INFORMATION FOR STUDENTS: Documentation Guidelines for Attentional Deficit/Hyperactivity Disorder

Printable version of these guidelines

Under the Americans With Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and may be entitled to reasonable accommodations and rights to equal access to programs and services. To establish that an individual is covered under the ADA, the documentation must indicate that the disability substantially limits one or more major life activity, and supports the request for services, accommodations, academic adjustments, and/or auxiliary aids. A diagnosis of a disorder/condition alone does not automatically qualify an individual for accommodations under the ADA.

The mission of the Consortium on ADHD Documentation was to develop standard criteria for documenting attention deficit disorders, with or without hyperactivity (ADHD). Modified versions of these guidelines can be used by postsecondary personnel, examining, certifying, and licensing agencies, and consumers who require documentation to determine reasonable and appropriate accommodation(s) for individuals with ADHD. Although the more generic term, Attention Deficit Disorder (ADD), is frequently used, the official nomenclature in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association, © 1994) is Attention-Deficit/Hyperactivity Disorder (ADHD), which is used in these guidelines. The guidelines provide consumers, professional diagnosticians, and service providers with a common understanding and knowledge base of the components of documentation that are necessary to validate the existence of ADHD, its impact on the individual's educational performance, and the need for accommodation(s). The information and documentation to be submitted should be comprehensive in order to avoid or reduce unnecessary time delays in decision-making related to the provision of services.

Clinical documentation of ADHD that 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.

In the main section of the document, the Consortium presents guidelines in four important areas:

1. Qualifications of the evaluator
2. Recency of documentation
3. Comprehensiveness of the documentation to substantiate the ADHD
4. Evidence to establish a rationale to support the need for accommodation(s)

Appendix A provides diagnostic criteria for ADHD from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994). Appendices B, C, and D provide recommendations for consumers, suggestions for assessment, and a listing of resources and organizations, respectively.

back to top

This document provides guidelines necessary to establish the impact of ADHD disabilities on the individual's educational performance and participation in other University programs and activities, and to validate the need for accommodations. 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 learning disabilities and psychiatric disabilities, evaluators should consult the appropriate companion guidelines as found at learning disability documentation guidelines for learning disabilities and psychiatric disability documentation guidelines for psychiatric disabilities.

Information and documentation submitted by students to verify accommodation eligibility must be comprehensive in order to avoid unnecessary delays in decision making related to the provision of requested accommodations.

Documentation Guidelines

I. A Qualified Professional Must Conduct the Evaluation

Professionals conducting assessments and rendering diagnoses of ADHD must have training in differential diagnosis and the full range of psychiatric disorders. 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. 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: clinical 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.

Use of diagnostic terminology indicating an ADHD by someone whose training and experience are not in these fields is not acceptable. It is also not appropriate for professionals to evaluate members of their own families. All reports should be on letterhead, typed, dated, signed, and otherwise legible. The receiving institution or agency has the responsibility to maintain the confidentiality of the individual's records.

back to top

II. Documentation Should be Current

Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the disability on academic performance, it is in an individual's best interest to provide recent and appropriate documentation. In most cases, this means that a diagnostic evaluation has been completed within the past three years. Flexibility in accepting documentation that exceeds a three-year period may be important under certain conditions if the previous assessment is applicable to the current or anticipated setting. If documentation is inadequate in scope or content, or does not address the individual's current level of functioning and need for accommodation(s), reevaluation may be warranted. Furthermore, observed changes may have occurred in the individual's performance since previous assessment, or new medication(s) may have been prescribed or discontinued since the previous assessment was conducted. In such cases, it may be necessary to update the evaluation report. The update should include a detailed assessment of the current impact of the ADHD and interpretive summary of relevant information and the previous diagnostic report.

back to top

III. Documentation Should be Comprehensive

A. Evidence of Early Impairment

Because ADHD is, by definition, 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 transcripts, report cards, teacher comments, tutoring evaluations, past psychoeducational testing, and third party interviews when available.

B. Evidence of Current Impairment

In addition to providing evidence of a childhood history of impairment, the following areas must be investigated:

1. Statement of Presenting Problem
A history of the individual's presenting attentional symptoms should be provided, including evidence of ongoing impulsive/ hyperactive or inattentive behaviors that significantly impair functioning in two or more settings.

