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Disabilities and Health-related Needs

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Guidelines for Writing Diagnostic Reports

These guidelines review the components of a comprehensive diagnostic report, i.e., psychological, psychoeducational, neuropsychological, etc. They will be useful to evaluators who write diagnostic reports for individuals with disabilities who are planning to take one of ETS's graduate or professional licensing examinations. Evaluators can also help prevent delays in processing by reviewing ETS's Documentation Guidelines for specific disabilities.


Appearance of the diagnostic report

Documentation should be legible (typed or printed in English on letterhead), dated and signed. It should include the name, title and professional credentials (degree and license or certification number) of the evaluator, the test taker’s identifying information (full name and date of birth) and the sources of information upon which evaluation findings and recommendations are based (e.g., clinical interviews, self-report and third-party questionnaires, psychometric tests, relevant education or medical records, etc.). For evaluations conducted via tele-assessment, please see ETS Tele-Assessment Guidance (PDF).


Recency of the disability documentation and documentation updates

Documentation must address a test taker’s disability-related functional limitations as they directly apply to the life activity of taking a standardized test. To facilitate this, most testing agencies, including ETS, have guidelines regarding the suggested recency of disability documentation. Generally, for all disability categories, information regarding the test taker's longer standing history of disability is very important, and documentation should verify the functional impact of the disability as it relates to the current test-taking situation. For learning disabilities (LD), ADHD or autism spectrum disorders (ASD), a diagnostic evaluation completed within the past 5 years and/or when the test taker was at least 16 years of age may be helpful. For psychiatric disabilities, traumatic brain injuries (TBI) and other disabilities that are more changeable or modifiable with medication or treatments, documentation (i.e., letter/report) dated within 1 year of the date of the accommodations request typically provides a good understanding of the functional impact of the test taker's disability-related functional limitations in the current testing situation. For a traumatic brain injury, acquired brain injury or brain surgery that occurred more than 1 year ago, documentation from 1–3 years after the event occurred may be helpful. If the disability is a permanent health or sensory impairment (e.g., cerebral palsy, blindness, etc.), a rationale provided by a qualified professional generally provides sufficient understanding of the test taker's functional limitations as related to the current testing situation.

ETS has concerns about the increasing cost of neuropsychological and psychoeducational evaluations that many test takers with disabilities may have to bear. For test takers with LD and/or dual diagnoses of LD/ADHD, a comprehensive reevaluation is no longer necessary. Instead, a documentation update may be sufficient when the test taker:

  1. has a longstanding history of LD or LD/ADHD (and preferably which has been documented); and 
  2. has received accommodations through the Disability/Accessibility office on campus or through their employer's HR office. [Please note that if a test taker has been approved for accommodations on another standardized test (e.g., SAT®, ACT®, GMAT®, LSAT®, MCAT®, etc.), verification of such prior approval is sufficient. Reevaluation is not needed if the test taker is requesting the same accommodations which another testing agency has previously approved.]

If a documentation update is indicated, it is often helpful to send earlier documentation along with updated information (if documentation is more than 5 years old). The update should demonstrate the ongoing impact of the disability on academic performance. Since intellectual functioning is typically stable in adulthood, re-administration of a cognitive measure such as the WAIS or a similar instrument is not necessary if such a measure was administered in the evaluation covered by the initial report. A documentation update should include:

  1. a historical review of earlier testing, and
  2. recent information which demonstrates the ongoing impact of the disability on academic performance. Updated achievement and/or processing measures may be helpful.

Reason for referral and history of the problem

The reason for referral should be clearly stated by the evaluator. There should be a clear and detailed history that supports the reason for referral, along with corroborative data from educational and/or other relevant records whenever possible. This may, for example, include failed courses, multiple incompletes in coursework, slow reading or an uneven job history. If accommodations are needed in the testing situation but not in other circumstances, the report should clarify and provide a rationale for this distinction. Prevalent diagnostic criteria suggest that a disability in learning, attention, etc., that is substantially limiting to a major life activity usually affects areas other than test taking as well.


