ADA-based accommodations in higher education: a survey of clinicians about documentation requirements and diagnostic standards

De-Implementing Inappropriate Accommodations Practices

Educational accommodations, which alter the manner in which instruction or assessments are administered, are often an appropriate part of a student’s academic program. However, accommodations are frequently overused and have significant limitations. De-implementing inappropriate accommodations is a complex task, but one made easier through a clear understanding of the factors that cause and maintain those accommodations practices. In the present paper, we use the logic of functional behavioral assessment to better understand why evaluators and school staff recommend and provide inappropriate accommodations. We identify problematic background beliefs, specific antecedents, and reinforcing consequences for inappropriate accommodations, before describing several effective strategies for de-implementing those accommodations.

How Is ADHD Assessed and Documented? Examination of Psychological Reports Submitted to Determine Eligibility for Postsecondary Disability

Objective: To examine how ADHD evaluations are documented for postsecondary students requesting disability eligibility. Method: A total of 100 psychological reports submitted for eligibility determination were coded for documentation of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, methods and instruments used in the evaluations, and recommended academic accommodations. Results: Results showed that a minimal number of reports (≤1%) documented that students met all DSM criteria for ADHD. Psychologists rarely documented childhood impairment, symptoms across settings, or the use of rule-outs. Symptom severity was emphasized over current impairment. The majority of psychologists utilized a multi-informant, multi-method evaluation approach, but certain methods (e.g., symptom validity tests, record reviews) were limited in use. Most reports included recommendations for academic accommodations, with extended time being the most common (72%). Conclusion: This study raises awareness to the aspects of adequate ADHD evaluation and subsequent documentation that can be improved by psychologists. Recommendations are made regarding valid documentation of ADHD for disability determination purposes.

Comparing Age- and Grade-Based Norms on the Woodcock-Johnson III Normative Update

There has been a marked increase in accommodation requests from students with disabilities at both the postsecondary education level and on high-stakes examinations. As such, accurate identification and quantification of normative impairment is essential for equitable provision of accommodations. Considerable diversity currently exists in methods used to diagnose learning disabilities, including whether an impairment is normative or relative. This study investigated the impact on impairment classification if grade-based norms were used to interpret identical raw scores compared with age-based norms. Fourteen raw scores distributed equally across the adult range of the Woodcock-Johnson III Normative Update subtests were scored using norms for either age (18-29 years) or grade (13-17). The results indicate that raw scores receive a significantly lower standardized score (and thus percentile ranking) when grade-based norms are used. Furthermore, the difference between age- and grade-based scores increases dramatically as raw scores decrease, and there is a significant interaction between age and grade in the standard scores obtained. This study provides evidence to suggest that using different norms may result in different decisions about diagnoses and appropriate accommodations.

Evaluation and Management of Mental Health Disability in Post-secondary Students

PURPOSE OF REVIEW

Due to the interdisciplinary nature of mental health disability in post-secondary educational settings, there is limited information available in the general psychiatric literature. This paper aims to familiarize psychiatrists with issues surrounding mental health disability in post-secondary educational settings. In this manuscript, we review critical aspects of the evaluation and management of post-secondary students who may be entitled to academic accommodations as a result of impairment from psychiatric diagnoses. We discuss common misconceptions about mental health impairment and best practices to mitigate its burden. We review relevant legislation and literature from psychiatric, psychological, and higher education journals and include multidisciplinary expert opinions.

RECENT FINDINGS

Mental illness is increasingly common in the post-secondary student population. When symptoms are severe, they can lead to academic impairment or disability. Nationwide data suggests an increase in post-secondary students requesting accommodations for mental health-related impairments. Recent guidelines from the American Psychiatric Association and The Jed Foundation aim to familiarize mental health providers, evaluators, administrators, students, and their families with best practices related to evaluating and managing mental health disability in post-secondary educational settings. Evaluating, accommodating, and managing mental health disability during the post-secondary years are complicated processes. Legislation and nuanced evaluations can guide evaluating psychiatrists and administrators in recommending appropriate accommodations. By being knowledgeable about relevant legislation, best practices for evaluations, and available student resources, psychiatrists will be able to collaborate effectively with all stakeholders.

