HISTORY AND DEVELOPMENT OF THE ALLEN COGNITIVE LEVELS

The history of the development of Allen Cognitive Levels has resulted from a fine balancing act between what could be learned from theoretical literature, and its relation to experiments and observations, and the requirements of clinical practice.  The development of the Allen Cognitive Levels by Professor Allen has followed a pattern that, essentially, has remained constant.  Whenever Allen unearthed information in scientific literature, she checked the information for relevance to the concept of cognitive levels and generously had no hesitation in sharing her findings and any new concepts she developed, with other healthcare therapists.  The validity of each concept was then checked against clinical observations.  Inevitably many new concepts were either discarded or modified.  The primary criteria for retaining a concept was, it had to be of identifiable benefit to patient care. Concepts that explained clinical observations were then included in handouts at workshops teaching experienced clinicians. Feedback from those workshops was then used to refine and provide clarity in explaining concepts.  Finally, the concept was formalized for publication.  Thus, the final published papers were only made possible by the contributions of a significant number of therapists and the willing participation of many patients.  The authors of those papers have acknowledged feeling humbled by the ever present awareness that this process of knowledge development has been a collaborative effort.

1965:   The cognitive levels had their origin in developmental psychology.  While she was reading the book ‘Piaget's Theory of Intellectual Development’ written by Sylvia Opper and Herbert Ginsburg, Professor Allen noticed similarities between the first two years of human life and adults with mental disorders.  The original description of the cognitive levels was derived from Piaget’s sensori-motor period stages. For her, when Piaget spoke about such things as understanding of cause and affect relationships, became the information she was seeking. This information coupled with her wealth of hands-on working knowledge of delays in childhood development, she began to notice the similarities between what many of her patients with mental health disorders were doing and what she had observed in the children she treated. 

In her quest to make order out of what she was observing she was joined by her colleague, Nancy Lewis. Both of them spent months working with people with schizophrenia using different craft items to see what they could do and what they couldn’t do.  One example of this was using plastic flowers where wire had to be bent and arranged at different angles. Allen and Lewis knew from experience that the patients would not be able to make an iris flower, as there were too many angles and steps but that their patients may be able to make petals for daisies. This was narrowed down to being able to make individual petals and then the therapists would then arrange these petals into flowers and secure the wires into stems.

The cognitive levels developed as Allen and Lewis dug deeper into analysing the cognitive complexity of craft projects. In their day-to-day work they noted how psychiatric patients at the Eastern Pennsylvania Psychiatric Hospital went about making individual items.  This lead them into trying to predict what a person with schizophrenia was able to do and so they ventured into the realms of activity analysis and the knowledge that they were  on the road to predicting behavior.  This became exciting work for both Claudia and Nancy and their enthusiasm overflowed to Betty Tiffany, Head of the Department at Eastern Pennsylvania Psychiatric Institution EPPI, who would come to their work area to discuss findings and to support them in the work they were doing. During the later stages of her employment at EPPI, Claudia began continuing education sessions for graduate therapists where many a discussion took place concerning the different components of levels.  These interactions between therapists lead to the development and use of tile patterns to note differences in the quality of human behavior. Their findings were also taught by Allen at the University of Pennsylvania and were then included in the curriculum of Philadelphia’s occupational therapy schools.

1971-72:   As the use of Allen’s six cognitive levels increased, the need for a screening tool became apparent.  Allen was then working at Johns Hopkins Hospital in Baltimore, where she developed the forerunner of a test, using a mosaic tile trivet, which she offered as a suitable screen.  However, this performance measure was not acceptable to most therapists on practical grounds, because it was messy and cumbersome to carry.  Therapists wanted a performance measure that was quick, portable, reusable, and sensitive to the different levels of the ability to function.  This requirement then led to the development of the leather lacing assessment tool.  The first kits were hand-made with a lot of variation in materials and instructions.  Scoring was very simple: level threes did the running stitch; level fours did the whipstitch; level fives did the single cordovan stitch.  Nancy Lewis collaborated with Allen in developing the materials for the first continuing education workshop conducted at the Community College of Baltimore, and the cognitive levels were included in the certified occupational therapy assistant program.

