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Newsletter Three

Q&A on ACLS

Joan Riches, an OT from Canada wrote with the following questions and Claudia responded:

Question: How and by whom was the Comparison of Various Medical Scales, in Carol Bertrand's book, Starting an Allen’s Program in a Geriatric Facility, developed?  Answer: Claudia Allen did an analysis of the cognitive demands of the ratings of the other scales. I do not expect the validity to be 100%; validity never is. The correspondence is an estimate.

Question: Sometimes people do really weird stuff with the cordovan stitch that doesn't fall neatly into any of the scoring descriptions for the cordovan. How do you score their efforts? Lots of discussion around this. Told them it is an indication of a possible focal lesion. Needs more investigation. Guessed that we score before the first 'weird'. Promised to check it out with you.  Answer: That's why the ADM was developed. You can ball park the score from an understanding of the underlying mental structures described in the new structures book or from an understanding of abilities in Understanding Cognitive Performance Modes. The focal lesion in imagining a line is more apt to show up earlier as an ACL Score 3.2.

Question: The test guidelines state "stop the test when an error is made and not corrected. Score the highest level achieved." Should this instruction be followed religiously? Several therapists said they find it hard to stop, want to give another chance etc. I asked what the score is in that instance and they said it stays at the first uncorrected error. It seems to me they are double-checking themselves and will stop as indicated when they have more experience. Any problem with what they are doing? Asked if it seemed to bother clients and they said, no.  Answer: Stopping the test after a mistake is made is meant as a guideline and not rigid. The point is to get their "Best Ability to Function" Stopping the running stitch is pretty obvious because they are so confused. With experience I think people learn when to not even try the single cordovan.

Question: "untwists at least one whip stitch without pulling it out". What cues, instructions can we give? What are we to do when they do pull their stitches out? I realize I ask if they can correct without pulling out. Answer: If people are fiddling with the twists in the whip and it is taking them forever to get 3 stitches and a score of 4.4, I do not even try to go any further. When I do their score is seldom higher that 4.4 and it can take 20 to 30 minutes to find that out. It hardly seems to be worth the aggravation for me or the patient.

Question: Then we had a lot of discussion about verbal feedback especially when asked for reassurance and validation. Teresa Howell's thesis helped a lot in the overall discussion of using the ACLS as they seem to be refining their observations. Answer: With the single cordovan stopping and timing verbal cues and demo are difficult. I try to follow the expression on their face and their comments, offering help when they look confused or frustrated. As a guideline, some evidence of learning should be observable within 10 minutes. With obsessive compulsive disorders and some depressions, people will sometimes refuse to quit, for an hour. I've been known to leave it with them and come back for by test later If it takes them that long to figure it out, their problem solving abilities are not going to be very functional anyway.

The same repetition of the same error also frequently occurs in shifting from the small to the large ACLS. I'm glad we have this resource for beginning therapists who accept weak hands, arthritis, and poor vision as reasonable explanations for difficulties. I think it clarifies that the problem is in the head, not the hands or the eyes.4. I do too. As soon as they start to pull it out, say "Can you do it without pulling in out?" If they do not speak your language, put your hand on theirs and shake your head "no".

Claudia Allen on Schizophrenia

The following are Claudia Allen’s comments on schizophrenia. She has written very little about schizophrenia, but have had a daily confrontation with the lack of resources for them in Los Angeles County. From these experiences she has reached the following conclusions:

