The term ADHD, sometimes referred to as ADD, is used in this document, following the official nomenclature in the Diagnostic and Statistical Manual of Mental Disorders, (4th edition DSM-IV-TR [American Psychiatric Association], 2000). This document is consistent with national standards and synthesizes current knowledge about ADHD and explains diagnostic criteria for documenting ADHD that could be used by postsecondary personnel, licensing and academic agencies, and consumers requiring documentation to determine appropriate accommodations. The objective of this revised document is to provide students, and their evaluators, with guidance about the specific information needed to support requests for accommodations.
Diagnostic criteria as specified in the Diagnostic and Statistical Manual of Mental Disorders, (4th edition DSM-IV-TR [American Psychiatric Association], 2000) are used as the basic guidelines for determination of an Attention Deficit/Hyperactivity Disorder diagnosis. Students with an ADHD diagnosis must meet basic DSM-IV-TR criteria including the following:
Demonstrating that they exhibit a sufficient number of symptoms (listed in DSM-IV-TR) of Inattention and/or Hyperactivity/Impulsivity that have been persistent and maladaptive. The exact symptoms should be specified and described in detail and it should be shown how the student meets criteria for a long-standing history of impairment.
Since ADHD is by definition a disorder that is first exhibited in childhood or early adolescence, the documentation must provide evidence to support a childhood onset of symptoms and associated impairment. Individualized Education Plans (IEPs), 504 Plans, early psycho-educational academic reports, teacher comments, documentation from tutors or learning specialists, and disciplinary records may all be useful sources of collateral information (but, in and of themselves, are not considered clinical documentation for the purpose of granting accommodations at Harvard University).
Providing objective evidence demonstrating that current impairment from the symptoms is present in two or more settings. Since ADHD tends to affect people over time and across situations in multiple life domains, it is necessary to show that the impairment is not confined to only the academic setting or to only one circumscribed area of functioning.
A determination that the symptoms of ADHD are not a function of some other mental disorder (such as mood, anxiety, or personality disorders, substance abuse, low cognitive ability, etc.) or situational stressors (such as relationship issues, family, or financial crisis, etc.).
Indicating the specific ADHD diagnostic subtype (Predominantly Inattentive Type, Hyperactive Impulsive Type, Combined Type, or Not Otherwise Specified) is required.
In addition, the following information explains some important considerations regarding ADHD documentation:
- A qualified diagnostician must conduct the evaluation.
Professionals conducting assessments and rendering diagnoses of ADHD must be qualified to do so. Comprehensive training in the differential diagnosis of ADHD and other psychiatric disorders and direct experience in diagnosis and treatment of adolescents and adults with ADHD is necessary.
- Documentation must be current.
Because the provision of reasonable accommodations and services is based upon assessment of the current impact of the student's disability on the academic activity, it is necessary to provide "recent" and appropriate documentation. In most cases, this means that a diagnostic evaluation must have been completed within the past three years.
- A detailed academic history must be provided.
Because developmental disabilities such as an ADHD are usually evident during early childhood (though not always diagnosed), historical information regarding the individual's academic and behavioral functioning in elementary and secondary education should be provided. Self-report alone, without any accompanying historical data that validate developmentally deviant ADHD symptoms and impairment, is not sufficient.
- The documentation should build a case for and provide a sound rationale for the ADHD diagnosis.
An ADHD evaluation is primarily based on an in-depth history reflecting a chronic and pervasive history of ADHD symptoms and associated impairment beginning during childhood and persisting to the present day. The evaluation should provide a broad, comprehensive understanding of the applicant's relevant background including family, academic, behavioral, social, vocational, medical, developmental, and psychiatric history. There should be an emphasis on how the ADHD symptoms have manifested across various settings over time, how the applicant has coped with the problems, and what success the applicant has had in coping efforts.
- Test scores alone are not sufficient to establish an ADHD diagnosis.
Test scores or selective subtest scores alone should not be used as the sole basis for the diagnostic decision. A neuropsychological or psycho-educational assessment can be helpful in identifying the individual's pattern of strengths and weaknesses and whether there are patterns supportive of attention problems. However, a comprehensive testing battery alone, without illuminating a pattern of real world functional impairment, will not be sufficient to establish an ADHD diagnosis or a disability. Checklists and/or ADHD symptom rating scales can be a helpful supplement in the diagnostic process, but by themselves are not adequate to establish a diagnosis of ADHD.
