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Section 2.22: Appendix DSP3

SPECIFIC DOCUMENTATION GUIDELINES

The following specific documentation guidelines are organized into nine disability categories: (1) learning disabilities; (2) attention-deficit hyperactivity disorder; (3) pervasive developmental disorders; (4) acquired brain injuries; (5) psychological disorders; (6) acuity disorders; (7) mobility disorders; (8) systemic disorders; and (9) other disabilities. In addition, all disability categories are required to follow the general documentation guidelines provided above.

  1. Learning Disabilities

    Learning disabilities is a general term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical skills. These disorders are intrinsic to the individual, presumed to be due to central nervous system dysfunction, and may occur across the life span. Problems in self-regulatory behaviors, social perception, and social interaction may exist with learning disabilities but do not, by themselves, constitute a learning disability. Although learning disabilities may occur concomitantly with other disabilities (e.g., sensory impairment, mental retardation, serious emotional disturbance), or with extrinsic influences (such as cultural differences, insufficient or inappropriate instruction), they are not the result of those conditions or influences (NJCLD, Learning Disabilities: Issues on Definition, January, 1990).

    • General documentation guidelines listed in Section 2.22.02.
    • Clear and specific identification of a learning disability must be stated in the documentation. For example, the terms "Learning styles" or "Learning differences" are not synonymous with a learning disability.
    • Documentation of a developmental and educational history consistent with a learning disability.
    • Since the manifestations of a learning disability may change over the period of childhood and adolescence, documentation must reflect either data collected within the past three years or after the age of 18.
    • Information gained from standardized assessment instruments is one essential piece of the methodology used to diagnose learning disabilities. Therefore, documentation of learning disabilities must include standardized measures of academic achievement and cognitive processing abilities that have age-appropriate normative data for high school/college students or older adult non-traditional students. All standardized measures must be represented by standard scores and percentile ranks based on published norms.
    • Documentation of a functional limitation(s) in one or more of the following areas of academic achievement:
      • Reading (decoding, fluency, and comprehension)
      • Mathematics (calculations, math fluency, and applied reasoning)
      • Written Language (spelling, fluency, and written expression)
    • Documentation of relative strength(s) in academic achievement in order to establish the presence of a significant discrepancy between academic domains. The presence of a significant discrepancy will typically require a difference of one standard deviation between scores. However, qualified professionals may use other widely accepted metrics for documenting a significant difference between two scores (e.g., standard error of measurement).
    • Documentation that alternative explanations for the academic limitation(s) have been considered and ruled out (e.g., low cognitive ability, lack of adequate instruction, emotional factors such as anxiety or depression).
    • Documentation of a pattern of cognitive processing weaknesses and strengths that is associated in a meaningful way with the identified area(s) of academic limitation.
    • Both processing weaknesses and processing strengths must be identified and must represent a significant discrepancy between cognitive domains. The presence of a significant discrepancy will typically require a difference of one standard deviation between scores. However, qualified professionals may document a significant difference between two scores using other widely accepted metrics (e.g., standard error of measurement).
    • Processing weaknesses and strengths must be evident on multiple measures and not based on a single discrepant score on an individual test or subtest.
      • Cognitive Processing Skills (selection dependent upon case)
        • Attention
        • Executive Functions
        • Fluency/Automaticity
        • Memory/Learning
        • Oral Language
        • Phonological/Orthographic Processing
        • Visual-Motor
        • Visual-Perceptual/Visual-Spatial
    • Documentation that alternative explanations for the cognitive limitation(s) have been considered and ruled out (e.g., low cognitive ability, lack of adequate instruction, emotional factors such as anxiety or depression).
    • These guidelines are intended to guide the review of documentation and cannot substitute for the expertise and clinical judgment of a qualified professional. Failure to fully meet each of the above criteria does not automatically preclude a diagnosis of learning disabilities. In some circumstances, this diagnosis may be justified, based on an expert's integration of a student's history, test performance, and current functioning.
  2. Attention-Deficit/Hyperactivity Disorder (AD/HD)

    AD/HD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development. The manifestations of AD/HD result in functional impairment in at least two settings (e.g., academic, occupational, social). The diagnosis of AD/HD is based on the specific criteria included in the current version of the DSM of the American Psychiatric Association.