People with schizophrenia tend to function between ACL 3.8 to ACL 4.6, with the majority functioning at ACL 4.2. ACL 4.2 seems to be the ceiling for the majority of people with this horrible disease.
Schizophrenia seems to be a progressive disease. People who remitted to ACL 4.6 in their 20s, often get no higher than ACL 4.2 in their 40s. This a chronic disease with a ceiling on their ability to function that is so low that they cannot live alone or work outside of a protected environment. And. It is rare for any of them to think that there is anything the matter with their ability to function. They want a customary life style.
Improvement in the ACL score is seen during acute hospitalization. The most common change is from ACL 3.8 to 4.2. We frequently use crafts to assess the change in ACL score. We use crafts because that is what the patients will usually agree to do. There are no magical powers in crafts; it is entirely pragmatic. If they hate crafts and refuse to do them, we try something else that requires new learning. In the worst case scenario, when they refuse to most everything, we have base the assessment on how well they eat and dress.
Psychotropic drugs best explain this change in ability to function. The new drugs are not a lot better than the old drugs. No magical awakenings are happening. The new drugs get a few people a mode or two higher. Some MDs are better than others in prescribing meds that change their ACL scores. The change, however, has only a slight impact on their quality of life and burden of care. The improvements make them easier to manage, but most people go back to the living situation they had prior to admission.
People with schizophrenia do not like the side effects of their psychotropic drugs, so they stop taking them. Their ACL score declines; their burden of care increases; and they get re-hospitalized. We still need more effective drugs that would be worth taking. I still hope to see the magical awakenings we dream about in the movies.
Crafts, verbal discussions, and educational exercises do not change the ACL score. The ability to function is controlled by the brain. You cannot talk the biology of the brain into working better. The disease produces dreadful effects on ability to function, and try as we may, the basic problems do not go away.
People who have a chronic disability need rehabilitation to learn to live with the disability. Rehabilitation is not life long. Teaching modules should be used to get in, teach them something realistic and important and get out. Too much of mental health practice is unfocused on ambiguous goals that offer the false hope of overcoming a chronic cognitive disability. To me, the homeless mentally ill and the mentally ill inmates are a testimony to the dangers of false hope. In rehabilitation, they should be able to get what they can learn and apply in about a month. Repetitive drilling does not seem to improve learning effectiveness. Your work seems to address these problems, which is why I have followed it.
Generalization of learning is an important factor to consider. I have seen people with schizophrenia in verbal and education groups who could learn "to talk the talk," but couldn’t do a thing with the information outside of the group. Between ACL 3.8 to 4.2, I do not think that generalization occurs. A little bit of generalization does occur at ACL 4.6. When I read study results, I check the age to see if the sample is stacked with ACL 4.6s. ACL 4.6 is a narrow portion of the population and isn’t getting us any closer to understanding what to do with the majority. If generalization does not occur, then what do we do? I’ve been trying to answer that question for years.

First I think that people functioning in Allen cognitive level three and four need to be maintained in day care programs that meet two or three times a week. Maintenance programs are life long. They do not fit into mainstream community activities. Activities need to simplified so that they can use their remaining abilities effectively. Medicare will pay for that, so it is available to those who will agree to go.

Second, I think we need to do a better job of care giver education. Families and board and care operators need to have a better understanding of the disease process. They need help in setting up environmental compensations with realistic safety precautions. The chapters in Understanding the Cognitive Performance Modes are divided by ACL numbers and include safety precautions for each mode.

