Documentation Requirements

The provision of all reasonable accommodations and services are based upon assessment of the impact of the student’s disability on his/her academic performance at any given time. Therefore, providing recent and appropriate documentation relevant to the student’s learning environment is in the student’s best interest. A school plan such as an individualized education program (IEP) or a 504 plan is insufficient documentation, but it can be included as part of a more comprehensive assessment battery. Individual "learning styles," "learning differences," "academic problems" and "test difficulty or anxiety," in and of themselves, do not constitute a learning disability. In addition, a prior history of accommodations does not, in and of itself, validate the provision of a similar accommodation. Please refer to the guidelines below when submitting documentation. Review the Services for Students with Disabilities handbook for more specific information.  * Please be advised that in order to protect confidentiality, we do not accept faxed documentation. Students are encouraged to bring documentation with them when meeting with the Disability Services Coordinator.

Guidelines for ADD/ADHD Disorder Documentation

Rationale: Attention-Deficit Hyperactivity Disorder poses a particular difficulty to the evaluator of adults and older adolescents. It does so not only because it requires the mental health professional to delve deeply into the individuals past behavior, but because ADHD shares overlapping symptoms with a host of psychiatric disorders and medical conditions. Therefore, a complete evaluation that includes information from multiple sources, objective measures such as rating scales and personality inventories, diagnostic clinical interviews, academic records, etc. has the best chance of making a clear and definitive diagnosis possible.

Even with students who have been diagnosed as a child or young adolescent either by a physician, psychologist, or other mental health professional, need a current evaluation because the symptom pattern can change over time, the level of severity of impairment will alter in specific areas over time, and the accommodation needs may differ as a student gets older and/or develops compensatory skills and coping strategies.

The report should be current (no more than three years old) on letterhead, typed, dated, signed and otherwise legible.

1. The ADHD evaluation should be conducted by a licensed psychologist or other mental health professional qualified by academic coursework, supervised training, and experience.
2. The ADHD evaluation should be comprehensive:
   
   

   a. Evidence of early impairment. Because ADHD is by definition an early childhood disorder, it is essential that evaluation contain a clinical summary of historical information establishing presence of the disorder in childhood. The evidence should come from multiple sources. Examples of where this information may be gleaned are:

   • transcripts and reports cards
   • teacher comments, IEP’s, 504 Plans
   • parent and student comprehensive life-span questionnaires, parent and student interviews
   • previous psycho-educational testing
   • retrospective rating scales completed by parents, guardians, siblings, former teachers, and/or other relative who have intimate knowledge of the student’s childhood behavior.

   b. Evidence of current impairment. The evaluation should contain objective evidence of on-going inattentive and/or hyperactive/impulsive behavior that significantly impairs functioning in two or more settings. Again, this evidence should come from multiple sources and not just self-report. This information can be garnered from:

   • rating scales completed by student, former teachers, parents or guardians, siblings, significant others or friends who have known student at least six months, or extended family members who have an intimate knowledge of the students behavior
   • clinical interviews and comprehensive questionnaires completed by students and parents or guardians that cover developmental history, medical history, academic history, family history for presence of ADHD and other learning disorders, educational problems, or psychological difficulties considered appropriate by the examiner
   • review of previous testing
   • review of school records
   • personality inventories such as the Personality Assessment Inventory, the Symptom Checklist 90-Revised, and the Minnesota Multiphasic Personality Inventory-II are good sources of information on overall psychological functioning.

   c. Alternative diagnoses or explanations should be explored. The examiner should investigate the possibility of a dual diagnosis or an alternative psychological, behavioral, neurological, or personality disorder that may confound the diagnosis of ADHD. The clinical interview and personality inventories such as those mentioned above are primary, but not the only, appropriate resources for this information assisting in this process.

   d. Other psychological testing.

i. IQ Tests. Routine administration of a complete individually administered IQ test, such as the Wechsler tests is unnecessary. However, they may be appropriate when there are specific questions about specific cognitive deficits. In most cases a brief screening measure is sufficient. No evaluation should rely mainly on IQ test data in making an ADHD diagnosis.

ii. Continuous Performance Tests. As of this writing none of the popular CPT’s has proven reliable when testing adults. They may be useful to the evaluator by providing an opportunity for him or her to observe the student cope with a task of sustained attention. However, no evaluation should rely heavily on a CPT when making an ADHD diagnosis

e. Evaluation must include a specific diagnosis. The evaluation should contain a specific differential (the student’s impairments are due to ADHD and not some other disorder) diagnosis of ADHD that uses direct language and eschews terms such as "suggests," "is indicative of," or "attention problems." The diagnosis should be based on the Diagnostic and Statistical Manual–IV.

f. Rationale for accommodations. Each student should be treated as an individual. Therefore, any accommodation suggested for a student should be accompanied by the reasons that justify the granting of that accommodation.