ADHD Assessment in College Students: Psychologists’ Adherence to DSM-5 Criteria and Multi-Method/Multi-Informant Assessment

The evidence-based assessment of attention-deficit/hyperactivity disorder (ADHD) depends on adherence to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) diagnostic criteria and reliance on multi-method/multi-informant data. Although nearly all psychologists endorse these practices, college students with ADHD may lack documentation supporting their diagnoses. We reviewed the documentation submitted by 214 undergraduates diagnosed with ADHD and receiving academic accommodations for this condition. Their clinicians also completed a checklist that described their assessment procedures. Relatively few psychologists assessed all DSM-5 criteria, based on either the psychologist’s self-reported assessment procedures (23.4%), written documentation (14.0%), or multi-method/multi-informant data (10.3%) such as educational/medical records, results of rating scales, or interviews with other informants. Psychologists were least likely to assess students’ areas of impairment or to rule out alternative causes for students’ self-reported symptoms. This lack of adherence to DSM-5 criteria and overreliance on students’ self-reports can threaten the reliability of diagnosis and the appropriateness of medication and accommodations that follow.

Accommodation Decision Making for Postsecondary Students With Learning Disabilities: Individually Tailored or One Size Fits All?

Clinicians uniformly recommend accommodations for college students with learning disabilities; however, we know very little about which accommodations they select and the validity of their recommendations. We examined the assessment documentation of a large sample of community college students receiving academic accommodations for learning disabilities to determine (a) which accommodations their clinicians recommended and (b) whether clinicians' recommendations were supported by objective data gathered during the assessment process. In addition to test and instructional accommodations, many clinicians recommended that students with learning disabilities should have different educational expectations, standards, and methods of evaluation (i.e., grading) than their nondisabled classmates. Many of their recommendations for accommodations were not supported by objective evidence from students' history, diagnosis, test data, and current functioning. Furthermore, clinicians often recommended accommodations that were not specific to the student's diagnosis or area of disability. Our findings highlight the need for individually selected accommodations matched to students' needs and academic contexts.

Psycho-Educational Evaluations for University Students in One Clinic

The number of university students requesting services based on the Americans with Disabilities Act for learning disabilities and ADHD-related difficulties has increased, although there are limited reports in the literature describing these evaluations. The current study describes a sample of 140 individuals (59% women) who presented for psycho-educational evaluation at the university psychology clinic. The students were individually administered self-report, cognitive, academic, and attention measures as indicated, and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Difficulties with mathematics, attention, and reading concerns were the most frequent presenting complaints. 46 students met criteria for one or more learning disorders and 20 students met criteria for a diagnosis of ADHD. Test scores are summarized and findings compared with the literature.

When Average Is Not Good Enough: Students With Learning Disabilities at Selective, Private Colleges

Adolescents with learning disabilities disproportionately come from lower socioeconomic status backgrounds, show normative deficits in academic skills, and attend 2-year, public colleges instead of 4-year institutions. However, students with learning disabilities are well represented at the United States' most expensive and selective postsecondary institutions. We examined the psychoeducational functioning of students receiving accommodations for learning disabilities at a private, selective, liberal arts college. We also determined whether students had objective evidence supporting their disability diagnoses and academic accommodations. Most students showed above-average cognitive abilities, average academic skills, and no evidence of impairment. Although nearly all students reported academic problems, most lacked objective evidence of academic difficulties prior to college as well as relative or normative deficits in broad academic skills or fluency. Results indicate a need for greater reliance on objective, multimethod/multi-informant data in the diagnostic process. Results also highlight limitations in the current professional guidelines for documentation decision making in higher education.

Postsecondary ADHD Documentation Requirements: Common Practices in the Context of Clinical Issues, Legal Standards, and Empirical Findings

OBJECTIVE

To evaluate the information postsecondary institutions require when determining disability service eligibility for students with reported ADHD.

