Diagnositicans Understanding Manuscript

Documenting Disabilities in Postsecondary Settings:
Diagnosticians’ Understanding of Legal Regulations and Diagnostic Standards
Allyson G. Harrison, Benjamin Lovett, Michael Gordon
Increasing numbers of students with learning disability and ADHD diagnoses are applying for
accommodations in postsecondary education and employment settings. However, students’
documentation of these conditions is often substandard. One possible reason for this is that
clinicians have failed to apply proper criteria when determining disability status. We surveyed
119 clinicians who diagnosed these conditions in students applying for accommodations, to
determine clinician levels of knowledge about appropriate diagnostic and legal standards. We
found weak clinician knowledge on certain key issues, including the meaning of functional
impairment and understanding of the different laws governing academic accommodation of
children versus adults. The average respondent’s score on a 30-item true/false questionnaire was
only 69% correct. Implications of these results for practice and future research are discussed.
Documenting Disabilities in Postsecondary Settings:
Diagnosticians’ Understanding of Legal Regulations and Diagnostic Standards
Over the past two decades, there has been a considerable increase in the number of
students requesting disability-related accommodations in postsecondary education settings (e.g.,
Ranseen & Parks, 2005). This includes applications for accommodations on classroom tests,
college and graduate/professional admissions tests, certification and licensure tests, and even
employment evaluations. The increase in accommodation requests parallels growth in the
numbers of individuals with disabilities now attending college (College Committee on Disability
Issues, 2004; Heiman & Precel, 2003; Ontario Human Rights Commission, 2003; Mull,
Sitlington, & Alper, 2001; Sharpe & Johnson, 2001) and/or seeking professional employment
(Katsiyannis, Zhang, Landmark, & Reber, 2009), and the growth in special resources available to
students with disabilities in these settings (Madaus, 2011).
Students with disabilities are legally entitled to provision of appropriate accommodations,
services, and supports in their postsecondary programs to ensure that their impairments do not
unfairly interfere with their ability to participate equally and to demonstrate mastery of course
material (Katsiyannis, Zhang, Landmark, & Reber, 2009). Accommodations, however, must be
individualized, determined based on the interaction between the nature of the task in question
and the current impairments experienced by the individual (Roberts, 2012).
Most students with disability diagnoses in postsecondary settings report learning,
cognitive, or psychiatric disorders rather than physical or sensory handicaps (e.g., Government
Accountability Office, 2011; Ontario Human Rights Commission, 2003). Learning and attention
problems are particularly common in these students (Ontario Ministry of Training, Colleges and
Universities, 2008). Therefore, one consequence of the growth in access for students with
disabilities has been a market for psychoeducational evaluations that explicitly address
accommodation needs in postsecondary contexts. This is especially important for the many
students who were never diagnosed in childhood and who first receive diagnoses in college or
after. However, even for students with earlier diagnoses, there is often a “documentation
disconnect”; that is, the documentation that supported special education services does not
sufficiently address someone’s needs after secondary school (Gormley, Hughes, Block, &
Lendmann, 2005; National Joint Committee on Learning Disabilities [NJCLD], 2007; Sitlington
& Payne, 2004).
The increase in formal evaluations is a positive development, increasing postsecondary
access for students who need various accommodations. However, there are also several potential
problems with this process. First, the dynamics of the evaluation process can lead to
overdiagnosis of disabilities. Unlike school-based special education evaluations, those
evaluations conducted by private diagnosticians are paid for directly by students and their
families. This fact, combined with the client’s desired outcome (a positive diagnosis, access to
accommodations and other services) may lead clinicians to make diagnoses with insufficient
evidence or in order to assist students in obtaining accommodations (Wolforth, 2012). In Canada,
the incentives for a diagnosis are especially high; for instance, students accessing governmentsponsored bursaries to pay for an updated psychoeducational assessment will only receive a
reimbursement for this expense if the assessment results in a learning disability diagnosis.
Clinicians may discount the effects of these incentives, despite the large literature establishing
the effects of financial incentives on diagnostic test performance (for discussion, see Chafetz,
Prentkowski, & Rao, 2011).
Second, and relatedly, many clinicians do not use formal measures to detect clients who
may be investing low effort or exaggerating symptoms in order to obtain a disability diagnosis.
