attention to: continuous actions and effects on objects in new activity

motor behavior: initiates alterations in fine motor actions to produce new effects

communication behavior: stops working to talk; expresses feelings; questions activity purpose

duration/time: recognizes need to schedule infrequent events; inconsistent

intonation in speech

5.0

Level 5.2

discriminating between parts of new activities

weekly check-ins

pays attention to: surface properties of objects: sheen, edge; sets of objects: style, kit, typical use

motor behavior: alters posture to improve primary effects; improves surface and edge properties

communication behavior: talks while working

duration/time: uses time pieces, calendars, memory aids

Level 5.4

engaging in self-directed learning in new activities

weekly check-ins

pays attention to: spatial properties of objects:part/whole, negative space/overlaps, joints, angles, ≤ ¼”

motor behavior: controls fine motor actions ins mall spaces; reorganizes work space

communication behavior: insists on own methods; considers explanations of potential secondary effects

duration/time: alters work pace for short periods

Level 5.6

considering social standards

weekly check-ins

pays attention to: features of social context: trends, fashion, holiday, season, conventions, values, social groups

motor behavior: adjusts elements to create symmetry, harmony, balance; compares instructions; anticipates surface properties available objects

communication behavior: discusses and compares primary and secondary effects before acting

duration/time: alters work pace to meet external standards on request

social bonding, anticipated safety, driving, care of children and care of others

5.6

Level 5.8

consulting with others

weekly check-ins

pays attention to: chain of events represented by available objects; inevitable secondary effects

motor behavior: anticipates spatial properties of available objects before acting

communication behavior: seeks advice to avoid hazards

duration/time: initiates altered pace: considers time, properties, effects; future: 1 week

Level 6

-planned actions

-premeditated activities

-individual anticipates the consequences of their actions

-an effective and efficient course of action is planned

-attention to detail

-problem-solving, more abstract thinking, anticipating errors

-can follow written instructions

At ACL Level 3, a person's manual actions are most often in response to:

A) Verbal commands

B) Visual cues

C) Tactile cues

D) Goal-directed thinking

C) Tactile cues

Which of the following is a common characteristic of someone at ACL Level 3?

A) Ability to solve new problems independently

B) Short attention span, up to 30 minutes

C) Understanding of cause-and-effect relationships

D) B and C

D) B and C

What level of assistance is typically required for a person at ACL Level 3?

A) No assistance

B) Minimal assistance for setting up tasks

C) Moderate assistance with one-to-one supervision

D) Total assistance for all tasks

C) Moderate assistance with one-to-one supervision

Which of the following actions is likely for a person functioning at ACL Level 3?

A) Engaging in goal-directed tasks independently

B) Performing repetitive actions with no clear awareness of the end goal

C) Correcting mistakes based on visual cues

D) Anticipating and solving unexpected problems

B) Performing repetitive actions with no clear awareness of the end goal

What type of cues does a person at ACL Level 4 respond to most effectively?

A) Tactile cues

B) Verbal commands

C) Tangible, visible cues

D) Abstract symbols

C) Tangible, visible cues

A person at ACL Level 4 demonstrates:

A) Independent new learning

B) Ability to correct errors only when clearly visible

C) No awareness of familiar end-products

B) Ability to correct errors only when clearly visible

Which of the following is true about attention span in ACL Level 4?

A) It is typically up to 15 minutes

B) It is generally good for up to one hour

C) It lasts only a few minutes

D) It depends entirely on the complexity of the task

B) It is generally good for up to one hour

What level of assistance is typically required for a person at ACL Level 4?

A) No assistance, they are fully independent

B) Minimal assistance for task setup and safety

C) Moderate assistance for all daily activities

D) Total assistance, even for simple tasks

B) Minimal assistance for task setup and safety

At ACL Level 5, individuals primarily learn new tasks through:

A) Following verbal instructions

B) Independent reasoning and anticipation

C) Trial-and-error problem-solving

D) Complete reliance on others for guidance

C) Trial-and-error problem-solving

A person at ACL Level 5 may exhibit poor judgment because they:

A) Are unaware of physical cues around them

B) Lack symbolic thought to plan or anticipate mistakes

C) Are unable to engage in any form of learning

D) Have a very short attention span

B) Lack symbolic thought to plan or anticipate mistakes

What is true about decision-making at ACL Level 5?

A) It is based on logical reasoning

B) It is influenced by personal preferences or social standards

C) It consistently reflects long-term planning

D) It is always fully informed and deliberate

B) It is influenced by personal preferences or social standards

What level of assistance is typically required for a person at ACL Level 5?

