(available in PDF format, 8.5" x 14" 4-fold: Attention-Deficit/Hyperactivity Disorder Documentation Guidelines)
Definition of Disability
The Americans with Disabilities Act (ADA), as amended by the ADA Amendments Act of 2008, and Section 504 of the Rehabilitation Act of 1973 are Federal laws that offer protection to individuals with disabilities. They prohibit discrimination and mandate the granting of accommodations to ameliorate the impact of disabling conditions. The goal is to afford equal access and opportunity for qualified persons with disabilities. In order to determine whether an individual is entitled to these protections for a disability due to Attention-Deficit/Hyperactivity Disorder (ADHD), SDS requires objective evidence (documentation). Such documentation must corroborate that the individual’s condition fits the definition of “disability.”
These laws define disability as:
- a physical or mental impairment that substantially limits one or more of the major life activities of such individual,
- a record of having such an impairment, or
- being regarded as having such an impairment.
A condition is considered a disability if it prevents or substantially limits the ability to perform a major life activity, or significantly restricts the condition, manner or duration in performing the major life activity as compared to most people in the population. The analysis of “substantially limits” is a comparative term with regard to the average person on the dimensions of severity and impact. A condition is therefore not a disability if it results in only mild limitations.
The Purpose and Use of Documentation
- To establish the right to protection from discrimination.
Non-discrimination is an assurance that individuals with disabilities will not be excluded from or provided with lesser access to programs and activities based on assumptions rooted in stereotypes or perceptions of ability that are not based in fact. Non-discrimination also provides freedom from harassment based on perceptions of disability.
The documentation submitted to SDS for protection from discrimination based on disability without a request for accommodation can be quite brief. A diagnostic statement from an appropriate professional, a past history of recognition as a person with a disability, or self-identification including information related to how others may regard the individual as having a disability could suffice as the basis for protection from discrimination.
- To understand the impact of the condition in a university setting and to determine modifications that may be need to afford equitable access.
If the impact of the disability results in a barrier to equitable access or opportunity, reasonable accommodations can be provided to address the barrier. Reasonable accommodations include modifications to a policy, procedure or practice and the provision of auxiliary aids and services. Accommodations are deemed unreasonable when they fundamentally alter the nature of a program or service or represent an undue administrative or financial burden.
Documentation required for the provision of accommodations or services must clearly identify the functional limitation(s) of the condition and provide information that identifies how the current impact of the disability is expected to interact with the university’s structure of courses, testing methods, program requirements, etc.
Cornell University requires current documentation of disabilities using well-known diagnostic criteria that are valid for adult populations. ADHD Disability documentation must include the following elements:
A. Qualifications of the Evaluator
Professionals conducting assessments and rendering diagnoses of ADHD and making recommendations for accommodations must be qualified to do so. Comprehensive training and relevant experience in differential diagnosis and the full range of psychiatric disorders are essential. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports should be on letterhead, typed, dated, and signed.
B. Evidence of Prior Onset and Early Impairment
Because ADHD is, by definition in the DSM-IV-TR, first exhibited in childhood (although it may not have been formally diagnosed) and manifests itself in more than one life setting, providing relevant historical and background information is essential. A comprehensive assessment should include a clinical summary of objective historical information that establishes the presence of ADHD symptoms throughout childhood and adolescence as garnered from sources such as: transcripts, report cards, parent and teacher comments, tutoring evaluations, pediatrician's records and prior psycho-educational evaluations. Information collected via a comprehensive diagnostic interview should consist of self-report data and direct observations and this information should be integrated with data from informed and relevant third party sources such as parents, co-workers or teachers. Specific areas of inquiry include:
- Developmental history including birth history, achievement of milestones and maturation
- Family history for presence of ADHD and other educational, learning, physical, or psychological difficulties deemed relevant by the examiner
- Relevant medical and medication history, including the absence of a medical basis for the symptoms being evaluated
- Relevant psychosocial history and any relevant interventions
- A thorough academic history of elementary, secondary, and postsecondary (if applicable) education
- A review of prior psycho-educational test reports to determine whether a stable pattern of strengths or weaknesses is supportive of attention or learning problems
- Relevant employment history, if applicable
- An accounting for any periods during which the student was symptom-free
- Relevant history of prior therapies
C. Evidence of Current Impairment
Statement of Presenting Problem—A description of the individual's present symptoms should be provided, including evidence of ongoing impulsive/hyperactive or inattentive behaviors that significantly impair functioning in two or more settings.