This occurs despite research conducted over 20 years ago which showed that low effort or
avoidance of disliked tasks could negatively influence children’s performance on achievement
tests and result in inaccurate diagnoses (Adleman, Lauber, Nelson, & Smith, 1989). Moreover,
symptoms of learning and attention problems can also be convincingly feigned—that is, students
who are deliberately attempting to feign a learning disability (LD) or attention
deficit/hyperactivity disorder (ADHD) can easily score in the “clinical” range on many tests used
to diagnose these problems (e.g., Booksh, Pella, Singh, & Gouvier, 2010; Frazier, Frazier, Busch,
Kerwood, & Demaree, 2008; Harrison, Edwards, & Parker, 2007; 2008; Jachimowicz &
Geiselman, 2004), and clinicians are unable to identify suboptimal effort accurately using
clinical judgment alone (Faust, Hart, & Guilmette, 1988; Faust, Hart, Guilmette, & Arkes, 1988).
Even more worrisome, a substantial minority of those seeking assessments for learning and
attention disorders in postsecondary settings are found, upon closer inspection, to have been
exaggerating their symptoms or purposely exhibiting poor effort during diagnostic testing
(Harrison, 2006; Harrison & Edwards, 2010; Sollman, Ranseen, & Berry, 2010; Suhr, Hammers,
Dobbins-Buckland, Zimak & Hughes, 2008; Sullivan, May, & Galbally, 2007; see also Gordon,
2009, for a striking case of malingering in a testing accommodations case). Formal assessments
of symptom credibility should be included in any such assessments (Harrison, Green, & Flaro,
2012), yet in our own consulting work, the present authors see that fewer than 10% of applicants
have documentation that includes formal assessments of symptom credibility.
Finally, clinicians may not understand the standards for certifying someone as legally
disabled and needing accommodations at the postsecondary level. These standards are distinct
from the standards for clinical diagnosis, since a person may meet diagnostic criteria for a
disorder, but not be sufficiently impaired in their activities to meet disability certification
standards and require accommodations. Diagnosis concerns whether or not someone has a
disorder; disability certification concerns how the disorder affects the person in real-world
settings. In both Canada and the United States of America, provision of academic
accommodations and supports at the elementary and secondary school level is governed by
specific legislation that applies only to publically funded educational systems. In the US, the
Individuals with Disabilities Education Act (IDEA) requires that special education services be
given to students with certain kinds of disabilities, and accommodations are just a small part of
those services. In Canada, each province has specific educational legislation that applies to the
K-12 school system. For instance, in Ontario, provisions governing special education were
introduced into the Education Act by the Education Amendment Act, 1980, more commonly
known as Bill 82 (Government of Ontario, 1981). This legislation allows elementary and
secondary schools to provide academic accommodations and supports to any student who is
identified as “an exceptional learner”; this legislation was part of a worldwide movement
towards providing all children with the opportunity for a publicly funded education, regardless of
Special education laws do not apply to postsecondary studies; in Canada, Human Rights
legislation (provincial and federal) applies. Eligibility for accommodations under this legislation
requires, in part, a diagnosis of a disability, but that diagnosis, in and of itself, does not
necessarily compel accommodation, even if that person was given special education services in
the past (Roberts, 2012). Instead, at the postsecondary level, special education per se is not
available, and accommodations are only provided when the impairments that flow from a
disorder interfere with equal ability to access and utilize the educational system. Furthermore,
Human Rights legislation does not guarantee the right to an education nor does it guarantee that
accommodations will result in successful performance. It requires only that a student be given an
equal opportunity to participate and that artificial barriers to such equal participation be removed
or minimized. Unlike accommodations and supports at the K-12 level, postsecondary programs
are also not obliged to provide accommodations that would undermine the essential requirements
of a course or examination.
