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Documentation Information by Disability Type

Learning Disability

Assessments pertaining to a learning disability must provide clear and specific diagnostic evidence that a learning disability does or does not exist, and includes a ruling out of alternative explanations for the presenting symptoms. For diagnostic purposes, descriptions of "learning differences" or "learning styles" are insufficient. In addition, the adult version of assessment instruments should be administered (e.g. the WAIS-III instead of the WISC-III). The summary and recommendations should provide a clear explanation of how the learning disability impacts the student's ability to function in a major life activity (e.g. learning), with recommendations for accommodations that directly relate to the current testing results. Recommendations based upon past services rather than on current test results are not acceptable.

Attention Deficit/Hyperactivity Disorder

The following should be included in a comprehensive assessment:

A clinical summary of objective historical information, identifying symptoms indicative of ADHD throughout childhood, adolescence, and adulthood as revealed from report cards, teacher comments, and past psycho-educational testing; and third party interviews when available. Testing/documentation should be provided by professionals trained in diagnosing AD/HD. Such professionals include licensed clinical psychologists or neuropsychologists, psychiatrists, and/or other relevantly trained medical doctors. Documentation of ADHD should include the following:

• Evidence of early impairment;
• Evidence of impairment in two or more current settings (home and school; school and work, etc.);
• Psychological evaluation, with identification of DSM-IV criteria met
• Diagnosis based on DSM-IV criteria. The evaluator should use direct language in the diagnosis of ADHD, avoiding the use of terms such as "is indicative of," or "attention problems." Individuals who report only problems with organization, test anxiety, memory and concentration in selective situations do not fit the diagnostic criteria for ADHD;
• Assessment of achievement;
• Description of medications and/or educational interventions used.

Psychiatric Disabilities

The term "psychiatric disabilities" is a generic term, referring to a variety of conditions involving psychological, emotional and behavioral disorders and syndromes, used for the purpose of determining eligibility for accommodations; and those symptoms must rise to the level of a disability as defined by Section 504 and ADA. The most common guide used to outline the criteria used in making these diagnoses is the Diagnostic and Statistical Manual, IV (DSM-IV). Please note that not all conditions listed in the DSM-IV are disabilities, or even impairments for purposes of 504/ADA. Therefore a diagnosis does not, in and of itself, constitute a disability necessitating legal accommodations under the ADA or 504 of the Rehabilitation Act of 1973. In most cases, documentation should be based on a comprehensive diagnostic/clinical evaluation that adheres to the guidelines outlined in this document.

Documentation should be provided by a licensed psychiatrist, psychologist, neuropsychologist, or clinical social worker. The diagnostic report should include the following components: a specific diagnosis; a description of current functional limitations in the academic environment; relevant information regarding medications expected to be in use during test administration and the anticipated impact on the test taker in this setting; relevant information regarding current treatment; and a specific request for accommodations with accompanying rationale.

Documentation of Psychiatric Disabilities should include the following:

1. Historical Information and Diagnostic Interview:
• History of presenting symptoms;
• Duration and severity of the disorder;
• Relevant developmental, historical, and familial data.
• Relevant medical and medication history, including the individual's current medication regimen and compliance, side effects (if relevant) and response to medication;
• Description of current functional limitations in different settings with the understanding that a psychiatric disability usually presents itself across a variety of other settings in addition to the residential and academic domain and that is expression is often influenced by context-specific variables (e.g., school-based performance);
• As relevant to the residential domain, a description of observed behaviors which likely impact dormitory life, and progression or stability of the impact of the condition over time;
• As relevant to the test taking performance, a description of the expected progression or stability of the impact of the condition over time;
• As relevant to the test taking performance, information regarding kind of treatment and duration and consistency of the therapeutic relationship.
2. A specific diagnosis.
3. A description of current functional limitations in the academic environment as well as across other settings.
4. Relevant information regarding medications expected to be in use and their anticipated impact on the student in this setting.
5. Relevant information regarding current treatment.
6. Specific request for accommodations with accompanying rationale.

Physical Disabilities

In most cases, documentation should be based on a comprehensive diagnostic/clinical evaluation that adheres to the guidelines outlined in this document. Documentation should be provided by a qualified physician. Documentation does not need to meet the three year current documentation standard if the condition is considered to be permanent or unchanging in nature. Conditions which are known to change over time or that have evidenced recent change may necessitate more current evaluation.

In addition to a history of presenting symptoms, date of onset, duration and severity of the disorder, and relevant developmental and historical data, the diagnostic report should include the following components:

• A specific diagnosis;
  A description of current functional limitations in the academic environments, as well as across other settings. The description should include medical information describing the degree to which the current functional limitations restrict the condition, manner, or duration under which the student can engage in academic activities;
• Relevant information regarding any medications that may impact academic performance; relevant information regarding current treatment for this or any other conditions, and the degree of impact on test taking or need for academic accommodations;
• Rationale for each accommodation requested. A link must be established between the requested accommodations and the functional limitations of the individual that are pertinent to the anticipated accommodations requested.