The Allen Cognitive Battery was pioneered in the 1970s in Los Angeles by a small group of occupational therapists led by Claudia Allen. It was developed in an occupational therapy department for patients with psychiatric disorders as a quick assessment, designed to be not culturally biased or language-based, and which could be sensitive to small changes in how medication alters a patient’s day-to-day functioning. The first publication was in 1982 (Allen 1982) and the ‘test’ materials first distributed in 1985. Since that time, the procedure for administering the testing has been formalized and inter-rater reliability has been established among patients in psychiatric, acute and long-term care facilities.

In the USA the FIPM has been adopted for use to meet the requirements of Medicare. In 1965, the Social Security Act established Medicare as a prepaid medical insurance plan extending health coverage to almost all Americans aged 65 or older. Medicare requires that rehabilitation goals be functional, practical, sustainable and completed in a reasonable period of time. For the people with longer-term needs, goals must establish safe and effective maintenance programmes that will be sustained after therapy is discontinued. Allen proposed that the battery of assessments help occupational therapists to meet the Medicare requirements with rehabilitation goals that are relevant, reasonable and possible.

Historically, the cognitive and physical components of people have been assessed and treated separately. While there are many assessments for determining cognitive disability, the Allen’s Cognitive Levels constitutes one that defines cognitive functioning in the way that it affects the person’s engagement in occupation and with others. It is useful to all disciplines in the rehabilitation department, and in both the USA and the UK is used by occupational therapists to contribute to the findings of multidisciplinary teams. Although the FIPM and the battery of assessments have been developed for use by occupational therapists, they are also viewed by Allen as appropriate for use by other therapists, such as physiotherapists, who have an understanding of neuropsychology and experience in working with people having impairments of information-processing.

In May 2001, the World Health Organization (WHO 2002) endorsed the use of the International Classification of Functioning, Disability and Health (ICF). The ICF is a multi-purpose classification of health and health-related domains that helps to describe changes in body function and structure, and what a person with a health condition can do in a standard environment (their level of capacity), as well as what they actually do in their usual environment (their level of performance). These domains are classified from body, individual and societal perspectives by means of two components: body functions and structure, and activity and participation. The ICF also lists environmental factors that interact with all of these components (WHO 2002). Allen’s FIPM fits well with the ICF, as the assessments aim to identify both level of cognitive capacity and level of performance. Interpretation of the assessment findings guides the occupational therapist to create a helping, therapeutic environment that meets the individual’s needs and at the same time enables the individual to use their existing abilities to engage with their world.

The Allen assessment battery is now used widely in the UK by occupational therapists in a variety of clinical settings. The main users are those working with older people with dementia, because this has been the field where information about the FIPM has been most widely disseminated. The older persons’ specialist section of the UK College of Occupational Therapists (COTSS-OP) has created a dementia clinical forum where information and workshops about Allen’s model and materials have been featured. Increasingly, occupational therapists from other fields, including forensic psychiatry, adult psychiatry and learning disability, are also beginning to use the FIPM in practice.

In the USA, there are two websites dedicated to Allen’s modules. Allen’s Conferences, Inc. (http://www.allen-cognitive-levels.com/) is the official website of Allen’s Cognitive Levels and information about their products and some research is available. More recently a website, the Allen Cognitive Network (http://www.allen-cognitive-network.org/), has been developed by an association of Allen Cognitive Level advisors, whose aim is to network about the Allen Cognitive Battery and applications in various practice arenas.

Cognition may be defined as the full range of processes and mechanisms that support thinking, as well as the thoughts themselves, which can be viewed as the products of those processes. This definition encompasses cognitive skills, such as attention, concentration, memory, comprehension, reasoning and problem-solving, as well as the cognitive processes, including styles of thinking, interpretations, judgements and assumptions (O’Neill 2002). Allen proposes that cognition is the processing capacity that defines what a person pays attention to, their motor response and their verbal performance. This processing capacity determines how a person engages in everyday activities and with their environment.

The clinical reasoning of the FIPM is based on the scientific assumption that human functioning is a general qualitative capacity to use mental energy to guide motor and verbal performance. Cognitive and physical components are intrinsically related since the brain guides physical behaviour. Allen suggests that cognitive disability is viewed as ‘a restriction in voluntary motor action originating in the physical or chemical structures of the brain and producing observable limitations in routine task behaviour’ (Allen 1985, p 31). These motor actions are the movements that a person makes as they are carrying out their everyday activities. Allen is therefore proposing that an individual’s cognition can be assessed by observing their engagement in everyday activities.

Allen’s early work was influenced by Piaget’s theory of cognitive development and she attributes the idea that there are six possible levels of cognition to Piaget’s sensorimotor period (Allen 1985). She later developed her theory to include the influence of the Soviet psychologist Vygotsky, whose work also focused on activity (Vygotsky 1978).

Allen describes a patient’s cognitive progress as a continuum along two paths, motor performance and verbal performance, which are linked by attention. Attention is defined as the way that information is noticed and used. Use of information can be expressed in motor and verbal performance, in isolation or simultaneously. In order to understand a person’s ability to function, Allen proposes that the therapist must first have an understanding of cognitive processing. Because the variation in human behaviour is so diverse, and there are so many variables resulting from unique experiences and personality, Allen bases FIPM on the structuralism of Piaget. Structures are the mental components used to organize thinking and learning processes; the selection of these components is influenced by the purpose for thinking and learning. Allen has defined the structures in broad, general terms that are intended to be universal and therefore free from gender and cultural bias. These structures, or processes, guide the qualitative differences in the actions and activities of individuals, and can be organized as observations, speed, visual spatial, verbal prepositional and memory.

The conceptual framework of Allen’s FIPM is based on an understanding of these cognitive structures and the remaining abilities of the information-processing system. The model is designed to clarify remaining capacities in a disabled brain and is therefore an abilities-focused model.

Claudia Allen proposed six cognitive levels ranging from ‘coma’ (0.8) to ‘normal’ (6.0) (Allen et al., 1992 and Katz, 1998). Each level has three components: attention, motor control, and verbal performance. Table 9.1 summarizes the components of cognitive performance and the resulting impact on functional ability at each of these levels.

Allen (1996) summarizes the functional implications of the cognitive levels as:

The difference between levels 1 and 2 is the ability to attend to and grasp moving objects. Between levels 2 and 3 there is a difference in the ability to manipulate objects in a meaningful way.

In order to discriminate further between the levels, five modes of performance have been added to each cognitive level to allow the therapist to locate the patient’s function level more precisely. The five modes are each in a scale that increases by 2 points, i.e. 1.0, 1.2, 1.4, 1.6 and 1.8. At mode .0 the patient is likely to be functioning in only some of the described manner; at mode .2 the person is characteristically more likely to have problems of orientation in time and place. Mode .4 is a consolidation and the classic description of the level, whereas at mode .6 the person is likely to be open to the next level as thought orientation shifts up. At mode .8 the person is working at a composite level by adding information from the next level.

Allen states that an interval scale, which assumes equal distances between all points on the scale, is inappropriate when dealing with all the variables of human behaviour. Some abilities to function have a greater meaning to some individuals than others, and this will affect individual performance as much as will the integrity of the cognitive structures and the ability to process information. Allen’s Cognitive Level Scale is therefore ordinal. This means that there is not an equal distance between each mode, there is a larger distance in ability between point 4 and point 6 of a mode, and between point 8 and point 0 of a mode, than between any of the others.