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INFORMATION FOR STUDENTS: Documentation Guidelines for Learning Disabilities

Printable version of these guidelines


Introduction
Documentation Guidelines
  -   Evaluator Qualifications
  -   Recency of Documentation
  -   Substantiation of a Learning Disability
  -   Clinically Interpretive Summary
  -   Accountability and Confidentiality
Appendix A - Recommendations for Consumers
Appendix B - Tests for Assessing Adolescents & Adults


Introduction
The following document describes standard criteria for documenting learning disabilities (LD) that can be used to determine appropriate accommodations for individuals with learning disabilities in postsecondary settings. The two official nomenclatures designed to outline the criteria used in making these diagnoses are the Diagnostic and Statistical Manual, IV (DSM-IV) and the ICD-10. In instances where there may be multiple diagnoses including ADHD disabilities and psychiatric disabilities, evaluators should consult the appropriate companion guidelines as found at ADHD clinical documentation guidelines and psychiatric disability documentation guidelines. The guidelines provide students, professional diagnosticians, and service providers with a common understanding and knowledge base of those components of documentation which are necessary to validate a learning disability and the need for accommodation in this post-secondary setting. The information and documentation to be submitted should be comprehensive in order to avoid or reduce time delays in decision-making related to the provision of services. A minimum of two weeks advanced notice and submission of clinical documentation is required in order to complete the documentation review process.

This document presents guidelines in four important areas:

  1. Qualifications of the evaluator
  2. Recency of documentation
  3. Appropriate clinical documentation to substantiate the learning disability
  4. Evidence to establish a rationale supporting the need for accommodation(s).

Under the Americans with Disabilities Act Amendments Act (ADAAA) and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are guaranteed certain protections and rights to equal access to programs and services. In order to establish that an individual is covered under the ADAAA, the documentation must indicate that the disability substantially limits some major life activity, including learning. The following documentation guidelines are provided in the interest of assuring that a clinically documented learning disability appropriately verifies eligibility and may support some or all requests for accommodations, academic adjustments, and/or auxiliary aids.

Clinical documentation of a learning disability which is submitted to Accessible Education Office (AEO) for the purpose of seeking accommodations is expected to meet the standards set forth in these guidelines. All clinical documentation is reviewed by AEO and its consultants, as required, to determine what, if any, accommodations are appropriate to the settings for which they are intended. Although a previous history of accommodation may provide valuable insight into the student's ability to integrate into a previous setting, AEO makes independent judgment about Harvard settings and the appropriateness, if any, of accommodation requests.

Sometimes students may be asked to provide updated comprehensive information if their condition is potentially changeable and/or previous documentation doesn't include sufficient relevant information.

Appendix A provides consumers with recommendations for finding and working with a qualified professional. A suggested listing of standardized tests for assessing adolescents and adults with suspected learning disabilities is included in Appendix B.

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Documentation Guidelines

I. A Qualified Professional Must Conduct the Evaluation
Professionals conducting assessments and rendering diagnoses of specific learning disabilities and making recommendations for appropriate accommodations must be qualified to do so. Comprehensive training and relevant experience with an adolescent and adult LD population are essential. Competence in working with a culturally and linguistically diverse populations is also essential.

The name, title, and professional credentials of the evaluator, including information about license or certification (e.g., licensed psychologist) as well as the area of specialization,employment, and state in which the individual practices must be clearly stated in the documentation. For example, the following professionals would generally be considered qualified to evaluate specific learning disabilities provided that they have additional training and experience in evaluating adolescent/adult learning disabilities: clinical or educational psychologists; school psychologists; neuropsychologists; learning disabilities specialists; medical doctors with training and experience in the assessment of learning problems in adolescents and adults.

Use of diagnostic terminology indicating a specific learning disability by someone whose training and experience are not in these fields is not acceptable. It is not appropriate for professionals to evaluate members of their own families. All reports should be on letterhead, typed, dated, signed, and otherwise legible.

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II. Testing Must Be Current
Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on his or her academic performance, it is in a student's best interest to provide recent and appropriate documentation. In most cases, this means that testing usually has been conducted within the past three years.

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III. Documentation Necessary to Substantiate the Learning Disability Must Be Comprehensive
Prior documentation may have been useful in determining appropriate services in the past. However, documentation must validate the need for services based on the individual's current level of functioning in the educational setting. A school plan such as an Individualized Educational Plan (IEP) or a 504 plan is insufficient documentation in and of itself but can be included as part of a more comprehensive assessment battery. A comprehensive assessment battery and the resulting diagnostic report should include a diagnostic interview, assessment of aptitude, academic achievement, and information processing.