- Each accommodation recommended by the evaluator must include a rationale and be linked to data.
In addition to a comprehensive diagnostic evaluation, the report should also address the history of prior accommodations the student has received and the objective of those accommodations. Accommodations are not granted on the basis of a diagnostic label. Instead, accommodation requests need to be tied to evidence of current functional impairment that supports their use. The evaluator must describe the type and degree of impact the ADHD has (if one exists) on a specific major life activity and on the individual. A detailed explanation must be provided as to why each accommodation is recommended and should correlate specifically to identified functional limitations.
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It is important to note that a prior history of receiving accommodations in previous academic environments is not a guarantee one will be granted accommodations at Harvard University. Prior documentation may have been adequate in determining appropriate services or accommodations in the past. However, a prior history of accommodations without demonstration of a current need does not in itself warrant the provision of similar accommodations.
I. A Qualified Professional Must Conduct the Evaluation
Professionals conducting assessments, rendering diagnoses of ADHD and making recommendations for appropriate accommodations must be qualified to do so. Comprehensive training and relevant experience in differential diagnosis of the full range of psychiatric disorders are essential. Competence in working with culturally and linguistically diverse populations may also be required, depending on the applicant's background and academic history.
The following professionals generally would 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: licensed psychologists, neuropsychologists, psychiatrists, and other relevantly trained medical doctors. Documentation that relies on diagnostic terminology indicating ADHD 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 or children of close friends.
The name, title, and professional credentials of the evaluator, including information about licensure or certification, as well as the areas 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 in English, dated, signed, and otherwise legible.
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II. Documentation Must be Current
The provision of reasonable accommodations and services is based upon clear evidence of the current impact of the disability on the student's academic performance. In most cases, this means that a diagnostic evaluation has been completed within the past three years. If documentation is inadequate in scope or content, or does not address the individual's current level of functioning and need for accommodations, reevaluation may be required.
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III. Documentation Must Include the Following Components to Substantiate the Diagnosis
A. Evidence of Early Impairment
By definition in the DSM-IV-TR, ADHD is exhibited in childhood or early adolescence (although it may not have been formally diagnosed) and manifests itself in more than one setting. Relevant historical information is essential. A comprehensive assessment should include the following: 1) clinical summary of objective or first-hand data (anecdotal or narrative), such as teachers' reports, report cards, and rating scales filled out by parents, teachers or others; 2) IEPs or 504 Plans, and historical information that establishes symptomology indicative of ADHD throughout childhood, adolescence and adulthood that can be garnered from transcripts, teacher comments, tutoring evaluations, job performance evaluations, past psychoeducational testing, and third party interviews when available.
B. Evidence of Current Impairment
In addition to providing data related to a childhood history of an impairment, the following areas must be investigated:
1. Statement of Presenting Problem
What are the individual's current ADHD symptoms? These must include data of ongoing inattentive and/or impulsive/hyperactive behavior, that significantly impairs functioning in two or more settings (i.e., home, school, or employment).
2. Relevant Diagnostic Interview
The documentation should include a summary of the diagnostic interview conducted by a qualified evaluator. The diagnostic information obtained from the interview should consist of more than self-report, as information from third-party sources is critical in the diagnosis of ADHD. The diagnostic interview with information from a variety of sources should include, but not necessarily be limited to, the following:
- history of presenting ADHD symptoms, including evidence of ongoing inattentive and/or impulsive/hyperactive 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, effects of medication (either positive or negative), including whether the typical medical regime was in place at the time of the evaluation
- relevant psychosocial history and interventions
- relevant psychosocial history and interventions
- a thorough academic history of elementary, secondary and postsecondary education (i.e. previous standardized test scores, group-administered test scores, IEPs, 504 Plans, report cards, and/or listings of previously obtained accommodations and evidence of their effectiveness)
- a review of prior psychoeducational test reports to determine whether a pattern of strengths or weaknesses is supportive of attention or learning problems
- description of current functional limitations pertaining to an educational and/or work setting that presumably are a direct result of problems with attention
- information regarding the direct impact of the disability/diagnosed condition on academic performance and/or employment performance, as well as a rationale for each requested accommodation related to the impairment
C. Alternative Diagnoses or Explanations Must Be Ruled Out
Given the high rate of co-morbidity, it is recommended that evaluators investigate and discuss the possibility of dual diagnoses and alternative or coexisting mood, behavioral, neurological, personality disorders, etc. and/or other health issues that may confound the diagnosis of ADHD (e.g., substance abuse, sleep management, etc.). This process should include exploration of possible alternative diagnoses and medical and psychiatric disorders, as well as educational and cultural factors potentially affecting the diagnosis of ADHD.