1973:   The ACL leather lacing assessment tool and the research on the six cognitive levels, were brought to Los Angeles County-University of Southern California Medical Center (LAC-USC) by Allen, where the long-term collaboration with Catherine (“Cathy”) A. Earhart began.  Earhart was then working in a psychiatric unit with a token budget and on activities that required the detailed analysis of the cognitive complexity of real work tasks.  The generalization from crafts to work required a more explicit awareness of underlying mental structures.  The departure from Piagetian concepts was prompted by a clinical need for new mental structures.  Some of the mental processes observed in adult psychiatric patients were not defined by developmental psychology.

1974-75:   Allen joined the OT Faculty at USC where conflicts between the theoretical models followed in American Psychiatry were very apparent.  Research literature gave increasing support for a biological cause and for treatment of mental disorders.  The value of occupational therapy, in the role of environmental treatment, was subjected to serious questioning.  The question was asked, “If crafts can not cure schizophrenia, then what is the value of occupational therapy?”  The cognitive levels were used to measure changes in clients’ ability to function caused by psychotropic drugs.

1976:   Allen chaired the Mental Health Task Force on behalf of the Executive Board of the American Occupational Therapy Association (AOTA).  In this role she became convinced that weakness in practice was related to weakness in literature.  The role of occupational therapy to provide care for people with severe and persistent mental disorders was being ignored.  The feedback from a number of official committees established by AOTA was unfavorable and often hostile.  Allen became increasingly concerned about the future of the profession, the future of people with chronic mental disorders and the rate of increase in the homeless population.  She decided to reorganize her career with objectives aimed at assisting to correct these problems by providing and teaching at more workshops and expanding her study of knowledge development.  A major change in occupational therapy literature was needed, and the anxiety level of occupational therapists was high.

1977-1978:   Allen continued teaching and mentoring students throughout 1977-1978, during which period she commenced much of her research into the development of cognitive levels.  Standardization of the leather lacing kit (now called the ACL) was developed and published as part of several research projects.  The therapists at LAC-USC Medical Center participated in an investigation of the various ways in which this kit could best be tested.   Deborah S. Moore chose a standard procedure and initiated reliability and validity studies into the procedure.  Linda Riska Williams and Noomi Katz started looking at higher abilities and differences between the disabled and those without disabilities.

The assumption then was that the developmental process could be used to improve the abilities of people with mental disorders.  Clients functioning at cognitive level four were given cognitive level five tasks to do.  This was unsuccessful and was abandoned when clients became frustrated and did not improve.  The controversy which questioned the therapeutic value of cognitive levels arose following recognition of limits in the ability to function of those with persistent mental disorders.  The need to establish a theoretical model, to improve the activity performance of those with chronic mental disorders, was also recognized.

1980:   The first version of the Routine Task Inventory (RTI) was developed to provide for the analysis of activities of daily living.   Lois Heyings, Nanci Heinmann, and Debra Wilson worked on the practical aspects of living with a cognitive disability.  They compared leather lacing scores with caregiver reports on client performance during daily living activities.   The need to deal with the denial of a cognitive disability and inflated self-reports was apparent and fully recognized.

1982:   The first article on the Allen’s Cognitive Levels was published in the American Journal of Occupational Therapy as “Independence through Activity: The Practice of Occupational Therapy (Psychiatry)”.  The description of the six cognitive levels continued to include Piagetian terminology.

1984-85:  Most of Allen’s time was occupied writing, editing, re-writing, and re-editing her first book “Occupational Therapy for Psychiatric Diseases: Measurement and Management of Cognitive Disabilities”, published in 1985 by ‘Little and Brown’, it is now out of print.  This book defined the six cognitive levels, and basic terms such as action, activity, task, and task equivalence.  Piagetian jargon was replaced with standard dictionary definitions.  The applications were for psychiatric diseases but care was taken to leave open potential applications to other mental disorders, as the split between psychiatry and neurology was diminishing. The first version of the RTI was also included.

1987:   Allen was invited to give the Eleanor Clarke Slagle Lecture, the highest academic award which could be conferred on an occupational therapist by the American Occupational Therapy Association.  In her preparation for the lecture Allen refers to it as a year of terror.  Allen also used this year to study action and activity in Soviet psychology and explore the possibility of a typology for cognitive activity analysis.

