Guidelines for Documentation of Psychiatric Disabilities in Adolescents and Adults

July 2001

Office of Disability Policy
Educational Testing Service
Princeton, NJ 08541

Preface

The mission of the Task Force on Psychiatric Disabilities is to provide individuals, schools, professional diagnosticians and service providers with a comprehensive set of guidelines for documenting psychiatric disabilities. This documentation is necessary to validate both the presence of a disability and the need for reasonable accommodations for candidates seeking to register with various testing programs managed by Educational Testing Service (ETS). ETS acknowledges that each test taker's circumstances are unique, and that a flexible approach to documentation requirements for psychiatric disabilities is helpful to both individuals and their evaluators. These guidelines may also be used by licensing and testing agencies, secondary and postsecondary personnel, and consumers to verify eligibility for reasonable and appropriate accommodations under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA).

ETS encourages all institutions to provide secure storage for confidential and sensitive student information that may be used in support of requests for accommodations.

Confidentiality Statement

ETS will not release any information regarding an individual's diagnosis or documentation without his or her informed written consent or under compulsion of legal process. Information will be released only on a "need to know" basis, except where otherwise required by law. Furthermore, to safeguard the confidentiality of individuals with psychiatric disabilities, evaluators may withhold or redact any portion of the documentation that is not directly relevant to ETS's criteria for establishing a rationale for requested testing accommodations.

ETS encourages all institutions to provide secure storage for confidential and sensitive student information that may be used in support of requests for accommodations.

Introduction

Under the Americans with Disabilities Act (ADA) of 1990 and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and may be entitled to reasonable accommodations and equal access to programs and services. To establish that an individual is covered under the ADA, documentation must indicate that a specific disability exists and that the identified disability substantially limits one or more major life activities. A diagnosis of a disorder/condition/syndrome in and of itself does not automatically qualify an individual for accommodations under the ADA. The documentation must also support the request for accommodations, academic adjustments, and/or auxiliary aids.

ETS recognizes that "psychiatric disabilities" is a generic term used to refer to a variety of conditions involving psychological, emotional, and behavioral disorders and syndromes. The terms psychological disabilities and psychiatric disabilities are used interchangeably in this document. The two official sources designed to outline the criteria used in making these diagnoses are the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV-TR) and the International Classification of Diseases Manual, Tenth Revision (ICD-10). For the purpose of determining eligibility for accommodation, the symptoms must meet the ADA definition of a disability.

This document provides guidelines necessary to establish the impact of psychiatric disabilities on an individual's educational performance and to validate the need for accommodations. In instances where there may be multiple diagnoses, including learning disabilities and/or attention-deficit/hyperactivity disorders (ADHD), evaluators should consult the ETS policy statements at  Test Takers with Disabilities.

Information and documentation submitted by test takers to verify accommodation eligibility must be comprehensive in order to avoid unnecessary delays in decision making related to the provision of accommodations.

This document contains information regarding five important areas:

1. evaluator qualifications
2. recency of documentation
3. comprehensiveness of the documentation to support the diagnosis of a psychiatric disability
4. evidence to establish the functional limitation of the psychological condition supporting the need for accommodation(s)
5. multiple diagnoses

Appendices A, B, and C, respectively, provide recommendations for consumers, suggestions for assessment measures, and a listing of resources and organizations.

Terms

Psychiatric disabilities: Comprise a range of conditions characterized by emotional, cognitive, and/or behavioral dysfunction. Diagnoses are provided in the DSM-IV-TR or the ICD-10. Note that not all conditions listed in the DSM-IV-TR are disabilities, or even impairments for purposes of the ADA. Therefore, a diagnosis of a disability does not, in and of itself, meet the definition of a disability necessitating reasonable accommodations under the ADA or Section 504 of the Rehabilitation Act of 1973.

Major life activity: Examples of major life activities include walking, sitting, standing, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and other similar activities. In particular, individuals with psychiatric disabilities may also experience thinking disorders/psychotic disorders that may interfere with the test-taking situation (e.g., reading, writing, calculating).

Functional limitation: A substantial impairment in the individual's ability to function in the condition, manner, or duration of a required major life activity.

Documentation Requirements

I. A Qualified Professional Must Conduct the Evaluation

Professionals conducting assessments, rendering diagnoses of psychiatric disabilities, and making recommendations for accommodations must be qualified to do so. It is essential that professional qualifications include both (1) comprehensive training and relevant expertise in differential diagnosis of psychiatric disorders and (2) appropriate licensure/certification.

Qualified evaluators are defined as those licensed individuals who are qualified to evaluate and diagnose psychiatric disabilities or who may serve as members of the diagnostic team. These individuals or team members may include psychologists, neuropsychologists, psychiatrists, neuropsychiatrists, other relevantly trained medical doctors, clinical social workers, licensed counselors, and psychiatric nurse practitioners. Documentation may be provided from more than one source when a clinical team approach consisting of a variety of educational, medical, and counseling professionals has been used.