    • General documentation guidelines listed in Section 2.22.02.
    • Diagnosis and corresponding code from the most recent DSM must be included.
    • Assessment of the following diagnostic criteria is required and evaluation results must be included in the documentation:
      • Developmental history of either inattention and/or hyperactivity-impulsivity symptoms during childhood. The specific symptoms that were present in childhood should be stated in the documentation. Corroboration of childhood symptoms should be included, and may need to be gathered from a variety of possible data sources (e.g., parent/guardian report, school records, past evaluations). Evidence that these symptoms were associated with some functional impairment in home and/or school settings also must be included.
      • Current symptoms of either inattention and/or hyperactivity-impulsivity must be present. The specific symptoms that are present should be stated in the documentation. Self-reported current symptoms should be corroborated by an independent informant who has been able to observe the student's recent functioning with adequate regularity to provide this type of information. Evidence that these symptoms are associated with functional impairment in academic, occupational, and/or social settings also must be included.
      • The frequency/severity of both childhood and current AD/HD symptoms should be documented by comparison to individuals at a similar level of development. Documentation must include the results of standardized rating scales that provide comparison to age-based normative data.
  3. Pervasive Developmental Disorders

    4. Pervasive developmental disorders are characterized by severe and pervasive impairment in several areas of development including reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities. Several different disorders fall within this category including Asperger's Disorder and Autistic Disorder.

    1. Asperger's Disorder

      Asperger's Disorder is a pervasive developmental disorder characterized by qualitative impairment in social interactions and the presence of repetitive and stereotyped behaviors, interests, and activities.

      • General documentation guidelines listed in Section 2.22.02.
      • Diagnosis and corresponding code from the most recent DSM must be included.
      • Assessment of the following diagnostic criteria is required and evaluation results must be included in the documentation:
        • Developmental history that includes evidence of Asperger's Disorder symptoms in childhood and documents the absence of clinically- significant general delay in early cognitive or language development.
        • Documentation of current qualitative impairment in social interaction.
        • Documentation of current restricted, repetitive, and stereotyped patterns of behavior, interests, and activities.
        • Assessment of broad cognitive ability and language function using standardized assessment measures with age-appropriate norms.

    2. Autistic Disorder

      Autistic Disorder is a pervasive developmental disorder characterized by qualitative impairment in social interactions, qualitative impairment in communication affecting both verbal and nonverbal communication skills, and the presence of repetitive and stereotyped behaviors, interests, and activities.

      • General documentation guidelines listed in Section 2.22.02.
      • Diagnosis and corresponding code from the most recent DSM must be included.
      • Assessment of the following diagnostic criteria is required and evaluation results must be included in the documentation:
        • Developmental history that includes evidence of Autistic Disorder symptoms in childhood
        • Documentation of qualitative impairment in social interaction.
        • Documentation of qualitative impairment in communication.
        • Documentation of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities.
        • Assessment of broad cognitive ability and language function using standardized assessment measures with age-appropriate norms.

    3. Acquired Brain Injury (ABI)

      Brain injury can result from external trauma, such as a closed head or an object penetration injury, or internal trauma, such as a cerebral vascular accident or tumor. ABI can cause physical, cognitive, emotional, social, and vocational changes that can affect an individual for a short period of time or permanently. Depending on the location and extent of the injury, symptoms can vary widely. Understanding functional changes after an injury and resulting implications for education are more important than only knowing the cause or type of injury.