The article “Cognitive Disabilities: Measuring the Social Consequences of Mental Disorders” was published in The Journal of Clinical Psychiatry. This article developed the identification of interplay between psychiatric diagnoses, which are driven by the aetiology of the disease and cognitive disabilities, both of which are separate entities.  It examines the similarities and differences in a classification system that deals with functional ability and activity as a social consequence of a disease process.  This has not previously done in American psychiatry, or in American medicine.  This was the only article Professor Allen co-authored with her late husband, Doctor Robert Allen, who was a psychiatrist.  Earlier similar distinctions were made in a World Health Organization paper, “International Classification of Impairments, Disabilities, and Handicaps”, published in 1980.

1988:    The first desk top publication, The Expanded Activity Analysis, fore-runner to and succeeded by the ADM Manual, was published.  The activity analysis sets-up and analyses craft projects at each cognitive level.  The clinical reality at USC-LAC Medical Center was that therapists, in preparing reports, talked about and charted high and low cognitive levels, using such ill-defined terms as ‘high-high’ and ‘low-low’ to report sub-divisions in the breakdown of levels.  Because physicians were using those reports to assess and adjust client medications, the inter-rated reliability of the reports caused considerable concern.   Consequently, Allen recognized there was a need to develop modes for each of the cognitive levels.

Tina Blue joined and started working with Allen and Earhart in 1988.  Blue’s background, studying and working with physical disabilities, was invaluable to the team’s investigations. Convinced that the split between psychiatric occupational therapy and physical disabilities was artificial, Tina Blue OTR, with her knowledge of and experience in physical disabilities, was able to determine the alignment of disabilities and cognitive levels for inclusion in the team’s joint paper ‘Understanding Cognitive Performance Modes’.

1989-1991:   The development of Cognitive Performance Modes, which subdivide each cognitive level into five definable performance modes, was completed.  On a six-point scale, the cognitive levels were a lot easier to explain, learn, and teach.  Moreover, at times such as during brief acute care, a six-point scale was all that a therapist then considered necessary.  Later, when it was realized that important decisions need to be based on the client’s ability to function (discharge plans, life care plans, medication adjustments), increased sensitivity in the scale was seen as a requirement.  By observing clients whilst they were doing crafts at the clinic and during their daily living activities in the ward, Allen, Earhart and Blue noted each client’s quality of performance. They struggled to translate these observations into general patterns of behaviour, however, eventually; a twenty-six point scale emerged that was sensitive to small and important changes in ability to function.  The requirement then was that everything that had previously been analysed using only six cognitive levels had to be re-analysed using the new twenty six point scale.  Earhart then commenced updating self-care in the Enhanced RTI, using the twenty six point scale.  At the same time, Blue commenced analysing physical disability treatment methods and adaptive equipment.

1992:   ‘OT Treatment Goals for the Physically and Cognitively Disabled’ was published by AOTA.  This publication introduced cognitive performance modes.  The Enhanced RTI, and the analysis done on client daily living activities, was included in this book.  The activity analysis of physical disabilities based on cognitive levels, the Cognitive Performance Test ratings and the large ACL screen were included.

1993:    S&S Worldwide offered to produce the Allen Diagnostic Module and include an Instruction Manual and twenty-six craft projects.  The commitment to crafts was difficult to explain even to experienced therapists working in the fields of geriatrics and physical disabilities.  Changing practice to include crafts did not make sense to them. The explanation of the need to assess new learning capacity in order for clients to adapt to a changing environment, failed to overcome therapist concerns about the cost of crafts.  The established mental habits the therapists had when doing ADLs were a part of their established practice and were all they considered necessary where the placement of clients was in an institutional facility.

1992-1994:    Introductory ACL workshops were conducted sporadically throughout America and several intermediate workshops were offered each year in Pasadena CA.  In 1994, the “Safety Series Projects” were added to the ADM, providing a clearer assessment of new learning and reading comprehension, specifically at level five.

