Psychological Documentation

Psychological Documentation

Psychological disabilities is a generic term used by ODS to refer to a variety of conditions involving psychological, emotional, and behavioral disorders and syndromes. The two official sources outlining the criteria used by professionals when making psychological diagnoses are the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV-TR) and the International Classification of Diseases Manual, Tenth Revision (ICD-10). When determining eligibility for an accommodation, the symptoms must meet the legal definition of a disability.

This information is intended to provide the minimum standards for submitting documentation to the Office of Disabilities. These guidelines assist the office in determining reasonable accommodations for individuals with psychological disabilities and to establish the impact of psychological disabilities on a student's academic performance. 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 accommodations. There are three components to submitting documentation on the basis of a psychological disability: Qualified professional, Current, Comprehensive. See descriptions below for a detailed explanation of each component.

Qualified Professional

Professionals conducting assessments and rendering physical diagnoses must be qualified in the specific area for which they are making recommendations. A qualified professional must have (1) comprehensive training and relevant expertise in the specialty and (2) appropriate licensure/certification. Professionals such as physicians, surgeons, optometrists, audiologists, occupational and physical therapists, neurologists, and other health and learning specialists, must provide documentation within their areas of expertise. Professionals should utilize the most recent evaluation tools available in the profession. Professionals who render a diagnosis outside of their area of expertise will not be considered in support of an accommodation. Comprehensive documentation may include reports from several professionals or a team. Evaluations and diagnoses from family members, even when the family member is a qualified professional, will not be accepted for professional and ethical reasons.

All documentation must include the name, title, and credential of the professional completing the report or evaluation. The report must be in English, typed, and on professional letterhead. The documentation should include current contact information for the professional. All reports/evaluations must be signed by the professional and include information about the license or certification of the professional, area of specialization, employment, and the state in which the individual practices.

Current Documentation

Documentation submitted must have been completed within the

  • past three years for learning disabilities
  • past six months for medical disabilities
  • past six months for ADHD
  • past six months for psychological disabilities

Reasonable accommodations are determined based on the current functioning of the individual. This cannot be determined without recent documentation. All instruments used by an examiner must be the most recent version at the time of testing to be considered current. Discretion by the director may be used in accepting documentation for some permanent conditions. In cases where the disability is long-term, comprehensive documentation may be submitted that is older but a recent evaluation update by the treating professional is required. For example, the diagnosis of Tourette's syndrome may have occurred in childhood. In this case, documentation should be submitted from the initial diagnosis as well as a report from a qualified professional documenting the current symptoms, levels of functioning, treatment, and medications. The update should address the current levels of functioning and all components listed under comprehensive documentation for the specific disability. Moreover, reports and/or evaluations should specifically address limitations or impairments related to the academic environment. Reasonable accommodations are based on the current impact of the disability and not the potential impact of the disability or the possibility of experiencing symptoms related to a disability, medication, or treatment. It is imperative that professionals be detailed and explicit when describing the current functioning of the individual.

Comprehensive Criterion

Documentation must be based on a comprehensive diagnostic/clinical evaluation that includes each of the following components:

1. History of the disability, psychological assessment, and diagnostic interview:

  • history of presenting symptoms
  • duration and severity of the disorder
  • developmental, historical, and familial background information
  • relevant medical and medication history, including the individual's current medication regimen, compliance, side effects (if relevant), and response to medication
  • a description of the expected progression or stability of the impact of the condition over time
  • A list of the assessment procedures and evaluation instruments used to make the diagnosis along with a psychological report of the results. Standard scores should be included in the report or attached. See below for assessment instruments.