For students with learning or attention disorders to request accommodations at the
postsecondary level, they must provide documentation that not only reports a diagnosis of a
disability, but also explains how impairments arising from that condition interfere with equal
participation in the current setting. Determining impairment, however, is difficult. Unlike the
United States where there is a clearly defined demarcation (functioning substantially below the
average person; Lovett, Gordon, & Lewandowski, 2009), Canadian human rights laws have
focused on equality of opportunity to participate in society rather than on delineating a definition
of how to determine who is disabled (Harrison & Holmes, 2012). For instance, the Canada
Student Loans Program (CSLP) defines a permanent disability as a “functional limitation caused
by a physical or mental impairment that restricts the ability of a person to perform the daily
activities necessary to participate in studies at a post-secondary school level or the labour force
and is expected to remain with the person for the person's expected life.” (Government of
Canada, 2009). No parameters, however, help clinicians define at what specific level an
individual must be performing in order to qualify as functionally limited. We return to this point
Problems in the Diagnosis of High-Incidence Disabilities
Assessing learning and attention problems is especially vulnerable to the concerns raised
above, since there are a variety of methods by which these problems are diagnosed. In the first
study to examine documentation consistency, McGuire, Madaus, Litt, and Ramirez (1996)
examined the documentation submitted by 415 college students to support their LD diagnoses.
These investigators found “serious problems in the type and quality of documentation” submitted
(p. 301). For instance, fewer than half of the psychological reports submitted mentioned the
students’ academic achievement. Moreover, many reports that mentioned achievement did not
administer any formal academic skills testing, instead contributing only vague and generic
statements about students’ reported performance in school or on high-stakes tests. Finally, almost
half of the reports contained no information about when an initial diagnosis of LD had been
made, despite the importance of early history when assessing developmental disorders in college
More recent work suggests that problems of inadequate documentation continue. For
instance, Harrison, Nichols, and Larochette (2008) reviewed the documentation submitted by
247 students, all seeking accommodations and related services at one of three Ontario
postsecondary institutions under the LD classification. Fully one quarter of students failed to
submit any documentation, and other students only submitted special education documents or a
physician’s letter. Although over half of the students submitted a psychologist’s report, fewer
than half of these reports even included a clear statement of a diagnosis, and not all of the clear
diagnostic statements were for LD. These findings are similar to those reported by Reed, Lewis,
and Lund-Lucas (2006), who found half of the students with LD who were surveyed arrived at
their respective Canadian postsecondary institutions with inadequate disability documentation.
Even when the types of documentation are equivalent across applicants, marked
variability in diagnostic standards is still found. Sparks and Lovett (2009) examined the
diagnostic test scores (IQ and academic achievement scores) of 378 U.S. college students who
had been diagnosed with LD and provided accommodations. Given that there is disagreement in
the field over how to diagnose this disorder, these investigators applied five different sets of
objective criteria for diagnosis of LD to these assessment reports (three sets based on IQAchievement discrepancies, one based on the DSM-IV, and one requiring early onset and low
achievement), and found that more than half of the students failed to meet any of the five sets of
criteria even though they had already been diagnosed and provided with accommodations.
Moreover, fewer than 10% of the students met sets of criteria that required academic impairment
in an absolute sense (i.e., academic achievement test scores of 1 standard deviation below the
mean or lower). Sparks and Lovett’s results have been replicated by a more recent study (Weis,
Sykes, & Unadkat, 2012) finding that many diagnosed college students fail to meet objective
criteria for LD.
Studies regarding diagnosis of attention deficit hyperactivity disorder (ADHD) have been
just as disappointing. For instance, Joy, Julius, Akter, and Baron (2010) examined the files of 50
medical students with ADHD diagnoses who requested accommodations on the COMLEX exam
(taken by osteopathic physicians for licensure). There are five official criteria required for
diagnosing ADHD found in the current edition of the Diagnostic and Statistical Manual of
Mental Disorders, the DSM (American Psychiatric Association, 2000), and Joy et al. coded each
applicant’s file to indicate whether each of the five criteria was met. Remarkably, only seven
files (14%) had evidence demonstrating that the applicant met all five criteria, and most
applicants’ files only met one or two of the criteria. In sum, studies of the diagnosis of learning
and attention problems suggest that many clinicians make diagnoses without necessarily
adhering to published or agreed upon diagnostic standards.
