ADHD Documentation Requirements
In response to the expressed need for guidance related to the documentation of Attention Deficit/Hyperactivity Disorders (AD/HD) when a referral is made to the University of Missouri-Columbia, the Office of Disability Services (ODS) has developed the following guidelines. These guidelines were adapted from the Policy Statement for Documentation of Attenmtion Deficit/Hyperactivity Disorders in Adolescents and Adults and used by permission of Educational Testing Service (ETS). The primary intent of these guidelines is to provide students and professional diagnosticians with a common understanding of those components of documentation that are necessary to validate AD/HD and the need for accommodations.
I. A Qualified Professional Must Provide the Documentation
Professionals 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 following professionals would generally be considered qualified to evaluate and diagnose ADHD provided they have comprehensive training in the differential diagnosis of ADHD and direct experience with an adolescent or adult ADHD population: psychologists, neuropsychologists, psychiatrists, and other relevantly trained medical doctors. It may be appropriate to use a clinical team approach consisting of a variety of educational, medical, and counseling professionals with training in the evaluation of ADHD in adolescents and adults.
The name, title, and professional credentials of the evaluator -- including information about license or certification as well as the area of specialization, employment, and state or province in which the individual practices should be clearly stated in the documentation.
All reports should be on letterhead, typed, dated, signed, and otherwise legible.
II. THE Documentation Must Be Current
A diagnostic evaluation must have been completed within the past three years and must include a detailed assessment of the current impact of the ADHD and an interpretative summary of relevant information and the previous diagnostic report.
III. Evidence of Early Impairment must be Included
Because ADHD is, by definition in the DSM-IV, first exhibited in childhood (although it may not have been formally diagnosed) and manifests itself in more than one setting, relevant historical information is essential. The following should be included in a comprehensive assessment: clinical summary of objective historical information establishing symptomology indicative of ADHD throughout childhood, adolescence, and adulthood as garnered from any of the following sources: transcripts, report cards, teacher comments, tutoring evaluations, and past psycho-educational testing.
Third party interviews should be included when available.
IV. Evidence of Current Impairment on an individual's ability to perform academic tasks must be Included
The diagnosis of ADHD is strongly dependent on a clinical interview in conjunction with a variety of formal and informal measures. Since there is no one test, or specified combination of tests, for determining ADHD, the diagnosis of an attention deficit/hyperactivity disorder (ADHD) requires a multifaceted approach. Any tests that are selected by the evaluator should be technically accurate, reliable, valid, and standardized on the appropriate norm group. The following list includes five broad domains that are frequently explored when arriving at an ADHD diagnosis. This listing is provided as a helpful resource but is not intended to be definitive or exhaustive.
1. Clinical interview - The evaluator should: 1) provide retrospective confirmation of ADHD; 2) establish relevant developmental and academic markers; 3) determine any other co-existing disorders; and 4) rule out other problems that may mimic ADHD.
Specific areas to be addressed include:
· history of presenting attentional 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 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 education
· a review of prior psycho educational test reports to determine whether a pattern of strengths or weaknesses is supportive of attention or learning problems
· relevant employment history
· description of current functional limitations pertaining to an educational setting that are presumably a direct result of problems with attention
· relevant history of prior therapy
· family history
· results of a neuro-medical history
· presence of ADHD symptoms since childhood
· presence of ADHD symptoms in last 6 months
· evidence that symptoms cause a "significant impairment" over time
· results of clinical observation for hyperactive behavior, impulsive speech, distractibility
· an accounting for periods in which the student was symptom-free
· presence of other psychiatric conditions (mood or anxiety disorders, substance abuse, etc.)
· indication that symptoms are not due to other conditions (e.g., depression, drug use, neuromedical problems)
· relevant medication history
· determination of which remediation approaches and/or compensating strategies are and are not currently effective.
· determination of what accommodations, if any, have alleviated symptoms in the past or in the present setting.
2. 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.
Selected examples include:
Wender Utah Rating Scale
Brown Attention-Activation Disorder Scale
Beck Anxiety Inventory
Hamilton's Depression Rating Scale
Conners Teacher Rating Scale (age 3-17 years)
Conners Parent Rating Scale (age 3-17 years)
3. Neuro-psychological and psycho-educational testing - Cognitive and achievement profiles may suggest attention or information processing deficits. No single test or subtest should be used as the sole basis for a diagnostic decision.
Acceptable instruments include, but are not limited to:
Wechsler Adult Intelligence Scale - III (WAIS-III)
Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability
Kaufman Adolescent and Adult Intelligence Test
Scholastic Abilities Test for Adults (SATA)
Stanford Test of Academic Skills (TASK)
Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Achievement
Wechsler Individual Achievement Test (WIAT)
or specific achievement tests such as
Nelson-Denny Reading Skills Test
Stanford Diagnostic Mathematics Test
Test of Written Language - 3 (TOWL-3)
Woodcock Reading Mastery Tests - Revised
Detroit Tests of Learning Aptitude - 3 (DTLA-3) or Detroit Tests of Learning Aptitude - Adult (DTLA-A).
Information from subtests on WAIS-R or Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability, as well as other relevant instruments, may be useful when interpreted within the context of other diagnostic information.
4. Medical evaluation - Medical disorders may cause symptoms resembling ADHD. Therefore, it may be important to rule out the following:
Neuroendocrine disorders (e.g., thyroid dysfunction)
Impact of medication on attention if tried, and under what circumstances
5. Collateral information - Include third party sources which can be helpful to determine the presence or absence of ADHD in childhood.
Description of current symptoms (e.g., by spouse, teachers, employer)
Description of childhood symptoms (e.g., parent)
Information from old school and report cards and transcripts
V. The report must include a specific diagnosis of ADHD based on the DSM-IV diagnostic criteria.
The diagnostician should use direct language in the diagnosis of ADHD, avoiding the use of such terms as "suggests," "is indicative of," or "attention problems."
VI. An Interpretative Summary Must Be Provided
A well-written interpretative summary based on a comprehensive evaluative process is a necessary component of the documentation. Because ADHD is in many ways a diagnosis that is based upon the interpretation of historical data and observation, as well as other diagnostic information, it is essential that professional judgment be utilized in the development of a summary, which must include
demonstration of the evaluator's having 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 are used to determine the presence of ADHD
indication of whether or not the candidate was evaluated while on medication, and whether or not the prescribed treatment produced a positive response
indication and discussion of the substantial limitation to learning presented by the ADHD and the degree to which it affects the individual in the academic, classroom, testing, or learning 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
VII. Each Accommodation Recommended by the Evaluator Must Include a Rationale
The diagnostic report must include specific recommendations for accommodations that are realistic and that postsecondary institutions, as well as examining, certifying, and licensing agencies can reasonably provide. 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 no prior accommodations were provided, the qualified professional and/or the candidate must include a detailed explanation of why no accommodations were needed in the past and why accommodations are needed at this time.