2. Assessment in each of the following FOUR domains:

Aptitude or Intelligence Assessment:

A complete assessment with all subtests, standard scores and percentiles is required. Assessment must be based on a comprehensive battery that does not rely on any one test or subtest. The Wechsler Adult Intelligence Scale-Revised (WAIS-IV) is the preferred instrument. The professional judgment of the evaluator in choosing tests is important, therefore, other acceptable instruments are:

  • Kaufman Adolescent & Adult Intelligence
  • Stanford-Binet Intelligence 5th Edition (SB-V)

Psychological Assessment: An assessment or inventory of the specific area of personality. Acceptable measures include:

  • Minnesota Multiphasic Personality Inventory-II (MMPI-II)
  • Millon Clinical Multiaxial Inventory-III (MCMI-III)

Achievement: A comprehensive academic achievement battery is required with all subtests, standard scores and percentiles. Acceptable measures include:

  • Woodcock-Johnson III: Tests of Achievement
  • Wechsler Individual Achievement Test (WIAT)
  • Scholastic Abilities Test for Adults (SATA)
  • Stanford Test of Academic Skills (Task)

As a supplement, other specific achievement measures may be useful when interpreted along with other diagnostic information:

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

Information Processing: All relevant areas of information processing should be assessed.

  • Short and long-term memory
  • Auditory and visual processing
  • Processing speed
  • Executive functioning
  • Motor Ability Acceptable measures for information processing include, but are not limited to:
  • Woodcock-Johnson III: Tests of Cognitive Ability
  • Detroit Tests of Learning Aptitude-3

3. DSM-IV multi-axial diagnosis and GAF:

  • The report must include a specific diagnosis based on the DSM-IV-TR or ICD-10 diagnostic criteria and include the specific diagnostic section in the report with a numerical and nominal diagnosis from DSM-IV-TR or ICD-10. Evaluators are encouraged to cite the specific objective measures used to substantiate the diagnosis. The evaluator should be explicit and detailed when describing the diagnosis of a psychological disorder.

4. Description of current functional limitations caused by the disorder as they pertain to the academic environment:

  • A description of current functional limitations in different settings with the understanding that a psychological disorder usually presents itself across a variety of settings other than just the academic domain and that its expression is often influenced by context-specific variables (e.g., school-based performance).

5. Accommodations that result in a fundamental or substantial alteration of the nature of the educational program and are not reasonable as a matter of law and will, therefore, not be granted.

  • Information regarding any medications that may impact academic performance. The use of medication does not support or negate the presence of a disability. Many individuals often benefit from pharmacological treatments or therapies; however, this alone does not justify the need for an accommodation.

6. Information regarding current treatment, and

  • Information regarding kind of treatment and duration/consistency of the therapeutic relationship
  • The evaluator must also investigate and rule out the possibility of other potential diagnoses involving neurological and/or medical conditions or substance abuse, as well as educational, linguistic, sensorimotor, and cross-cultural factors that may result in symptoms mimicking the purported psychiatric disability.
  • Changes since the last assessment
  • Is the individual presently a threat to self or others

7. Specific accommodations being requested along with accompanying rationale.

  • The evaluator must describe the degree of impact of the diagnosed psychological disorder on a specific major life activity such as learning, as well as the degree of impact on the individual. A link must be established between the requested accommodations and the functional limitations of the individual within the academic environment. A diagnosis in and of itself does not automatically warrant an accommodation. For example, test anxiety alone is not a sufficient diagnosis to support requests for accommodations. Given that many individuals may perceive that they might benefit from extended time in testing situations, evaluators must provide specific rationales and justifications for the accommodation. A prior history of accommodations, without demonstration of current need, does not in and of itself warrant the provision of accommodations. Psychoeducational, neuropsychological or behavioral assessments are often necessary to support the need for testing accommodations based on the potential for psychiatric disorders to interfere with cognitive performance.

8. Accommodations can NOT be provided until documentation is complete.

Accommodations that result in a fundamental or substantial alteration of the nature of the educational program and are not reasonable as a matter of law and will, therefore, not be granted.

Please contact the Office of Disability Services should you have any questions.

Office of Disability Services
E-mail: disabilityservices@miami.edu
Phone: (305) 284-2374
Fax: (305) 284-1999