Guidelines for Documentation of Employee Neurodevelopmental Disabilities

Please provide these guidelines to your diagnosing/treating professional.

Note: These guidelines are applicable to requests for accommodation of a neurodevelopmental disorder, as defined in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including but not limited to specific learning disorders, Autism Spectrum Disorder, and ADHD.

Introduction: To Employees

In order to fully evaluate your request for accommodation, W&L will need adequate documentation of your disability and your need for accommodation by virtue of the specific functional limitations of your disability.

Note: a diagnosis of any impairment, though required, does NOT in and of itself automatically mean that you have a "disability" under the ADA or that you qualify for a reasonable accommodation under the ADA. While a neurodevelopmental impairment may be a source of discomfort or stress, an employee who has an impairment, even one that constitutes a "disability" under the ADA, may not necessarily require accommodation.

You should refrain from taking medication during testing that might alter your performance on tasks. You should consult with your evaluator about testing on or off medication. Testing off medication will increase the possibility that the testing will show current functioning more accurately.

W&L has developed these guidelines to assist your diagnosing/treating professional(s) in preparing the documentation needed to support your accommodation request. The Executive Director of Human Resources (or designee) will maintain all such documentation received in a confidential file, separate from the remainder of your personnel record, and will disclose the documentation only in accordance with law or your consent.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Information for Diagnosing/Treating Professionals

Definitions Applicable To All Employee Accommodation Requests

A "disability" is a physical or mental impairment/disorder/condition/syndrome (hereinafter "impairment") that substantially limits one or more major life activities. Physical or mental impairments include, for example (but are not limited to), blindness and visual impairments, deafness and hearing impairments, mobility impairments, neurodevelopmental disorders, diagnosed emotional or psychological disorders, and some chronic illnesses such as asthma or diabetes. An impairment that is episodic or in remission can constitute a disability if it substantially limits an individual in a major life activity when it recurs.
Note: a diagnosis of any impairment, though required, does NOT in and of itself automatically mean that the individual has a "disability" under the ADA or that the individual qualifies for a reasonable accommodation under the ADA. While a neurodevelopmental impairment may be a source of discomfort or stress, an employee who has an impairment, even one that constitutes a "disability" under the ADA, may not necessarily require accommodation.
"Major life activities" include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating and working. A major life activity also includes the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine and reproductive functions.
An impairment only constitutes a "disability" when it prevents an individual from performing a major life activity that the average person in the general population can perform or when the individual is substantially limited as to the condition, manner or duration he/she can perform a particular major life activity as compared to the average person in the general population.
A "qualified employee with a disability" is an employee with a disability who, with or without reasonable accommodations, can perform the essential functions of his or her position.
A "reasonable accommodation" is a reasonable modification or adjustment to an employment position or the provision of auxiliary aids/services that allows an otherwise qualified employee with a disability to perform the essential functions of his or her position.

Guidelines For Documentation Of A Neurodevelopmental Disorder And Need For Accommodation

In order to verify eligibility for employment accommodation under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, employees should provide documentation that their neurodevelopmental impairment currently substantially limits some major life activity and that they need a workplace accommodation by virtue of the specific functional limitations of the neurodevelopmental impairment. The following documentation guidelines are provided in the interest of assuring that documentation of neurodevelopmental disorders, including specific learning disorders (LD) and Attention-Deficit/Hyperactivity Disorder (ADHD), is appropriate to verify eligibility and to support requests for reasonable accommodations. These guidelines apply to both LD and ADHD, as well as other disorders that affect neurodevelopmental abilities, except where indicated to relate exclusively to ADHD. W&L reserves the right to request additional documentation as necessary to fully evaluate individual requests for accommodation.

I. A Qualified Professional Must Conduct a Current Evaluation

Professionals conducting assessments and rendering diagnoses of neurodevelopmental disorders must have comprehensive relevant training in differential diagnosis of neurodevelopmental disorders and experience with adults. The following professionals would generally be considered qualified to evaluate and diagnose neurodevelopmental disorders: clinical psychologists, neuropsychologists, and educational psychologists, psychiatrists (ADHD).

Because the provision of reasonable accommodations is based on assessment of the current functional impact of the employee's disability, it is in an employee's best interest to provide documentation of recent testing. This generally means that a comprehensive evaluation should have been conducted within the past three years using the adult version of assessment tools. If documentation is inadequate in scope or content, or does not address the individual's current level of functioning, reevaluation and/or additional testing will be required. If the impairment is one that is episodic or has been in remission, the Executive Director of Human Resources (or designee) may require documentation describing the functional impact of the impairment at the time it recurs.

Note: a psychiatric evaluation without the relevant testing is not acceptable.

II. Documentation Must Be Comprehensive

Evidence of Impairment: A Diagnostic Interview
Relevant Testing
Evidence of DSM-5 Criteria (ADHD)

Note: For documentation of LD, all elements of Subparts A and B must be provided. For documentation of ADHD, all elements of Subparts A, B, and C must be provided.