Clinician Understanding of Disability Law
Even when clinicians use evidence-based strategies for diagnosing disability conditions,
it is unclear if their determinations of legal disability status and their recommendations for
accommodations are appropriately made. Indeed, a study of American clinicians suggests weak
understanding of how to apply disability laws in diagnostic situations. Gordon, Lewandowski,
Murphy, and Dempsey (2002) surveyed 147 diagnosticians who had performed evaluations used
by students requesting accommodations on a law school entrance exam. In the United States,
these issues are governed primarily by the Americans with Disabilities Act (ADA), which
requires that “reasonable accommodations” be given to individuals who are substantially
impaired, relative to the general population, in “major life activities” such as reading (Latham &
Latham, 2011).
Gordon et al. (2002) found widespread misunderstanding of ADA’s key provisions. For
instance, over half of the surveyed clinicians indicated that a client would be disabled under
ADA with an average reading score, as long as the client’s IQ was well above average.
Similarly, over a third of the clinicians indicated that ADA provides for accommodations that
will “guarantee that the individual…will perform at his or her best.” Indeed, although the 27
items on the survey had a true/false design (and therefore respondents could get a 50% correct
score through random guessing), the average correct score was only 75%. Gordon et al.
concluded that their results indicated a need for increased training in disability evaluations,
specifically focused on “current case law, guidelines for documentation, and the importance of
providing valid, empirically based evidence of substantial impairment in real-life functioning”
(p. 362).
In the present study, we aimed to extend Gordon et al.’s (2002) work to a Canadian
sample, where the relevant disability-related laws are somewhat different. We expected that there
might also be an effect of time, since approximately a decade had passed since Gordon et al.
surveyed clinicians, and disability issues have become more prominent in the interim.
Students seeking disability-related accommodations for LD or ADHD must present their
Disability Services Office at college or university with documentation from a professional
diagnosing their disability. In the present ethics-approved study, a survey was mailed to all
clinicians who had authored LD or ADHD-specific documentation that had been submitted
between 2008-2011 either by grade 12 students from across Ontario who were participating in an
online transition program for students identified as having LD or ADHD1, or by students seeking
academic accommodations at a major Canadian university2. This yielded a list of 119 individuals
(45 male; 38%) who were registered Psychological service providers. Apart from three clinicians
who practiced Psychology in British Columbia, clinicians to whom surveys were sent came from
all regions of Ontario and there was no one city or region that was disproportionally represented.
Of the 119 surveys distributed (by either regular mail alone or both mail and email), 12
envelopes were returned unanswered (five clinicians had retired; five had moved with no
forwarding address; two indicated that they no longer practiced in this area of psychology). In
addition, three participants specifically indicated via email that they did not wish to participate in
this survey, and one more indicated that she only assessed children in K-12 and so did not feel
she needed to understand the requirements for accommodation at the postsecondary level. This
left 103 viable potential participants, and we received completed surveys from 58 of them
(37.9% male), yielding a response rate of 56%.
Of the respondents, 37 were doctoral level psychological practitioners (see Table1). The
single largest group of professionals consisted of clinical psychologists (39.6%) followed by
school/educational psychologists (22.4%), psychological associates (12.1%), and 25.6% either
did not respond or represented other specialties. The mean age of respondents was 56.4 years
(SD = 8.2), the mean number of years in practice was 23.5 (SD=9.8), and the mean number of
LD and ADHD assessments conducted during the past year was 18.2. With few exceptions,
individuals who returned the survey considered themselves to be experts in the diagnosis of LD
and ADHD (see Table 3).
A questionnaire was developed, consisting of two parts. The first part comprised 30
true/false questions modeled after the survey by Gordon et al. (2002), examining respondents’
knowledge of diagnostic and human rights issues. The questions focused on several issues: the
differential relevance of special education versus human rights laws in making disability
determination for students at the postsecondary level; the appropriateness of diagnosing LD or
ADHD when students exhibit only relative weaknesses (i.e., compared to their other skills); the
relevance of early history in making diagnoses and accommodation decisions in postsecondary
settings; the importance of using formal diagnostic criteria when assessing LD and ADHD; and
the appropriateness of making diagnoses when a client only shows symptoms of a disorder in
testing situations (e.g., test anxiety, or a history of poor performance only on timed exams).