A) No assistance; they are completely independent

B) Minimal assistance for complex problem-solving

C) Constant supervision for safety

D) Total assistance for all daily tasks

B) Minimal assistance for complex problem-solving

You are working with a client who functions at ACL 3.0. During a therapy session, you present them with a hairbrush. The client grasps the brush but does not seem to use it purposefully. What would be the most appropriate next step to assist this client in using the brush effectively?

A) Verbally explain how to use the brush

B) Physically guide their hand to brush their hair

C) Wait to see if they figure out how to use it

D) Introduce a new, more complex object

B) Physically guide their hand to brush their hair

A client at ACL 3.0 is presented with a simple stacking game. They grasp the pieces but repeatedly drop them after a few seconds. How can you best support this client in completing the task?

A) Give them verbal instructions

B) Demonstrate the task first

C) Use hand-over-hand assistance to guide their movements

D) Change the activity to something more complex

C) Use hand-over-hand assistance to guide their movements

Your client at ACL 3.2 is engaging in a task where they need to distinguish between a spoon and a fork to complete the activity. They repeatedly reach for the spoon when the fork is needed. How would you assist them to successfully use the correct utensil?

A) Provide verbal prompts

B) Physically place the correct utensil in their hand

C) Allow them to explore both objects until they make the right choice

D) Ask them to watch another client using the correct utensil

B) Physically place the correct utensil in their hand

Your client at ACL 3.4 is folding towels. They begin the task but stop after folding one or two towels. What can you do to help them continue the activity and sustain their actions?

A) Provide constant verbal instructions throughout

B) Provide tactile cues, such as pointing to the remaining towels, and physically demonstrate the folding process again

C) Allow them to take a break and resume later

B) Provide tactile cues, such as pointing to the remaining towels, and physically demonstrate the folding process again

A client at ACL 3.4 starts a puzzle but quickly becomes distracted and abandons the task. What strategy would be most effective to help them complete the activity?

A) Verbally prompt them to focus

B) Provide simple verbal and physical cues, like pointing to the next puzzle piece

C) Remove the puzzle and introduce a different task

D) Increase the complexity of the puzzle to sustain their attention

B) Provide simple verbal and physical cues, like pointing to the next puzzle piece

A client at ACL 3.6 is helping set the table. After placing a few items, they notice that a plate is out of place but don't correct it. How can you encourage them to fix the mistake?

A) Point out the mistake verbally

B) Allow them to continue without correcting the error

C) Physically adjust the plate for them

D) Point to the plate and ask them to move it to the correct spot

D) Point to the plate and ask them to move it to the correct spot

While baking, a client at ACL 3.6 notices that they spilled flour but does not attempt to clean it up. How can you encourage them to address the spill?

A) Ignore the spill and continue the task

B) Verbally prompt them to clean up the flour

C) Hand them a cloth and point to the flour

D) Clean up the flour for them and have them focus on the baking task

C) Hand them a cloth and point to the flour

Your client at ACL 3.8 is asked to sweep the floor. They begin the task and work steadily but fail to notice some areas that need attention. How can you guide them toward sensing completion?

A) Let them continue without interference

B) Verbally point out the areas they missed

C) Hand them the broom and gesture toward the areas that need sweeping

D) Stop the task and introduce a different one

C) Hand them the broom and gesture toward the areas that need sweeping

A client at ACL 3.8 is involved in a painting activity. They paint most of the picture but stop before finishing certain areas. What is the best approach to help them complete the task?

A) Verbally prompt them to complete the missing areas

B) Encourage them to continue painting by pointing out the unfinished sections

C) Offer them a new brush to stimulate their interest in continuing

D) Let them decide when the painting is complete

B) Encourage them to continue painting by pointing out the unfinished sections

A client grasps a hairbrush you give them, but they do not use it purposefully. They hold the object but need you to physically guide their hand to begin brushing their hair. Which ACL level is this client functioning at?

A) 3.0

B) 3.2

C) 3.4

D) 3.6

A) 3.0

A client is sorting silverware but frequently reaches for the wrong utensil (spoon instead of fork). They do not correct the error until you physically place the correct utensil in their hand. Which ACL level is this client functioning at?

A) 3.0

B) 3.2

C) 3.4

D) 3.8

B) 3.2

A client starts folding towels but stops after completing one or two. You need to provide a tangible cue, like pointing to the remaining towels, to prompt them to continue. Which ACL level is this client functioning at?

A) 3.0

B) 3.2

C) 3.4

D) 3.6

C) 3.4

A client is helping set the table. They place a plate out of position and notice it's out of place but do not fix the error until you physically point to the plate and suggest they move it. Which ACL level is this client functioning at?