A. Evidence of Impairment: A Diagnostic Interview

The report of assessment should include a comprehensive diagnostic interview that includes relevant background information from a variety of sources to support the diagnosis. The report of assessment should include, but not necessarily be limited to, all of the following areas as relevant to the disability and the current request for accommodation(s):

a description of the presenting problem(s);
a thorough history providing evidence that learning or attentional problems began early, typically in elementary school or before, including objective evidence of ongoing issues that have significantly impaired functioning over time;
a developmental history;
an academic history, including results of prior standardized testing, reports of classroom performance, behavior, notable trends, and prior accommodations and self-accommodations used in secondary and postsecondary school;
family history as relevant to the impairment;
psychosocial history;
relevant medical and medication history, including (but not limited to) the absence of a medical basis for the present symptoms;
history of relevant prior psycho- or other therapy;
a discussion of dual diagnoses, alternative or coexisting mood, behavioral, neurological and/or personality disorders, and exploration of possible other mental health problems, such as depression and anxiety, or attentional or other problems that are not better explained by other mental health conditions.

B. Relevant Testing: Neuropsychological/Psychoeducational Evaluation in Unmitigated State

The neuropsychological or psychoeducational evaluation for the diagnosis of a neurodevelopmental disorder should provide clear and specific evidence that a neurodevelopmental disorder does or does not exist. The data should logically connect the specific substantial limitation to learning or other major life activity for which the employee requests accommodation. The test findings must document both the nature and severity of the neurodevelopmental impairment(s) involved.

Employees should refrain from taking medication during testing that might alter their performance on tasks. Employees should consult with their evaluator about testing on or off medication. Testing off medication will increase the possibility that the testing will show current functioning more accurately.

It is not acceptable to administer only one test, nor is it acceptable to base a diagnosis on only one of several subtests. The tests used must be reliable, valid, and standardized for use with an adult population.

Actual test scores must be provided. Age norms should be used unless not available for that specific test. In addition to test scores, interpretation of results is required. Test protocol sheets or scores alone are not sufficient.

Domains to be addressed should include the following:

1) Cognitive Ability

A complete aptitude assessment is required with all subtests and standard scores. The preferred instrument is the Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV). Other acceptable instruments include, but are not limited to, the Woodcock - Johnson Psychoeducational Battery -IV: Tests of Cognitive Ability; the Stanford-Binet Intelligence Scale: Fifth Edition.

2) Achievement

A complete achievement battery, with all subtests and standard scores, must be provided. The battery should include current levels of academic functioning in reading (decoding and comprehension), mathematics, and written language. If an accommodation request includes extended time for work projects, timed measures of relevant academic skills should be included. Accommodation recommendations based on an ADHD diagnosis require evidence from a full psychoeducational evaluation that the employee has deficits directly related to each accommodation request. For instance, if extended time for work projects is being requested, testing should include academic fluency measures and other timed measures of academic skills showing that the employee is substantially impaired in his/her ability to complete the work in a timely manner.

Recommended instruments include, but are not limited to, the Woodcock - Johnson Psychoeducational Battery -IV: Tests of Achievement; the Nelson - Denny Reading Skills Test; the Gray Oral Reading Test - Fifth Edition; and the Wechsler Individual Achievement Test - III. The Wide Range Achievement Test - 4 (WRAT-4) is not a comprehensive measure of achievement and therefore is not acceptable if used as the sole measure of achievement.

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; motor ability) must be assessed, including the nature and extent of all processing deficits, in addition to other information provided regarding functional impairment.

Acceptable instruments include, but are not limited to, the Detroit Test of Learning Aptitude - 4 (DTLA-4), the Wide Range Assessment of Memory and Learning -2 (WRAML2), Wisconsin Card Sort, Trails A and B, Rey-Osterrieth Complex Figure Drawing (REY-O). Information from subtests on the WAIS-IV, or the Woodcock - Johnson Psychoeducational Battery -IV; Tests of Cognitive Ability, Wechsler Memory Scale - IV, Luria-Nebraska Neuropsychological Battery, Halstead-Reitan Neuropsychological Battery, as well as other instruments may be used to address these areas. For employees with ADHD, computerized assessment of attentional functioning, (e.g., Continuous Performance Test (CPT)), is strongly encouraged. Weaknesses in Processing Speed or Executive Functions do not automatically qualify an employee for extended time; rather, an accommodation for extended time must be supported by data that clearly shows work pace deficits on timed measures specifically related to academic/workplace skills, such as reading, writing, and/or math.

4) Other Assessment Measures

Other standard and formal assessment measures (e.g., personality, clinical, or behavior inventories) may be integrated with the above documents to help support a dual diagnosis, or to disentangle the neurodevelopmental disorder from coexisting mood, behavioral, neurological, and/or personality disorders. In addition to standardized test batteries, it is also very helpful to include informal observations of the employee during the test administration. Nonstandard measures and informal assessment procedures may be helpful to determine performance across a variety of domains.

