Documenting attention-deficit/hyperactivity disorder
Evaluations for accommodations based on Attention-Deficit/Hyperactivity Disorder (ADHD) must include the following:
- Assessment by a Qualified Evaluator
- Current Testing/Assessment
- Comprehensive Documentation
- Relevant Assessment Batteries
- Review of DSM-IV Criteria
- Specific Diagnosis
- Clinical Summary
- Rationale for Accommodations
Assessment by a Qualified Evaluator
As with other disabilities, the evaluation must be conducted by a qualified evaluator. Professionals conducting assessments and rendering diagnoses of ADHD must be qualified to do so. Comprehensive training in the differential diagnosis of ADHD and other psychiatric disorders and direct experience in diagnosing and treating adults is necessary. The evaluator’s name, title, and professional credentials, including information about his or her license or certification as well as the area of specialization, employment, and state in which the individual practices should be clearly stated in the documentation.
Testing/assessment must be current. The determination of whether an individual is significantly limited in functioning is based on how the impairment currently affects the individual’s ability to take an exam. An evaluation or an update should have been conducted within the past five years.
Documentation substantiating the ADHD must be comprehensive. Because ADHD is, by definition, first exhibited in childhood (although it may not have been formally diagnosed) and in more than one setting, objective, relevant, historical information is essential. Information verifying a chronic course of ADHD symptoms from childhood through adolescence to adulthood-such as educational transcripts, report cards, teacher comments, tutoring evaluations, job assessments, and the like-are necessary.
- The evaluator is expected to review and discuss DSM-IV diagnostic criteria for ADHD and describe the extent to which the candidate meets these criteria. The report must include information about the specific symptoms exhibited and document that the candidate meets criteria for long-standing history, impairment, and pervasiveness.
- A history of the individual’s presenting symptoms must be provided, including evidence of ongoing impulsive/hyperactive or inattentive behaviors (as specified in DSM-IV) that significantly impair functioning in two or more settings.
- The information collected by the evaluator must consist of more than a self-report. Information from third-party sources is critical in the diagnosis of ADHD. Information gathered in the diagnostic interview and reported in the evaluation should include, but not necessarily be limited to, the following:
- History of presenting attention symptoms, including evidence of ongoing impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time
- Developmental history
- Family history for presence of ADHD and other educational, learning, physical, or psychological difficulties deemed relevant by the evaluator
- 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 education
- A review of psycho-educational test reports to determine if a pattern of strengths or weaknesses is supportive of attention or learning problems
- Evidence of impairment in several life settings (such as home, school, work) and evidence that the disorder significantly restricts one or more major life activities
- Relevant employment history
- A description of current functional limitations relative to the NCEES exam in particular that are presumably a direct result of the described problems with attention
- A discussion of the differential diagnosis, including alternative or coexisting mood, behavioral, neurological, and/or personality disorders that may confound the diagnosis of ADHD
- An exploration of possible alternative diagnoses that might mimic ADHD
Relevant Assessment Batteries
A neuropsychological or psycho-educational assessment may be necessary in order to determine the individual’s pattern of strengths or weaknesses and to determine whether there are patterns that support attention problems. Test scores or subtest scores alone should not be used as the sole basis for the diagnostic decision. Scores from subtests on the Wechsler Adult Intelligence Scale-III (WAIS-III), memory functions tests, attention or tracking tests, or continuous-performance tests do not in and of themselves establish the presence or absence of ADHD. They may, however, be useful as one part of the diagnostic process. Checklists and/or surveys can supplement the diagnostic profile but by themselves are not adequate for the diagnosis of ADHD. When testing is used, standard scores must be provided for all normalized measures.
Review of DSM-IV Criteria
The diagnostic report must include a review of the DSM-IV criteria for ADHD both currently and retrospectively and specify which symptoms are present (see DSM-IV for specific criteria). According to DSM-IV, “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.” Other criteria include the following:
- Symptoms of hyperactivity-impulsivity or inattention that cause impairments that were present in childhood
- Current symptoms that have been present for at least the past six months
- Impairment from the symptoms present in two or more settings (school, work, home)
The report must include a specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. Individuals who report problems with organization, test anxiety, memory, and concentration only on a situational basis do not fit the prescribed diagnostic criteria for ADHD. The use of any medications, and their effectiveness, should be reported. A positive response to medication by itself is not supportive of a diagnosis, nor does the use of medication in and of itself support or negate the need for accommodation.
A well-written clinical summary based on a comprehensive evaluative process is a necessary component of the assessment. The clinical summary must be written by the qualified evaluator and must include the following:
- Demonstration that the evaluator has ruled out alternative explanations for inattentiveness, impulsivity, and/or hyperactivity as a result of psychological or medical disorders or noncognitive factors
- Indication of how patterns of inattentiveness, impulsivity, and/or hyperactivity across the life span and across settings have been used to determine the presence of ADHD
- Indication of the substantial limitation presented by ADHD and the degree to which it affects the individual in the context for which accommodations are being requested
- Indication as to why specific accommodations are needed and how the effects of ADHD symptoms, as designated by the DSM-IV, are mediated by the accommodations
Rationale for Accommodations
The evaluator must describe the impact of ADHD (if one exists) on a specific major life activity, as well as the degree of significance of this impact on the individual. The diagnostic report must include a specific, detailed explanation as to why each accommodation is recommended and should be correlated with specific identified functional limitations. Documentation should address the need for accommodations based on the individual’s current level of functioning. The documentation should include any record of prior accommodations or auxiliary aid, including information about specific conditions under which the accommodation was used (for example, standardized testing, final exams). However, a prior history of accommodation without demonstration of a current need does not in and of itself warrant the provision of a similar accommodation. If no prior accommodation has been provided, the qualified professional and/or individual being evaluated should include a detailed explanation as to why no accommodation was used in the past and why accommodation is needed at this time.
Because of the challenge of distinguishing ADHD from normal developmental patterns and behaviors of adults—including procrastination, disorganization, distractibility, restlessness, boredom, academic underachievement or failure, low self-esteem, and chronic tardiness or inattendance—a multifaceted evaluation must address the intensity and frequency of the symptoms and whether these behaviors constitute an impairment in a major life activity.