Cognitive Disability Frames of Reference

Cognitive disability frames
of reference
• Main Focus
Assessing level of cognitive function and providing task appropriate to
that level.
• Target population
People across all the age span
• Based on Allen’s cognitive disability theory

Cognitive disability theory
• The theory of cognitive disabilities, developed by Claudia kay allen,Focuses
on the effect of impaired thinking on task performance.
• Allen’s statements
“just as physical disablities restrict the physical ability to do a

voluntary motion action,a cognitive disability restricts the cognitive
ability to do a voluntary motor action”
“Cognititive disabilities may prevent patients from successfully

adapting to life outside a hospital or supervised living situation.
Allen’s principles
• Based on Piaget's stages of cognitive development and
neurobiological science.
• Cognitive behavior is based on biological factors and potential for

improvement is dictated by these factors.
• Once the maximum cognitive level has been achieved, compensations

must be made biologically, psychologically, or environmentally.
• Central to the theory is the importance of assessing learning ability.

Allen’s definitions
• Cognitive disability: a limitation in sensorimotor actions originating in the

physical or chemical structures of the brain and producing observable and
assessable limitation in routine task behavior.
• Maximizing engagement and participation is done by assessing the cognitive

impairment; using assistance and environmental adaptations to compensate for
activity limitations; and promoting routines that allow for continued participation
in daily occupations
Use of cognitive disability theory
• When there is a need to measure and monitor a client's problem-solving
ability and safety while performing daily activities.
• For grouping together clients who function at similar levels of cognitive

disabilities
• For training caregivers in providing assistance while facilitating best

ability to function
• For providing a pragmatic approach to living with the consequences of

illness or injury
Cognitive Levels
• Assessment and intervention are based on how the client learns and performs tasks
• Cognitive performance is placed on a continuum divided into 6 levels that are

further divided into modes
• Outlines 3 dimensions of task performance at each level:
- Attention: What sensory stimulation capture interest
- Motor actions: Observed during task performance to make assumptions about

perception, understanding, and intention
- Conscious awareness: awareness to determine appropriate actions

Allen Cognitive Levels
Level 1- Automatic Actions (bed bound)
• - Behavior is mostly reflexive
• - Responds to internal or subliminal cues
• - Arousal and response elicited for only a few seconds at a time
• - Self-care performed by caregivers
• - Intervention- Sensory Stimulation

Allen Cognitive Levels
Level 2- Postural Actions
• - Can be stimulated to perform postural actions in response to
proproceptive cues
• - Can overcome the effects of gravity
• Can imitate gross motor actions
• - Can assist with hygiene and dressing
• - Can feed self
• - Interventions: Movement or exercise groups based on imitation
Allen's Cognitive Levels
Level 3-Manual actions

• - Respond to tactile cues to perform manual actions
• - Actions based on interest in objects at arm's reach
• - Attention span can be maintained up to 30 minutes and is influenced
by the materials we give them
• Can perform basic grooming independently with some reminders and
can walk to familiar places, but gets lost
• - Intervention: Repetitive tasks including IADLs
• - Emergence of Cause and Effect, but actions are - disorganized
• - Potentially dangerous items must be placed out of reach

• Level 4- Goal Directed Activities: Big step for independence
• - Activities are purposeful and able to perform short tasks
• - Basic ADLs are intact and may ask for assistance
• - Needs assistance with new tasks, and for anticipating needs and managing
money
• - Attends up to one hour and attends to samples, possessions, understands
errors (beginning), from their questions we can infer what they are thinking
about
• - Requires visual demonstrations for tasks because doesn't follow verbal and
written directions
• - Interventions: Reinforce familiar routines and perform repetitive drilling
• - 4.4 lowest mode to live alone

Level 5-Exploratory Actions/Independent Learning through new
activities
• Uses trial and error, use inductive reasoning, and are capable of new
learning
• - Novelty and variation are sought
• - Concrete thinkers, so have difficulties with imagining - long-terms

consequences of actions or inactions
• Timing for cooking, money management, purchasing needed items,
cleaning clothing, and getting prescriptions refilled are problems
• - Attention to discovery of new effects and remembers where they are
• - Has poor social awareness -
• - Interventions: Learning to improve the effects of their actions to

considering social skills (empathy)
Level 6- Planned activities
• Absence of disability
• Attention to symbolic, hypothetic, social rules and obligations, what

would happen if...?
• Assumed to be the "normal".

