A failure to provide a positive experience while doing the activity is a serious problem for an affirmative activity, but no big deal for an evaluative activity. To sustain long-term engagement in doing the activity, an affirmative sense of some kind must be formed.

When creating affirmative activities, obsolete identities can often be seen as an obstacle. The person may dislike doing activities which are seen as being beneath them. They may refuse treatment as they do not see themselves as having a problem. Using the person's obsolete identity to create affirmative activities may be the solution. Nancy Reagan would help her husband Ronald Reagan get ready for a "working day at the office". He would eat breakfast, get dressed nicely in his suit and go to the office. The secretaries had blank paperwork for him to sign and he was happily occupied.

A favorable sense of identity, comfort, safety, security, satisfaction, pleasure, or achievement can be formed while people with a cognitive disability are doing activities. Measures of attendance and sustained attention time can quantify being busy. We all know that being busy is not always affirmative, i.e. a necessary evil. Confirming the value and dignity of a person requires a decent lifestyle that includes favorable activity experiences. Nothing to do between meals is the antonym, and the message received by the person is disrespectful.

Direct assistance is required when the person is unable to carry out all or part of the task. Sometimes the caregiver needs to set up the task when the person lacks the ability to plan the task, e.g. for a person functioning in ACL 3 High, the caregiver lines up the clothing on the bed in the correct order for the person to get dressed.

Verbal Cues

Verbal cues are one or two word phrases used to prompt the person into action. Verbal cues are only helpful when the person has a mental picture of what they need to do.

Visual Cues

Visual cues is information that the person can understand which prompts them into action.

To change the task, you can either:

• Select a task that only uses the qualities of information that the person can pay attention to.
• Limit the duration of the task to fit within their attention span.
• Slow down the task to match their information processing speed.

Use the title of the modes to see all the information that the person can use and all the information that is ignored. Remember that the scale is hierarchical.

You can adjust task demands by either changing the task, providing cues and demonstrations or direct assistance.

A description of the ACLs has been created that can be included in the appendices of the report. This information is downloadable here.

The recommendations will directly relate to the reason for writing the report. Having worked with others who have to read these reports, I know their pet hate is when clinicians write a recommendation and don't explain nor justify it. Not stating the logic behind your recommendation is not a convincing way to write a report.

Communication strategies are listed for the person and significant others in the modes. Communication strategies use the quality of information that the person is able to understand. I really enjoy working with the Speech Language Pathologists in the US. I wish this group of clinicians would spread to use of the ACDM internationally to their speech counterparts.