A) 3.0

B) 3.4

C) 3.6

D) 3.8

C) 3.6

A client is sweeping the floor. They work steadily but miss a few areas. You guide them toward these areas by gesturing, and they complete the task. Which ACL level is this client functioning at?

A) 3.0

B) 3.4

C) 3.6

D) 3.8

D) 3.8

A client at ACL 3.0 is engaged in a craft project that involves stringing beads. They show interest and are able to complete the task, but they often forget where they placed the beads and need constant supervision to ensure safety. What is the best approach to support them?

A) Let them continue working independently

B) Provide them with a specific spot for the beads and guide them back if they forget

C) Offer them verbal reminders to focus on their task

D) Suggest they try a different craft that requires less supervision

B) Provide them with a specific spot for the beads and guide them back if they forget

A client at ACL 3.2 is folding laundry but has difficulty determining if the items are neatly folded. They continue to fold without assessing the end result. What is the best way to assist them?

A) Leave them to finish on their own

B) Check their work for them and fold the clothes as needed

C) Provide verbal instructions on how to fold each item

D) Encourage them to focus on the repetitive action of folding without judgment

D) Encourage them to focus on the repetitive action of folding without judgment

A client at ACL 3.4 is sorting coins into piles but becomes easily distracted and loses focus. They require constant supervision to stay on task. What is the most effective way to maintain their attention during this activity?

A) Provide verbal prompts to remind them to keep sorting

B) Set a timer for short intervals to encourage quick sorting

C) Use hand-over-hand guidance to help them stay focused

D) Let them sort at their own pace without interference

C) Use hand-over-hand guidance to help them stay focused

A client at ACL 3.6 is stacking blocks. They notice when the blocks fall and repeat the action to see what happens. Which characteristic best describes their cognitive functioning?

A) They can anticipate the outcome and adjust their actions accordingly.

B) They focus on the immediate cause-and-effect of their actions but need close supervision.

C) They ignore the effects of their actions and continue without any adjustment.

D) They plan the entire activity and do not require feedback to continue.

B) They focus on the immediate cause-and-effect of their actions but need close supervision.

A client is capable of preparing a snack and handling small purchases, but they need someone to remove potentially dangerous objects from their environment and help them adjust to any minor changes in their daily routine. Which ACL level is this client functioning at?

A) 4.0

B) 4.2

C) 4.4

D) 4.6

A) 4.0

A client is capable of fixing a cold meal and making small purchases in the neighborhood but requires close supervision to remove dangerous objects and to help when minor changes in their routine cause confusion. Which ACL level is this client functioning at?

A) 4.0

B) 4.2

C) 4.4

D) 4.6

A) 4.0

Your client can walk to familiar locations in their neighborhood and follow a simple, familiar bus route. However, they need close supervision to remove dangerous objects outside of their visual field and to solve problems that arise from environmental changes. Which ACL level is this client functioning at?

A) 4.0

B) 4.2

C) 4.4

D) 4.6

B) 4.2

A client can manage a daily allowance, go to familiar places in the neighborhood, and be left alone for part of the day. However, someone must check their environment daily for hazards and help solve new problems. Which ACL level is this client functioning at?

A) 4.0

B) 4.2

C) 4.4

D) 4.6

C) 4.4

A client can live alone but requires daily assistance to ensure personal safety. They can manage a daily allowance but need help with bills and may need reminders to attend community events or complete household chores beyond their routine. Which ACL level is this client functioning at?

A) 4.2

B) 4.4

C) 4.6

D) 4.8

C) 4.6

A client lives alone and participates in a regularly scheduled community activity. They also succeed in supportive employment with the help of a job coach. They need daily assistance to monitor safety and ensure proper problem-solving methods. Which ACL level is this client functioning at?

A) 4.0

B) 4.4

C) 4.6

D) 4.8

D) 4.8

A client can navigate familiar places and follow simple bus routes, but they need close supervision to address changes in their environment and to ensure dangerous objects are removed. Which ACL level is this client functioning at?

A) 4.2

B) 4.4

C) 4.6

D) 4.8

A) 4.2

A client can manage basic daily tasks and a small allowance and be left alone for part of the day. However, they need someone to perform daily safety checks and assist with new problems in their environment.

Which ACL level is this client functioning at?

A) 4.0

B) 4.2

C) 4.4

D) 4.6

C) 4.4

A client can live alone with regular support to monitor their safety. They need help with paying bills and require reminders for household chores and attending community events outside of their daily routine. Which ACL level is this client functioning at?

A) 4.2

B) 4.4

C) 4.6

D) 4.8

C) 4.6