ALLEN COGNITIVE LEVEL SCREEN (ACLS)

PROPONENT:

Claudia Kay Hoover Allen

An occupational therapist and theorist who developed a six-level test of cognitive functioning that could be observed in the progression
and remission of not only mental illness but also dementia. Her work has expanded to all age groups and any diagnosis that produces
a diminished cognitive capacity.
• Awareness
• Gross body movements
• Manual actions
• Familiar activity
• Learning new activity
• Planning new activity

The cognitive disabilities model was started and developed by Claudia K. Allen, MA, OTR, FAOTA and her colleagues at the Eastern
Pennsylvania Psychiatric Institute. Their focus was mainly the “sensorimotor actions originating in the physical or chemical structures
of the brain and producing observable and assessable limitations in routine task behavior” (Allen, 1985). Allen and other therapists
continued their work at John Hopkins Hospital, Baltimore and in 1974 at LAC+USC Medical Hospital.

She characterized modes within each level to precisely indicate the cognitive functioning of individuals. The modes are:
.0 information from the whole level
.2 characteristics of time and place
.4 description of the level
.6 shifting of thought orientation to the next level
.8 understands the information from the two levels but cannot understand how they fit together

She is internationally recognized for her work in the development of a cognitive disabilities model to better understand and serve the
needs of individuals with mental illness. Her construct of “functional cognition” has become a useful term for describing the focus of
concern of the cognitive disabilities model. During late 1960s, she began working on the cognitive levels at Eastern Pennsylvania
Psychiatric Institution. Within each level, there are three components:

• Attention
• Motor control
• Verbal performance

PURPOSE

Allen Cognitive Level Screen (ACLS) provides a quick measure of learning and problem-solving activities. It also evaluates an individual’s
ability to make decisions and perform basic skills safely. The test is done by having the individual learn and perform a series of stitches
on a piece of leather.
• To measure the cognitive level of the clients, specifically the processing skill. It includes the learning potential, performance
abilities that can help detect if there are possible problems in cognition.
• To screen functional cognition for persons whose cognitive abilities appear to be in the range of 3.0 to 5.8 on the Allen scale
of cognitive levels of performance.
• To understand the client’s level of cognitive ability and determine at what level they’re at (at the beginning of the treatment
and at all points during treatment)
• To improve their ability to function despite limitations
• To obtain a quick measure of global cognitive processing capacities, learning potential, and performance abilities
• To detect problems related to functional cognition
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TO WHOM IT CAN BE ADMINISTERED

This model can be applied to all areas of activity in the OTPF such as ADLs, iADLs, education, work, play, leisure and social participation.
Because this model focuses on the role of process skill (cognition), habits and routines, the analyzation of activity demands and the
effect of physical and social context, this is applicable to people with conditions that has cognitive deficits such as dementias, acquired
head injuries, chronic mental illness, chronic diseases affecting the nervous system and developmental disabilities.

It is mainly used for patients with psychiatric disorders, chronic mental illness and dementia as it tests patients that have problems in
global cognitive processing capacity. It is administered to adolescents with psychiatric disorders and adults who experienced TBI OR
CVA.

CONCEPT

1. Allen Cognitive Level Screen (ACLS)

2. Large Allen Cognitive Level Screen (LACLS) – for clients with vision of hand function problems

3. Disposable Large Allen Cognitive Level Screen (LACLS [D]) – single used tool for those clients whom infection control precautions
must be observed.

ALLEN’S SCALE OF COGNITIVE LEVELS OF MODE

• 0 – Coma: indicates that you are unable to respond / generalized reflective actions.

• 1 – Awareness: indicates that cognition and awareness is extremely impaired and a total care for 24 hour a day is
necessary. The client only responds to internal cues.
1.0 Withdrawing from noxious stimuli – 24 hour nursing care for artificial feeding and turning to maintain skin
integrity.
1.2 Responding to stimulation – same care as 1.0
1.4 Locating stimulation – 24 hour nursing care to feed regular diet and initiate rolling bed for skin care.
1.6 Rolling in bed – same care as 1.4
1.8 Raising body parts – 24 nursing care to place cup and spoon in hand and sustain eating, establish route for
voiding, and bathe

• 2 – Gross body movements: indicates that cognition is severely impaired but the mobility is present, hence requires maximum
assistance to move body in space or overcome effects of gravity, prevent wandering, and assist with all ADLs such as bathing,
eating, and hygiene.
2.0 Overcoming gravity – 24-hour nursing care to transfer from bed to chair, provide food, and do bathroom
activities
2.2 Righting reactions – 24-hour nursing care to prevent standing id unable to weight- bear, transfer on sliding board
or a pivot transfer, provide food, and do bathroom activities.
2.4 Aimless walking – 24-hour nursing care to initiate and assist with all ADLs and to prevent wandering and getting
lost.
2.6 Directed walking – 24 nursing care to resist walking to even surfaces in safe locations such as a room, building,
or yard.
2.8 Grabbing – 24-hour care to stabilize grab bars, rails, furniture, point out stairs, edge of bathtub, provide food,
and bathe.

