In our courses we are often asked the specific order in which the Allen assessments should be administered in order to achieve the best results. Claudia Allen, in her 1992 book entitled "OT Treatment Goals for the Physically and Cognitively Disabled" suggests a certain administrative process. Citations from this resource book are provided throughout this article. Through our years of experience using the Allen assessments, our team would concur with her general recommendations. However, we must express the importance of flexibility within this process. It is never beneficial to approach this assessment process in a rigid manner. Therefore, I will also describe some common deviations from Claudia's suggested process below.
Step 1: Begin With Interview
My first step always involves an interview with the resident and/or their family member and/or their professional caregiver. In this interview I am seeking to build a solid rapport and to discreetly gather information to assist in identification of Allen level. I am listening for hallmarks associated with each Allen level. Essentially I am doing the Routine Task Inventory through interview. Of course, I always seek to verify this interview information through observation of performance in a subsequent session.
This approach is supported in "OT Treatment Goals for the Physically and Cognitively Disabled" as stated below:
"Prior to administering any of these standard evaluation tools, the therapist should establish a method for getting to know the patient and finding out what requests for service the patient and other caregiver have. The most common format is a functional interview. The purpose of the interview is to learn as much as possible about the individual's functional history and how the consequences of an illness are changing the individuals' ordinary activities. The specific questions asked during the interview are influenced by the phase of the illness . . . "
My interview begins with asking relatively vague questions and then moves to more specific questions based upon what I hear.
Example Interview Dialog:
Vague question presented by the therapist: "Tell me about an average day."
Specific follow-up questions from the therapist could be:
- "How do you decide what to wear each day?"
- "Does anyone assist you with getting dressed or undressed?"
- "Tell me about the type of assist needed."
I am then listening specifically for information from the client and caregiver that are indicators of Allen level performance.
Example Interview Dialog Continued:
Specific responses to follow-up questions could be:
- Therapist: "How do you decide what to wear each day?"
- Response from Client: "I just get something out of the closet. No specific thing I do."
- Therapist: "Does anyone assist you with getting dressed or undressed?"
- Response from Client: "No, I do it myself."
- Response from Caregiver: "I need to help her a little bit each day."
- Therapist: "Tell me about the type of assist needed."
- Response from Caregiver: "I need to pick out the right outfits. If I don't she might wear the same thing over and over again. And her clothes are often mismatched. But she can dress herself completely once I help her select her clothing. Wouldn't you say that is true, Mom?"
- Response from the Client: The client may or may not agree.
Throughout this interview I strive to establish a therapeutic rapport with the client and her family member. Therefore I am very careful not to make the client feel as if she is being talked about in a negative way or being identified as telling a lie. Also, I want to be sure to follow up any potentially negative comment with a positive. Praising the client throughout the interview is often a very helpful strategy.
For example, with the above dialog I might add this statement during or at the conclusion of the interview:
"Mrs. Smith, it certainly sounds as if you are doing quite well for yourself. It is clear you take a lot of pride in your appearance as you look wonderful. And, that outfit you are wearing really shows off your beautiful blue eyes."
Sometimes I may select to conduct the interview of the client separate from the interview with the family member/caregiver. At the conclusion I share my initial thoughts sensitively and diplomatically with the family member/caregiver, and with the resident if it is appropriate to do so.
I am hopeful that this first interview provided me with some insight into the client's Allen Cognitive Level and has also helped me to gain trust and respect with the client and the client's family member/caregiver.
Claudia Allen acknowledged the power of client and caregiver interview and the sensitivity required of the interviewer when she stated:
"Many caregivers are sources of reliable information. The fastest way to evaluate the pattern of activity performance is to interview the caregiver. Conduct the interview in a way that the patient will not hear what the caregiver is saying.
A self-report may be helpful around level 4 when patients are unaware of their disability. Score the self-report according to what the patient says he or she can do. Score the observation according to what he or she does, and then compare the scores. This approach has been used when legal decisions must be made and seems to be fair to the patient."