1994:   Allen and Delaune Pollard (an Australian Occupational Therapist) travelled together to the United Kingdom, where they both presented papers at the World Federation of Occupational Therapists Conference in London.    Here they teamed up with Sandra David, who also presented a paper at the conference.

1995:   Allen Conferences Incorporated was established with twenty-five conferences being conducted throughout America.  S&S Worldwide was contracted to develop the Allen Cognitive Levels Documentation Program.

In December, the book Understanding Cognitive Performance Modes was published.  This was the first publication to contain levels of function.  All other publications had been organized by activity or treatment settings. It took a year and a half for occupational therapists to start using the Allen Battery.  Occupational therapy is all about the ability to function and therapists should know what to expect with each mode of performance.   The ability to function is similar to a child’s age and individual differences (personality, culture, diagnosis, and activity) are additional to the general expectation.

1996:   In January, the Allen Cognitive Levels Documentation Program was included for the first time in the S&S Worldwide catalogue.  The software took the time consuming drudgery out of writing a comprehensive report on ability to function.  The program offered to therapists the capability to easily write initial assessments, progress notes, and discharge reports.  The name leather screening tools was changed to Allen Cognitive Level Screen (ACL) and Larger Allen Cognitive Level Screen (LACL).

In June, the first Allen Authorized Instructor Course was conducted.  Nineteen attendees were qualified as Allen Authorized Instructors.  Allen Conferences assisted therapists to develop workshop materials and to ensure the quality of teaching.  One-day workshops were offered and Olin commenced a regular schedule of one-day workshops.  Six more projects were added to the ADM to assist with the assessment of people who could only use one hand doing projects.

1998:   The traditional use of crafts proved to be an excellent vehicle for testing the functional use of working memory. When the placement of a client in the community, or in a new setting, is being considered, the ability to use working memory to adapt to new situations must also be taken into consideration.  This guideline was introduced by Linda Levy, OTD, OTR/L, who made the suggestion for working and procedural memories to be included in the information processing model to assist with the clear explanation of the use of crafts.

1999:   Managed care and Medicare reform combined to develop a real need for therapists to use their time and resources in an efficient and effective manner.  The components of the Allen Battery recognized and responded to this need. The specific requirement was to satisfy a significant and continuing increase in education.  The first stage of the workshops was re-designed to provide therapists with advice on the resources available to them and to help them sort out and use those resources.  The second stage of the workshops was re-designed to provide flexibility in the use of cognitive levels to identify the mental structures used for activity analysis.  Workshop responses consistently indicated that there should be more activity analysis, including examples specific to each therapist’s clinical caseload.

Allen Conferences recognized a need to train more educators with a variety of clinical backgrounds.  Letters were sent to all OTs and OTA schools offering a number of attendance places either free, or at reduced prices.

The International Association of Allen Authorized Advisors was established in March of 1999. Three certifications of continuing competency ’Capable Advisor’, Skilled Advisor’ and ‘Master Advisor’ (Initially called ‘Capable Cognitive Clinician’, ‘Skilled Cognitive Clinician’ and ‘Master Cognitive Clinician’) were defined.

The AOTA National Certification Board’s 1999 Survey of Work Practices found that 55,000 Occupational Therapists and 65,000 Occupational Therapy Assistants are now using this model. 

2001:  Allen Conferences ceased to exist.  Ivelisse Lazzarini and Claudia Allen presented the Allen Cognitive Levels to a diverse audience at the Walter Reed Military Training Centre in Washington and at the Mayo Clinic.  

The Allen Cognitive Levels are used throughout the San Antonio Hospital in Texas:  Nursing Facilities to Assisted Living Residential Care Homes in Ohio.  Accepted as the assessment for Alzheimer’s Association in USA; Veteran Affairs in Minneapolis and Salisbury VAMC, North Carolina.

A new National Medicare CPT Code: 975X1 is to be established in the USA using the Allen Cognitive Levels.

The Theory is taught in all major universities and colleges in USA, particularly at the Medical Research Unit, University of Southern California; Creighton University, Omaha; St Scholastic, Duluth; Boston University and Minnesota University.