METHOD

ADHD documentation requirements of 200 U.S. institutions were surveyed by reviewing guidelines posted on disability services websites.

RESULTS

Whereas virtually all institutions required documentation, findings revealed significant variability in requirements across institutions. Required variables most often included a qualified evaluator (80%), diagnostic statement (75%), and identification of substantial limitations (73%), but only 5 of 46 evaluated variables were required by at least 50% of institutions. Supportive data such as diagnostic criteria, standardized assessment results, and rationale for accommodations were rarely required.

CONCLUSION

The majority of institutions required little to verify ADHD as a disability. Furthermore, there was little agreement on what components are essential for verification. When integrated with research, a large portion of guidelines failed to address identified weaknesses in ADHD diagnosis and disability determination.

Effects of Extended Time for College Students With and Without ADHD

OBJECTIVE

The number of students with a disability requesting test accommodations has been steadily increasing in higher education settings. The present study examined the effects of extra time on the reading comprehension performance of college students with and without ADHD.

METHOD

A modified version of The Nelson-Denny Reading Test was completed by 38 college students with ADHD and 38 matched controls under three conditions: standard time, time and one half, and double time.

RESULTS

Groups did not differ in the number of items attempted or correctly answered at standard time, time and one half, or double time. Comparing the ADHD group at extended time to non-ADHD peers at standard time, the ADHD group attempted and answered significantly more test items.

CONCLUSION

Extra time conferred an advantage to the ADHD group, suggesting that extended time accommodations are not specific and perhaps not necessary for all college students with an ADHD diagnosis.

Community college students with learning disabilities: evidence of impairment, possible misclassification, and a documentation disconnect

Recent research suggests that most 4-year college students diagnosed with specific learning disability (SLD) do not meet objective criteria for the disorder, show normative deficits in academic skills, or have childhood histories of SLD. The purpose of this study was to examine the functioning of students diagnosed with SLD attending community college. We reviewed SLD documentation for 359 community college students previously diagnosed with SLD and receiving academic accommodations. Most students met objective criteria (82.3%) and were first diagnosed in childhood (93.3%). Most students also showed average intellectual functioning and below-average to borderline academic achievement. However, 27.3% showed uniformly low ability and achievement scores, suggesting possible misclassification. Students who failed to meet objective criteria for SLD often submitted test data that lacked current, adult-normed standardized test scores; many were diagnosed based on response to intervention and submitted only an individualized education program or summary of performance. This finding provides initial evidence of a disconnect between the qualitative documentation that secondary schools provide and the quantitative documentation that postsecondary institutions require for SLD classification.

Documenting Hidden Disabilities in Higher Education

Once students with disabilities leave high school, they must take proactive steps to document their disabilities to educational institutions or employers when requesting accommodations. The Association on Higher Education and Disability (AHEAD) has been the principal organization offering suggestions on documentation requirements, and AHEAD’s recently revised guidance involves radical changes to the suggested requirements. AHEAD now recommends that students’ self-reports and disability services professionals’ impressions take precedence over external, objective records. This article reviews the relevant research to evaluate the evidence base for the revised guidance, finding it lacking in important ways as it applies to hidden disabilities (learning, cognitive, and psychiatric disabilities). The evidence supporting various sources of disability documentation is reviewed, and implications for policy and practice are discussed.

Documenting Disabilities in Postsecondary Settings

Increasing numbers of students with learning disability and attention deficit/hyperactivity disorder (ADHD) diagnoses are applying for accommodations in postsecondary education and employment settings. However, students’ documentation of these conditions is often substandard. One possible reason for this is that clinicians have failed to apply proper criteria when determining disability status. We surveyed 119 clinicians who diagnosed these conditions in students applying for accommodations to determine clinician levels of knowledge about appropriate diagnostic and legal standards. We found weak clinician knowledge on certain key issues, including the meaning of functional impairment and understanding of the different laws governing academic accommodation of children versus adults. The average respondent’s score on a 30-item true/false questionnaire was only 69% correct. Implications of these results for practice and future research are discussed.