• 3 – Manual actions: indicates that cognition is severely impaired and the client perform spontaneous manual actions in
response to tactile cues and their attention span only last for 30 minutes, hence requires moderate assistance and supervision
with ADLs by providing cues to prevent unsafe, erratic, or unpredictable actions that interfere with appropriate sequencing.
3.0 Grasping objects – 24-hour nursing care to elicit habitual motions for activities of daily living and to complete
motions for an acceptable level of hygiene.
3.2 Distinguishing object - 24-hour nursing care to place objects needed to do the activities of daily living in front of
person and to complete motions for an acceptable level of hygiene

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 3.4 Sustaining actions on objects – close supervision to place objects needed to do activities of daily living in front of
person and sequence through the necessary steps to achieve acceptable results. One caregiver can supervise
three persons at a time.
3.6 Noting effects on objects – close supervision to provide the materials needed for activities of daily living, to
remind person to finish necessary steps, to check results, and to remove access to dangerous objects.
3.8 Using all objects – close supervision to get materials out that are needed to do activities of daily living, to check
results, and to remove dangerous objects

• 4 – Familiar activity: indicates that cognition is moderately impaired. Client is aware of tangible cause and understands visible
cause-and-effect relationships. Minimum assistance is required to set up goal- directed activities with tangible results and
correct repeated mistakes. Training is also required to learn new activities (with no expectations for generalization of learned
techniques).
4.0 Sequencing – close supervision to remove dangerous objects and solve any problems occurring through minor
changes in routine. Client may fix self a cold meal or snack and make small purchases in the neighborhood.
4.2 Differentiating features – close supervision to remove dangerous objects outside of the visual field and to solve
any problems arising from minor changes in the environment. Client may spend a daily allowance, walk to
familiar locations in the neighborhood, or follow a simple, familiar bus route.
4.4 Completing goal – client may live with someone who does a daily check on the environment and removes any
safety hazards and solves any new problems. They may be left alone for part of the day with procedure for
obtaining help by phone or from a neighbor or may manage a daily allowance and go to familiar places in the
neighborhood.
4.6 Personalizing – client may live alone with daily assistance to monitor personal safety, manage a daily allowance,
but bills and other money management concerns require assistance. They may require reminders to do household
chores, attend familiar community events, or do anything in addition to daily household routine.
4.8 Rote learning – client may live alone with daily assistance to monitor safety and check problem- solving
methods. They may get self to a regularly scheduled community activity or succeed in supportive employment
with a job coach.

• 5 – Learning new activity: indicates that cognition is mildly impaired. Client is able to learn new ways of doing things through
trial-and-error problem solving and detects the best effect by exploring distinctive properties of objects and trying different
actions. They exercise poor judgment with no symbolic thought to plan actions or anticipate potential mistakes and may
make impulsive decisions or abrupt changes in their course of action.
5.0 Continuous neuromuscular adjustments – client may live alone with weekly checks to monitor safety and check
problem-solving methods. They may succeed in supportive employment with a job coach and get to regularly
scheduled valued community activity.
5.2 Discriminating between parts of an activity – client may live alone with weekly checks to monitor safety and
examine potentially dangerous effects of impulsive behavior. Person may succeed in supportive employment
with a job coach and participate in valued community events.
5.4 Self-directed learning – client may live alone and work in a job with a wide margin of error. They may not be safe
in jobs with a high potential for industrial accidents.
5.6 Considering social standards of context – client may respond to supervision that identifies hazards occurring as
secondary effects of their actions. Person may be relied upon to follow safety precautions consistently.
5.8 Consulting with others – client may benefit from assistance in planning for the future. Person may benefit from
discussion of complications such as fatigue, joint protections, functional positioning, etc.

• 6 – Planning new activity: there is no indicated cognitive impairment thus, no supervision is required. The clients’ executive
functioning ability allows them to make decisions using good judgement and complex thought processes to plan ahead for
the future and prevent errors.
6.0 Planning without objects – client may consider several hypothetical plans of action and establish abstract criteria
for selecting the best plan.

