ACLS-5/LACLS-5 Interpretation FAQs (8)

1. Does the environment affect the validity of the assessment?

Yes. A well-lit space with few distractions is preferred. If, in the administrator’s judgment, the environmental factors may have influenced performance, this should be noted in interpreting the score.

2. How do you use a score on the ACLS when it is the only performance data that you were able to get prior to the person being discharged?

ACLS scores are estimates of a person’s ability to function and are not intended to be used in isolation. In situations where it is the only performance data available administrators must clearly indicate that the score is an estimate of present abilities only and requires verification. It should not be used as the sole basis for discharge recommendations.

3. If you are limited to only 20 minutes of time for evaluation, is it worth doing the ACLS (vs. an ADM or other observation?)

The ACLS should be part of a comprehensive evaluation process which minimally includes record review and interview to ascertain occupational history, present needs, and the person’s goals. While the ACLS can be administered in 20 minutes its purpose is to provide an estimate of abilities, and the scores obtained must be verified by further assessments. ADM assessments target a narrower range of abilities on the Allen scale and are selected based on ACLS scores or other skilled observation.

4. How can the OTR interpret the screen score when the COTA administers the test, if the OTR has not been trained in administering the test?

Administrators of the ACLS must consider all relevant factors when assigning a score to get reliable first estimate of abilities. A COTA with appropriate qualifications may administer the ACLS and assign scores. An OTR who works with a trained COTA should probably seek training in administration from the COTA. The OTR is responsible for interpreting the meaning of ACLS scores and scores from other related assessments to develop interventions that target identified goals in collaboration with the client and/or caregivers.

5. Is test-retest learning a problem with the ACLS? Is there an optimal amount of time that should elapse before re-testing with the ACLS?

As with any activity, it is possible to train a person to make a stitch they otherwise cannot imitate or discover on their own. The test ceases to be a test of new learning and problem solving when this occurs. Time lapse between administrations of the ACLS to minimize the impact of learning has not been studied but as with other activities, is influenced by the person’s cognitive level. Clinical observations of performance in ADM assessments with a similar range of task demands suggests that persons functioning in level 3 always require demonstrations and prompts to engage in actions that they have been trained to perform previously. Persons functioning in modes 4.0 – 4.4 who are trained to do a series of new actions similar to the single cordovan stitch (ADM Ribbon Card) are apt to forget the series after approximately two weeks. Persons functioning in modes 4.6 – 5.0 who are trained to do a new series of actions similar to the single cordovan stitch (ADM Needlepoint Key Ring) will likely remember it with some prompting several weeks later. Persons in modes 5.2 and above usually recall sequences similar to the single cordovan stitch they have learned without assistance several weeks later (ADM Needlepoint Key Ring.)

6. It seems the assumption is that the ACLS is administered early on. Is it OK to build rapport with the person prior to administration, as I do? I work in a long-term care facility.

Establishing rapport with a person is always advised as part of an assessment process. The ACLS assessment and related tools are used in long term care facilities not only for persons who are receiving Medicare Part A rehab therapy services but for long term residents to establish a baseline, assist with set up of maintenance programs and monitor for changes in functional cognition that may impact the resident’s safety and care needs.

7. Is there a Spanish language version of the manual or do you anticipate one?

Yes, a Spanish language version of the manual is available through our vendors as of May, 2010.

8. Are there plans to translate the manual into any other languages?

Yes, a Japanese language translation of the manual is scheduled to be completed summer, 2010. Other translations may follow as the need is recognized or as the Committee supports proposed research of the tool in those languages.

ACLS-5/LACLS-5 Administration FAQs (17)

1. Why is the person not asked to make three running stitches but completing at least three is part of the rating criteria?

Each task in the ACLS-5 contains visual and verbal cues that match hypothesized abilities described by the Allen cognitive levels and modes. The abilities required to perform the running stitch task are associated with cognitive level 3: attention to repeating familiar actions, ability to see an immediate striking visual effect, and an awareness of simple nouns and verbs that describe actions and effects. Requesting the person to complete three stitches sets a short term goal, an ability associated with cognitive level 4. Therefore completing a specified number of stitches is not requested in this task. Similarly, when errors are made in the running stitch task, the person is not asked to compare their stitches to the sample stitches because awareness of a sample/goal is not expected in level 3. Making at least three running stitches is thought to verify that the person did not accomplish the running stitch by chance.

2. Is it permissible to stand or walk while giving the assessment if the person can not or will not sit?

This may be done only if necessary, and should be noted when reporting the score.

3. The directions say “Hand leather to the person” but you have stated that the person should reach for the leather. Please clarify

This is a good question because “Hand the leather . . .” does not specify how this transfer is to be done. After each demonstration of a stitch, the administrator should release the needle so that the lacing/shoelace falls naturally. In the running stitch task the needle falls in front of the leather and in the whipstitch and single cordovan stitch tasks the needle falls towards the back of leather. The administrator holds the leather in front of the person within reach and waits for the person to grasp the leather. Reaching for and grasping the leather is a required behavior for a score of 3.0 in the running stitch task. Placing the leather in the person’s hand should be considered assistance as described in the Frequent Observations column of the “Less than 3.0” score.

5. Can the verbal cue be the specific direction from the administration instructions that relates to what they are doing wrong?