2. Diagnostic Interview
The information collected for the summary of the diagnostic 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 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
• Review of prior psychoeducational 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

C. Rule Out Alternative Diagnoses or Explanations
The evaluator must investigate and discuss the possibility of dual diagnoses, and alternative or co-existing mood, behavioral, neurological, and/or personality disorders which may confound the diagnosis of ADHD. This process should include exploration of possible, alternative diagnoses, and medical and psychiatric disorders as well as educational and cultural factors impacting the individual that may result in behaviors mimicking an Attention-Deficit/Hyperactivity Disorder.

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 take timed tests. 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. The evaluator must objectively review and include with the evaluation report relevant background information to support the diagnosis and its impact within the current educational environment. 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 functions 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 accommodation.

E. Identification of DSM-IV Criteria
According to the DSM-IV, "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. 78). A diagnostic report should include a review and discussion of the DSM-IV criteria for ADHD both currently and retrospectively and specify which symptoms are present (see Appendix A for DSM-IV criteria). In diagnosing ADHD, it is particularly important to address the following criteria: symptoms of hyperactivity/ impulsivity or inattention that cause impairment which must have been present in childhood; current symptoms that have been present for at least the past six months; impairment from the symptoms present in two or more settings (for example, school, work, and home); clear evidence of significant impairment in social, academic, or occupational functioning; and symptoms which 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).

F. Documentation Must Include a Specific Diagnosis
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 terms such as "suggests," "is indicative of," or "attention problems." Individuals who report only problems with organization, test anxiety, memory and concentration in selective situations do not fit the proscribed diagnostic criteria for ADHD. Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself does not confirm a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation(s).

G. An Interpretative Summary Should 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 should include:

• Demonstration of the evaluator having ruled out alternative explanations for inattentiveness; impulsivity, and/or hyperactivity as a result of psychological or medical disorders or non-cognitive 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 student was evaluated while on medication, and whether or not there is a positive response to the prescribed treatment
• Indication and discussion of the substantial limitation to learning presented by the ADHD and the degree to which it impacts the individual in the 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 accommodation(s)

back to top

IV. Each Accommodation Recommendation by the Evaluator Should Include a Rationale
The evaluator(s) should describe the impact, if any, of the diagnosed ADHD on a specific major life activity as well as the degree of impact on the individual. The diagnostic report should include specific recommendations for accommodations that are realistic and that postsecondary institutions, examining, certifying, and licensing agencies can reasonably provide. A detailed explanation should be provided as to why each accommodation is recommended 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 should 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 should 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 a like accommodation. If no prior accommodations were provided, the qualified professional and/or the individual should include a detailed explanation as to why no accommodations were used in the past and why accommodations are needed at this time.

Because of the challenge of distinguishing normal behaviors and developmental patterns of adolescents and adults (e.g., procrastination, disorganization, distractibility, restlessness, boredom, academic underachievement or failure, low self-esteem, and chronic tardiness or inattendance) from clinically significant impairment, a multifaceted evaluation should address the intensity and frequency of the symptoms and whether these behaviors constitute an impairment in a major life activity.

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.

back to top

V. 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.

back to top

APPENDIX A

DSM-IV DIAGNOSTIC CRITERIA FOR ADHD

A. Either (1) or (2):

(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often "on the go" or often acts as if "driven by a motor"
• Often talks excessively

Impulsivity

• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The 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).

The DSM-IV specifies a code designation based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months.
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

314.9 Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified: This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.

Permission is required to reproduce the DSM-IV. Contact the American Psychiatric Association, Washington, DC.
(The information in this appendix is taken from Diagnostic and Statistical Manual of Mental Disorders (4th edition, pp. 83-85), © 1994, by the American Psychiatric Association, Washington, DC. Reprinted with permission.)

back to top

APPENDIX B: Recommendation for consumers

• Contact the disability services coordinator at a college or university for possible referral sources; and/or
• Contact a physician who may be able to refer you to a qualified professional with demonstrated expertise in ADHD.