The original questions used in the Gordon et al. (2002) survey were developed by expert
consensus. All items relevant to Canadian postsecondary practices were retained. For those that
addressed American legislation regarding accommodation of students with disabilities, items
were revised to reflect relevant Canadian or provincial legislation. In addition, three new
questions were developed for inclusion. These items were created based on the experience of the
lead author and dealt with issues identified as problematic in disability documentation at
Canadian postsecondary institutions. These items were then provided to a group of six Canadian
Disability Services experts for review and revision prior to being included in the survey.
Additionally, in order to minimize the possibility of respondents answering questions in a biased
manner (e.g. all true or all false), items were written so that correct responses varied between
true and false.
The second part of the questionnaire asked about demographic information. In addition to
typical demographic questions (age, gender, number of years in practice, etc.), respondents were
asked if they considered themselves to have expertise in diagnosing ADHD and LD, how often
they assess students for these conditions, and how often their evaluations result in positive
diagnoses of these conditions. We were interested in determining if clinicians’ understanding of
legal standards and best practices in clinical diagnosis were related to their self-reported
expertise and diagnostic record.
Contact information for each assessor was obtained from the letterhead of the provided
assessment report. In this way, the Disability Services Office could decouple the identity of the
assessor from the diagnostic report provided, and thus protect the identity of the students in
question. The method of soliciting participation for this survey followed an approach
recommended by Dillman (1991), which purports a success rate of 75%. This method involves
sending waves of invitations. Thus, one advance-notice letter/e-mail and three waves of letter/email surveys were sent to potential participants. These professionals were told that completion of
the questionnaire would be taken as consent to participate. Paper copies were sent to all
participants and included a self-addressed stamped envelope in which to mail the completed
survey, and were provided with a separate self-addressed envelope in which they could return a
ballot to win one of eight prizes (three $100 gift certificates for purchase of psychological test
materials, five $10 gift certificates to a popular coffee company). In this way, the identity of the
individuals was protected while also offering an incentive to participate.
In the letter of introduction, participants were informed that they could complete the
survey either on paper or by email, and an anonymous survey link was provided if they preferred
to complete they survey on-line. In addition, email addresses for 64 of the assessors were also
obtained. These individuals were also sent an email invitation using an on-line survey provider
(Survey Monkey). The introductory letter soliciting participation via email was identical to the
paper version with the exception that it also included a link on which recipients could click if
they did not wish to receive any further emails regarding this survey. Survey Monkey has the
advantage that it can track response rate and automatically resend a second and third email to
non-responders, while keeping the actual names of respondents confidential. On-line participants
were offered the option of being redirected to a separate location after completing the survey
where they were asked to enter their names into the prize draw electronically.
Table 2 presents the results of the survey, ordered by the proportion of respondents who
answered each item correctly. We computed a total score for each respondent, simply their
proportion of correct answers3.The average correct score of respondents was 69.2% (SD = 14.8),
with the scores ranging from 23.3% to 96.7% correct. No respondent answered every item
correctly, and fewer than 15% of respondents obtained a score of 85% or above, which might be
taken to signal mastery.
We were also interested in the knowledge levels of different groups who participated in
the survey. However, many groups (e.g., physicians) were too small to perform meaningful
statistical tests comparing the groups, and several respondents chose not to respond to the
optional demographic questions. An exception was respondents’ level of education; we found
that there was no difference between the knowledge of evaluators trained at the masters level (n
= 13, M = 68.26, SD = 14.4) and those trained at the doctoral level (n = 36, M = 68.71, SD =
15.4), t(47) = .09, n.s.
Finally, we were interested in which areas of information were known to more
respondents. None of the 30 questions were answered correctly by all respondents. Twelve items
were answered correctly by at least 85% of respondents, and most of these items concerned
diagnostic standards for LD and ADHD. On the other hand, four questions were answered
correctly by fewer than one third of respondents; these items concerned the purpose of
accommodations, the distinction between K-12 and postsecondary legislation, the assessment of
effort in diagnostic testing, and choosing appropriate norms for determining disability status in
postsecondary settings. The item with the lowest proportion of correct responses queried whether
the purpose of accommodations is to “allow a disabled individual to perform at his or her best”;
only 12.3% of respondents recognized this to be false.
Table 3 presents the results of the supplemental questions; we note several trends here.
