Documenting Psychiatric Disabilities

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.

ETS Office of Disability Policy
Task Force on Psychiatric Disabilities
Acknowledgments
Introduction
Documentation Requirements

A Qualified Professional Must Conduct the Evaluation
Documentation Must Be Current
Documentation Necessary to Support the Diagnosis Must Be Comprehensive
Multiple Diagnoses
Confidentiality

Appendix A: Recommendations for Consumers
Appendix B: Assessing Adolescents and Adults with Psychological Disorders
Appendix C: Resources and Organizations

ETS Office of Disability Policy

Sheree Johnson-Gregory, Director
Loring C. Brinckerhoff, Disability Accommodations Specialist

Task Force on Psychiatric Disabilities

Arunas J. Kuncaitis, Co-chair
Collaborations in Clinical Care
Canton, Massachusetts

Stuart S. Segal, Co-chair
University of Michigan

Phyllis Brown-Richardson
Long Island University – Brooklyn Campus

Patricia Carlton
The Ohio State University

Cyndi Jordan
Hutchison School
University of Tennessee Center for Health Sciences

Nancy Pompian
Dartmouth College

Louise H. Russell
Harvard University

Deborah E. Taska
Arizona State University

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Acknowledgments

The Task Force on Psychiatric Disabilities wishes to express its appreciation to the individuals who served on the following panels and the external consultants listed below for their insightful comments and review of these guidelines:

College Board Review Panel
ETS Review Panel for Testing Accommodations

External Consultants

John L. Barton, Ph.D.
Director, Clinical Psychology Center
Arizona State University

Kenneth Benedict, Ph.D.
Licensed Psychologist
North Carolina Neuropsychiatry, P.A.

Betsy Busch, M.D.
Assistant Professor of Pediatrics
Tufts University School of Medicine

Mark S. Greenberg, Ph.D.
Neuropsychologist, Department of Psychiatry
Harvard University Medical School

Eric Heiligenstein, M.D.
Clinical Director, Psychiatric Services
University of Wisconsin-Madison

Leighton Y. Huey, M.D.
Professor and Chairman, Department of Psychiatry
University of Connecticut School of Medicine

Peter S. Jensen, M.D.
Ruane Professor of Science in Child Psychiatry
Columbia University

Richard F. Kaplan, Ph.D., ABPP/CN
Associate Professor, Department of Psychiatry
University of Connecticut School of Medicine

Charles Klink, Ph.D.
Director, University Counseling Services
Virginia Commonwealth University

Bruce L. Levine, Ph.D.
Adjunct Assistant Professor of Psychiatry
Dartmouth Medical School

Robert L. Mapou, Ph.D., ABPP/CN
Clinical Neuropsychologist
Independent Practice
Silver Spring, Maryland

Mark Reed, M.D.
Director, Counseling and Human Development
Dartmouth College

Larry B. Silver, M.D.
Clinical Professor of Psychiatry
Georgetown University Medical Center

Lorraine E. Wolf, Ph.D.
Clinical Director, Office of Disability Services
Boston University

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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 ETS policy statements.

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.

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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.

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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.

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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).
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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:
1. history of presenting symptoms
2. duration and severity of the disorder
3. relevant, developmental, historical and familial data
4. relevant medical and medication history, including the individual's current medication regimen compliance, side effects (if relevant) and response to medication
5. 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)
6. if relevant to test taking performance, a description of the expected progression or stability of the impact of the condition over time
7. if relevant to test taking performance, information regarding kind of treatment and duration/consistency of the therapeutic relationship
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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.

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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.

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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.

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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. The ETS guidelines for documentation of psychiatric disabilities as well as policy statements pertaining to LD and ADHD can be found at Test Takers with Disabilities. They may also be obtained by contacting:

ETS Disability Services
P.O. Box 6054
Princeton, NJ 08541-6054
Telephone: 609-771-7780
TTY: 609-771-7714 (for hearing or speech impaired)
Fax: 609-771-7165
E-mail: stassd@ets.org
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V. Confidentiality

ETS will not release any information regarding an individual's diagnosis or medical information 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 disabilities, evaluators may withhold or redact any portion of the documentation that is not directly relevant to ETS's criteria for establishing a disability as defined by the ADA and a rationale for requested testing accommodations.