In selecting a qualified professional:

• Ask what experience and training he or she has had diagnosing adolescents and adults;
• Ask whether he or she has training in differential diagnosis and the full range of psychiatric disorders. Clinicians typically qualified to diagnose ADHD may include clinical psychologists, physicians, including psychiatrists, and neuropsychologists;
• Ask whether he or she has ever worked with a postsecondary disability service provider or with the agency to whom you are providing documentation; and
• Ask whether you will receive a comprehensive written report.

In working with the professional:

• Take a copy of these guidelines to the professional; and
• Be prepared to be forthcoming, thorough, and honest with requested information.

As follow-up to the assessment by the professional:

• Schedule a meeting to discuss the results, recommendations, and possible treatment;
• Request additional resources, support group information, and publications if you need them;
• Maintain a personal file of your records and reports; and
• Be aware that any receiving institution or agency has a responsibility to maintain confidentiality.

back to top

APPENDIX C: Suggestions for Assessment

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
4. Rule out other problems that may mimic ADHD

Specific areas to be addressed include:

• 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
• Extent of functional impairment across settings (e.g., academic, occupational, social)
• An accounting for periods in which student was symptom-free
• Presence of other psychiatric conditions (mood or anxiety disorders, substance abuse, etc.)
• Indication that symptoms are not sue 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 documents include, but are not limited to:

Aptitude/Cognitive Ability

• 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 Cognitive Achievement
• Wechsler Individual Achievement Test (WIAT)

• Nelson-Denny Reading Skills Test
• Stanford Diagnostic Mathematics Test
• Test of Written Language - 3 (TOWL-3)
• Woodcock Reading Master 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

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)
• Neurologic disorders
• Impact of medication on attention if tried, and under what circumstances

5. Collateral information
Include third party sources that 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., by parent)
• Information from old school and report cards and transcripts

back to top

APPENDIX D: Resources and Organizations

Association on Higher Education and Disability (AHEAD)
University of Mass Boston
100 Morrissey Blvd.
Boston, MA 02125-3393
(617) 287-3880 voice/TTY
(617) 287-3881 FAX
http://www.AHEAD.org
An excellent organization to contact for individuals with disabilities who are planning to attend college and who will need accommodations. Numerous training programs, workshops, publications and conferences.

Children and Adults with Attention Deficit Disorders (CHADD)
8181 Professional Place, Suite 201
Landover, MD 20785
(800) 233-4050 voice (toll free)
(301) 306-7070 voice
(301) 306-7090 FAX
http://www.chadd.org
CHADD is a national organization with over 32,000 members and more than 500 chapters nationwide that provides support and information for parents who have children with ADD and adults with ADD.

Council for Exceptional Children
1920 Association Drive
Reston, VA 22091-1589
(888) CEC-SPED voice (toll free)
(703) 620-3660 voice
(703) 264-9446 TTY
(703) 264-9494 FAX
http://www.cec.sped.org
The largest international professional organization committed to improving educational outcomes for individuals with disabilities.

International Dyslexia Association (IDA)
8600 LaSalle Road
Chester Building, Suite 382
Baltimore, MD 21286-2044
(410) 296-0232 voice
(800) ABCD-123 messages
(410) 321-5069 FAX
http://www.interdys.org
The IDA is an international, non-profit organization dedicated to the study and treatment of learning disabilities and dyslexia. For nearly 50 years, the IDA has been helping individuals with dyslexia, their families, teachers, physicians, and researchers to better understand dyslexia.

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

Recording for the Blind & Dyslexic (RFB&D)
20 Roszel Road
Princeton, NJ 08540
(609) 452-0606 voice
(800) 221-4792 voice (book orders only)
(609) 520-7990 FAX
http://www.rfbd.org
RFB&D is recognized as the nation's leading educational lending library of academic and professional textbooks on audiotape from elementary through post-graduate and professional levels. Students with print disabilities can request cassette or diskette versions of books and order 4-track tape players.

back to top

February 2000

Adapted From the Consortium on ADHD Documentation © 1998
Loring Brinkerhoff, Chairperson, Educational Testing Service; Kim Dempsey, Law School Admission Council; Cyndi Jordan, University of Tennessee - Memphis; Shelby Keiser, National Board of Medical Examiners; Joan McGuire, University of Connecticut - Storrs; Nancy Pompian, Dartmouth College; Louise H. Russell, Harvard University