      • General documentation guidelines listed in Section 2.22.02.
      • Documentation of date of occurrence/diagnosis and the nature of the neurological illness or traumatic event that resulted in brain injury.
      • Depending upon the functional domains impacted by the injury, assessments of cognitive and academic deficits and strengths, psychosocial-emotional functioning, and/or motor/sensory abilities relevant to academic functioning may be essential components of documentation of the impact of an acquired brain injury for an individual student.
      • Impairments following an acquired brain injury may change rapidly in the weeks and months after the injury, and a more stable picture of residual weaknesses may not be apparent for 1-2 years after an injury. More recent documentation may be necessary to adequately assess the student's current accommodation needs.
      • Cognitive and academic processing weaknesses and strengths must be evident on multiple measures and not based on a single discrepant score:
        • Academic Achievement
          • Reading (decoding, fluency, and comprehension)
          • Mathematics (calculations, math fluency, applied reasoning)
          • Written Language (spelling, fluency, written expression)
        • Cognitive Processing Skills
          • Attention
          • Executive Functions
          • Fluency/Automaticity
          • Memory/Learning
          • Oral Language
          • Phonological/Orthographic Processing
          • Visual-Motor
          • Visual-Perceptual/Visual-Spatial

    4. Psychological Disorders

      Some individuals experience significant disruptions in mood, thinking, and behavioral regulation that are secondary to a psychological disorder. Many different psychological disorders can interfere with cognitive, emotional, and social functioning and may negatively impact a student's ability to function in an academic environment. The symptoms and associated impairment may be either chronic or episodic. Test anxiety by itself is not considered a psychological disorder. Complete descriptions and diagnostic criteria for psychological disorders are available in the current version of the DSM.

      • General documentation guidelines listed in Section 2.22.02.
      • DSM diagnosis and corresponding DSM code.
      • Description of the history, current symptoms, and severity of the disorder.
      • Description of the expected progression or stability of the disorder.
      • Description of the current functional limitations impacting academic performance resulting from the disorder.

    5. Sensory Disorders

      Deaf and Hard of Hearing

      Individuals who are deaf or hard of hearing experience a reduction in sensitivity to sound. Amplification may not assist the individual in interpreting auditory stimuli. Individuals who are deaf or hard of hearing from birth may experience lags in the development of speech and most often have language-based deficiencies.

      • General documentation guidelines listed in Section 2.22.02.
      • Description of the history, current symptoms, and severity of the disorder.
      • Description of the expected progression or stability of the disorder.
      • Description of the current functional limitations impacting academic performance resulting from the disorder.

      Visual Disorders

      Visual impairments are disorders in the function of the eyes that cannot be adequately corrected by medical or surgical intervention, therapy, or conventional eyewear. Individuals with visual disorders may not have any useable vision or the vision may be extremely limited (light, color or shadow perception only).

      • General documentation guidelines listed in Section 2.22.02.
      • Description of the history, current symptoms, and severity of the disorder.
      • Description of the expected progression or stability of the disorder.
      • Description of the current functional limitations impacting academic performance resulting from the disorder.

    6. Mobility Disorders

      Mobility impairments refer to conditions that limit a person's coordination or ability to move. Some mobility impairments are congenital while others are the result of illness or physical injury. The functional abilities and limitations resulting from the impairment will vary from individual to individual.

      • General documentation guidelines listed in Section 2.22.02.
      • Description of the history, current symptoms, and severity of the disorder.
      • Description of the expected progression or stability of the disorder.
      • Description of the current functional limitations impacting academic performance resulting from the disorder.

    7. Systemic Disorders

      Systemic disabilities are conditions affecting one or more of the body's systems, including the respiratory, immunological, neurological, circulatory, or digestive systems. Systemic disabilities are often unstable therefore, the need for and type of reasonable accommodations may change over time.

      • General documentation guidelines listed in Section 2.22.02.
      • Description of the history, current symptoms, and severity of the disorder.
      • Description of the expected progression or stability of the disorder.
      • Description of the current functional limitations impacting academic performance resulting from the disorder.

    8. Other Disabilities

      Disabilities as defined by the ADA that are not covered by the guidelines described above may be eligible for accommodations to University System policies.

Last Updated: 02/2009

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