Evaluation measures used in the report

It is important that all evaluation measures used in the report are reliable, valid and age-appropriate and that the most recent edition of each psychometric measure is used. When an evaluator uses a psychometric measure that is not age-appropriate, it should be noted in the report narrative, and the rationale for the instrument's use should be provided. Similarly, if an evaluator readministers a test within a 1- to 2-year period, the evaluator should acknowledge that there may be a practice effect that can impact the scores. Evaluators should heed prevailing professional standards for evaluation of the disability being explored. For example, such standards indicate that a screening measure such as the WRAT should not be used as the exclusive measure of achievement, but it may used to complement additional diagnostic measures. The testing should be sufficient for the evaluator to arrive at a DSM (i.e., Diagnostic Statistical Manual of Mental Disorders of the American Psychiatric Association) or ICD (i.e., International Classification of Diseases of the World Health Organization) diagnosis that can be supported by evaluation data.

Scores (i.e., all subtests and composite scores) should be reported as standard scores, scaled scores and/or percentiles as applicable. Age- and grade-equivalent scores are not standard scores. They may be reported for the additional information they may provide; however, they may not be used as a substitute for standard scores, scaled scores or percentiles.

It is important to report all test composite and subtest scores. If the test provides index scores and cluster scores, all these scores should be reported as applicable. While qualitative categorizations such as "average" and "below average" are helpful, they are inexact and may have different meanings in different contexts; actual score data are needed. Consistent with ethical clinical practice, it is important that the evaluator not base the entire diagnosis of the disability on a single subtest or a single discrepancy measure. Objective evidence of the functional limitations should be supported across multiple tests/subtests that measure the same ability in the assessment battery. Similarly, objective data should be corroborated with data obtained via other assessment methods (i.e., direct observation, clinical interview, record review, informant reports, etc.). Please refer to the ETS Guidelines for Documentation of a Learning Disability in Adolescents and Adults and the ETS Guidelines for Documentation of Attention-Deficit/Hyperactivity Disorder in Adolescents and Adults.


Relevant developmental, educational and medical histories

An early history of a disability can be a key factor in understanding the impact of an ongoing disability. If relevant, it is helpful for evaluators to report that the disability was identified early in the test taker's academic career and how it manifested itself. Did the test taker have trouble learning to read, write or do mathematical calculations in school? Were there attention or time-management issues? Are there any school records? physician’s notes? therapist’s notes?, etc.? There are often valid reasons why the test taker was not identified previously (e.g., disability testing may have been inaccessible for many reasons, varying cultural beliefs about disability, etc.). It is helpful when this is addressed in the documentation. If diagnostic criteria for a particular diagnosis require a history of symptoms and no explanation is provided of why such history was not observed or reported, the need for accommodations may be unclear and/or difficult to determine.

In some instances, there may be diagnostic reports from previous years that can be cited to support the impact of the disability over time. Corroboration of the test taker's self-report with verified documentation (i.e., report cards, standardized testing reports, relevant medical records, etc.) is very helpful. Medical histories are often particularly relevant in cases involving test takers with attention disorders, seizures, traumatic brain injury and co-morbid psychiatric disorders as well as other conditions. If a test taker takes medication to alleviate the symptoms of the disabling condition, this information should also be addressed in the evaluation report. Additionally, the test taker's response to treatment should be included in the report.


A clear statement of the disability

Consistent with ethical clinical practice, a diagnosis should be based on multi-modal assessment that includes and integrates data gathered via multiple methods, i.e., clinical interview, direct observation, psychometric testing, record review and information from third-party informants as applicable. A diagnosis is based on a view of the whole person. It is helpful for the evaluator to comment on the process by which a test taker approached evaluation tasks that required memory, attention, concentration and sustained attention. For most individuals, consistent with prevalent clinical standards, determination of "rule-outs" is important (i.e., ruling out other possible diagnoses that mimic the stated disability, such as depression or anxiety). Differential diagnosis provides a better understanding of the test taker's needs. If the test taker is on medication at the time of testing, the evaluator should state this and discuss how this may affect performance on a high-stakes test (i.e., many medications have side effects that mitigate some functional limitations while causing others).


Use of appropriate achievement measures

When appropriate and when viewed in light of the individual's intellectual functioning and processing abilities, diagnostic achievement testing should reflect a substantial limitation to learning relative to the norm group (i.e., a deficit in contrast to a relative weakness). A core battery that is robust enough to address all the test taker’s presenting problems that are currently impacting performance typically provides information that is helpful for accommodations determination.