In a maintenance program, I think the patients/clients should select the content of the groups. Some will want crafts; others will want intellectual pursuits. I do not see the need for a contest between OT and psychology. I do see a need for us to work together because we address different aspects of cognitive functioning that I will try to describe. I would agree with not needing to badger these people with the endless stress management and coping skills I see happening in Partial Hospitalization Programs. Having schizophrenia is bad enough without making them feel guilty about not getting well. The groups should be enjoyable, making the best out of tragic life circumstances.
The content of the activity does influence the kind of information that is being processed. In rehabilitation for levels three and four, I think we are dealing with three different kinds of intelligence: crystallized, fluid, and procedural memories. I realize this is weird, but bear with me. I’ll try to keep is short and simple. When your modules include vocabulary and arithmetic, I think you are taping into crystallized abilities that are retained between ACL 3.8 to 4.6. These verbal propositional abilities are usually in tact and used to "talk the talk." I think verbal abilities are also taped with pictured simulations of safety precautions. That is the concern that therapists have when they critique paper and pencil tasks. I think psychology contributes a lot to our understanding of how the left hemisphere functions work with these kinds of exercises.
The other hemisphere guides visual spatial abilities, or fluid intelligence. The problem is that people are quite capable of describing what they would do, but not able to act on it in a real visual spatial situation. They can describe what they ought to do, but they do not get the information they need translated into the real visual spatial context. I think this may be why generalization does not occur. Crafts have value when they tape visual spatial abilities and are not fooled by in tact verbal propositional abilities. A lot of daily life involves adapting to a changing environment through the manipulation of material objects. The information that needs to be processed in working memory and stored in long-term memory is visual spatial. This is where I think OT’s legacy fits into the scheme of things. To put crafts into the attic would be a mistake. We are just beginning to understand what these underlying mental structures are and how they influence daily life. That’s the topic of the book I’m writing now, and it’s bloody hard.
There is another major confounding factor. Rehabilitation therapists use a lot of activities of daily living (ADL), which have to be the most over learned habits that we could name. Procedural memories can be used without conscious awareness. The more a type of activity has been done prior to onset, the better it seems to be etched into the brain. Even reading and writing have an element of habit. Many people with schizophrenia can read instructions that they cannot follow. Procedural memories usually explain why a person looks better in ADLs or one particular activity. The use of procedural memories does not predict how well a person will do outside of the treatment setting. Outside of institutions we must assume that the environment is constantly changing. We need to know how the working and long term memories are processing through the verbal propositional and visual spatial abilities to make those kind of predictions. Unfortunately for those with schizophrenia, their information processing systems are not working very well, and they do not adapt well to a changing environment. To protect our clients and the community, we need to consider all three types of information.

How To Start With the Allen’s Cognitive Levels

We get several calls a month asking how to start using the Allen’s Cognitive Levels. The best way to start is to take a Stage One course How to use the Allen’s Cognitive levels in Daily Practice. For those not able to get to a course soon, the following are some suggestions:

The minimum purchases to get started are

The Allen Cognitive Level Screen or ACLS. (It’s sometimes called the "leather lacing kit") This costs $10.59 (catalog number CU158). The kit comes with instructions for setting up the screen and for scoring the results.
The book: Understanding Cognitive Performance Modes. (Catalog number CU 198, cost $35.00). Once you’ve determined a patient’s ACL mode using the ACLS, you refer to the book to look up the ACL Mode. The section on the particular ACL mode will help you determine the person’s abilities, treatment procedures, and safety precautions.

Four other items are almost as essential:

A large Allen Cognitive Level Screen or LACLS. (CU159, $17.99). This is useful in geriatric setting where the patients have poor eyesight.
The book: Starting an Allen’s Program in a Geriatric Facility. (Catalog CU203, $15.00). This book was written to help therapists start using the Allen Cognitive levels. It offers practical advice on how to get the staff interested, samples of documentation, and initial craft projects with which to start.
The video tape Administering the ACLS (Catalog CU213, $59.95). This 110 minute tape shows you how to set up the ACLS, and eight actual patient screens ranging from ACL Mode 3.3 to ACL Mode 5.6. For people starting to use the ACLS without a class, this tape is essential.
The book, Structures of the Cognitive Performance Modes, (No catalog number yet, $35.00) contains the theory of the Allen’s Cognitive Levels generally and for each mode plus written descriptions of each of the performance modes.

The above materials can be ordered either from Allen Conferences or from S&S Worldwide (1 800 243 9232). Allen Conferences maintains an informative web site at www.allen-cognitive-levels.com. You can reach an Allen Authorized Instructor at Allen Conferences (1 800 853 2772).

