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Allen Cognitive Level Screen

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Purpose

The ACLS measures functional cognition in individuals whose behavior appears to reflect impairments in cognitive processing.

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Instrument Details

Acronym ACLS, ACLS-5, LACLS-5, ACLS-90, ACLS-2000

Area of Assessment

Cognition

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

Cost is variable depending on the retailer.

Key Descriptions

  • Based on Allen Cognitive Levels from 0.0-6.0, the ACLS assesses an individual’s motor movements following basic instruction (3.0), as well as one’s performance in skill acquisition (up to 5.8).
  • Participant must complete three tasks.
  • Minimum score: 3.0; maximum score: 5.8
  • Test administrator instructs the participant to complete three basic stitching patterns using leather, lace, and a leather lacing tool.
  • Further instructions can be found in Manual for the ACLS-5 and LACLS-5 (2007).

Number of Items

3

Equipment Required

  • One pre-punched 4x5 inch rounded, tan leather rectangle finished on one side
  • One large-eyed, blunt sewing needle
  • Two brass, threaded, locking needles
  • One skein of leather lace with two visibly distinct sides
  • One skein of waxed linen thread

Time to Administer

20 minutes

Required Training

Reading an Article/Manual

Required Training Description

The ACLS is designed to be administered and scored by occupational therapists or other healthcare professionals who have experience working with individuals with cognitive impairments; administrators should also understand the cognitive disabilities model.

Age Ranges

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

+

years

Instrument Reviewers

Berglund, Olivia; Coronel, Martina; Rath, Jonathan; Sheehan, Hannah

(Master of Occupational Therapy Students)

Faculty mentor: Danbi Lee, PhD, OTD, OTR/L

Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington, Seattle

ICF Domain

Body Function

Measurement Domain

Cognition

Considerations

The ACLS-5 is the most current version, published in 2007 and revised in 2009. The assessment should be used for individuals with adequate or adapted fine motor skills, vision, and hearing. The Large Allen Cognitive Level Screen (LACLS-5) version is available for further accessibility.

Additional versions of the ACLS that are included in this measurement summary include ACLS-90, the 1990 version of the ACLS, and the ACLS-2000, the version of the instrument published in 2000.

Mental Health

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Normative Data

Inpatient Psychiatric Patients: (David & Riley, 1990; n = 71 patients admitted to general hospital psychiatric unit during a 13-month period; Mean Age = 36.99 (12.18); mood disorder, 54%; schizophrenia, 13%; adjustment disorder, 11%; anxiety disorder, 6%; impulse control disorder, 4%; somatoform disorder, 4%; psychoactive substance use disorder, 4%; organic mental disorder, 1%; various other diagnoses, 3%)

  • Mean ACL score = 4.9 (0.85)

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Schizophrenia (Chan & Yeung, 2008; n = 201; Mean Age = 43.14 (9.9); Chinese sample)

  • Poor predictive validity of the ACLS-2000 predicting community and social functioning assessed by the Chinese version of the Multnomah Community Ability Scale (r = 0.11).

Schizophrenia (Velligan et al., 1998; n = 110; Mean Age = 35.7 (9.7); subjects discharged from state hospital over 3 year period, follow-ups 1.5-3 years post-discharge)

  • Excellent predictive validity of the ACLS-90 for global functioning 1 to 3.5 years later as assessed by the Social and Occupational Function Scale (r = 0.60)
  • Adequate predictive validity of the ACLS-90 for level of social effectiveness, occupational function, and productive activity as assessed by the Multinomah Community Ability Scale, Levels of Functioning Scale, and Lehman work and Productive Activity Scale, respectively. (r = 0.40, 0.37, 0.46, in the sequence presented)

Schizophrenia (Secrest, et al., 2000; n = 33 adult men with schizophrenia or schizoaffective disorder; Mean Age = 47.94)

  • Excellent predictive validity of ACLS with Routine Task Inventory (r = 0.67) predicting task performance
  • Poor predictive validity of ACLS with the number of preservative errors on Wisconsin Card Sorting Test (WCST) (r = -0.47)
  • Adequate predictive validity of ACLS with number of categories obtained on WCST (r = 0.57) predicting executive function, cognitive dysfunction, and community functioning in patients with chronic schizophrenia
  • Poor predictive validity of ACLS with number of hours worked per week (r = 0.21)

Inpatient Psychiatric Patients: (Henry et al., 1998, n = 100 inpatients consecutively admitted to acute mental health unit of hospital during a 6-week period; Mean Age = 39.57 (14.75); schizophrenia, bipolar disorder n = 39; major depression, PTSD/dissociative disorder, anxiety disorder n = 61)

  • Adequate predictive validity of the ACLS-90: patients with mean score of 4.92 discharged to independent living situation, patients mean score of 4.50 discharged to supported living situation (r = 0.34)

