CHAPTER 24: ALLEN COGNITIVE LEVEL SCREEN (ACLS)

Description

The Allen Cognitive Level Screen (ACLS) battery is a standardized assessment that requires the client to physically perform hand manipulation activities by stitching thin leather laces into various pieces of leather. The test is composed of three types of stitches: a running stitch (easiest), a whipstitch, and a single cordovan stitch (hardest), as well as two different sizes of leather to be stitched. It is thought that the somewhat complex activity of stitching has the ability to measure a person’s attention, visuomotor control, and verbal performance that are considered important aspects of several occupational performance indicators. During assessment, the subject is graded according to his or her ability to cognitively understand and physically perform the activities relative to the amount and type of cues needed for successful task completion. The ACLS comprises seven scoring levels which can be used to predict a person’s ability to engage in life tasks from (0) coma, (1) awareness, (2) gross body movements, (3) manual actions, (4) familiar activity, (5) learning new activities, and (6) planning new activities. Each level is further defined into sequential ascending abilities for more accurate scoring. For example, a person determined to be functioning at level 3.0 would be able to “grasp objects” and would require 24-hour nursing care to elicit habitual motions for activities of daily living (ADLs) and to complete motions for an acceptable level of hygiene, whereas a person functioning at level 3.8 would be able to “use all objects” with close supervision to get materials out that are needed to do ADLs, as well as to check results, and to remove dangerous objects (Allen, 1991). The assessment has no time limit but can typically be completed in less than 15 minutes.

Psychometrics

Early research found inter-rater reliability to be r = 0.91 among 20 subjects. (Howell, 1993). A study of the original 6 cognitive levels using 32 subjects found nearly perfect inter-rater reliability at r = 0.99 with levels ranging from 2 to 6 (Allen, 2000). A study of 71 persons admitted to a psychiatric unit found the mean score of the sample to be 4.9 with no significant correlations found between the ACLS, the Beck Depression Inventory, or the Minnesota Multiphasic Personality Inventory scales; however, a moderate correlation was found between the Symbol-Digit Modalities Test at r = 0.520 and subject age at r = –0.424 (David & Riley, 1990). A study of 31 persons post-stroke found a moderate positive correlation between the (large) ACLS activities (version 3 to 5.8) and the Assessment of Motor and Process Skills motor subtest (AMPS-M) at r = 0.57, as well as a moderate to high positive correlation between the AMPS-P process scale (r = 0.66) (Marom, Jarus, & Josman, 2006).

Advantages

The ACLS measures several domains such as cognitive, visuomotor, and hand/finger dexterity, and there is a fair amount of research in support of its use in clinical practice. It is easy to administer and no training or certifications are needed. Allen Conferences Inc. maintains a website devoted to the measure where it can be purchased along with other products offering insight into the ACLS.

Disadvantages

The test can be time consuming (> 30 minutes) and problematic for certain populations, such as those with major neurocognitive disorders or those individuals with advanced physical disability. Scoring may not accurately reflect ability for those clients with only hand or motor issues and no cognitive deficits.

Administration

The ACLS requires the subject to perform a leather lacing activity composed of lacing stitches of increasing complexity and includes a running stitch, whipstitch, and single cordovan stitch into two separate pieces of leather. The 7-level hierarchical scoring system of the ACLS has 27 separate scoring options or descriptors that are used to predict a subject’s ability to engage in occupation and includes (2.4) Aimless Walking which is suggestive of the need for 24-hour nursing care to initiate and assist with all ADLs and to prevent wandering and getting lost (Allen, 1991). During assessment of the running and whipstitch various interventions and cueing may be used and scoring is relative to the amount and type of cues provided. When attempting the single cordovan stitch the task difficulty jumps from 4.4 to 5.8 as an outcome of creating an opportunity to observe learning without a demonstration (Allen, 2000)

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