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Documentation Guidelines

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Learning Disability Documentation Guidelines

These guidelines are adapted from the Association on Higher Education and Disability Ad Hoc Committee on Learning Disabilities.

Under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, individuals with learning disabilities are guaranteed certain protections and rights of equal access to programs and services; thus the documentation should indicate that the disability substantially limits some major life activity. The following guidelines are provided in the interest of assuring that LD documentation is appropriate to verify eligibility and to support requests for accommodations, academic adjustments and/or auxiliary aids.

All information obtained in diagnostic and medical reports will be maintained and used in accordance with applicable confidentiality requirements.

Documentation Guidelines

I. Qualifications of the Evaluator

Professionals conducting assessments, rendering diagnoses of learning disabilities, and making recommendations for appropriate accommodations must be qualified to do so. Comprehensive training and direct experience with an adolescent and adult LD population is 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/province in which the individual practices should 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 the assessment of learning problems in adolescents and adults:

  • Licensed Clinical or Educational Psychologist
  • Licensed Clinical Neuropsychologist
  • Licensed School Psychologist
  • Certified Learning Disability Specialist

Use of diagnostic terminology indicating a learning disability by someone whose training and experience are not in these fields is not acceptable. It is of utmost importance that evaluators are sensitive and respectful of cultural and linguistic differences in adolescents and adults during the assessment process. It is not considered appropriate for professionals to evaluate members of their families. All reports should be on letterhead, typed, dated, signed and otherwise legible. 

II. Documentation

The provision of all reasonable accommodations and services is based upon assessment of the impact of the student's disabilities on his or her academic performance at a given time in the student's life. Therefore, it is in the student's best interest to provide recent and appropriate documentation relevant to the student's learning environment.

In some instances, documentation may be outdated, inadequate in scope, or content. It may not address the student's current level of functioning or need for accommodations because observed changes may have occurred in the student's performance since the previous assessment was conducted. In such cases, it may be appropriate to update the evaluation report. Since the purpose of the update is to determine the student's current need for accommodations, the update, conducted by a qualified professional, should include a rationale for ongoing services and accommodations. 

III. Substantiation of the Learning Disability

Documentation should 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, but it 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, information processing and a diagnosis.

A. Diagnostic Interview

An evaluation report should include the summary of a comprehensive diagnostic interview. Learning disabilities are commonly manifested during childhood, but not always formally diagnosed. Relevant information regarding the student's academic history and learning processes in elementary, secondary and postsecondary education should be investigated. The diagnostician, using professional judgment as to which areas are relevant, should conduct a diagnostic interview which may include: a description of the presenting problem(s); developmental, medical, psychosocial and employment histories; family history (including primary language of the home and the student's current level of English fluency); and a discussion of dual diagnosis where indicated.

B. Assessment

The neuropsychological or psycho-educational 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, should consist of and be based on a comprehensive assessment battery that does not rely on any one test or subtest.

Evidence of a substantial limitation to learning or other major life activity must be provided. A list of commonly used tests is included in Appendix B. Minimally; the domains to be addressed must include the following:

    1. Aptitude- A complete intellectual assessment with all subtests and standard scores reported.
    2. Academic Achievement -A comprehensive academic achievement battery is essential with all subtests and standard scores reported for those subtests administered. The battery should 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 and motor ability) should be assessed.

Other assessment measures such as 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 determine a learning disability and differentiate it from co-existing neurological and/or psychiatric disorders (i.e., to establish a differential diagnosis). In addition to standardized tests, it is also very useful to include informal observations of the student during the test administration.

C. Specific Diagnosis

Individual "learning styles," "learning differences," "academic problems" 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 terms such as "suggests" or "is indicative of."

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

D. Test Scores

Standard scores and/or percentiles should be provided for all normed measures. Grade equivalents are not useful unless standard scores and/or percentiles are also included. The data should logically reflect a substantial limitation to learning for 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 should 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. Clinical Summary

A well-written diagnostic summary based on a comprehensive evaluation 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 by the evaluator with background information, observations of the client during the testing situation, and the current context. It is essential, therefore, that professional judgment be utilized in the development of a clinical summary.

The clinical summary should include:

    1. demonstration of the evaluator's having ruled out alternative explanations for academic problems as a result of poor education, poor motivation and/or study skills, emotional problems, attentional problems and cultural/language differences;
    2. indication of how patterns in the student's cognitive ability, achievement and information processing reflect the presence of a learning disability;
    3. indication of the substantial limitation to learning or other major life activity presented by the learning disability and the degree to which it impacts the individual in the learning context for which accommodations are being requested; and...
    4. an indication as to why specific accommodations are needed and how the effects of the specific disability are accommodated.

The summary should also include any record of prior accommodation or auxiliary aids, including any information about specific conditions under which the accommodations were used (e.g., standardized testing, final exams, licensing or certification examinations).

IV. Recommendations for Accommodations

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 does not, in and of itself, warrant the provision of a similar accommodation.

The diagnostic report should include specific recommendations for accommodations as well as an explanation as to why each accommodation is recommended. The evaluators should 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 should support recommendations with specific test results or clinical observations.

If accommodations are not clearly identified in a diagnostic report, the disability service provider may seek clarification and, if necessary, more information. The final determination for providing appropriate and reasonable accommodations rests with the institution.

In instances where a request for accommodations is denied, a written grievance or appeal procedure is in place and may be obtained from the Office of Disability Services.