A. Diagnostic Interview
Because learning disabilities are commonly manifested during childhood, though not always formally diagnosed, relevant historical information regarding the student's academic history and learning processes in elementary, secondary, and postsecondary education must be investigated and documented. An evaluation report should include the summary of a comprehensive diagnostic interview by a qualified evaluator. By using a combination of student self-report, interviews with others, and historical documentation such as transcripts and standardized test scores, the diagnostician should provide a summary of the following:

1. A description of the presenting problem(s);

2. Developmental history;

3. Relevant medical history including the absence of a medical basis for the present symptoms;

4. Academic history including results of prior standardized testing; reports of classroom performance;

5. Relevant family history, including primary language of the home, and the student's current level of fluency of English;

6. Psychosocial history;

7. Relevant employment history;

8. A discussion of dual diagnosis, alternative or co-existing mood, behavioral, neurological, and/or personality disorders along with any history of relevant medication and current use which may impact the individual's learning; and exploration of possible alternatives which may mimic a learning disability when, in fact, one is not present.

B. Assessment

The neuropsychological or psychoeducational evaluation for the diagnosis of a specific learning disability must provide clear and specific evidence that a learning disability does or does not exist. Assessment, and any resulting diagnosis, must consist of and be based on a comprehensive assessment battery which does not rely on any one test or subtest.

Objective evidence of a substantial limitation to learning must be provided. A list of acceptable tests is included in Appendix A. Minimally, the domains to be addressed must include the following:

  1. Aptitude/ Cognitive Ability
    A complete intellectual assessment with all subtests and standard scores reported is essential.
  2. Academic Achievement
    A comprehensive academic achievement battery is essential with all subtests and standard scores reported for those subtests administered. The battery must include current levels of academic functioning in relevant areas such as reading (decoding and comprehension), mathematics, and oral and written language.
  3. Information Processing
    Specific areas of information processing (e.g., short- and long-term memory; sequential memory; auditory and visual perception/ processing; processing speed; executive functioning; motor ability) should be assessed.
  4. Other Assessment Measures

Non-standard measures and informal assessment procedures or observations may be helpful in determining performance across a variety of domains. Other formal assessment measures may be integrated with the above instruments to help rule in or rule out the learning disability to differentiate it from co-existing neurological and/or psychiatric disorders, i.e., to establish a differential diagnosis. The evaluator should address why these assessments were included in addition to the standard measures. In addition to standardized tests, it is also very useful to include informal observations of the student during the test administration.

C. The Documentation Must Include a Specific Diagnosis
Nonspecific diagnoses, such as individual "learning styles," "learning differences,""academic problems," "computer phobias," "slow reader," and "test difficulty or anxiety," in and of themselves do not constitute a learning disability. It is important to rule out alternative explanations for problems in learning, such as emotional, attentional, or motivational problems, that may be interfering with learning but do not constitute a learning disability. The diagnostician is encouraged to use direct language in the diagnosis and documentation of a learning disability, avoiding the use of such terms as "suggests" or "is indicative of."

If the data indicate that a learning disability is not present, the evaluator must state that conclusion in the report.

D. Actual Test Scores from Standardized Instruments Must be Provided
Standard scores and/or percentiles must be provided for all normed measures. Reports of grade equivalents must be accompanied by standard scores and/or percentiles. The data must logically reflect a substantial limitation to learning which the student is requesting the accommodation. The particular profile of the student's strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations.

The tests used should be reliable, valid, and standardized for use with an adolescent/adult population. The test findings must document both the nature and severity of the learning disability. Informal inventories, surveys, and direct observation by a qualified professional may be used in tandem with formal tests in order to further develop a clinical hypothesis.

E. Each Accommodation Recommended by the Evaluator Must Include a Rationale
It is important to recognize that accommodation needs can change over time and are not always identified through the initial diagnostic process. Conversely, a prior history of accommodation, without demonstration of a current need, does not in and of itself warrant the provision of a like accommodation.

The diagnostic report must include specific recommendations for accommodation(s) as well as a detailed explanation of why each accommodation is recommended. The evaluator(s) must describe the impact the diagnosed learning disability has on a specific major life activity as well as the degree of significance of this impact on the individual. The evaluator(s) should support recommendations with specific test results or clinical observations. If no prior accommodation(s) has been provided, the qualified professional and/or the student should include a detailed explanation of why no accommodation(s) was used in the past and why an accommodation(s) is needed at this time.

If an accommodation(s) is not clearly identified in the diagnostic report, AEO will seek clarification, and, if necessary, more information. AEO will make the determination as to whether appropriate and reasonable accommodations are warranted and can be provided to the individual.