 

Concurrent validity:

Inpatient Psychiatric Patients: (Scanlan & Still, 2013; n = 225 individuals from eight inpatient psychiatric units; Mean Age = 39.6 (13.2); schizophrenia n = 154; schizoaffective disorder n = 20; other psychoses n =14; bipolar disorder/mania n = 12; depression n = 11; “other” n = 14)

  • Adequate concurrent validity of the ACL with functional performance in personal care/basic ADLs, telephone use, travel/transport, shopping, cooking, washing/laundry, housework (r = 0.48, 0.35, 0.33, 0.44, 0.45, 0.41, 0.48 respectively)
  • Poor concurrent validity of the ACL with functional performance in money management (r = 0.29) and medication management (r = 0.19)

Schizophrenia (Leung & Man, 2007; n = 61 chronic schizophrenic patients,  Mean Age = 45.07; n = 61 more than 6 months stay in existing psychiatric setting, Mean Age = 29.84; Chinese sample)

  • Excellent concurrent validity of the Chinese version of ACLS (CACLS) and Chinese version of Mini Mental State Examination (CMMSE) total as well as CACLS and Chinese version of Functional Needs Assessment (CFNA) total (r = 0.609, 0.714 respectively)
  • Adequate to excellent concurrent validity of CACLS and CFNA’s subsets (r = 0.456-0.737)

Schizophrenia (Velligan et al., 1998)

  • Excellent concurrent validity of the ACLS-90 to the Functional Needs Assessment (FNA). (rho = ~0.56)
  • Adequate concurrent validity was found between ACLS-90 and multiple neuropsychological tests, including Hopkins Verbal Learning, Digits Backward, Finger Tapping, Simple Reaction Time, Inhibition, Continuous Performance Test, and Hooper Visual Organization assessment. (rho = 0.30 to 0.62)
  • Poor concurrent validity found between ACLS-90 and Digits Forward and Choice Reaction time. (rho = 0.28, 0.16, respectively)

Schizophrenia (Velligan et al., 1995; n = 110; Mean Age = 34.6 (7.5); subjects experienced consecutive admissions to inpatient hospital over 18 months)

  • Excellent convergent validity demonstrated between ACLS-90 and FNA was demonstrated across the whole study, among participants identified as non-Hispanic whites, and participants identified as Mexican-Americans. (r = 0.66, 0.67, 0.60, respectively)
  • Adequate convergent validity was found between FNA and ACLS-90 among study participants that identified as African-American. The authors noted that unlike the other groups represented, there were no occupational therapists or researchers in the study that were from their own identified ethnic group. (r = 0.46)

Schizophrenia (Keller & Hayes, 1997; n = 58; n = 41 living in community, n = 17 living in long-term psychiatric hospital; Mean Age = 35.50 (9.85))

  • Adequate convergent validity of adaptive functioning was found between ACLS-90 and the Life Skills Profile (LSP) among total score and subtests for communication, nonturbulence, and self-care. (r = 0.54, 0.37, 0.40, 0.53, respectively)
  • Poor convergent validity of adaptive functioning was found between ACLS-90 and the LSP subtests for responsibility and social contact. (r = 0.26, 0.28, respectively)

Construct Validity

Schizophrenia (Leung & Man, 2007)

  • Construct validity supported since the mean rank of the control group (87.75) was significantly higher than the schizophrenia group (33.8).

Schizophrenia (Su et al., 2011; n = 76; n = 35 scored 4 on ACLS, Mean Age = 37.83 (10.25); n = 41 scored 5 on ACLS, Mean Age=37.73 (9.28); Taiwanese Sample)

  • Construct validity supported: the mean rank of participants that scored a 5 on ACLS compared to participants that scored a 4 on ACLS was significantly higher for processing speed, immediate verbal recall, delayed verbal recall, and working memory (p≤0.006)

Schizophrenia (Chan & Yeung, 2008)

  • Construct validity supported: ACLS scores were significantly different by living situations (long-stay care homes, halfway houses, supported hostel/housing, living with family, and living alone). (p=0.000)

 

Convergent Validity:

Substance Use: (Rojo-Mota et al., 2017; n = 232 participants with addictions currently undergoing addiction rehabilitation treatment; Mean Age = 38.26 (11.66); Spanish sample)

  • Adequate convergent validity of the ACLS-5 with the visuospatial test of the Montreal Cognitive Assessment (MoCA) (r = 0.43)
  • Poor convergent validity of the ACLS-5 with the attentional and abstraction tests of the MoCA (r = 0.18, 0.18)
  • Poor convergent validity of the ACLS-5 with the Prefrontal Syndrome Index  (r = –0.19 to 0.07)