C. Identification of DSM-5 Criteria (ADHD only)

According to the Diagnostic and Statistical Manual of Mental Disorders: (DSM-5) (2013), 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. A diagnostic report should include a review and discussion of the DSM-5 criteria for ADHD and specify which symptoms are present from those specified in the criteria. The following diagnostic criteria for ADHD are specified in the DSM-5 (American Psychiatric Association, 2013):

Either (1) or (2)
1. 1. Five (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
  - Inattention (Note: symptoms not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions)
    1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (e.g., overlooks or misses details, work is inaccurate)
    2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading)
    3. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)
    4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side-tracked)
    5. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficult keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines)
    6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; in older adolescents or adults, preparing reports, completing forms, reviewing lengthy papers)
    7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools. wallets, keys, paperwork, eyeglasses, mobile telephones)
    8. Is often easily distracted by extraneous stimuli (in older adolescents or adults may include unrelated thoughts)
    9. Is often forgetful in daily activities (e.g., doing chores, running errands; in older adolescents or adults, returning calls, paying bills, keeping appointments)
2. Five (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
  - Hyperactivity (Note: symptoms not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.
    1. Often fidgets with or taps hands or feet or squirms in seat
    2. Often leaves seat in situations when remaining seated is expected (e.g., leaves place in the classroom, office or other workplace)
    3. Often runs about or climbs in situations in which it is inappropriate (in adolescents or adults, may be limited to feeling restless)
    4. Often unable to play or engage in leisure activities quietly
    5. Is often "on the go" acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with)
    6. Often talks excessively
  - Impulsivity
    1. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation)
    2. Often has difficulty waiting his/her turn (e.g., while waiting in line)
    3. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; in adolescents or adults, may intrude into or take over what others are doing)
Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, or occupational functioning.
The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

The DSM-5 specifies a code designation based on presentation

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type (F90.2): if both Criteria A1 and A2 are met for the past 6 months
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type (F90.0): if Criterion A1 is met but Criterion A2 is not met for the past 6 months
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type (F90.1): if Criterion A2 is met but Criterion A1 is not met for the past 6 months
- Specify if: in Partial Remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning, "In Partial Remission" should be specified.
- Specify Current Severity
  - Mild: Few, if any, symptoms in excess of those required to make
    the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
  - Moderate: Symptoms or functional impairment between "mild" and "severe" are present.
  - Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
314.01 Unspecified Attention-Deficit/Hyperactivity Disorder (F90.9): This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the full criteria for Attention-Deficit/Hyperactivity Disorder or other specific neurodevelopmental disorder, where the clinician chooses not to specify the reason that the criteria are not met for ADHD, and includes presentations in which there is insufficient information to make a more specific diagnosis.
314.01 Other Specified Attention-Deficit/Hyperactivity Disorder (F90.8): This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the full criteria for Attention-Deficit/Hyperactivity Disorder or other specific neurodevelopmental disorder, where the clinician chooses to communicate the specific reason that the presentation does not meet the criteria. This is done by recording ("other specified attention-deficit/hyperactivity disorder" followed by the specific reasons (e.g., "with insufficient inattention symptoms").

III. Documentation Must Include a Specific Diagnosis and Demonstrate a Substantial Limitation to a Major Life Activity as Compared to the Average Person in the General Population

The report must include a specific diagnosis of a neurodevelopmental disorder. For example, "individual learning styles," "learning differences," "attention problems," and "test anxiety" are not by themselves neurodevelopmental disorders for which accommodations will be granted. The specific diagnosis must be supported by test data, academic history, anecdotal and clinical observations that may include comments about the employee's level of motivation, study skills, and other non-neurodevelopmental factors. These findings must demonstrate that the employee's functional limitations are due to the diagnosed disorders.

It is important that the diagnostician demonstrate having ruled out alternative explanations for workplace problems, such as emotional, medical, or psychological disorders, or motivational problems that may interfere with a major life activity, but which do not, in and of themselves, constitute a neurodevelopmental disorder.

IV. Recommended Accommodations with Rationale

The comprehensive report must recommend specific accommodations. The diagnostician must include a detailed explanation as to why each recommended accommodation is necessary and must reference specific current functional limitations (determined through test results and clinical observations) that support the need for the accommodation. The report may also include an explanation of current treatments, medications, or other accommodations and/or self-accommodations, including any patient-reported information on effectiveness of such measures. An Individualized Education Program and/or 504 Plan can be included as part of a comprehensive report, but is insufficient by itself to establish the rationale for a recommended accommodation.

Note: It is important to note that no specific accommodation suggested by an evaluator is guaranteed by Washington and Lee University. The University's obligation is to provide a reasonable accommodation to an otherwise qualified employee with a disability, not necessarily to provide particular accommodations requested or recommended.