3. A typical ADHD evaluation might include, but not be limited to the following:

a. Brief IQ Screen: e.g., Kaufman Brief Intelligence Test, Shipley Institute of Living Scale
b. Comprehensive histories: developmental, medical, educational, social, psychological, occupational, substance use, and family.
c. Multiple source interviews: Interview with student. Corroborative interviews with parents, guardians, teachers, significant others, extended family members, etc. as available.
d. Rating scales: scales assessing student’s retrospective behavior from multiple sources such as student, parents or guardian, former teachers, siblings, significant others, etc. Examples: DSM-IV based scales, Wender Utah Rating Scale.
e. Rating scales: scales assessing student’s current behavior from multiple sources such as student, parents or guardian, former teachers, siblings, significant others, etc. Examples: DSM-IV based scales, Attention-Deficit Scale for Adults, Conners Adult ADD Scales.
f. A personality inventory: an instrument such as the Symptom Checklist 90-Revised, the Personality Assessment Inventory, or the Minnesota Multiphasic Personality Inventory-II
g. CPT: A Continuous Performance Test may be included as a part of an evaluation such as the Conners Continuous Performance Test, the Gordon Diagnostic System, or the Test of Variable Attention. No evaluation should rely solely or too heavily for a definitive diagnosis.

4. While close adherence to the guidelines greatly increases the likelihood of an evaluation’s acceptance, there may be situations where the documentation may deviate from the guidelines and still be acceptable. Each individual’s circumstances will be considered on a case-by-case basis. If you have any questions regarding your documentation, please contact the Disability Services Coordinator.

(The information in the section above was developed by Dr. G. Atkinson, Clemson University, Clemson, SC. Used and/or adapted with permission, July 3, 2003.)

Guidelines for Learning Disability Disorder Documentation

All reports should be current within 3 years, typed on official letterhead, dated, signed, and include specific recommendations for reasonable accommodations. Professionals conducting assessments must be qualified to do so. The evaluation must be done by a Licensed Psychologist, LD Specialist, Neurosychologist, or an appropriately credentialed psycho-educational professional.

Acceptable documentation must include:

• A summary of a comprehensive diagnostic interview
• Clear and specific evidence that a learning disability does or does not exist
• A comprehensive assessment of aptitude
• A comprehensive academic achievement battery with all subtests and standard scores reported for those subtests administered
• Include specific areas of information processing
• Evidence that the evaluator has ruled out alternative explanations for academic problems such as poor education, poor study habits, /motivation, emotional problems, attentioanl problems, and cultural/language differences.
• A detailed description of how disability impacts/ limits a major life activity in a learning context.
• Nature of learning disability and specific diagnosis as designated in the current edition of the Diagnostic and Statistical Manual.
• A description of severity/longevity of condition; and
• Indication of why specific accommodations are needed and how the effects of the specific disability are accommodated
• Indication of prior accommodations or auxiliary aids and conditions under which accommodations were used (e.g. standardized testing, licensing exams, etc.)

Guidelines for Psychiatric Disabilities

Documentation for a psychiatric disability needs to be submitted on official letterhead, dated, signed, and should include the following components:

• A specific diagnosis by a licensed professional, qualified in the appropriate discipline.
• A clear statement of the illness (DSM IV coded), summary of the present symptoms, and a prognosis.
• Documentation needs to be current, describe how the condition impacts the student’s learning environment, current status of student, and recommendations for accommodations.
• Medical information relating to the impact of medication and/or treatment on the student’s ability to participate in all aspects of the academic environment.
• Recommendations for accommodations must be supported by disability related rationale.

Guidelines for Physical Disabilities

Due to the variation of physical disabilities, students need to contact the Disability Services Coordinator to determine appropriate documentation on an individual basis.