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 LEVEL SKILLS/ABILITIES
ACL 0: Coma & Unresponsive
ACL 1: Automatic & Reflexive • Minimal response to the environment
• Cognition and awareness are extremely impaired
• Attention span: Few seconds
• Needs total assistance

ACL 2: Postural & Gross motor
• Can help care giver with simple tasks
• Mobility is present/Gross motor movement
• Assisted in hygiene, bating, and most of ADL’s
• Attention span: Minutes
• Maximum assistance

ACL 3: Manual/Repetitive • Learns simple task with repetition

• Attention span: 30 minutes
• Moderate assistance
• Can now imitate running stitch

ACL 4: Goal-directed • Can do simple tasks

• Visual cues/matching
• Attention span: Hours
• Minimal assistance
• Can now imitate whip stitch

ACL 5: Exploratory/Independence • New learning & generalizing

• Mild cognitive impairment
• Capable of learning new things and function quite well
• Attention span: Weeks long
• Weekly supervised
• Can now imitate cordovan stitch with overt trial and error

ACL 6: Mental Problem Solving • No cognitive disability

• Deciding using good judgement and complex thought process to plan ahead
the future
• Multistep task using analytical reasoning
• Can imitate cordovan stitch with covert/mental trials and error

ADMINISTRATION

It consists of learning three visual-motor tasks (leather-learning stitches: running, whip, single cordovan) with increasingly complex
activity demands, which quickly estimates the individual’s learning and problem-solving abilities. In order to complete these tasks, the
client should be able to attend to the therapist’s verbal and demonstrated instructions and cues, understand the feedbacks given from
the motor actions while making the stitches, and use sensory and motor cues from the material objects.

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A. Materials
Standard Allen Cognitive Level Screen (ACLS): Contains: 1 pre-punched 4x5 inch rounded, tan leather rectangle, 1 large-eyed, blunt
sewing needle, 2 brass, threaded, locking needles, 1 hank of leather lace and 1 hank of wax linen thread.

Large Allen Cognitive Level Screen (LACLS): This is a large form of the ACLS for clients with impaired vision or hand function who have
difficulty using the standard ACLS leather piece. Research studies have demonstrated correspondence with the ACLS. Includes: 1 pre-
punched 6x7 inch rounded, tan leather rectangle, 1 shoelace with plastic tips on each end, 2 large brass threaded locking needles, 1
hank of wide leather lace with 2 visibly distinct sides.

B. Other Preparations Before Administering ACLS:

1. Practice holding the leather so the client can clearly see the demonstration. An administrator should be able to do all three
stitches while standing or sitting on the person’s left.
2. 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.
3. Select a location for the screening that offers the best light and the fewest distractions.
4. Construct a brief interview that can be used to get to know the client before administration of the screen. If rapport can be
established with the client, it less likely to get a refusal to try the screen
5. Always start with the running stitch. If the client 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.
6. Be prepared to stop the screen when an error is made and not corrected. Score the highest level achieved.
7. It is good practice to have a LACLS and an extra ACLS handy on the floor with your left hand. With this preparation, when
the client 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.

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C. Setup the ACLS
1. Prepare the kit before administering the test.
2. Get the shoelace and make a three running stitches from the upper left side of the leather rectangle going to the right.
3. Get the permalok needles, then insert the leather lace into the needle. Insert the prepared end of the lacing into the needle
and “screw” the needle onto the lacing. Prepare another lace and needle with the same steps.
4. Using one of the prepared laces and needle, set up the whipstitch by completing four stitches
5. Lastly, set up the single cordovan stitch by completing four stitches

D. How to Administer
Preparation for Administering the ACLS:
1. 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.
2. 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.
3. Ask “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.
4. Ask “can you see the holes.” If no, change to the LACLS.

5. Demonstrate to the client how to do the stitch, start with the RUNNING STITCH.
ADMINISTRATION INERVENTION FOR ERROR
a. Introduction of the tool and running stitch • “Is yours like mine?” “No.” Go to step 3. If spontaneous
b. The first demonstration of running stitch fixing occurs, no further intervention may be required.
c. Provide the second demonstration if needed • “Yes” or no response to question of “Is yours like
d. Completion criteria: 3 correct running stitches in mine?”“You have a mistake. Can you find it? Show me
consecutive holes where it is.”
e. If the individual is unable to obtain the completion criteria,
score the observation and move to Task 2. • “How is it different?” Points to or names error. Go to step
f. If the individual successfully completes 3 correct running 5. Keep quiet if the person starts to fix it spontaneously.
stitches in consecutive holes, move to Task 2. • Does not identify error. “Your mistake is right here,” while
pointing to the error. “I want you to make yours look just
like mine.”
• “Can you fix it?” Attempts to fix by removing error and
starting over.
• 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.