Coaster Rating Sheets: sp spatial properties and sf surface features

Question: On the bottom of the coaster rating sheets, there are two phrases that I don’t understand. (sp) after 5.8 and 5.4 and sf) after 5.6 and 5.2. What do these mean?  Answer: sf stands for surface features and sp stands for spatial properties. Refer to modes 5.2 through 5.8 in Understanding Cognitive Performance Modes. Note the emphasis on surface features in 5.2 and 5.6 and the emphasis on spatial properties in 5.4 and 5.8. In both 5.8 and 5.6, the person will read/execute with verification but in 5.8 their comprehension is restricted to spatial properties and in 5.6 comprehension is restricted to surface features. A study of the abilities section of these four modes is really called for.

 

Hemispheres and Rehabilitation Potential

The ACLS is

Visual motor process

Right hemisphere dominant

Normal range 5.4 to 5.8

With respect to the Norms

85% Normal Population is Right handed and Left hemisphere dominate for language

6 % of Normal Population is Left Handed and Left Hemisphere dominate for language

6% of Normal Population is Right handed and Right hemisphere dominant for language

2% of Normal Population is Left handed and Right hemisphere dominant for language

What this means:

Normal Population Right handed, Left hemisphere dominate for language (85%)

Left Hemisphere Damage Right hemisphere damage
Impaired use of dominant hand
Good use of dominant hand
Aphasia
No Aphasia
Good ACLS
Poor ACLS
Good rehabilitation potential for visual motor processes
Poor rehabilitation potential

Left Handed and Left Hemisphere dominate for language (6 %)

Left Hemisphere Damage Right hemisphere damage
Good use of dominant hand
Impaired use of dominant hand
Aphasia
No aphasia
Good ACLS
Poor ACLS
Excellent rehabilitation potential
Poor rehabilitation potential

Normal Population Right handed and Right hemisphere dominant for language (6%)

Left Hemisphere Damage Right hemisphere damage
Impaired use of dominant hand
Good use of dominant hand
No Aphasia
Aphasia
Good ACLS
Poor ACLS
Good rehabilitation potential
Poor rehabilitation potential

Left handed and Right hemisphere dominant for language (2%)

Left Hemisphere Damage Right Hemisphere Damage
Good use of dominate hand
Impaired use of dominate hand
No aphasia
Aphasia
Good ACLS
Poor ACLS
Excellent rehabilitation potential
Very poor rehabilitation potential

 

Using the Allen’s with Dementia

Question: Has the ACL ever been used to show a set rate of decline for dementia?   Answer: The quick answer is Yes of course. The rate of decline is measured by the ACL. When a person with dementia reaches a long-term care facility, the person is normally an ACL 4.4 or below, probably in the range of 3.6 to 2.4. The ACL offers 12 distinct, repeatable modes between 4.4 (At 4.6 a person is still scanning the environment and can live alone with daily supervision) and 2.2 (At 2.2, a person can raise themselves in bed but cannot walk). For each of these modes, the book Understanding Cognitive Performance Modes provides a list of the person’s remaining abilities, the therapists and therapeutic goals applicable for the person, the adaptive equipment the person can cognitively handle, and a list of safety precautions.

The more detailed answer would have a problem with the words "show a set rate of decline". You could measure the rate of decline by recording the time the person spent in each mode as the dementia progressed. But I don’t think the decline would be at a set rate.

Question: Have any general studies been done on using the ACL to show changes with Alzheimer’s?Answer: I don’t know of any general, published studies. But therapists have routinely been using the ACL to track the decline of a Alzheimer’s patient in the same fashion as a dementia patient. An OT in Illinois has been offering a two day course on using the ACL with dementia and Alzheimer’s patients for several years. Contact would be Kim Wachol 630 773 6670.

Question: If a drug is used, has the ACL been used to (track) changes in behavior?Answer: Of course. That’s one of the standard uses for the ACL in psychiatric facilities. Remember that the ACL has 26 defined, repeatable modes between 6.0 (a normal cognitively functioning human) and 1.0 (coming out of a coma). No other published scale has that sensitivity.

 

 

Copyright 2001 Allen Conferences, Inc.
Last modified: February 25, 2000