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Test Accommodations Attention-Deficit/Hyperactivity Disorder (ADHD)
 
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Attention Deficit / Hyperactivity Disorder (ADHD)
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•SPEX Accommodation Request
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SPEX Accommodations Guidelines and Questionnaire

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 IV. Attention-Deficit / Hyperactivity Disorder (ADHD)

Documentation for applicants submitting a request for accommodation based on Attention-Deficit / Hyperactivity Disorder (ADHD) should contain all of the items listed in the General Guidelines section.  The following information explains the additional issues documentation must address relative to ADHD.

1.The evaluation must be conducted by a qualified diagnostician.
  Professionals conducting assessment and rendering diagnosis of Attention-Deficit Hyperactivity Disorder 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 adults is necessary. The evaluator's name, title and professional credentials, including information about license or certification as well as the area of specialization, employment and state in which the individual practices, should be clearly stated in the documentation.

2.Testing / assessment must be current.
  The determination of whether an individual is "significantly limited" in functioning is based upon assessment of the current impact of the impairment on the SPEX or USMLE testing program. (See General Guidelines for more information.)

3.Documentation necessary to substantiate the Attention Deficit Hyperactivity Disorder must be comprehensive.
  Because ADHD is, by definition, first exhibited in childhood (although it may not have been formally diagnosed) and in more than one setting, objective, relevant, historical information is essential. Information verifying a chronic course of ADHD symptoms from childhood through adolescence to adulthood, such as educational transcripts, report cards, teacher comments, tutorial evaluations, job assessments and the like are necessary.
  1. The evaluator is expected to review and discuss DSM-IV diagnostic criteria for ADHD and describe the extent to which the patient meets these criteria. The report should include specific information about the specific symptoms exhibited and document that the patient meets criteria for longstanding history, impairment and pervasiveness.
  2. A history of the individual's presenting symptoms should be provided, including evidence of ongoing impulsive/hyperactive or inattentive behaviors (as specified in DSM-IV) that significantly impair functioning in two or more settings.
  3. The information collected by the evaluator should consist of more than self-report. Information gathered in the diagnostic interview and reported in the evaluation 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 post-secondary education;
    • Review of psychoeducational test reports to determine if a pattern of strengths or weaknesses is supportive of attention or learning problems;
    • Evidence of impairment in several life settings (home, school, work, etc.) and evidence that the disorder significantly restricts one or more major life activities;
    • Relevant employment history;
    • Description of current functional limitations relative to an educational setting and to SPEX in particular that are presumably a direct result of the described problems with attention;
    • A discussion of the differential diagnosis, including alternative or coexisting mood, behavioral, neurological and/or personality disorders which may confound the diagnosis of ADHD; and
    • Exploration of possible alternative diagnoses which may mimic ADHD.
4.Relevant assessment batteries.
  A neuropsychological or psychoeducational assessment may be necessary in order to determine the individual's pattern of strengths or weaknesses and to determine whether these are patterns supportive of attention problems. Test scores or sub-test scores alone should not be used as the sole basis for the diagnostic decision. Scores from subtests on the Wechsler Adult Intelligence Scale-III (WAIS-III), memory functions tests, attention or tracking tests, or continuous performance tests do not in and of themselves establish the presence or absence of ADHD. They may, however, be useful as one part of the process in developing clinical hypotheses. Checklists and/or surveys can serve to supplement the diagnostic profile but by themselves are not adequate for the diagnosis of ADHD. When testing is used, standard scores should be provided for all normed measures.

5.Identification of DSM-IV Criteria.
  A diagnostic report should include a review of the DSM-IV criteria for ADHD both currently and retrospectively and specify which symptoms are present (see DSM-IV for specific criteria). According to 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". Other criteria include:
  1. Symptoms of hyperactivity-impulsivity or inattention that cause impairment must have been present in childhood.
  2. Current symptoms that have been present for at least the past six months.
  3. Impairment from the symptoms present in two or more settings (school, work, home).
6.Documentation should include a specific diagnosis.
  The report should include a specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. Individuals who report only problems with organization, test anxiety, memory and concentration on a situational basis do not fit the prescribed diagnostic criteria for ADHD. Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself is not supportive of a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation(s).

7.A clinical summary should be provided.
  A well-written diagnostic summary based on a comprehensive evaluative process is a necessary component of the assessment. The clinical summary must 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 the substantial limitation to learning presented by the ADHD and the degree to which it impacts the individual in the context for which accommodations are being requested (e.g. impact on the SPEX or USMLE program); and
  4. 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).
8.Each accommodation recommended by the evaluator should include a rationale.
  The evaluator should describe the impact of the ADHD (if one exists) on a specific major life activity as well as the degree of significance of this impact on the individual. The diagnostic report should include specific recommendations for the accommodation(s). A detailed explanation must be provided as to why each accommodation is recommended and should be correlated with specific identified functional limitations. Prior documentation may have been useful in determining appropriate services in the past.

However, documentation should validate the need for the accommodation(s) based on the individual's current level of functioning. The documentation should include any record of the prior accommodation(s) or auxiliary aid, including information about specific conditions under which the accommodation was used (e.g. standardized testing, final exams, NBME subject exams, etc.). However, a prior history of accommodation(s), without demonstration of a current need, does not in itself warrant the provision of a similar accommodation. If no prior accommodation has been provided, the qualified professional and/or the individual being evaluated should include a detailed explanation as to why no accommodation was used in the past and why accommodation is needed at this time.

Because of the challenge of distinguishing ADHD from normal development patterns and behaviors of adults, including procrastination, disorganization, distractibility, restlessness, boredom, academic underachievement or failure, low self-esteem and chronic tardiness or in attendance, a multifaceted evaluation should address the intensity and frequency of the symptoms and whether these behaviors constitute an impairment in a major life activity.


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