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Treatment of ADHD

SHAC Standards for Documenting ADHD

 

Introduction

These guidelines are provided to help the evaluating professional document findings in a manner that provides SHAC psychiatrists sufficient data when considering treatment with medication, meets ADA requirements, and supports the request for learning accommodations.

Documentation must be comprehensive and include information about the history of the condition (e.g. childhood symptoms), verify the existence of a current condition, address the type and severity of the condition, as well as discuss concurrent or alternative explanations for the symptoms.

Please Note:
  • Medical Records must be from a psychiatrist and not a general practitioner (see Qualifications below). Also, records from a psychiatrist who has not seen the student within the last three years not considered sufficient documentation without an accompanying psychological evaluation.
  • Students described as experiencing test anxiety or difficulties with organization, memory, or concentration in specific situations may not have an impairment that rises to the level of a disability under the Americans with Disabilities Act. The diagnosis alone is not enough to establish eligibility for accommodations under the ADA, as there must also be evidence of "substantial limitations" across multiple major life activities.
  • Similarly, evaluators are encouraged to advise students that treatment of ADHD is complex, and psychiatrists take many factors into account when considering the use of medication as part of the treatment plan. While a student with proper documentation may be given a consultation appointment with a SHAC psychiatrist, treatment decisions are made on an individual basis.
  • Evaluators are encouraged to inform students that while recommendations in the report may be helpful, some may be outisde the scope of the programs, services, or medical treatment offered by a university, employer, or other governing body.

Qualifications of the Evaluator

The professional who conducts the evaluation and makes the diagnosis must be qualified to make the diagnosis of ADHD and to recommend appropriate academic accommodations. Experience with diagnosing ADHD in adolescents and young adults is essential. The evaluator must also have training in differential diagnosis of the full range or psychiatric and learning disorders. Professionals typically qualified to make this diagnosis include: Clinical Psychologists, Neuropsychologists, and Psychiatrists.

Developmental and Educational History

The report must contain edivdence to establish a pattern of symptoms and impairment in multiple settings across childhood (e.g. before age 12), adolescence, and adulthood (up to the present) in two or more settings. Obtaining this historical information may involve review of medical/academic records and consultation with other people in the student's life (e.g. parents, roommates, employers, and friends).

Include the student's diagnostic history of ADHD and any family history of physical or psychological problems deemed relevant by the examiner (historical education impact). Include information substantiated in medical and educational records, if available. This may include a review of previous psycho-educational or personality testing, including the dates, results, and recommendations. Discuss history of any medication prescribed - both current and past, as well as response, adverse reactions, and side effects. Accommodation history should also be discussed.

Evidence of Current Symptoms, Including Severity of Impairment in Multiple Settings

The report should include a thorough clinical history that outlines global performance of the individual and the current impact of ADHD in several major life functions. Life areas to be assessed include: family functioning, educational history, legal history, social functioning, occupational history, and medical/physical history. Additionally, the report should document previous and current substance use, misuse, abuse, or dependence.

Current functional limitations due to the disability should include information regarding the severity, duration, and impact of the impairment across multiple areas of life (e.g. academic, occupational, and social settings). Discussion should include a rationale for ways in which the student's symptoms are substantially more severe than others of that age.

Relevant Testing Must Be Provided

Neuropsychological or psychoeducational assessment is required in order to determine the current impact of the disorder on the individual's ability to function. All data must logically reflect a substantial limitation to functioning for which the individual is requesting accommodations or treatment. Norm-referenced checklists and surveys, computerized continuous performanec tests, and attention/tracking tests can be used to supplement the diagnostic profile, but are not in and of themselves sufficient. If self-report measures are used, SHAC requests that these protocols be included as an addendum to the report for treatment comparison purposes.

Reports should include evaluation of intellectual functioning and information processing, including verbal and perceptual reasoning, processing speed, short and long term memory, auditory and visual perception and processing, and executive functioning. Academic achievement should include current levels of academic functioning in such relevant areas as reading (decoding and comprehension), mathematics, and oral and written language.

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 profile of the student's strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations or treatment.

Effects of Medication: An indication of whether or not the student was evaluated on medication and the degree to which the prescribed treatment reduces the level of impairment.

Specific Diagnosis Based on DSM-IV Criteria

The report should include an explicit statement about the presence of the diagnosis. This includes a review of the presence or absense of specific diagnostic criteria for ADHD based on the DSM-IV. This should also include date(s) for all prior diagnoses and data that were used to establish the diagnosis. Evidence regarding the diagnosis should include more than a self-report by the test-taker.

Alternative or Concurrent Explanations of Symptoms Should Be Ruled Out

The evaluator must investigate other explanations for symptoms as well as other disorders that may be mistaken for ADHD or co-exist with ADHD. The documentation must investigate and discuss the possibility of situational factors, dual diagnoses and alternative or coexisting mood, behavioral, neurological, and/or personality disorders that may confound the ADHD diagnosis. The evaluator must discuss how these factors may have influenced the testing and diagnosis, as well as prognosis and subsequent treatment.

Alternative explanations may include the following:

  • Psychological Factors (e.g. stress, anxiety, depression, grief, chaotic lifestyle, low self-esteem, bipolar disorder, obsessive-compulsive disorder, eating disorders, personality factors) 
  • Medical Factors (e.g. sleep apnea, seizure disorders, tic disorders, psychosis, brain trauma)
  • Substance Use/Abuse/Dependence Factors (e.g. current and past history of use and treatment)
  • Educational Factors (e.g. lack of exposure to academic material, inadequate study skills or interest, knowledge of language, procrastination, disorganization)
  • Cultural Factors (e.g. language base other than English, different modes of interaction and communication with professional/medical providers [strangers], cultural norms regarding acceptable behavior)

Clinical Summary

 

The report should include an integrative interpretive summary that is based on the comprehensive evaluation. It should support both the diagnosis and the need for accommodations and/or treatment. Professional judgment should be used to interpret and integrate historical information, clinical observations, and test data in order to arrive at a summary of the evaluation and a specific diagnosis.

The summary should also include evidence of the disorder across childhood, adolescence, and adulthood, evidence that there is an impact of the disorder in multiple settings, evidence that the ADHD limits learning or major other life activities. The summary should discuss the severity and duration of symptoms as well as the anticipated impact of the ADHD in higher education, work, and social environments.

Evidence that Supports the Necessity of Accommodations and Treatment

Accommodation and treatment needs change over time. Prior documentation may have been useful in determining appriopriate sevices in the past. However, current documentation should validate the need for services based on the individual's present level of functioning.

Current Educational Impact: Describe current and significant impact of the symptoms on academic functioning. Accommodations are provided for a condition only when it imposes a substantial limitation as compared to the average population. Accommodations are not provided for (relative) weaknesses, areas needing improvement, below expectancy performance, or mild disabilities.

Accommodation Rationale: Recommendations for academic accommodations should state:

  1. Why the accommdation is needed, based on a specific functional limitation documented in the assessment.
  2. How the accommodation will mitigate the effects of the student's symptoms.
  3. History and Types of Accommodations received and used, as well as consistency and circumstances of use.

Disability Resource Center

Please include in the report instructions on how to apply for learning accommodations.

Students should submit their documentation and schedule an intake appointment with the Disability Resurce Center, which is located on the first floor of the Smith Memorial Student Union building (SMSU), room 116. Phone: (503) 725-4150, Fax: (503) 725-4103.