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

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Appendix A

Recommendations for Consumers
1. If you are currently not under the care of a qualified professional and need assistance in identifying one, contact:
  1. your primary care physician to discuss obtaining a referral
  2. the disability services coordinator or college counselor and/or mental health service provider at a college or university for possible referral sources
  3. the high school guidance office and/or a counselor
  4. a physician who may be able to refer you to a qualified professional with demonstrated expertise in psychological disorders
2. In selecting a qualified professional ask:
  1. what experience and training he or she has had diagnosing adolescents and adults
  2. whether he or she has training in differential diagnosis and the full range of psychological disorders. Clinicians typically qualified to diagnose psychiatric disabilities include psychologists, neuropsychologists, psychiatrists, neuropsychiatrists, other relevantly trained medical doctors, clinical social workers, licensed counselors and psychiatric nurse practitioners
  3. whether he or she has ever worked with a postsecondary disability service provider, a high school guidance counselor, or with the agency to which you are providing documentation
  4. whether you will receive a comprehensive written report
3. In working with the professional:
  1. take a copy of these guidelines to the professional
  2. be prepared to be candid and thorough in providing requested information
4. As follow-up to the assessment by the professional:
  1. schedule a meeting to discuss the results, recommendations and possible treatment
  2. request additional resources, support group information and publications if you need them
  3. maintain a personal file of your records and reports
  4. be sure to discuss the issues of confidentiality with the professional both at the outset of the evaluation as well as during the follow-up meeting
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Appendix B

Assessing Adolescents and Adults with Psychological Disorders

This appendix contains selected examples of tests and instruments that may be used to supplement the clinical interview and support the presence of functional limitations. All tests used should be current and have sufficient reliability, validity, and utility for the specific purposes for which they are being employed. All tests should also be normed on relevant populations, and the results should be reported in standard scores and/or percentile ranks. Tests that have built-in validity scales or indicators are preferred over those that do not.

1. Rating scales: Self-rater or interviewer-rated scales for categorizing and quantifying the nature of the impairment may be useful in conjunction with other data, but no single test or subtest should be used solely to substantiate a diagnosis.

Acceptable instruments include, but are not limited to:
- Beck Anxiety Inventory
- Beck Depression Inventory-II
- Brief Psychiatric Rating Scale (BPRS)
- Burns Anxiety Inventory
- Burns Depression Inventory
- Children's Depression Inventory
- Hamilton Anxiety Rating Scale
- Hamilton Depression Rating Scale
- Inventory to Diagnose Depression
- Multidimensional Anxiety Scale for Children (MASC)
- Profile of Mood States (POMS)
- State-Trait Anxiety Inventory (STAI)
- Taylor Manifest Anxiety Scale
- Yale-Brown Obsessive-Compulsive Scale
2. Neuropsychological and psychoeducational testing: Cognitive, achievement and personality profiles may uncover attention or information-processing deficits, but no single test or subtest should be used solely to substantiate a diagnosis.

Acceptable instruments include, but are not limited to:

Aptitude/Cognitive Ability
- Kaufman Adolescent and Adult Intelligence Test
- Stanford-Binet, Fourth Edition
- Wechsler Adult Intelligence Scale-III (WAIS-III)
- Woodcock-Johnson-III - Tests of Cognitive Abilities
Academic Achievement
- Scholastic Abilities Test for Adults (SATA)
- Stanford Test of Academic Skills (TASK)
- Wechsler Individual Achievement Test-II (WIAT-II) with reading rate
- Woodcock-Johnson-III - Tests of Achievement
Specific achievement tests, such as
- Nelson-Denny Reading Test
- Stanford Diagnostic Mathematics Test
- Stanford Diagnostic Reading Test
- Test of Written Language-3 (TOWL-3)
- Woodcock Reading Mastery Tests-Revised
Information Processing
- California Verbal Learning Test-II
- Category Test
- Continuous Performance Test
- Detroit Tests of Learning Aptitude-Adult (DTLA-A)
- Detroit Tests of Learning Aptitude-3 (DTLA-3)
- Halstead-Reitan Neuropsychological Test Battery
- Rey-Osterrieth Complex Figure Test
- Stroop Interference Test
- Trail Making Test
- Wechsler Memory Scale III (WMS-III)
- Wisconsin Card Sorting Test
Information from subtests on the WAIS-III or Woodcock-Johnson-III - Tests of Cognitive Abilities, as well as other relevant instruments, may be useful when interpreted within the context of other diagnostic information.