Diagnoses of psychological disabilities documented by family members will not be accepted due to professional and ethical considerations even when the family members are otherwise qualified by virtue of training and licensure/certification. The issue of dual relationships as defined by various codes of professional ethics should be considered in determining whether a professional is in an appropriate position to provide the necessary documentation.

Finally, the name, title, and credentials of the qualified professional writing the report should be included. Information about license or certification, as well as the area of specialization, employment, and state or province in which the individual practices, should also be clearly stated in the documentation. All reports should be in English, typed or printed on professional letterhead, dated, and signed.

II. Documentation Must Be Current

Due to the changing nature of psychiatric disabilities, it is essential that a test taker provide recent and appropriate documentation from a qualified evaluator. Since reasonable accommodations are based upon the current impact of the disability, the documentation must address the individual's current level of functioning and the need for accommodations (e.g., due to observed changes in performance or medication changes since previous assessment). If the diagnostic report is more than six months old the test taker must also submit a letter from a qualified professional that provides an update of the diagnosis, a description of the test taker's current level of functioning during the preceding six months, and a rationale for the requested testing accommodations.

III. Documentation Necessary to Support the Diagnosis Must Be Comprehensive

In most cases, documentation should be based on a comprehensive diagnostic/clinical evaluation that adheres to the guidelines outlined in this document. The diagnostic report should include the following components:

1. a specific diagnosis (see III.B)
2. a description of current functional limitations in the academic environment as well as across other settings (see III.A.5)
3. relevant information regarding medications expected to be in use during test administration and the anticipated impact on the test taker in this setting (see III.A.4)
4. relevant information regarding current treatment
5. a specific request for accommodations with accompanying rationale (see III.D).

III A. Historical Information, Diagnostic Interview, and/or Psychological Assessment

The information collected for the summary of the diagnostic interview should include, but is not limited to, the following:

• 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 compliance, side effects (if relevant), and response to medication
• a description of current functional limitations in different settings with the understanding that a psychological disorder usually presents itself across a variety of settings other than just the academic domain and that its expression is often influenced by context-specific variables (e.g., school-based performance)
• if relevant to test taking performance, a description of the expected progression or stability of the impact of the condition over time
• if relevant to test taking performance, information regarding kind of treatment and duration/consistency of the therapeutic relationship

III B. Documentation Must Include a Specific Diagnosis

The report must include a specific diagnosis based on the DSM-IV-TR or ICD-10 diagnostic criteria and include the specific diagnostic section in the report with a numerical and nominal diagnosis from DSM-IV-TR or ICD-10. Evaluators are encouraged to cite the specific objective measures used to help substantiate the diagnosis. The evaluator should use definitive language in the diagnosis of a psychiatric disorder, avoiding such wording as "suggests, has problems with, or may have emotional problems."

Given that many individuals benefit from prescribed medications and therapies, a positive response to medication in and of itself does not confirm a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodations.

III C. Alternative Diagnoses or Explanations Should Be Ruled Out

The evaluator must also investigate and rule out the possibility of other potential diagnoses involving neurological and/or medical conditions or substance abuse, as well as educational, linguistic, sensorimotor, and cross-cultural factors that may result in symptoms mimicking the purported psychiatric disability.

III D. Rationale for Requested Accommodations Must Be Provided

The evaluator must describe the degree of impact of the diagnosed psychiatric disorder on a specific major life activity, as well as the degree of impact on the individual. A link must be established between the requested accommodations and the functional limitations of the individual that are pertinent to the anticipated testing situation. Accommodations will be provided only when a clear and convincing rationale is made for the necessity of the accommodation. A diagnosis in and of itself does not automatically warrant approval of requested accommodations. For example, test anxiety alone is not a sufficient diagnosis to support requests for accommodations. Given that many individuals may perceive that they might benefit from extended time in testing situations, evaluators must provide specific rationales and justifications for the accommodation. A prior history of accommodations, without demonstration of current need, does not in and of itself warrant the provision of accommodations. If there is no prior history of accommodations, the evaluator and/or the test taker must include a detailed explanation of why accommodations were not needed in the past, and why they are now currently being requested. Psychoeducational, neuropsychological or behavioral assessments are often necessary to support the need for testing accommodations based on the potential for psychiatric disorders to interfere with cognitive performance.

IV. Multiple Diagnoses

Multiple diagnoses may require a variety of accommodations beyond those typically associated with only a single diagnosis, and therefore the documentation must adhere to ETS policy. For example, when accommodations are requested based on multiple diagnoses (e.g., a psychological disability with an accompanying learning disability), documentation should also comply with the ETS policy statements pertaining to the documentation of these specific disabilities. In such instances, an evaluator may want to consult with ETS's policies and guidelines for documentation.