Note: Client interview is often unreliable in Allen Level 4 or lower; therefore you can not count on it to be true. Caregiver interview is also at risk for being unreliable due to lacking knowledge, denial of the person's disability, etc. Therefore, as Claudia Allen stated, it is always a good idea to verify any reports with observation.
We also recommend that you conduct interviews with your therapy team members to gather this type of information. For example, if an OT has performed a complete morning ADL routine with the client and you feel this OT can accurately report, feel free to gather this information from that OT.
Step 2: Routine Task Inventory (RTI)
As stated previously we recommend that you or a therapy colleague observe and evaluate the person's performance in daily activities using the RTI, as a follow-up to interview. This is an important second step.
Citation from "OT Treatment Goals for the Physically and Cognitively Disabled":
"Two of the standardized evaluation instruments that have been developed to measure the cognitive levels are . . . the ACLS and the RTI. The RTI described behaviors that may be observed while a person is doing selected activities. Common tasks that are apt to be difficult for the cognitively disabled person are identified. The observance of a single activity is problematic. Poor performance may be excused by a problem with that activity, rather than a disability. If the activity has no meaning to the patient, poor performance can be explained by a lack of motivation or interest in the activity. Observing the performance of several activities, some of which have face validity, has greater credibility."
Hopefully the clinician is beginning to see a pattern of behavior emerge through interview and RTI observation. The next step can be to administer the ACLS or the placemat.
Step 3 and 4: Placemat and/or ACLS
Per Claudia Allen,
"The ACLS gives a quick estimate of the person's current ability to learn. The individual is asked to do three leather lacing stitches. The ACLS can be administered to a person functioning in levels 3 through 5. Greater cooperation is usually achieved by talking to the patients before asking them to try the leather lacing. The ACLS provides a quick estimate of the person's ability to learn. This test is usually performed at the end of the initial interview."
As previously stated, I often continue with the RTI observation before administering the ACLS. But, if I feel very confident in the caregiver report information and confident that I have established a therapeutic rapport, I may administer the ACLS or placemat test at the end of the initial interview as Claudia suggests. In that case I may choose to continue my RTI observation assessment on a subsequent visit.
The placemat test, like the ACLS, seeks to evaluate higher level cognitive skills such as learning and problem solving. A therapist can also select another one of Claudia Allen's Allen Diagnostic Module (ADM) tests other than the placemat, such as the turtle key ring or recessed tile boxes.
Make your ADM assessment tool selection decisions based upon various elements such as:
- Visual or other requirements of the testing tool
- Level of interest and motivation of the client
- Allen level that the tool is capable of testing
Some of the assessment tools from the ADM can test into level 5 and some ceiling in level 4. This will definitely be an important factor to consider when selecting. The ACLS does test into level 5's. Therefore I will almost always administer this tool when I believe that my client is performing in a High Allen Level 4 or higher.
This article seeks to present some structure to what are considered semi-standardized assessment methods. However, we must remember that if we know the Allen Cognitive Levels we are always observing performance in daily activities and therefore we are always assessing. Assessment and treatment occur concurrently in this frame of reference.
Don't feel pressured to administer a formal assessment such as the ACLS or placemat test on a certain date and time. It is of the utmost importance to always consider the client's mood and interest. For example, if you planned to administer the ACLS on the second day that you see your client and he or she is simply not in the mood, select a different assessment tool or simply engage the person in everyday activities such as an ADL, IADL, exercise, etc. Use your skills of cognitive activity analysis and ability to identify the person's capabilities to learn, problem solve, and attend, as defined by the Allen levels, to gather additional evaluation information. Continue with your formal assessments when able and as needed.
Summary of Recommended Steps
Step 1: Interview with caregiver and/or client
Step 2: Routine Task Inventory
Step 3 and 4: Placemat or other ADM project and/or ACLS
Note: If the client does not appear to be functioning at least at Allen level 3 after completing steps 1 and 2, it is not recommended to attempt to administer the placemat or ACLS as the person needs "manual action" ability to participate in these tests. Therefore, we recommend using sensory stimulation and activity analysis to evaluate persons performing in Allen Levels 1 and 2.