Duke University/Health System s2

Duke University/Health System Disability Management System, 402 Oregon Street, Suite 102, Box 90142, Telephone: (919) 668-6213, Fax: (919) 668-3977, http://www.access.duke.edu Documentation Guidelines for Learning Disabilities

Duke University/Duke University Health System is committed to providing equal employment opportunities to qualified employees with disabilities for purposes of Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act of 2008 To establish that an individual is covered under these laws, employees must submit current documentation confirming that a disability substantially limits one or more major life activities as compared to the average person in the general population.

The following guidelines are designed to provide employees and professional diagnosticians with a common understanding and knowledge base of the components of documentation which are necessary to validate the existence of a learning disability, its impact on the individual’s employment performance, and accommodation(s) that are necessary in the work place. These guidelines contain information regarding: I. Qualifications of the Evaluator II. Current and Age-Appropriate Testing Data

III. Necessary Components of a Comprehensive Evaluation/Diagnostic Report A. Diagnostic Interview B. Ability/Cognitive Testing C. Academic Achievement Testing D. Information Processing Testing E. Reporting Test Scores F. Other Assessment Procedures G. Building a Significant Case for the Diagnostic Conclusions H. Ruling out Other Possible Causes for the Learning Problems I. A Specific Diagnosis J. Providing a Justification & Rationale for each Recommended Accommodation IV. Clinical Interpretive Summary

The final determination of disability status and necessary accommodations rests with the University/Health System and is based on an interactive process including, but not limited to, a review of supporting documentation (i.e. evaluation/diagnostic reports, records and information) submitted by the employee as outlined below. Accommodations must be tied to current functional impairment(s).

I. Qualifications of the Evaluator The professional conducting the evaluation and making the diagnosis must be qualified to make the diagnosis, make recommendations as to necessary accommodations and have direct experience working with an adult population. The documentation must include the name, title, and professional credentials of the evaluator, including information about licensure and/or specialization. In general diagnoses of disabilities by family members will not be accepted even when the family members are otherwise qualified by virtue of training and licensure/certification. All reports should be on letterhead, typed, dated, signed, and otherwise legible. II. Current and Age Appropriate Testing Data is Required Since reasonable accommodations are based upon the assessment of the current impact of the disorder on the essential functions of a particular position; evaluation/diagnostic reports must address the individual’s current level of functioning and the need for accommodations. If the documentation is inadequate in scope or content, or is not relevant to the individual’s current functional impairments and need for accommodations, additional information may be required. III. History of Impaired Functioning Since developmental disorders such as learning disabilities are commonly manifested during childhood (though not always diagnosed), historical information regarding the individual’s history and learning problems should be documented and provided. Self report alone, without any accompanying historical records and information that validate developmental learning problems, are generally not sufficient.

IV. Records and Information that Support a History of Impaired Functioning Examples of historical records include, but are not limited to, previous psycho-educational evaluation reports, written comments from present and past teachers, documentation from past tutors and/or learning specialists, Individualized Education Plans (IEPs), 504 Plans, report cards from kindergarten, elementary, junior high, and high school, college transcripts, job performance evaluations and the like.

IV. Necessary Components of the Comprehensive Evaluation and Diagnostic Report A. Diagnostic Interview  A description of the presenting problem(s)  Relevant developmental history  Relevant academic history  Relevant family history, including primary language of the home, and the employee’s current level of fluency in English  Psychosocial history  Relevant employment history B. Ability/Cognitive Testing The evaluation must contain a complete intellectual assessment with all cluster and subtests reported as standard scores. Screening instruments are not acceptable. The following instruments are recommended; use of other instruments should be justified by the diagnostician:  Wechsler Adult Intelligence Scale- III (WAIS III)  Stanford-Binet Intelligence Scale- IV  Kaufman Adolescent and Adult Intelligence Test C. Academic Achievement Testing It is essential to include a comprehensive standardized achievement battery with all cluster and subtests reported as standard scores and/or percentile rank scores. Screening instruments are not acceptable. The following instruments are recommended; use of other instruments should be justified by the diagnostician. 1) Comprehensive Measures of Achievement  Scholastic Abilities Test for Adults (SATA)  Woodcock-Johnson III- Tests of Achievement 2) Specific Measures of Achievement Specific achievement tests are useful when the results are used to support comprehensive achievement/cognitive test results and provide other diagnostic information. Acceptable specific measures of achievement include, but are not limited to:  Nelson-Denny Reading Test  Gray Oral Reading Test  Stanford Diagnostic Test  Test of Written Language (TOWL-3)  Woodcock Reading Mastery Tests-Revised

Specific Measures of Achievement such as those listed above are not comprehensive diagnostic measures of achievement and thus:  Not acceptable if used as the sole measure of achievement.  Not sufficient, in and of themselves, to establish a learning disability.