6. After completing the running stitch, proceed to the demonstration of WHIPSTITCH.

ADMINISTRATION INERVENTION FOR ERROR
a. Introduction to the tool and whip stitch There are two errors that does not always occur, the cross and
b. The first demonstration of whip stitch the twist. If it did not occur, the administrator will be the one to
c. Completion criteria: 3 correct whip stitches in consecutive introduce the error.
holes including recognizing and correcting the cross in the • “I am going to make a mistake to see if you can correct it”
back and twisted lace errors. • The administrator will make the error while hiding the ACLS
d. Provide encouragement and cues as needed from the client. On the backside of the ACLS, push the

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 e. If the individual does not try to complete at least one
whipstitch with encouragement, provide a second
demonstration.
f. If they make an error, note the behavior and allow time for
the individual to identify and correct the error.
g. If the individual is unable to obtain the completion criteria,
score the observations and move to task 3.
h. If the individual is able to meet the completion criteria
including the identification and correction of errors, move
to Task 3.
i. If the individual completes 3 whip stitches without errors,
continue to the problem-solving whip stitch errors.
7. Now, introduce the SINGLE CORDOVAN STITCH. Hand the leather to the client and point to the stitch. “Can you do this stitch
by yourself?”
• The finished product will be shown and the individual will
be asked if he/she can do the stitch
• If the individual displays frustration or refusal, assistance • Bring the needle to the front of the leather. Push the needle
in the form of demonstration may be offered
• The demonstration shall only be done twice
• If demonstration has not been provided and the individual
has been attempting to perform the stitch, the therapist
may provide verbal cues. The therapist may ask the
individual first if he/she needs help. If it is needed, the
therapist may give hints such as “This part was done
correctly.”
• If verbal cues do not improve the individual’s stitching,
demonstration may be offered.
• Completion criteria: 3 correct single cordovan stitches in
consecutive holes
• If the individual seeks reassurance if he/she is doing the
stitch correctly, the therapist may respond in a non-
directive way by saying “What do you think?” or “Keep
going”
• If the individual says “This seems wrong” or “This does not
seem right,” the therapist may ask the individual to point
to him/her which part is wrong and encourage the
individual to fix it.
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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 client. “Can you show me my
mistake?” “Can you fix it?”
• If the client 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 client. “I have
made another mistake.” “Can you show me my mistake?”
“Can you fix it?”
• If the client starts to correct the twist by taking the stitch
out, stop the client. Ask “Can you do it without taking the
lacing out of the hole?”
• If it is too hard for the client. You may demonstrate it to the
client.
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.”
• No more than two demonstration can be scored. A third
demonstration may be provided if the client insisted but it
is not scored.
7
SCORING
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 client 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.

WHIP STITCH
3.6 • Does at least one whipstitch in the correct location.
• No skipped holes.
3.8 • Doesn’t recognize twist, cross errors in back when cured.
• Does recognize running stitch error but is unconcerned about the 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 the back.
4.4 • Can untwist at least one whipstitch without pulling it out.
• Stops after 3 stitches.

SINGLE CORDOVAN
5.8 • Completes 3 single cordovan stitches without a demonstration or a verbal cue by examining the sample and using
trial and error.
5.6 • Completes 3 single cordovan stitches without a demonstration but requires a cue to do the stitch correctly.
5.4 • One direction is given.
• Corrects errors in directionality, tangled lacing, or tightening in sequence without a second demonstration.

REFERENCE
• Allen Cognitive Level Screen. Retrieved from https://allen-cognitive-levels.com/acls.htm
• Earhart, C. A. (2009). Brief History of the Cognitive Disabilities Model and Assessments. Retrieved from http://www.allen-cognitive-
network.org/index.php/allen-cognitive-model/brief-history
• Heerema, E. (2020, January 9). What Is the Allen Cognitive Level Screen (ACLS)? Tasks, scoring and usefulness of the ACLS. Retrieved from
https://www.verywellhealth.com/what-is-the-allen-cognitive-level-screen-4129962
• 100 Influential People in Occupational Therapy: Claudia K. Allen, MA, OTR, FAOTA. (n.d.). Retrieved from http://www.otcentennial.org/the-100-people/allen
• ACLS Scoring. (n.d.). Retrieved from https://allen-cognitive-levels.com/acls.htm
• Allen,C.K., Austin, S.L., Earhart, C.A., McCralth, D.B., & Rlska-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, 33-39.
• Heerema, E. (2020, January 9). What Is the Allen Cognitive Level Screen? Retrieved from https://www.verywellhealth.com/what-is-the-allen-cognitive-level-
screen-4129962

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