No. This would be giving a direction, not a verbal cue. The verbal cue should direct attention to the location of the problem but not describe the solution. For example….”Look at how the lace goes through the hole” or “You have the first part right,” and “Is there another way you can go through the loop?”.

6. When is the verbal cue provided? Immediately after the error is made, or prior to the person re-attempting the stitch?

Answered The verbal cue is provided when the person’s problem solving is not progressing, when they stop trying, or when they ask for assistance.

7. What kind of positive reassurance may be given as the person works through the tasks?

Encouragement cues are described in the manual, such as “Keep trying”, “I appreciate the effort”, “Many people find this difficult.” Encouragement cues should not include hints or validation such as “That’s better,” “That’s right,” “Now you figured it out.”

8. Should the administrator make it clear that this is a “test”?

Yes. “I am interested in seeing how you . . . etc.” is part of introducing this test/assessment. Further explanations at the level of the person’s understanding may be given as needed.

9. May the administrator read from the manual or have it visible to set the stage that you are testing/lending credibility to the test when challenged by the person?

Reading directions from the manual during administration is not recommended because the administrator’s full attention should be paid to the person’s performance. Most persons, including professionals from other disciplines, are not familiar with performance tests. Administrators should be able to explain what this test is examining to address these concerns. A glossy manual, despite the professional appearance, does not legitimize a test.

10. Should the administrator demonstrate the test with the left hand for left-handed persons?

Clinical experience over the years suggests that scores are not affected by which hand the administrator uses, though this has not been formally tested. This may be because left-handed persons typically are accustomed to following demonstrations given by right-handed persons. Until there is reason to believe that the handedness of the administrator creates problems, it is recommended that administrators use their dominant hand.

11. Should the administrator sit on a specific side of the person?

Sitting to either side is acceptable, as long as the administrator holds the leather in front of the person during demonstrations, and has a clear view of the person’s performance. Sitting to the person’s right to administer the test right-handed and to their left for left-handed administration may make it easier for the administrator to demonstrate the stitches without obstructing the person’s view.

12. Since used lacing gets deformed after multiple use, do you recommend changing the lacing periodically?

The lacing should be replaced when it becomes soft and does not twist easily, or when it becomes soiled with use so that the two sides are not distinctly different in color or texture.

13. How can a score of 3.4 in the running stitch be equivalent to a score of 3.4 in the whipstitch? The latter seems like a higher level of functioning.

Whipstitch task demands are hypothesized to be more complex than the running stitch task demands. Within each task, the “Hypothesized Abilities” column in the Scoring Tables describes the underlying abilities that are hypothesized to enable the performance observed for that score. These abilities are further hypothesized to reflect a pattern of abilities described by a mode of performance. Clinical experience suggests that abilities associated with mode 3.4 are viewed both as the person completes the three running stitches correctly, and as the person completes some actions within the whipstitch task. There are similar equivalent task demands in the whipstitch and single cordovan stitch tasks at scores of 4.2 and 4.4. The internal consistency of the hierarchy of task demands has not been tested as of this writing.

14. Is there a score in any stitch where you would decide not to continue on to the single cordovan stitch?

Continuing on to the next task whether or not the person completes the preceding task successfully is the standard procedure in version 5, but the administrator may end the test at any time for a good reason. Simply hypothesizing that the person will fail at the next task would not constitute reason enough to abandon the standardized procedure. Continuing to the next task will confirm or refute this hypothesis. On the other hand, observing that the person is becoming excessively upset by the task demands might be a good reason to end the test. In making this decision, however, it is important to be aware that the screen score may not reflect the person’s actual performance abilities. Notation of this factor should be made when interpreting the score.

15. Why do scores on the ACLS stop at 5.8?

The task demands in the ACLS as currently administered do not require use of cognitive abilities described at theoretical level 6, which include imagining and planning out a course of action with objects that are not present. Forming a new sequence of actions and considering secondary effects with present objects uses abilities associated with 5.8 and these abilities are used in solving the problem of independently discovering how to make three single cordovan stitches without assistance.

16. If a person completes 3 successful cordovan stitches with the whipstitch lacing, how do you score this?

This question represents a situation that is highly improbable from a theoretical perspective, because the error of using the wrong lace is unlikely to be made by a person capable of making 3 correct single cordovan stitches independently. The task demands of the single cordovan stitch include attention to/consideration of all the available visible cues, and the ability to flexibly adjust actions to produce better effects while considering secondary effects of their actions. In this scenario, the whipstitch lace would be crossing the back of the leather and clearly visible to the person who presumably would be looking on the back (this ability is established by mode 4.6). If this cue were ignored for some reason, there would also be the unused lace immediately adjacent to the completed stitches which would have to be ignored by the person to make this serious error. If for some reason the person were not aware of these two striking visible errors, the administrator should (after allowing the person time to find this error) offer a verbal prompt “Would you like some help?” and then provide one verbal cue that directs the person’s attention to the problem area such as “How does the back look?” However unlikely, atypical performances do occur and need to be explained if possible by further questioning and observation, in this case: Is the person making the error on purpose? Did the person experience a temporary lapse of attention or confusion?

17. Can this test be administered by an assistant? A COTA?

Yes, provided that the assistant has been trained and has demonstrated competency in administration and establishes inter-rater reliability in scoring with other therapists. The assistant can also assign a score, but cannot interpret the score. Interpretation of scores is the role of the OTR.