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IV. A Clinically Interpretive Summary Must be Provided
A well-written diagnostic summary based on a comprehensive evaluative process is a necessary component of the report. Assessment instruments and the data they provide do not diagnose; rather, they provide important elements that must be integrated with background information, observations of the client during the testing situation, and the current context. It is essential, therefore, that professional judgment be used in the development of a clinical summary. The clinical summary must include:

  1. Indication that the evaluator ruled out alternative explanations for academic problems such as poor education, poor motivation and/or study skills, emotional problems, attentional problems, and cultural/language differences
  2. Indication of how patterns in cognitive ability, achievement, and information processing are used to determine the presence of a learning disability
  3. Indication of the substantial limitation to learning presented by the learning disability and the degree to which it effects the individual in the learning context for which accommodations being requested
  4. Indication of why specific accommodations are needed and how the effects of the specific disability are mediated by the accommodation

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IV. Accountability and Confidentiality
Reasonable accommodation(s) may help to ameliorate the disability and to minimize its impact on the student's clinically documented difficulties in this particular setting.

The determination for reasonable accommodation(s) rests with AEO in collaboration with the individual with the disability and, when appropriate, faculty, all of whom have a responsibility to maintain confidentiality of any information. The student is responsible for obtaining and providing AEO with all relevant materials in a timely manner. AEO may not release any part of the documentation without the individual's informed consent. If the requested accommodations are not clearly identified in the diagnostic report, AEO reserves the right to seek additional clinical information pertaining to determination of eligibility for requested accommodations.

January 1999

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Appendix A - Recommendations for Consumers

1. For assistance in finding a qualified professional:
a. contact the disability services coordinator at the institution you attend or plan to attend to discuss documentation needs; and
b. discuss your future plans with the disability services coordinator. If additional documentation is required, seek assistance in identifying a qualified professional.

2. In selecting a qualified professional:
a. ask what his or her credentials are;
b. ask what experience he or she has had working with adults with learning disabilities; and
c. ask if he or she has ever worked with the service provider at your institution or with the agency to which you are sending material.

3. In working with the professional:
a. take a copy of these guidelines to the professional;
b. encourage him or her to clarify questions with the person who provided you with these guidelines;
c. be prepared to be forthcoming, thorough, and honest with requested information; and
d. know that professionals must maintain confidentiality with respect to your records and testing information.

4. As follow-up to the assessment by the professional:
a. request a written copy of the assessment report;
b. request the opportunity to discuss the results and recommendations;
b. request additional resources if you need them; and
c. maintain a personal file of your records and reports.

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Appendix B - Tests for Assessing Adolescents and Adults

When selecting a battery of tests, it is critical to consider the technical adequacy of instruments including their reliability, validity and standardization on an appropriate norm group. The professional judgment of an evaluator in choosing tests is important.

The following list is provided as a helpful resource, but it is not intended to be definitive or exhaustive.

Aptitude
 -  Wechsler Adult Intelligence Scale - Revised (WAIS-R)
 -  Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability
 -  Kaufman Adolescent and Adult Intelligence Test
 -  Stanford-Binet Intelligence Scale (4th ed.)

The Slosson Intelligence Test- Revised and the Kaufman Brief Intelligence Test are primarily screening devices which are not comprehensive enough to provide the kinds of information necessary to make accommodations decisions.

Academic Achievement
 -  Scholastic Abilities Test for Adults (SATA)
 -  Stanford Test of Academic Skills
 -  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

Specific achievement test are useful instruments when administered under standardized conditions and interpreted within the context of other diagnostic information. The Wide Range Achievement Test - 3 (WRAT-3) is not a comprehensive measure of achievement and therefore is not useful if used as the sole measure of achievement.

Information Processing
Acceptable instruments include:
 -  the Detroit Tests of Learning Aptitude - 3 (DTLA-3)
 -  the Detroit Tests of Learning Aptitude - Adult (DTLA-A)
 -  information from subtests on WAIS-R
 -  Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability
 -  other relevant instruments.

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Adapted from Ad Hoc Committee on Learning Disabilities Revised July 2001 ©Educational Testing Service 1999 Loring Brinckerhoff, Ad Hoc Committee Chairperson, ©Educational Testing Service; Joan McGuire, Ad Hoc Committee Liaison to the Board, University of Connecticut - Storrs; Kim Dempsey, Law School Admission Council; Cyndi Jordan, University of Tennessee - Memphis; Shelby Keiser, National Board of Medical Examiners; Catherine Nelson, ©Educational Testing Service; Nancy Pompian, Dartmouth College; Louise H. Russell, Harvard University

AHEAD - Guidelines for Documenting LD - July 1997

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