The 8 Levels

The 8 Cognitive Functioning Levels in Detail

Level 8: “Planning/Multi-Tasking”
Level 7: “Out the Door”
Level 6: “Organize the Therapy Hour”
Level 5: “Beyond the Room”
Level 4: “Follow a Time Schedule”
Level 3: “Moving Around the Room”
Level 2: “What Time is It?”
Level 1: “Initiating the Next Step”

Level 1: “Initiating the Next Step” is the lowest level of functioning addressed in this therapy system. The person typically sits until told what to do. He is not oriented to time, environment or others. He does not initiate conversation and has trouble following basic verbal directions. The goal is to get the person to initiate to moving on to the next step in a sequence. This can be as simple as carrying through all the steps in the basic task of brushing teeth. Hopefully the person will be slightly higher functioning and will learn to initiate moving on to the next task in series of tasks such as brushing teeth, combing hair, putting on deodorant, etc. This level requires intensive training and repetition.

Level 2: “What Time is It?” emphasizes having the person attend to time throughout therapy sessions so that he will begin to initiate moving on to the next task or exercises based on what time it is. He is starting to follow more complex verbal commands and respond appropriately to others. He is beginning to find things that are not in his immediate field of view. There are 2 types of activities that can be practiced in therapy sessions: “Time Blocks” and “Interrupts”. The time changes need to be in short time intervals (5,10, or 15 minutes) so the person gets repeated opportunities to practice. At this level the person frequently loses track of time if too much time elapses between tasks.

Level 3: “Moving Around the Room” is the last of the low levels of functioning. The person is emerging from the post-traumatic phase of recovery as he is retaining new memories and becoming oriented to the time and his environment. The goal for therapy at this level is to have the person navigate his way around the room to carry out a variety of tasks. He may now be doing some simple reading so tasks can be more complex. He also is now oriented to the time of day so is able to initiate moving on to the next task at the specified time, although he may need an alarm to compensate. He needs to have his errors corrected for him so that he does not learn inappropriate ways to carry out tasks.

Level 4: “Follow a Time Schedule” is the beginning of mid-level functioning. Since the person showed at earlier levels that he knows what time it is, he is now expected to not only keep track of what tasks to carry out during the session – but also remember to start and stop them on time. At this stage the person has learned to find his way within the immediate therapy room and is branching out to nearby roooms. He may be using a compensatory device (low tech or high tech) to compensate for deficits in time management or memory. He may need supervision to carry out unfamiliar tasks. He often does not realize that he is making errors until they are pointed out to him.

Level 5: “Beyond the Room” is the level where the person starts to practice finding his way within buildings. There are 3 types of activities to practice: “Repeats”, “Sequenced Routes” and “Complex Scavenger Hunts”. A main focus at this level is to determine what navigation method works best for the person to find his way. This includes using maps, reading signs, attending to landmarks, asking for directions and reading directions. At this level the person can attend to time points while engaged in complex tasks. He is also starting to use mental strategies to keep himself organized and stay on time. He is starting to become aware that he is having difficulties but may deny it.

Level 6: “Organize the Therapy Hour” is the first level where the therapist begins to reduce the amount of structure he provides the person during the session. Thus the activities at this level are designed to have the person practice executive functioning skills. The therapist still declares what tasks and/or exercises he wants the person to complete – but it is up to the person to organize those tasks and exercises. He needs to plan by prioritizing tasks according to rules, adhering to time limits, estimating time needed for tasks and finally carrying them out. A major emphasis at these higher levels is to guide the person in “thinking about what he is thinking about” to develop self-awareness.

Level 7: “Out the Door” is the community reintegration phase of cognitive rehab. The activities at this level allow the person to show that he is safe and efficient navigating unfamiliar community environments. Persons who are at this level are on the way to being independent – able to care for themselves and manage in the community including driving or using public transportation. Lesson plans for this level have the person practice planning efficient routes and attending to safety in community settings. He may need to use compensatory devices or mental strategies to make up for his deficits. He is beginning to develop insight into his problem areas and learning to compensate as necessary.

Level 8: “Planning/Multi-tasking” is the highest in the hierarchy. Persons at this cognitive level have good potential to return to their pre-morbid roles including home management, return to school and work. The therapist asks the person to carry out complex projects and high level multitasking activities during the session. There is very little structure provided to the person as he is presented these activities. The therapist’s role is to provide guidance to the person and get him to think about how he can be more efficient as he performs higher level compensatory techniques to carryout out projects. The person is taught to question what he is doing and generate alternative solutions when problems arise.