2002:  The Allen Cognitive Advisors Ltd was established, a non-profit educational organization, with a corporate mission to:

1.        Promote educational and clinical use of the Allen Cognitive Battery

2.        Provide an organized method for the exchange of information relating to human cognition, behaviours associated with cognitive changes, and promotion of the best ability to function.

3.        Educate health care providers and caregivers in more effective methods of caring for those with cognitive disability. 

4.        Increase the empathy of health care providers and their understanding of the systemic, biological changes that result from behaviour changes associated with altered cognitive ability.

5.        Encourage research that incorporates the Allen Cognitive Battery.

6.        Recognize differing skill levels in administering and interpreting the Allen Cognitive Battery and provide a mechanism for recognition and certification of clinical skills

The organization provides training and clinical mentoring to support and recognize three levels of clinical competence in the administration and interpretation of the Allen Cognitive Battery.

 The Foundation Members of Allen Cognitive Advisers Board are as listed:

Ex Offico Members of the Board are:

2003:  Members of the board undertook to revise the three clinical publications; revise the ADM, develop cost effective projects; establish criteria for the three phases of adviser competency efficiency training; organize the second ‘Symposium in Cognition: Exploring Current Clinical Practice and Research Relating to the Allen Cognitive Battery’ to be held in Florida in early October 2003.

2004:  Following the the highly successful 'Allen Symposium 2003' held at the College of Public Health, University of South Florida, Tampa, the Allen Cognitive Advisers Board meet for a full day session on Sunday 2 November.  At this meeting the board accepted two new members and farewelled Yasmin Ortin, who had resigned from her position.  In March 2004, Ivelisse Lazzarini and Tina Champagne resigned their positions on the board due to other commitments.

In October 2004, the members of the Allen Cognitive Advisors held the 2004 Allen Symposium in conjunction with the College of Health Sciences, Chicago State University.  This symposium was highly attend by participants, who came from a diversity of settings within the USA, as well as members travelling from Canada and Australia.

A special thanks needs to be extended to Sarah Austin, who put in the hard yards into preparation

The members of the Allen Cognitive Network (ACN) Ltd., Board are:

·  Sandra David OTR, MHE, Augusta, Georgia, USA (President)

·  Sallie Taylor, OTR, Brentwood, MO, USA (Vice President)

·  Debora Olin, OTR, Madison, WI, USA (Treasurer)

·  Sarah Austin, MS, OTR/L, Chicago, IL, USA

·  Teresa Carlson, OTR/L, Bolivar, Ohio, USA

·  Cathy Earhart, OTR/L, Pasadena, CA, USA

·  Angela Edney, MSA, OTR/L, Coral Springs, FL, USA

·  Deane McCraith, MS, OTR/L, LMFT, Boston, MA, USA

·  Delaune Pollard, AccOT, Bahrs Scrub, Qld., Australia

·  Michele Stanley, PT, Cross Plains, WI, USA

·  Tom Tucker, COTA, Texas, USA

·  Linda Riska Williams, OTR, MS, Camarillo, CA, USA

 Ex Offico Members of the Board are:

·   Claudia Kay Allen, MA, OTR, FAOTA (USA) Cozina, USA

·   Tina Blue OTR/L, St Thomas, Caribbean Islands, USA

·   Joan Riches, OT, High River, AB, Canada

The Allen Diagnostic Manual (ADM) has been up dated by Catherine Earhart, OTR/L, who works at the Medical Centre at University of Southern California.  This has been a large and complex procedure and has taken a huge amount of time and effort as projects needed to be trialled and inter-rater reliability established on a large and wide range of projects before eleven projects were selected.  The projects selected meet the guidelines established by Earhart and her team of therapists.   Also, these eleven projects were chosen as they meet the current requirements of portability, reduced cost to purchase, shorter time frames to complete within a therapy session, cross-cultural suitability and have a greater appeal to a wider age group of clients. 

Research is being conducted on different projects listed in the ADM by Sarah Austin, Chicago State University in conjunction with therapists working in clinical settings within USA.