D. Relevant Testing Information Must be Provided
The assessment of the individual must not only establish a diagnosis of ADHD, but must also demonstrate the current impact of the ADHD on an individual's ability to learn. It is important to discuss differential diagnoses, the possible cause of the disability and its impact if it cannot be ameliorated without accommodations. Ideally, the documentation should address why the requested accommodation is better than other possible accommodations. In addition, neuropsychological or psychoeducational assessment is important in determining the current impact of the disorder on an individual's ability to function in academically related settings. Such assessments might include assessment of intellect, achievement, processing speed, fluency, executive functioning, language, memory and learning, attention, etc. A complete psychoeducational or neuro-psychological assessment is the preferred primary tool for determining the degree to which the ADHD currently impacts individuals in higher education.
The reporting of test scores must be complete, not selective. If grade equivalents are reported, they must be accompanied by standard scores and/or percentiles. Test scores or subtest scores alone should not be used as a sole measure for the diagnostic decision regarding ADHD. Selected subtest scores from measures of intellectual ability, memory function tests, attention or tracking tests, or continuous performance tests do not in and of themselves establish the presence or absence of ADHD. Checklists and/or surveys can serve to supplement the diagnostic profile, but in and of themselves are not adequate for the diagnosis of ADHD and do not substitute for clinical observations and sound diagnostic judgment. All data must logically reflect a substantial limitation to learning for which the individual is requesting the accommodation.
E. Identification of DSM-IV-TR Criteria
The current version of the Diagnostic and Statistical Manual of Mental Disorders, (4th edition DSM-IV-TR [American Psychiatric Association], 2000) known as the DSM-IV-TR, should be utilized in all determinations. According to the DSM-IV-TR, "the essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development" (p. 85). Just having the symptoms, however, is not sufficient for diagnosis, as a large proportion of adolescents and adults report experiencing some of the ADHD symptoms listed in the DMS-IV-TR. A diagnostic report should include a review and discussion of the current DSM-IV-TR criteria for ADHD both, currently and retrospectively, and specify which symptoms are now present (see Appendix A for DSM-IV-TR criteria).
In diagnosing ADHD, it is particularly important to address the following criteria:
- symptoms of inattention and/or hyperactivity/impulsivity causing significant impairment must have been present, in some form, in childhood or early adolescence
- current symptoms that have been present for at least the past six months
- significant impairment from the symptoms is present in two or more settings (for example, school, work, home), including examples
- clear evidence of significant impairment in social, academic, or occupational functioning
- symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Alternative diagnoses should be ruled out.
F. Documentation Must Include a Specific Diagnosis
The report must include a specific diagnosis of ADHD (including the subtype) based on the current DSM-IV-TR diagnostic criteria. The qualified professional should provide a rationale and supportive data to substantiate this diagnosis.
Individuals who only report problems with daily organization, test anxiety, difficulty with timed testing, memory, or concentration in selective situations do not fit the prescribed diagnostic criteria for ADHD. Similarly, while executive function issues are commonly seen in students who have ADHD, these students with executive function issues who do not meet the DSM-IV-TR criteria for ADHD would not qualify under the ADHD classification. A positive response to medication by itself does not constitute a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation(s).
Because of the challenge of distinguishing the range of normal behaviors and developmental patterns of adolescents and adults (e.g., procrastination, disorganization, distractibility, restlessness, boredom, academic under-achievement or failure, low self-esteem, chronic tardiness, or inattendance) from clinically significant impairment, a multifaceted evaluation should address the severity and frequency of the symptoms and whether these behaviors constitute an impairment in a major life activity.
It is not sufficient for a current evaluation report simply to refer to a prior diagnosis as confirmatory evidence of ADHD. The current assessment needs to reconfirm the diagnosis with supportive clinical data and an updated rationale for accommodations.