Important Note: The Reading Fluency Subtest of the Woodcock Johnson III Tests of Achievement and the One-Minute Reading Rate Subtest of the Nelson Denny Reading Test will not, in and of themselves, be sufficient to document slow processing speed and/or reading rate.

D. Information Processing Testing Evidence of processing deficiencies might involve short and long-term memory, sequential memory, auditory and visual perception/processing, auditory and phonological awareness, processing speed, executive functioning, and/or motor ability. It is recommended that these functions be assessed to delineate the learning disability. Acceptable measures include but are not limited to:  Detroit Tests of Learning Aptitude – Adult (DTLA-A)  Wechsler Memory Scale – III (WMS-III)  Woodcock-Johnson Psychoeducational Battery III- Tests of Cognitive Ability Note: It is helpful to show how any weaknesses identified in these areas impact the individual’s real world functioning, major life activities, learning and reading.

E. Reporting Test Scores--All Test and Subtest Scores from Standardized Instruments Must be Provided Standard scores and/or percentile rank scores must be provided for all normed measures. If grade equivalent scores are reported, they must be accompanied by standard scores and/or percentile rank scores. The data must logically reflect a substantial limitation for which the employee is requesting the accommodation.

Tests used should be reliable, valid, and standardized for use with an adult population. Test findings must document both the nature and severity of the learning disability. Evaluators should use the most recent form of tests and should identify the specific test form as well as the norms used to compute the scores. It is helpful to list all test data in a score summary sheet appended to the evaluation.

F. Other Assessment Procedures Inspection of historical medical, psychiatric, academic, or vocational records, use of rating scales, input from collateral informants who know the individual well such as parents, teachers, tutors, coaches or clinical observations of behavior and mental status may be integrated with the above instruments to help support a differential diagnosis and/or disentangle the learning disability from co-existing neurological and/or psychiatric issues.

Non-standardized measures and informal assessment procedures (such as an informal reading tests, miscue analyses, etc.) may be helpful, especially if they serve to illuminate legitimate real world functional impairments in one or more life domains. Actual test scores must be provided (standard scores where available). G. Building a Significant Case for the Diagnostic Conclusions The evaluators/diagnosticians should provide a sound rationale to support the learning disability diagnosis, show how the deficits currently substantially limit the employee’s ability to perform a major life activity as compared to the average person in the general population. The diagnosis must consist of and be based on a comprehensive assessment battery that does not rely on any one test or subtest.

H. Ruling out Other Possible Causes for the Learning Problems This process should include exploration of possible alternative explanations for substantially limiting problems resulting from educational, language and cultural factors impacting the individual that may result in behaviors mimicking a learning disability.

I. A Specific Diagnosis The diagnostic report should include the specific diagnosis based on the Diagnostic and Statistical Manual-Fourth Edition (DSM-IV) and include classification code(s). The diagnostician should use direct language in the diagnosis and documentation of a learning disability, avoiding such terms as “suggests” or “is indicative of”. Non-specific diagnosis such as; “academic problems,” “computer phobias,” “slow reading”, in and of themselves, do not constitute a learning disability. J. Rationale and Justification for Each Requested Accommodation Accommodations are not granted on the basis of a diagnostic label: they must be tied to history and current functional impairment(s). Specific recommendations must include a detailed explanation as to why each accommodation is necessary. A link must be established between the requested accommodations and the current functional limitations of the individual that are pertinent to the workplace. Documentation should include any record of prior accommodations or auxiliary aids including information about the specific criteria used to grant prior accommodations/auxiliary aids, the conditions under which the accommodations/auxiliary aids were used and whether or not they were effective.

V. Clinical Interpretive Summary The following elements should be included in the clinical interpretive summary:  Demonstration that the evaluators have ruled out alternative explanations for the identified academic problems as being the result of poor education, poor motivation and/or study skills, emotional problems, attentional problems, substance abuse, or cultural or language differences  Indication of how patterns in cognitive ability, achievement and information processing (both in test scores and in real world functioning) were used to determine the presence of a learning disability  A list of any historical records and information that were inspected and an explanation of how these documents demonstrated a history of impairment that support a learning disability diagnosis.  Justification as to why each specific recommended accommodation is necessary.

02/10/2009