Inpatient Psychiatric Patients: (Schubmehl et al., 2018; n = 193 inpatients from a psychiatric unit in California in acute phase of a psychiatric illness diagnosis; Mean Age = 37.2 (14.4); schizophrenia, n = 47; schizoaffective disorder, n = 45; psychotic disorder NOS, n = 23; bipolar disorder, n = 53; major depressive disorder, n = 19)

  • Adequate convergent validity of the ACLS-5 with Trail Making Test Part A and Part B (r = 0.46 and 0.45, respectively)
  • Adequate convergent validity of the ACLS-5 with Controlled Word Association Test (r = .047)

Inpatient Psychiatric Patients: (David & Riley, 1990

  • Adequate convergent validity of the ACL with the Symbol-Digit Modalities Test (r = 0.521)
  • Adequate convergent validity of the ACL with the Shipley Institute of Living Scale Abstraction and IQ (r = 0.355 and 0.311, respectively)
  • Poor convergent validity of the ACL with the Shipley Institute of Living Scale: Vocabulary (r = 0.252)

Inpatient Psychiatric Patients: (Mayer, 1988; n = 40 adult acute psychiatric inpatients; Mean Age = 33.0 (17.9); Mean Chronicity = 7.5 (6.9))

  • Adequate convergent validity of the ACL with the Wechsler Adult Intelligence Scale-Revised edition (WAIS-R): FSIQ, Digit Symbol, Digit Span, Object Assembly, and Picture Arrangement (r = 0.46, 0.59, 0.54, 0.55, and 0.59, respectively)
  • Excellent convergent validity of the ACL with the WAIS-R: Block Design (r = 0.618)

Pediatric Disorders

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Construct Validity

Convergent Validity:

Pediatric Mental Health: (Shapiro, 1992; n = 24 males with an emotional disturbance attending a private school in New York; Mean Age = 12.5(Range = 8-15))

  • Poor convergent validity of the ACL with Perceptual Memory Task full scale and subscales (r = -0.04 to 0.19)
  • Adequate convergent validity of the ACL with the raw and age equivalent Beery VMI scores (r = 0.42, 0.36 respectively)

 

Known Groups Method:

Pediatric Mental Health: (Lee et al., 2003; n = 61 consisting of 32 adolescents living in the community and 28 adolescents residing in residential mental health facilities; Mean Age = 14.8 (1.5))

  • Construct validity supported: Statistically significant difference in scores on the ACL-90 between groups (p<0.05)

Older Adults and Geriatric Care

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Cut-Off Scores

Older Adults and Dementia (Wesson et al., 2017; n = 87 older adults with no cognitive impairment, Mean Age = 82.5; n = 43 older adults with mild cognitive impairment (MCI), Mean Age = 83.1; n = 30 older adults with dementia; Mean Age = 79.2)

 

Cut-off Scores

Sensitivity

Specificity

No cognitive impairment vs Dementia

4.5

76.7%

90.8%

4.7

86.7%

81.6%

MCI vs Dementia

4.5

76.7%

74.4%

4.7

86.7%

60.5%

No dementia (No cognitive impairment & MCI) vs Dementia

4.5

76.7%

85.4%

4.7

86.7%

74.6%

No cognitive impairment vs MCI

5.1

67.4%

52.9%

Normative Data

Older Adults and Dementia (Wesson et al., 2017)

 

No cognitive impairment

MCI

Dementia

Mean (SD)

5.13(0.41)

4.94(0.47)

4.45(0.40)

Range

4.4–5.8

4.2–5.8

3.4–5.8

Construct Validity

Discriminant Validity

Older Adults and Dementia (Wesson et al., 2017)

  • Discriminant validity of LACLS-5 supported: Older adults with no cognitive impairment performed better than older adults with MCI  and older adults with dementia  performed the worst. The Assessment of Motor and Process Skills (AMPS) Motor scores for clinic participants were worse than the Sydney Memory and Ageing Study (MAS) participants in the dementia group (U = 36.5). Lower LACLS-5 scores were associated with increased age (F(1,148) = 5.95).

 

Convergent Validity

Older Adults and Dementia (Wesson et al., 2017)

  • Poor to adequate convergent validity of LACLS-5 with functional variables of AMPS Motor and Process (r = 0.29-0.53)
  • Poor convergent validity of LACLS-5 with Disability Assessment for Dementia BADL and IADL subscales (r = 0.29, 0.37 respectively)
  • Poor to adequate convergent validity of LACLS-5 with cognitive variables of Mini Mental State Examination, Trail Making Test Part A and Part B, Rey Auditory Verbal Learning Test, Boston Naming Test, and Controlled Oral Word Association Test (r = -0.33 - 0.46)

Bibliography

Allen, C. K., Austin, S. L., David, S. K., Earhart, C.A., McCraith, D.B., & Riska-Williams, L. (2007). Manual for the Allen cognitive level screen-5 (ACLS-5) and Large Allen cognitive level screen-5 (LACLS-5). ACLS and LACLS Committee.