G. Documentation Must Include Interpretation and Discussion of Diagnostic Findings
A well-written interpretation of findings based upon a comprehensive evaluative process is a necessary component of the documentation. An ADHD diagnosis is in many ways based upon the integration of relevant historical information and observation, as well as other diagnostic findings; therefore, it is essential that the evaluator's professional judgment be used to develop this section along the following guidelines.
- Evaluators should rule out alternative explanations for inattentiveness, impulsivity, and/or hyperactivity resulting from medical conditions, other psychological disorders, or noncognitive factors. The evaluator must describe the manner in which the possible alternatives were considered and ruled out (e.g., historical information, observation, or test results).
- Evaluators should demonstrate how patterns of inattentiveness, impulsivity, and/or hyperactivity have affected the individual across the life span and across developmentally appropriate settings (e.g., discipline at school, playground, and home for children; and occupational, interpersonal, financial, civic adjustment/responsibility for adults) in making a diagnosis of ADHD.
- Evaluators should describe whether or not the candidate was taking psycho-active medication at the time of the evaluation, and indicate the extent to which any and all of the treatment provides a positive response and/or negative side effects.
- Evaluators should specifically describe how ADHD substantially limits learning and to what degree the disorder affects the individual in the academic context for which the candidate is requesting accommodations.
- Additionally, evaluators should recommend what accommodations are needed based on how the disorder affects the candidate in the academic environment and what compensatory activities may occur as a result of the accommodation.
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IV. Each Accommodation Recommended by the Evaluator Must Include a Rationale
Postsecondary institutions and/or examining, certifying, licensing agencies and employers are obligated to provide reasonable accommodations. A detailed explanation supporting the need for each requested accommodation must be provided and correlated with specific functional limitations established through the evaluation process. Harvard University may approve some, all, or none of the requested accommodations depending on the sufficiency of the documentation provided. If the documentation is deemed insufficient, Harvard University will provide the student with an opportunity to address limitations in the diagnostic report. Students are urged to share the University's feedback with their evaluator for clarification, and in some cases, to provide requested information.
Prior documentation is useful in establishing an appropriate accommodation history but documentation must also 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 Education Program (IEP) or a 504 Plan is insufficient documentation in and of itself but can be included with 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, etc.) and whether or not they benefited the individual. For individuals who are not currently engaged in an educational setting, documentation must include a discussion of any prior educational accommodations and the condition under which the accommodations were used or the adaptive compensatory strategies used by the individual.
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 accommodations are needed at this time.
If the requested accommodations are not clearly identified in the diagnostic report, Harvard University may request clarification and, if necessary, more information. Harvard University will make the final determination of whether reasonable accommodations are warranted and deemed appropriate.
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Evaluators are encouraged to keep the following points in mind as they prepare disability documentation:
- An ADHD diagnosis should not be made without clear evidence of problems dating back to childhood, although, symptoms may not become functionally limiting until adolescence.
- There must be evidence of the functional impact of the disability based on DSM-IV-TR criteria. Having a disorder does not mean it is disabling.
- There is a need for multi-dimensional assessment that includes data from different sources (e.g., client, significant other, parents, school records, employment performance records, neuropsychological testing).
- An ADHD diagnosis should never be made solely from a symptom count based on a checklist or rating scales.
- While neuropsychological and psycho-educational testing is not yet able to reliably diagnose ADHD, it can help determine the current levels of severity of the ADHD and quantify the impact of the disorder on cognitive or academic functioning.
- Success in an educational arena is not by itself a reason to rule out the diagnosis of ADHD.
- Many evaluators recommend extra time and/or a separate testing room for students with ADHD without providing any rationale for the request. Again, all recommended accommodations must be accompanied by a data-driven rationale, which psychological and neuropsychological testing can be used to support.
Assessing Adolescents and Adults with ADHD
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 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 most recent version of the test should always be used unless the evaluator can offer a rationale for use of an older version. The following list includes a variety of measures for diagnosing ADHD and/or LD/ADHD. It is meant to be a helpful resource to evaluators but not a definitive or exhaustive listing.
The 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:
- Family history
- Results of a neuromedical history
- Presence of ADHD symptoms since childhood or early adolescence
- Presence of ADHD symptoms in the last 6 months
- Evidence that symptoms cause a significant impairment over time
- Qualitative information regarding the extent of current functional impairment (e.g., academic, occupational, social)
- Results of clinical observation for hyperactive behavior, impulsive speech, distractibility
- 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 and response to treatment
- An accounting for periods during which the student was symptom-free
- Determination of what accommodations, if any, have minimized the impact of functional limitations in the past or in the present setting
- Determination of which remediation approaches and/or compensating strategies are and are not currently effective
Rating Scales - Self-rated or interviewer-rated scales for categorizing and quantifying the nature of the impairment may be useful in conjunction with other data.