Fewer participants chose to respond to these optional questions, but of those who did, most
considered themselves to be experts in the assessment of both LD and ADHD. In addition, most
reported doing a significant number of LD/ADHD evaluations each year (at least approximately
one each month) and that most of their clients qualified as disabled. Finally, almost all
respondents indicated that they needed at least some additional training in these issues.
In this study, we surveyed clinicians who provided evaluations and supportive
documentation to students seeking accommodations related to LD or ADHD at a major Canadian
university. The survey concerned best-practice standards for diagnosis of these disabilities, as
well as relevant legal standards concerning disability status and the determination of appropriate
accommodations. Although the survey’s items were presented in a true/false format, allowing a
50% chance of getting the correct answer by guessing, the average score of respondents was only
69.2, and none of the respondents answered all items correctly.
Our average score of 69.2 is slightly lower than the average score of “approximately 75”
reported by Gordon et al. (2002). The similar scores suggest that Canadian evaluators are not
more knowledgeable than American evaluators about these issues, nor has knowledge increased
in the decade since Gordon et al.’s study. In any case, given the response format of the survey,
our average score is disappointingly low.
An item-level analysis reveals areas of stronger and weaker knowledge. Knowledge of
best-practice standards for assessing ADHD was an area of relative strength; the vast majority of
respondents understood that ADHD cannot be diagnosed using either psychological test scores or
self-reported symptoms alone, and that other disorders must be ruled out prior to making this
diagnosis. Another area of relatively strong knowledge was the process of applying for
accommodations; the vast majority of respondents understood the importance of recent and
comprehensive documentation, as well as the need to consider the appropriateness of
accommodations even when an applicant has indicated a desire for them. In contrast, respondents
had a particularly weak understanding of certain general issues in clinical assessment; fewer than
half of respondents understood the importance of using general population (or age-based) norms
when making judgments about disability, or the importance of using formal tests of response
effort (e.g., the Word Memory Test; Green, 2003) when judging if a client was putting forth full
effort during an assessment.
We also call out for special attention three items concerning issues that were of particular
interest. Although 86% of respondents recognized that it was inappropriate to make a diagnosis
of LD or ADHD when clients failed to meet official criteria, 14% felt that this was appropriate.
Even more respondents (31%) seemed to endorse the existence of a test-taking disability,
indicating that a person could qualify as having a disability even if their only area of impairment
was on timed, multiple-choice tests. Finally, almost half (44.6%) of respondents reported that the
purpose of a psychoeducational evaluation is to help the client secure those accommodations. It
appears, then, that many clinicians see their role as advocates rather than as objective evaluators.
Finally, if we ignore the accuracy of answers, we can examine respondents’ answers in
terms of agreement or consensus. On approximately half of the survey items, fewer than 75% of
the respondents gave the same answer (i.e., “true” or “false”). This either indicates a general lack
of professional consensus on these matters, or else guessing due to ignorance. Many of the
survey items in this group dealt with issues of impairment—how to determine if someone with
symptoms of LD or ADHD is actually impaired in real world settings, and who should serve as
the comparison for impairment standards.
Implications for Practice
One practice implication involves the training of clinicians with respect to diagnostic
assessment of LD and ADHD in postsecondary contexts, and related training in making
recommendations for educational accommodations. These topics are not covered in great detail
in the training of most clinical psychologists (the most common background of the evaluators in
our sample). Indeed, nowhere in Canada except perhaps in British Columbia is specific training
required to arrive at a diagnosis of LD or ADHD, apart from registration with a provincial
licensing body (Philpott & Cahill, 2008). Although psychologists and other professionals have
an ethical duty to obtain whatever further training is needed to perform in their chosen areas of
practice, the clinical issues covered by our survey constitute particularly neglected areas in which
it is difficult for clinicians to find adequate instruction. Given the growth in diagnosis of LD and
ADHD in postsecondary settings, relevant training programs (in clinical, school, and educational
psychology) must address these issues and direct students toward research-based resources for
further training including discussion of the psychologist’s role as an objective evaluator in
diagnostic contexts. Although the advocate is a recognized role that psychologists can play at
times, there are times where the psychologist is instead expected to provide objective
information to educational institutions and testing agencies, and at these times advocacy can
interfere with appropriate practice.