Assessment & Intervention
• Assessment & intervention are based on how the client learns

&performs tasks.
• Identification of a patients cognitive level involves careful evaluation.
• Assessment of cognitive levels can be used during acute phases of a

disorder to monitor progress and response to treatment.
• Changes in cognitive level are often related to effectiveness of
medication.It cannot be changed by occupational therapy treatment.
• Cognitive level is assessed by observing motor actions the patient

perform during a task & by inferring the sensory cue that the patient
was paying attention at the time.
Assessment
• Routine Task Inventory (RTI) and Cognitive Performance Test

(CPT):
➢Determine cognitive level based on everyday activities
➢Patients scoring at level 2 and above on RTI are then evaluated with
Allen’s cognitive level test.
Allen Cognitive Levels Screen (ACLS)
• Defines a cognitive level from 3.0 to 5.8
• Purpose: Gives a quick estimate of the client's current capacity to

learn .
Allen Diagnostic Module (ADM):
• Uses a dynamic approach to assess cognitive level while taking motivation

and socialization into account
• Performance is observed during a group centered around a variety of

standardized craft activities
• Crafts are viewed as being motivating
• Observation of response to instructions and sensory cues from materials and

tools provide the basis for prediction about function in other occupations
Intervention
The aim of intervention is to iden- tify accurately an individual's stable level of cog-
nitive disability and optimise his functioning within those constraints. This will
include:
• identifying activities the patient is able to perform
• identifying ways in which the patient can be helped to compensate for disabilities,
for example
❖ visual and verbal prompts
❖ adapted work tasks
❖ adapted environment
❖ support from carers/community staff
• avoiding undue stress by placing too few or too great demands on the
patient
• identifying whether new learning is possible (usually level 4 and

above) and creating optimum conditions for it to occur.
Role of OT
• Enabler of client's best ability to function by taking into account:
- Assistance needed from caregivers
- Adaptations of the environment
- Expected behaviors in ADLs
- Quality and quantity of cognitive and physical assistance needed at each level
Methods for Giving Cognitive Assistance
• Facilitating: Giving appropriate sensory cues
• Probing: Asking focused questions to encourage problem solving .
• Observing: How client processes cues and questions and try new
behaviors
• Rescuing: Stepping in when client becomes frustrated or is unable to

perform
Thank you...............

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Cognitive disability frames

• Based on Allen’s cognitive disability theory

“just as physical disablities restrict the physical ability to do a

“Cognititive disabilities may prevent patients from successfully

• Cognitive behavior is based on biological factors and potential for

• Once the maximum cognitive level has been achieved, compensations

• Central to the theory is the importance of assessing learning ability.

• Cognitive disability: a limitation in sensorimotor actions originating in the

• Maximizing engagement and participation is done by assessing the cognitive

• For grouping together clients who function at similar levels of cognitive

• For training caregivers in providing assistance while facilitating best

• For providing a pragmatic approach to living with the consequences of

• Cognitive performance is placed on a continuum divided into 6 levels that are

• Outlines 3 dimensions of task performance at each level:

- Attention: What sensory stimulation capture interest

- Motor actions: Observed during task performance to make assumptions about

- Conscious awareness: awareness to determine appropriate actions

Level 1- Automatic Actions (bed bound)

• - Behavior is mostly reflexive

• - Responds to internal or subliminal cues

• - Arousal and response elicited for only a few seconds at a time

• - Self-care performed by caregivers

• - Intervention- Sensory Stimulation

Level 3-Manual actions

• - Intervention: Repetitive tasks including IADLs

• - Emergence of Cause and Effect, but actions are - disorganized

• - Potentially dangerous items must be placed out of reach

• Level 4- Goal Directed Activities: Big step for independence

• - Activities are purposeful and able to perform short tasks

• - Basic ADLs are intact and may ask for assistance

• - Interventions: Reinforce familiar routines and perform repetitive drilling

• - 4.4 lowest mode to live alone

• - Novelty and variation are sought

• - Concrete thinkers, so have difficulties with imagining - long-terms

• - Attention to discovery of new effects and remembers where they are

• - Has poor social awareness -

• - Interventions: Learning to improve the effects of their actions to

Level 6- Planned activities

• Attention to symbolic, hypothetic, social rules and obligations, what

• Assumed to be the "normal".

• Assessment & intervention are based on how the client learns

• Identification of a patients cognitive level involves careful evaluation.

• Assessment of cognitive levels can be used during acute phases of a

• Cognitive level is assessed by observing motor actions the patient

• Routine Task Inventory (RTI) and Cognitive Performance Test

➢Determine cognitive level based on everyday activities

• Defines a cognitive level from 3.0 to 5.8

• Purpose: Gives a quick estimate of the client's current capacity to

• Uses a dynamic approach to assess cognitive level while taking motivation

• Performance is observed during a group centered around a variety of

• Crafts are viewed as being motivating

• Observation of response to instructions and sensory cues from materials and

• identifying whether new learning is possible (usually level 4 and

- Assistance needed from caregivers

- Adaptations of the environment

- Expected behaviors in ADLs

• Facilitating: Giving appropriate sensory cues

• Probing: Asking focused questions to encourage problem solving .

• Rescuing: Stepping in when client becomes frustrated or is unable to

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