Selected examples include:
- Achenbach System for Empirically Based Assessment (ASEBA)
- ADD-H Comprehensive Teachers Rating Scale (ACTeRS)
- ADDES-Secondary Age
- ADHD Rating Scale-IV
- ADHD Symptom Checklist - 4 (ADHD-SC4)
- Attention-Deficit Disorders Evaluation Scale: Secondary-Age Student (ADDES-S)
- Beck Anxiety Inventory (BAI)
- Beck Depression Inventory (BDI-II)
- Behavior Assessment System for Children-2 (BASC-2)
- Behavior Rating Inventory of Executive Functioning (child or adult version)
- Brown Attention-Deficit Disorders Scale
- Conners' Parent Rating Scale (age 3-17 years)
- Conners' Teacher Rating Scale (age 3 -17 years)
- Conners' Rating Scales-3 (Conners 3)
- Conners' Adult ADHD Rating Scales (CAARS)
- Conners' Comprehensive Behavior Rating Scales (Conners CBRS)
- Copeland Symptom Checklist for Adult Attention-Deficit Disorders (CSCAADD)
- Hamilton's Depression Rating Scale
- Wender Utah Rating Scale (WURS) and Parent's Rating Scale (PRS)
Observational Forms - primarily for children and teenagers in the classroom setting
Selected examples include:
- ADHD School Observation Code
- ADHD Direct Observation System
- BASC-2 Student Observation System
- CBC/Test Observation Form
- Child Behavior Checklist/Direct Observation Form
- School Hybrid Observation Code for Kids
Neuropsychological 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.
Selected examples include:
Specific achievement tests are useful instruments when administered under standardized conditions and when the results are interpreted within the context of other diagnostic information. The Wide Range Achievement Test - 4 (WRAT-4) or the Nelson-Denny Reading Test are not a comprehensive measure of achievement and should not be used as the sole measure of achievement.
Tests of Intellectual Functioning
- Kaufman Adolescent and Adult Intelligence Test
- Reynolds Intellectual Assessment Scales (RIAS)
- Stanford-Binet 5 (SB5)
- Wechsler Adult Intelligence Scale - IV (WAIS-IV)
- Woodcock-Johnson - III Tests of Cognitive Ability
Attention, Memory, and Learning
- Attention Capacity Test (ACT)
- Brown Attention-Deficit Disorder Scale
- California Verbal Learning Test-Second Edition (CVLT-II)
- Conners' Continuous Performance Test (CPT)
- Detroit Test of Learning Aptitude - 4 (DTLA -4)
- Detroit Test of Learning Aptitude-Adult (DTLA-A)
- Gordon Diagnostic Systems (GDS)
- Integrated Visual and Auditory Continuous Performance Test (IVA+Plus)
- Kagan Matching Familiar Figure Test (KMFFT)
- Paced Auditory Serial Test (PASAT)
- Test of Everyday Attention for Children (TEA-Ch)
- Tests of Variable Attention Computer Program (TOVA)
- WAIS-III Working Memory Index
- Wechsler Memory Scales - III (WMS-III)
- Behavior Rating Inventory of Executive Functioning (child or adult version)
- Delis-Kaplan Executive Function System
- Stroop Color and Word Test
- Trail Making Test Parts A and B
- Tower of London-Second Edition
- Wisconsin Card Sorting Test (WCST)
- Scholastic Abilities Test for Adults (SATA)
- Stanford Test of Academic Skills (TASK)
- Wechsler Individual Achievement Test - II (WIAT-II)
- Woodcock-Johnson Psychoeducational Battery - III: Tests of Achievement
Supplemental achievement tests such as:
- Gray Oral Reading Test (GORT 4th Ed).
- Nelson-Denny Reading Test (with standard and extended time)
- Stanford Diagnostic Mathematics Test
- Test of Written Language - 3 (TOWL-3)
- Woodcock Reading Mastery Tests - Revised
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)
- Neurologic disorders
- Impact of medication on attention if tried, and under what circumstances
- Sleep disorders
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