Documentation Guidelines for Learning Disabilities.
Professionals conducting assessments, rendering diagnoses of specific learning disabilities (LD), and making recommendations for appropriate accommodations must be qualified to do so. Comprehensive training and relevant experience with adolescent and adult LD populations are essential. Use of diagnostic terminology indicating a learning disability by someone whose training and experience are not in these fields is not acceptable. The following professionals would generally be considered qualified:
- Clinical or educational psychologists
- Medical doctors with demonstrated training and experience in the assessment of learning disabilities in adolescents and adults
Documentation must be comprehensive and recent within the last 3 years. Although the learning disability is ongoing, the severity and manifestations of the condition may change over time. The provision of reasonable accommodations and services is based upon SDRC’s assessment of the current impact of the individual's disability on his or her academic performance. Documentation should be provided on the official letterhead of the doctor, institution, and/or agency making the diagnosis. Documentation should be a typed comprehensive neuropsychological or psycho-educational evaluation that includes:
- The clinician’s name, title, license/certification credentials, phone/fax number, address, signature, and date(s) of treatment
- A description of presenting problems and relevant medical, developmental, and psychosocial history
- An academic history, including areas of uneven academic achievement and results of prior standardized tests
- A clear and specific diagnostic statement and explanation of functional limitations due to the learning disability using DSM-IV-TR criteria. Non-specific diagnoses, such as individual "learning styles", "learning differences", "academic problems", "slow reader", and "test difficulty" or "test anxiety", do not constitute a learning disability.
- A discussion of pre-existing or coexisting disorders, including behavioral, medical, neurological, and/or personality disorders, along with any history of medication use, that may affect the individual's learning
- Test scores from standardized instruments as well as grade and age equivalents
- An interpretive summary based on comprehensive evaluation. Psychometric assessment must consist of a comprehensive, individualized, standardized, and norm-appropriate assessment battery. Any resulting diagnosis must be based upon a pattern of performance across the battery. Any factors influencing the validity of the testing must be described. Selection of instruments should be based upon their sustainability, considering reliability and validity for use with the adult population. Minimally, the domains to be addressed in the evaluation must include the following:
- Aptitude/Cognitive Ability: A valid intellectual assessment with all subtests and standard scores. Brief forms of such assessments (e.g., KBIT 2, WASI) are not acceptable for initial documentation, but in some cases, may be suitable for a documentation update.
- Academic Achievement: A comprehensive academic achievement battery. The battery must assess basic and higher order skills of reading (sight vocabulary, decoding, sentence and text comprehension), writing (spelling, grammar, ideation), verbal expression, and math (calculation and reasoning), as well as fluency (timed performance) in these academic areas.
- Areas of Cognitive and Information Processing: Based upon the nature of the referral, the applicant's clinical presentation, and prior test results, evaluators should investigate realms of cognitive/information processing. These domains include, but are not limited to:
- Memory (e.g., visual and verbal acquisition, retrieval, retention, and recognition)
- Processing speed and cognitive fluency (e.g., timed psychomotor or graphomotor tasks, decision and naming fluency)
- Attention (e.g., visual and auditory spans of attention, scanning tasks, and vigilance assessment, including continuous performance tasks)
- Sensory-perceptual functioning (e.g., high-level visual, auditory, and tactile tasks)
- Executive functioning (e.g., planning, organization, prioritization, sequencing, self-monitoring)
- Motor functioning (e.g., tests of dexterity and handedness)
- Visual acuity and possible need for prescription eye glasses
- Recommendations for reasonable accommodations and explanations that link accommodations to specific academic tasks, and support such recommendations with a rationale based upon specific test results
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