Guidelines for Documentation of Attention-Deficit/Hyperactivity Disorder in Adolescents and Adults

Consortium on ADHD Documentation

Loring C. Brinckerhoff, Chairperson
Educational Testing Service

Kim M. Dempsey
Law School Admission Council

Cyndi Jordan
University of Tennessee – Memphis

Shelby R. Keiser
National Board of Medical Examiners

Joan M. McGuire
University of Connecticut – Storrs

Nancy W. Pompian
Dartmouth College

Louise H. Russell
Harvard University

Copyright © 1998 Consortium on ADHD Documentation

Acknowledgments

The Consortium wishes to acknowledge the contributions of the following individuals and expresses its appreciation and gratitude for their time invested in reviewing these Guidelines and for their insightful comments.

Russell Barkley, Ph.D.	Director of Psychology University of Massachusetts Medical Center
Michael Gordon, Ph.D.	Professor, Department of Psychiatry Director, ADHD Program State University of New York Health Science Center
Mark S. Greenberg, Ph.D.	Neuropsychologist, Department of Psychiatry Harvard Medical School
Leighton Y. Huey, M.D.	Department of Psychiatry Dartmouth Hitchcock Medical Center
Peter S. Jensen, M.D.	Chief, Developmental Psychopathology Research Branch National Institute of Mental Health
Lynda Katz, Ph.D.	President, Landmark College
Kevin R. Murphy, Ph.D.	Assistant Professor of Psychiatry Chief, Adult Attention Deficit Hyperactivity Disorder Clinic Department of Psychiatry University of Massachusetts Medical Center
Laura F. Rothstein, J.D.	Law Foundation Professor of Law Law Center University of Houston
Larry B. Silver, M.D.	Diplomat: General Psychiatry; Child/Adolescent Psychiatry
Marc Wilchesky, Ph.D., C. Psych.	Coordinator, Learning Disabilities Program Counselling and Development Centre York University
Joan Wolforth, M.A.	Coordinator, Office for Students with Disabilities McGill University

Consortium on ADHD Documentation

Guidelines for Documentation of Attention-Deficit/ Hyperactivity Disorder in Adolescents and Adults

Introduction
The Consortium's mission is to develop standard criteria for documenting attention deficit disorders, with or without hyperactivity (ADHD). These guidelines can be used by postsecondary personnel, examining, certifying, and licensing agencies, and consumers who require documentation to determine reasonable and appropriate accommodations(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. These guidelines provide consumers, professional diagnosticians, and service providers with a common understanding and knowledge base of the components of documentation which 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.

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; and 4) evidence to establish a rationale to support the need for accommodation(s). Attached to these guidelines are appendices giving diagnostic criteria for ADHD from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994), and Recommendations for Consumers.

Under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and assured services. In order to establish that an individual is covered under the ADA, 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 documentation of ADHD demonstrates an impact on a major life activity and supports the request for accommodations, academic adjustments, and/or auxiliary aids.

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.

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 which 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 (see Section III, G) and the previous diagnostic report.

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 is 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 childhood history of an 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 of 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 which may result in behaviors mimicking an Attention-Deficit/Hyperactivity Disorder.

D. Relevant Testing
Neuropsychological or psychoeducational assessment is important in determining the current impact of the disorder on the individual's ability to function in academically related settings. The evaluator should objectively review and include with the evaluation report relevant background information to support the diagnosis. 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 the 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 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 which 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:

1. 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 non-cognitive factors;
2. 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;
3. 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;
4. 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; and
5. 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).

IV. Each Accommodation Recommended 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 benefitted 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 of 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.

Reasonable accommodation(s) may help to ameliorate the disability and to minimize its impact on the student's attention, impulsivity, and distractibility. The determination for reasonable accommodation(s) rests with the designated disability contact person working in collaboration with the individual with the disability and when appropriate, college faculty. The receiving institution or agency has a responsibility to maintain confidentiality of the evaluation and may not release any part of the documentation without the individual's informed consent.

APPENDIX A
DSM-IV Diagnostic Criteria for ADHD*

The following diagnostic criteria for ADHD are specified in the DSM-IV (American Psychiatric Association, 1994):

1. 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
1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior of failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. 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
1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. 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)
4. often has difficulty playing or engaging in leisure activities quietly
5. is often "on the go" or often acts as if "driven by a motor"
6. often talks excessively
Impulsivity
7. often blurts out answers before questions have been completed
8. often has difficulty awaiting turn
9. often interrupts or intrudes on others (e.g., butts into conversations or games)
2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
   
3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
   
4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
   
5. 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, 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.

Note: From Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (pp. 83-85), by the American Psychiatric Association, 1994, Washington, D.C. Copyright © 1994 by the American Psychiatric Association. Reprinted with permission.

APPENDIX B
Recommendations for Consumers

1. For assistance in finding a qualified professional:
1. contact the disability services coordinator at a college or university for possible referral sources; and/or
2. contact a physician who may be able to refer you to a qualified professional with demonstrated expertise in ADHD.
2. In selecting a qualified professional:
1. ask what experience and training he or she has had diagnosing adolescents and adults;
2. ask whether he or she has training in differential diagnosis and the full range of psychicatric disorders. Clinicians typically qualified to diagnose ADHD may include clinical psychologists, physicians, including psychiatrists, and neuropsychologists;
3. 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
4. ask whether you will receive a comprehensive written report.
3. In working with the professional:
1. take a copy of these guidelines to the professional; and
2. be prepared to be forthcoming, thorough, and honest with requested information.
4. As follow-up to the assessment by the professional:
1. schedule a meeting to discuss the results, recommendations, and possible treatment;
2. request additional resources, support group information, and publications if you need them;
3. maintain a personal file of your records and reports; and
4. be aware that any receiving institution or agency has a responsibility to maintain confidentiality.

Copyright © 1998 Consortium on ADHD Documentation

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