2005:    In this year, the 2005 Allen Symposium was organised by Sallie Taylor, Vice President, Allen Cognitive Advisors Ltd and was hosted by Saint Louis University. Doisey School of Allied Health ,  Dept of Occupational Science & Occupational Therapy. The theme was 'Cognition and Occupation-Based Practice - Advances in Theory, Assessment & Clinical Applications of the Allen Cognitive Levels in Occupation-based Practice'.  This was voted by members and attendees as an extremely successful event and the credit for organising the symposium program goes to Deane McCraith, who spent many days organising the smooth running of this program.  Sallie Taylor did a wonderful job organising the venue and everything else that needed to be done to keep the program moving; many thanks Sallie for such a huge effort.

 

2005 Symposium Highlights

The official board meeting of ACA Ltd. was held on Sunday, 9 October. At this meeting there were changes made to the membership of the board, this occurred when Tom Tucker .announced his resignation  from the board to allow him time to follow his personal goals in life. Joan Riches was nominated to become a board member and she kindly offered to fill the vacant position.  Joan has tremendous organisation skills and since the board meeting has developed the Members Forum Page on the ACN Website, this was a huge undertaking, many thanks Joan for your hard work.

The members of the Allen Cognitive Network (ACN) Ltd., Board are:

·  Sandra David OTR, MHE, Augusta, Georgia, USA (President)

·  Sallie Taylor, OTR, Brentwood, MO, USA (Vice President)

·  Debora Olin, OTR, Madison, WI, USA (Treasurer)

·  Sarah Austin, MS, OTR/L, Chicago, IL, USA

·  Teresa Carlson, OTR/L, Bolivar, Ohio, USA

·  Cathy Earhart, OTR/L, Pasadena, CA, USA

·  Angela Edney, MSA, OTR/L, Coral Springs, FL, USA

·  Deane McCraith, MS, OTR/L, LMFT, Boston, MA, USA

·  Delaune Pollard, AccOT, Bahrs Scrub, Qld., Australia

·  Joan Riches, OT, High River, AB, Canada

·  Michele Stanley, PT, Cross Plains, WI, USA

·  Linda Riska Williams, OTR, MS, Camarillo, CA, USA

 Ex Offico Members of the Board are:

·   Claudia Kay Allen, MA, OTR, FAOTA (USA) Cozina, USA

·   Tina Blue OTR/L, St Thomas, Caribbean Islands, USA

2006:   The 5th Annual Allen Cognitive - Network Symposium on Cognition was held on October 20 - 21, 2006. Michele Stanley organised the the symposium program with the theme, "Context for Success: A Kinder Way of Caring”. The symposium featured a panel of noted clinicians detailing ways in which they have successfully used the Allen Cognitive model as a basis for successful program development in areas such as employee/human relations; adolescent work readiness programming, dementia environment and housing planning, acute and outpatient psychiatric programs, and SNF rehab facilities.  The symposium was hosted by the University of Indianapolis, Indiana.

Dr Robyn Hayes, Associate Professor, Department of Occupational Therapy, La Trobe University, Melbourne. VIC 3000, Australia presented the Key Note Address

The members of the Allen Cognitive Network (ACN) Ltd., Board, 2006 - 2007 are:

Sallie Taylor, OTR, Brentwood, MO, USA ( President)

Joan Riches, OT, High River, AB, Canada (Vice President)

Sandra David OTR, MHE, Augusta, Georgia, USA (Past President)

Teresa Carlson, OTR/L, Bolivar, Ohio, USA  (Secretary)

Debora Olin, OTR, Madison, WI, USA (Treasurer)

Sarah Austin, MS, OTR/L, Chicago, IL, USA

Cathy Earhart, OTR/L, Pasadena, CA, USA

Angela Edney, MSA, OTR/L, Coral Springs, FL, USA

Deane McCraith, MS, OTR/L, LMFT, Boston, MA, USA

Delaune Pollard, AccOT, Bahrs Scrub, Qld., Australia

Michele Stanley, PT, Cross Plains, WI, USA

Linda Riska Williams, OTR, MS, Camarillo, CA, USA

Kim Warchol, OTR/L, President of Dementia Care Specialists, Inc. Ikasca, Illinois

 Ex Offico Members of the Board are:

Claudia Kay Allen, MA, OTR, FAOTA (USA) Cozina, USA

Tina Blue OTR/L, St Thomas, Caribbean Islands, USA

 

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