3. Personality tests:

Acceptable instruments may include, but are not limited to:
- Millon Adolescent Personality Inventory (MAPI)
- Millon Clinical Multiaxial Personality Inventory-III (MCMI-III)
- Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A)
- Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
- NEO Personality Inventory-Revised (NEO-PI-R)
- Personality Assessment Inventory (PAI)
- Sixteen Personality Factor Questionnaire (16PF)
- Thematic Apperception Test (TAT)
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Appendix C

Resources and Organizations

Anxiety Disorder Association of America (ADAA)
11900 Parklawn Drive, Suite 100
Rockville, MD 20852
301-231-9350 voice
301-231-7392 fax
www.adaa.org
The ADAA promotes the prevention and cure of anxiety disorders and works to improve the lives of those who have them.

Association on Higher Education and Disability (AHEAD)
University of Massachusetts-Boston
100 Morrissey Boulevard
Boston, MA 02125
617-287-3880 voice/TTY
617-287-3881 fax
www.ahead.org
AHEAD sponsors numerous training programs, workshops, publications, and conferences for professionals in the field of higher education disability.

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CH.A.D.D.)
8181 Professional Place, Suite 201
Landover, MD 20785
1-800-233-4050 voice - toll free
301-306-7070 voice
301-306-7090 fax
www.chadd.org
CH.A.D.D. is a national organization with over 32,000 members and more than 500 chapters nationwide that provides support and information for parents of children with AD/HD and adults with AD/HD.

The Council for Exceptional Children (CEC)
1920 Association Drive
Reston, VA 22091-1589
703-620-3660 voice
703-264-9446 TTY
703-264-9494 fax
www.cec.sped.org
The CEC is the largest international professional organization committed to improving educational outcomes for individuals with disabilities.

The Internet Mental Health website, www.mentalhealth.com is another very good resource.

Learning Disabilities Association of America (LDA)
4156 Library Road
Pittsburgh, PA 15234-1349
412-341-1515 voice
412-344-0224 fax
www.ldanatl.org
LDA is the largest nonprofit volunteer organization advocating for individuals with learning disabilities. LDA has more than 600 local chapters and affiliates in 50 states, Washington, D.C., and Puerto Rico. LDA seeks to educate individuals with learning disabilities and their parents about the nature of the disabilities and inform them of their rights.

National Center for Learning Disabilities (NCLD)
381 Park Avenue South, Suite 1401
New York, NY 10016
212-545-7510 voice
212-545-9665 fax
Toll-free Information and Referral Service: 1-888-575-7373
www.ncld.org
NCLD provides the latest information on learning disabilities and resources available to parents, professionals, and adults with learning disabilities. Specific information about learning disabilities, as well as local referrals to schools, clinics, camps, colleges' parent support groups, and other sources of help are available.

National Depressive and Manic-Depressive Association (NDMDA)
730 North Franklin Street, Suite 501
Chicago, IL 60610-7204
1-800-826-3632 voice – toll free
312-642-0049 voice
312-642-7243 fax
www.ndmda.org
The NDMDA is a nonprofit organization aimed at helping people with depressive spectrum illnesses and their families.

Obsessive-Compulsive Foundation, Inc. (OCF)
337 North Hill Road
North Branford, CT 06471
203-315-2190 voice
203-315-2196 fax
www.ocfoundation.orgThe OCF is an international not-for-profit organization composed of people with OCD and related disorders, their families, friends, professionals and other concerned individuals.
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