Testing Accommodations Under the Amended Americans With Disabilities Act

The 2008 amendments to the Americans With Disabilities Act have now been followed by implementation guidelines from the Department of Justice. These guidelines take strong positions on how testing entities should review requests for testing accommodations from examinees with disabilities. In this article, themes from the guidelines are evaluated against the findings of recent empirical research, highlighting major discrepancies. In general, the Department of Justice places more trust in the accommodations expertise of K–12 schools, clinical professionals, and testing entities than is warranted by empirical research. This trust is likely to lead to excessive recommendation of testing accommodations, even when they threaten a test’s validity. Several implications of these findings for practice and policy are discussed.

Easier Said Than Done

A Canadian context for the diagnosis of students with specific learning disabilities (LD) was investigated in the present literature review. A systematic review of the literature was undertaken to determine the current and best practices in this field. Overall, no agreed upon definition of LD was identified, although core similarities in definitions were noted. Furthermore, recent research shows that many psychological assessments fail to adhere to any one definition when making this diagnosis, and as a result the diagnosis may or may not reflect the presence of a permanent disability that impairs academic functioning at the postsecondary level. There is, therefore, a need to adopt a consistent, evidence-based approach to diagnosis of LD in Canada. Recommendations regarding best practices and appropriate criteria for diagnosis of LD are discussed.

Assessment of ADHD documentation from candidates requesting Americans With Disabilities Act (ADA) accommodations for the National Board of Osteopathic Medical Examiners COMLEX exam

PURPOSE

Every year increasing numbers of candidates request special accommodations for high-stakes medical licensing examinations, due to ADHD, on the basis of the Americans with Disabilities Act (ADA). This poses significant challenges for both the applicant and the medical boards and has significant financial, legal, and ethical implications. The purpose of this survey is to review all applications requesting ADA accommodations, on the basis of ADHD, submitted to the National Board of Osteopathic Medical Examiners (NBOME) COMLEX exam.

METHOD

The authors review all 50 requests for special accommodations, on the basis of ADHD, submitted to the NBOME between 2005 and 2007. All requests are reviewed by the investigators independently and then cross-checked to determine interrater reliability.

RESULTS

Of all applicants, only 14% (7/50) provide sufficient documentation to support a diagnosis of ADHD. Interrater reliability is high.

CONCLUSIONS

The majority of applicants who request special testing accommodations on the basis of ADHD do not provide adequate documentation to the medical boards to support the diagnosis.

Learning Disability Documentation Decision Making at the Postsecondary Level

Students with learning disabilities (LD) transitioning from secondary school to postsecondary education must submit documentation verifying the existence of a disability and that describes a current and substantial limitation to learning. Preparing acceptable documentation can be a challenge for secondary personnel because of differing laws at the secondary and postsecondary levels and because of variation in the type of data required by each school. This study presents the results of a survey of 183 postsecondary disability service providers related to frequently required components of LD documentation. Although a clear diagnosis of LD was required by most respondents, there was variation in regard to other key components. Implications and suggestions for secondary transition practice are presented.

The Relation Between Comprehensive Assessment Procedures and Diagnostic Stability in School-Aged Children Identified With Learning Disabilities

Learning Disabilities (LDs) affect a significant number of students in elementary and secondary school. In order for these students, along with parents and teachers, to understand the nature of their specific difficulties, and have equal opportunity in academic settings, a comprehensive psychological report containing properly informed recommendations for accommodations must be provided. In the present study, previous psychological assessment reports of 100 Grade 7 and 8 LD identified students were evaluated based on gold standard criteria. Previous and current diagnoses were compared to test the hypothesis that less comprehensive previous assessment reports would be significantly associated with a change in diagnosis between assessments. This hypothesis was supported. In addition, many previous reports did not use a complete battery of tests or have a clear diagnostic statement. It was found that the various types of practitioners conducting preliminary assessments were a significant cause for disparity between reports. Recommendations for improved early diagnostic practices are discussed.