The report should convey the test taker’s current level of academic achievement in relevant domains, so the severity and significance of the impact of the test taker’s functional limitations on test taking can be understood. For example, when reading and reading speed are important considerations, professional standards indicate that the evaluator should assess and provide information regarding a test taker's reading rate, decoding and reading comprehension.

It is also often helpful if the evaluator can provide information in the report about the effects of extended time on test performance by using both timed and extended-time achievement measures to show the functional impact. For instance, a low index score in information processing speed (i.e., often assessed via measures that involve visual inspection time, reaction time or speeded naming), alone, does not necessarily support the presence of an academic deficit. Mathematical functioning in both computation and problem-solving should be addressed. Consistent with clinical standards in diagnostic and assessment practices, evaluators should keep in mind that one or two discrepant subtest scores in isolation do not necessarily establish the presence of a learning, psychiatric or neurological disability. This typically requires a multi-modal approach that integrates the test taker's history and lived experience in addition to psychometric testing when appropriate.


The clinical summary

A clinical summary that recaps the most salient points of the report and synthesizes key findings is very helpful and should include: the examinee’s strengths and weaknesses; the evaluator’s diagnostic formulation and the rationale to support it (i.e., what diagnostic criteria does the examinee meet? What other possible diagnoses or causal factors have been ruled out?); whether the diagnosis results in a disability (i.e., what, if any, functional impairment does the diagnosis cause generally across life contexts and specifically as related to test taking?). This should be supported by objective data as well as clinical observations; and what accommodations are needed to address these disability-related functional limitations? A direct link should be made between the disability-related functional limitation and the accommodation that is recommended to address it. If the candidate used additional time during the evaluation, then the evaluator should describe how this additional time was used (e.g., rereading materials? generally slow processing speed?). Again, it is suggested that the evaluator consider the test taker's perspective and lived experience in addition to psychometric test scores when appropriate to convey a more complete understanding of the test taker.


Determining reasonable accommodations based on functional limitations

Recommendations should be tailored to the individual, and each accommodation recommendation provided by the evaluator should be tied to specific history, test results and clinical observations. Accommodation recommendations which are not directly linked to disability-related functional limitations are of limited help to the test taker. If the test taker has received support services in college or on the job, it is helpful to state whether these were informally granted or approved through the disability/accessibility services office on campus, an employer’s human resources office, etc. If informal accommodations were granted by teachers in high school, this is helpful information to include. A test taker's history of accommodations in school, a previous 504 plan or an IEP all provide important information; however, they may not provide sufficient support for a current accommodation on a high-stakes test. Conversely, if a test taker has no past history of accommodations, but accommodations appear to be warranted now, the evaluator should explain the current functional limitations that warrant accommodation at this time. The disability-based rationale should be supported by objective data as well as clinical observations.

If extended testing time is necessary, the evaluator’s report narrative should provide a recommendation for a specific increment of extended testing time (i.e., 25%?  50%? 100%?, etc.). The rationale for this recommendation should be based on objective data as well as clinical observations. If a reader, basic four-function handheld calculator or separate room is requested, the documentation should specifically support the particular request. Evaluators should keep in mind that rest breaks are "off the clock" and do not reduce actual “on the clock” testing time. For some test takers, especially those with ADHD who may have difficulty sustaining attention for long periods of testing time, additional rest breaks may actually be more beneficial than extended testing time.


Test takers who are deaf or hard of hearing

Individuals who are deaf or hard of hearing are required to submit an audiogram or full audiometric report to ETS (please see ETS Guidelines for Documenting Hearing Loss). It would also be helpful to include a cover letter addressing the current functional impact of the disability, indicating its unchanging nature and the rationale for each requested accommodation.

Information regarding the onset of the hearing loss, and related educational placement and progress, is helpful to include in a cover letter from the qualified professional. Information about the current functional impact of the hearing loss, including its permanent or fluctuating nature and the effectiveness of hearing aids, cochlear implants and/or other assistive devices, is also useful, as is a rationale for each requested accommodation.


Test takers who are blind or have low vision

Individuals who are blind or have low vision should submit Documentation of Blindness and Low Vision in Adolescents and Adults. The professional should refer to specific tests, clinical observations or other objective data. The narrative report should also identify the functional impact of the visual impairment on processing speed, reading and/or test taking, as well as the test taker’s current use of accommodations, corrective lenses and/or support services.