This problematic nature of the advocacy role relates to a second, larger implication: many
respondents consistently endorsed diagnostic practices that would lead more people to be
diagnosed than meet official criteria. Therefore, we must conclude that concerns expressed, in
both scholarly and popular venues, about the overdiagnosis of LD and ADHD in highfunctioning populations (e.g., Lerner, 2004; Tapper, Morris, & Setrakian, 2006; Vickers, 2010)
have a rational basis. Although some such concerns have clearly been overblown (for discussion,
see Cook, Gerber, & Murphy, 2000; Englandkennedy, 2008), the results of the present study
suggest that many evaluators endorse practices that may lead to overdiagnosis.
As another implication for pratice, Disability Services Offices (DSOs) interested in
ensuring that appropriate standards are being followed must conduct their own thorough review
of documentation rather than relying on diagnosticians’ conclusions. Admittedly, some DSO
staff may not feel able to interpret psychoeducational assessment reports, but in fact many staff
without clinical background can be trained to identify certain common flaws in documentation.
When difficult cases arise, it is helpful to have consulting psychologists who have clinical
training but also expertise in relevant research and legal standards.
There may be an additional benefit to review by outside consultants, beyond the expertise
that they will have when well-chosen. Wolforth (2012) argued that clinicians who make
diagnoses and recommend accommodations are often in a position with a conflict of interests.
On one hand, the clinicians are being asked to provide an objective evaluation of the student, but
on the other hand, they are advocating for a client who is paying for their services. In an effort to
help their clients, some clinicians may err on the side of overdiagnosis and unnecessary
accommodation recommendations. More research must be done to evaluate how serious and
problematic this potential conflict of interest is, but an advantage of outside consultants is that
they lack such a conflict.
Finally, it would also be appropriate for postsecondary institutions to post clear
guidelines for incoming students on their websites outlining exactly the type of documentation
that is required for accommodation at the postsecondary level. This proactive step would put the
onus on the student and his/her clinician to ensure evidence is available to make appropriate
Limitations and Future Research Needs
Our study had expected limitations, each of which prompts needed future research. Our
sample was fairly small, and we surveyed only clinicians who authored reports submitted by
applicants seeking disability-related accommodations in one province; it is possible that
clinicians in different provinces are more aware of these postsecondary-specific accommodation
issues than are those in Ontario. Given the number of assessments each clinician in our survey
estimated s/he performs for students in general, however, we believe that our sample was
representative of evaluators who conduct such assessments for students seeking accommodations
at the postsecondary level, at least in Ontario; nonetheless, more research is needed at other
institutions in other provinces, and also by testing agencies. Larger samples would also allow
more refined analyses relating knowledge to specific evaluator characteristics. Although many
such institutions and agencies have shown reluctance to engage with the evaluators who provide
documentation submitted by students, such engagement is needed to ensure that the diagnoses
and recommendations can be trusted.
Another expected limitation involved the format of our survey; although the response
format allowed for easy coding of responses, it did not permit nuanced responses. We
intentionally designed items to be statements that could be reasonably scored simply as true or
false, but respondents may have had more complex views that led their knowledge to be
underestimated. Interviews, focus groups, or other research methods with open-ended survey
items would produce richer narrative information about evaluators’ perspectives on these issues,
and we would encourage such work.
1. High school students in the on-line transition group were planning to attend either
community college or university, and so were representative of a broad range of students
identified as exceptional learners within the province.
2. Given that provincial licensing bodies do not provide separate listings for clinicians who
undertake psychoeducational assessments for LD and ADHD, we felt that this method of
recruitment would ensure that the survey was distributed only to clinicians who engage in
this area of practice. Furthermore, this method allowed us to obtain a more accurate
response rate, since it was sent only to clinicians who were known to practice in this area
of psychology rather than to all registered psychologists in the province, many of whom
do not perform such assessments.
3. Occasionally, data for a particular respondent was missing for a particular item; we
calculated the score out of the number of questions that were answered.
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Table 1
Respondent Characteristics (N=58)
Highest degree earned
Year licensed
Not reported
Not reported
Clinical psychologist
School/educational psychologist
Psychological associate
Not reported
Before 1980
After 1999
Table 2
Knowledge Survey Items and Results
It is appropriate to make the diagnosis of ADHD based largely or solely on a pattern of scores from
psychological testing.