The diagnostic interview and data gathering process should address the following key areas:
- The history of presenting attentional symptoms, including evidence of past impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time
- A description of the current functional limitations in an educational setting (consider academics, housing, student employment)
- A description of accommodations, if any, that have minimized the impact of functional limitations both in the past and in the present
- A description of remediation approaches and/or compensating strategies that are/are not currently effective
D. Specific Diagnosis
The report must include a specific diagnosis of ADHD based on the DSM-IV-TR diagnostic criteria. According to the DSM-IV-TR, “the essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” Just having the symptoms, however, is not sufficient for a diagnosis. In diagnosing ADHD it is important to address the following criteria:
- Symptoms of inattention and/or hyperactivity/impulsivity causing significant impairment must have been present, in some form since childhood or early adolescence
- Current symptoms must have been present for at least the past six months
- Significant impairment from the symptoms is present in two or more settings (e.g., work, home, school)
The diagnostician should use direct language in the diagnosis of ADHD, avoiding the use of such terms and phrases as “suggests,” “may be indicative of,” or “raises suspicion of.”. The evaluator must confidently rule out normal variations in attentional capacity. Individuals who report only selective problems with organization, test anxiety, memory or concentration in restricted situations do not fit the prescribed diagnostic criteria for ADHD. Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself does not confirm a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation.
E. Assessment Information
The assessment of the individual must both establish a diagnosis and demonstrate the current impact of the ADHD on an individual’s ability to learn and/or function in the college environment. Because there is no specific test or combination of tests used for diagnosing ADHD, a multifaceted approach is required. A comprehensive neuropsychological or psycho-educational examination is the principal tool for determining the manner and degree to which the condition impacts the student on academic performance. These assessments include testing of intellect, achievement, processing speed, academic fluency, executive functioning, language, motoric coordination, spatial ability, memory and attention.
Actual test scores (including raw scores and standard score transformations) should be provided for all measures. Age-based norms (as opposed to grade-based norms) should be provided whenever possible as these best represent the reference point of the “average person.” Grade equivalents are not useful unless standard scores and percentiles are also included. Test scores or subtest scores in isolation are not to be used as the determining factor for the diagnosis. Checklists and/or surveys can serve to supplement the diagnostic profile but also are not adequate for a diagnostic determination. The data and clinical observations must serve to support a substantial limitation in learning for which the individual is requesting accommodation.
F. Alternative Diagnoses or Explanations
The evaluator must investigate and discuss the possibility of multiple diagnoses and alternative or coexisting mood, behavioral, neurological, and/or personality disorders that may confound the diagnosis of ADHD. This process should include exploration of possible alternative diagnoses and medical and psychiatric disorders as well as educational and cultural factors affecting the individual that may result in behavioral manifestation akin to Attention-Deficit/Hyperactivity Disorder.
G. Recommendations for Accommodations
The evaluator must describe the impact, if any, of the diagnosed ADHD on a specific major life activity as well as the degree of impact on the individual. The diagnostic report must include specific recommendations for accommodations that are appropriate, logistically feasible and equitable at the postsecondary level of education. A detailed explanation as to why each accommodation is recommended must be provided and should be correlated with specific functional limitations determined through interview, observation, and/or testing.
Although prior documentation may have been useful in determining appropriate services in the past, current documentation must validate the need for services based on the individual's present level of functioning in the educational setting. A school plan such as an Individualized Education Program (IEP) or a 504 plan is insufficient documentation in and of itself but can be included as part of a more comprehensive evaluative report. The documentation must include any record of prior accommodations or auxiliary aids, including information about specific conditions under which the accommodations were used (e.g., standardized testing, final exams, licensing or certification examinations) and whether or not they benefited the individual. However, a prior history of accommodations without demonstration of a current need does not in itself warrant the provision of like accommodations.
If accommodations have not been previously used by the student, the evaluator must include a detailed explanation of why accommodations have not been used in the past but are needed at this time. Because of the challenge of distinguishing normal behaviors and developmental variations in traits and behavioral patterns of adolescents and adults (e.g., procrastination, disorganization, distractibility, inadequate effort levels, restlessness, boredom, academic under-achievement or failure, low self-esteem, chronic tardiness or absenteeism) from clinically significant impairment, a multifaceted evaluation should address the intensity and frequency of the symptoms and whether these behaviors constitute impairment in one or more major life activities.
If the requested accommodations are not clearly identified in the diagnostic report, SDS may seek clarification and, if necessary, more information. SDS will make final determination of whether appropriate and reasonable accommodations are warranted and can be provided to the individual.
For a list of instruments and measures used in the diagnosis of ADHD and/or LD/ADHD, please visit our web site at: http://sds.cornell.edu/forms/ADHD_Assessment_Instruments.pdf