 

Chan, S. H. W., Yeung, F. K. C. (2008). Path models of quality of life among people with schizophrenia living in the community in Hong Kong. Community Mental Health Journal, 44, 97-112. https://doi-org.offcampus.lib.washington.edu/10.1007/s10597-007-9114-7

 

David, S. K., & Riley, W. T. (1990). The relationship of the Allen Cognitive Level Test to cognitive abilities and psychopathology. American Journal of Occupational Therapy, 44, 493-497. https://doi.org/10.5014/ajot.44.6.493

 

Henry, A. D., Moore, K., Quinlivan, M., & Triggs, M. (1998). The relationship of the Allen Cognitive Level test to demographics, diagnosis, and disposition among psychiatric inpatients. American Journal of Occupational Therapy, 52, 638-643. https://doi.org/10.5014/ajot.52.8.638

 

Keller, S. & Hayes, R. (1998). The relationship between the Allen Cognitive Level test and the Life Skills Profile. American Journal of Occupational Therapy, 52(10), 851-856. https://doi.org/10.5014/ajot.52.10.851

 

Lee, S. N., Gargiullo, A., Brayman, S., Kinsey, J. C., Jones, H. C., & Shotwell, M. (2003). Adolescent performance on the Allen Cognitive Levels Screen. American Journal of Occupational Therapy, 57(3), 342-346. https://doi.org/10.5014/ajot.57.3.342

 

Leung, S. B. & Man, D. W. K. (2007). Validity of the Chinese version of the Allen Cognitive Screen assessment for individuals with schizophrenia. OTJR: Occupation, Participation and Health, 27(1), 31-40. https://doi.org/10.1177/153944920702700105

 

Mayer, M. A. (1988). Analysis of information processing and cognitive disability theory. The American Journal of Occupational Therapy, 42, 176-183. https://doi.org/10.5014/ajot.42.3.176

 

Rojo-Mota, G., Pedrero-Pérez, E. J., Huertas-Hoyas, E., Merritt, B., & MacKenzie, D. (2017). Allen Cognitive Level Screen for the classification of subjects treated for addiction. Scandinavian Journal of Occupational Therapy, 24(4), 290-298. https://doi.org/10.3109/11038128.2016.1161071

 

Scanlan, J. N., & Still, M. (2013). Functional profile of mental health consumers assessed by occupational therapists: Level of independence and associations with functional cognition. Psychiatry Research208(1), 29-32. https://doi.org/10.1016/j.psychres.2013.02.032

 

Schubmehl, S., Barkin, S. H., & Cort, D. (2018). The role of executive functions and psychiatric symptom severity in the Allen Cognitive Levels. Psychiatry Research259, 169-175. https://doi.org/10.1016/j.psychres.2017.10.023

 

Secrest, L., Wood, A. E., & Tapp, A. (2000). A comparison of the Allen Cognitive Level test and the Wisconsin Card Sorting test in adults with schizophrenia. American Journal of Occupational Therapy, 54, 129-133. https://doi.org/10.5014/ajot.54.2.129

 

Shapiro, M. E. (1992). Application of the Allen Cognitive Level test in assessing cognitive level functioning of emotionally disturbed boys. American Journal of Occupational Therapy, 46(6), 514-520. https://doi.org/10.5014/ajot.46.6.514

 

Su, C. Y., Tsai, P. C., Su, W. L., Tang, T. C., & Tsai, A. Y. (2011). Cognitive profile difference between Allen Cognitive Levels 4 and 5 in schizophrenia. American Journal of Occupational Therapy, 65, 453-461. https://doi.org/10.5014/ajot.2011.000711

 

Velligan, D. I., Bow-Thomas, C. C., Mahurin, R., Miller, A., Dassori, A., & Erdely, F. (1998) Concurrent and predictive validity of the Allen Cognitive Levels assessment. Psychiatry Research 80, 287-198. https://doi.org/10.1016/S0165-1781(98)00078-X

 

Velligan, D. I., True, J.E., Lefton, R. S., Moore, T. C., & Flores, C. V. (1995). Validity of the Allen Cognitive Levels assessment: A tri-ethnic comparison. Psychiatry Research, 56, 101-109. https://doi.org/10.1016/0165-1781(95)02532-7

Wesson, J., Clemson, L., Crawford, J.D., Kochan, N.A., Brodaty, H., & Reppermund, S. (2017). Measurement of functional cognition and complex everyday activities in older adults with mild cognitive impairment and mild dementia: Validity of the Large Allen’s Cognitive Level Screen. American Journal of Geriatric Psychiatry, 25(5), 471-482. https://doi.org/10.1016/j.jagp.2016.11.021

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