The purpose of the Ontario Human Rights Code is to outlaw discrimination against individuals with
disabilities, not to optimize their academic performance.
Diagnosis of ADHD may be made mainly from self-reported symptoms on a survey like the Brown Attention
Deficit Disorders Scale.
A student identified prior to college/university under special education laws (such as Bill 82) would
automatically qualify for accommodations at college/university.
To assign a diagnosis of ADHD-Primarily Inattentive Type, the clinician must firmly rule out other psychiatric
and learning disorders that may better account for symptoms.
If an individual is diagnosed with LD or ADHD, the institution must provide any and all accommodations that
the applicant believes will be beneficial.
Data from self-report checklists documenting significantly above average symptoms of ADHD is sufficient to
demonstrate impaired functioning in two or more major life areas.
Testing organizations (e.g. ETS, MCAT) have the right to request complete documentation (including report
cards, transcripts, testing data, and a rationale for the diagnosis) in support of an accommodations request.
Most post-secondary documentation guidelines require that evaluations be conducted within three to five years
of the accommodations request.
Self-reports of early academic struggles or current problems are insufficient bases for documenting
To assist a student in obtaining test accommodations it is appropriate to make a diagnosis of LD or ADHD even
if clinical data do not completely meet agreed upon diagnostic criteria such as those in the DSM-IV.
Relative discrepancies between cognitive abilities and academic achievement are not a sufficient basis for
making a diagnosis of adult LD.
If someone is highly intelligent, it is likely that his or her ADHD symptoms will not appear until
college/university or graduate school.
A diagnosis of LD may be made on the basis of one or two outlier scores that are significantly discrepant from
the overall pattern of performance.
Well-controlled research has demonstrated conclusively that extra time on an examination helps individuals
with ADHD more than it does non-ADHD individuals.
Under the OHRC, an individual with a measured Full Scale IQ of 135 and a reading standard score of 110
could, because of the discrepancy in scores, qualify for accommodations as Reading Disabled.
Evidence that an individual reads slowly is sufficient to justify an accommodation of extra time.
Clinicians providing documentation are required to demonstrate how each proposed accommodation alleviates
the impact of the disability.
An individual can be considered disabled even if performance on timed, multiple choice exams is their only
area of weak functioning.
An adult can be classified as ADHD even if he had no significant childhood impairment, never required
accommodations prior to graduate school, and had no history of brain injury.
To be considered disabled at the post-secondary level, an individual has to show impairment when compared
to an average person in the population.
In Ontario, test anxiety is not a legitimate basis for declaring an individual as disabled.
If an individual has been assigned a clinical diagnosis of ADHD or LD, he or she automatically qualifies as
disabled under the Ontario Human Rights Code (OHRC).
Disability legislation such as the Ontario Human Rights Code was intended to help individuals with
disabilities improve their academic success and testing performance.
The purpose of a clinical evaluation for patients seeking accommodations is to help secure those
Individuals who have graduated from college/university without any prior diagnoses or formal
accommodations might still meet professional criteria for LD or ADHD because of the increased level of
difficulty present in graduate school.
Provincial legislation such as Bill 82 requires post-secondary institutions to accommodate students diagnosed
with disabilities.
To demonstrate the need for accommodations, clinicians should determine impairment by comparing a
patient’s test scores with norms for students at similar educational levels.
Studies show that clinicians are not able to reliably determine if a student is answering honestly and investing
good effort in testing without the aid of specific effort tests.
The purpose of accommodations is to allow a disabled individual to perform at his or her best.
Table 3
Respondents’ Supplemental Question Percent Endorsements (N= 58)
Are you an expert in the diagnosis of LD
Are you an expert in the diagnosis of ADHD
Experience with LD/ADHD
Approximately how many LD/ADHD evaluations do you conduct per year
Approximately how many evaluations do you conduct that are requested at least in part
to document the need for accommodations for someone in higher education
Of all the LD/ADHD evaluations you have conducted for individuals in higher
education seeking academic accommodations, approximately what percent of the time
have you found the individual to qualify as disabled?
Professional development
# of workshops attended in the past 5 years
# of books or journal articles read in the past 5 years
Do you feel you need more training?
Not at all
Very much