Learning Disabilities Medical Documentation Guidelines

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Guidelines for Medical Documentation When an Accommodation Request Is Based Upon a Diagnosis Learning Disabilities

Introduction

The National Conference of Bar Examiners (NCBE) is committed to providing reasonable and appropriate accommodations to candidates with documented disabilities, in accordance with the Americans with Disabilities Act as amended (ADAAA). Under the ADA, a person is disabled if he or she has a physical or mental impairment that substantially limits one or more major life activities.

NOTE: Some health-related needs may be met by way of a comfort aid. Comfort aids are items that candidates may bring into the testing room upon inspection by testing staff, and do not require pre-approval. A list of allowed comfort aids may be found on the Pearson VUE website at https://home.pearsonvue.com/test-taker/Test-accommodations/Comfort-aids.aspx

To support a request for test accommodations, applicants must submit documentation from a qualified professional that is on letterhead, typed in English, dated, and signed. The documentation must confirm the existence of the applicant’s impairment(s) and address the functional limitations that the applicant currently experiences because of the impairment(s). It should also provide a rationale for each accommodation requested. The current functional limitations caused by the impairment must be relevant to taking the MPRE, and the recommended accommodations must be necessary to ameliorate the current limitations.

A summary of what the medical documentation should address when an applicant seeks accommodations based upon a learning disability diagnosis is provided at the end of these guidelines for quick reference.

Description of the MPRE Administered Under Standard Conditions

The MPRE is a computer-based examination administered in a proctored setting at Pearson VUE testing centers. It is a two-hour timed examination consisting of 60 multiple-choice questions. Test items are written at an 11th- to 12th-grade reading level. Candidates record their answers by selecting the answer choice using either a mouse or a keyboard. Candidates are assigned seats in a quiet environment.

Essential Components of Supporting Documentation

A Qualified Professional Must Conduct the Evaluation

Professionals who diagnose specific learning disabilities (LD) must be qualified to do so. The professional should be licensed and have appropriate training and relevant experience with adolescent and adult LD populations. If the professional diagnoses multiple impairments, the professional must be qualified to make all the diagnoses. NCBE will not grant accommodations based on medical evaluations conducted by family members of an applicant because of the inherent conflict of interest.

The Diagnosis and Current Functional Limitations Must be Substantiated

The supporting documentation should substantiate the diagnosis and provide evidence of a substantial limitation in one or more major life activities that affect the applicant’s ability to take the MPRE under standard conditions. The documentation must validate the need for accommodations based upon the applicant’s current level of functioning.

Learning disability diagnoses should ordinarily be provided by way of a comprehensive report that reflects a thorough interview of the applicant and the use of appropriate assessments.

The Documentation Should Reflect More than an Applicant’s Self Report

Learning disorders commonly manifest during childhood (although not always formally diagnosed). Accordingly, in addition to an applicant’s self-report, relevant historical information regarding the applicant’s academic history and learning processes in elementary, secondary, and post-secondary education should ordinarily be addressed in the medical documentation that is submitted in support of the request, along with the results of any assessments that were administered in arriving at the diagnosis and other information that the professional deems relevant.  It is important to establish that the learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.

It is extremely helpful to have the following topics addressed in the documentation:

  • description of the presenting problem(s);
  • developmental history;
  • relevant medical history, including the absence of a medical basis for the symptoms;
  • academic history, including performance on other standardized tests, classroom performance, study habits, and participation in extra-curricular activities;
  • relevant family history, including primary language in the home;
  • review of any prior neuropsychological or psychoeducational test reports, or diagnoses found in other types of documentation;
  • relevant employment history;
  • discussion of pre-existing or coexisting disorders, including behavioral, medical, neurological, and/or personality disorders, along with any history of medication use and current medication, that may impact the applicant’s need for accommodations;
  • description of auxiliary aids, services, and accommodations previously used in non-academic settings;  
  • if available, documentation of an Individualized Education Program (IEP) and/or a 504 Plan;
  • academic performance in elementary, secondary, and postsecondary education;
  • whether accommodations were used by the applicant in educational settings and, if so, what those accommodations were;
  • performance on other standardized tests such as the SAT, ACT, and LSAT;
  • whether accommodations were used by the applicant on other standardized tests and, if so, what those accommodations were;
  • an exploration of possible alternative conditions that may mimic a learning disability when, in fact, one is not present (e.g., motivational problems).

The Documentation Should Include and Address Diagnostic Assessment Results

The neuropsychological, psychological, or psychoeducational evaluation must provide clear evidence that a specific learning disability exists. The assessment should consist of a comprehensive battery of tests that does not rely on any single test or subtest. Any resulting diagnosis should be based upon a clinical synthesis of the individual’s history, academic performance, and the comprehensive assessments.

Tests must be appropriately normed for the age of the applicant and should be administered in the standardized manner. Age-based standard scores, as well as the form of the test used, must be provided for all normed measures. Percentiles alone are not sufficient. It is helpful to list all test data in a score summary sheet appended to the report.

Any factors influencing the validity of the testing should be described. For example, if the test taker regularly takes medication but did not do so on the day of the testing, the evaluator should address the potential impact on test results and functioning.

The domains that are typically addressed include the following:

Cognitive Functioning

Acceptable measures include, but are not limited to, the Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV); the Woodcock-Johnson-IV: Tests of Cognitive Abilities (WJ-IV COG); and the Stanford-Binet Intelligence Scale (5th ed.).  All subtest and standard scores should be reported.

The Slosson Intelligence Test-Revised, the Wechsler Abbreviated Scale of Intelligence (WASI), and the Kaufman Brief Intelligence Test (K-BIT-2) are primarily screening devices. Therefore, while results on those assessments may be submitted, they should not be the only basis for evaluating cognitive functioning.

Achievement

Standard scores should be listed for all subtests, using age-based norms. The battery must include current levels of academic functioning in reading (decoding and comprehension). Math and writing skills are not assessed on the MPRE, so math and writing measures are not necessary. Acceptable instruments include, but are not limited to, the Woodcock-Johnson-IV: Tests of Achievement (WJ-IV); the Wechsler Individual Achievement Test-III (WIAT-III); the Stanford Test of Academic Skills; and the Woodcock Reading Mastery Tests.

If extended testing time is recommended as an accommodation, it is useful to also include a timed reading measure that has been normed on adults and which allows for both extended and regular administration, such as the Nelson-Denny Reading Test or the Scholastic Abilities Test for Adults (SATA). Standard scores must be provided, not just raw scores or percentiles.

Please note that the Nelson-Denny Reading Test and the Wide Range Achievement Test 4 (WRAT-4) are not comprehensive measures of achievement and should not be used as the sole measures of achievement. These tests provide useful information only when administered in conjunction with additional assessment measures.

Information Processing

Specific areas of information processing that affect efficient test-taking should be assessed (e.g., short- and long-term memory, sequential memory, attention, processing speed, auditory and visual perceptual functioning, executive functioning, and motor ability). The MPRE is a reading-based test and therefore measures that relate to the processing of words and sentences presented visually are most relevant. Acceptable instruments include, but are not limited to, the Detroit Tests of Learning Aptitude-Adult (DTLA-A); the WJ-IV COG; the Wechsler Memory Scale-III (WMS-III); and information from subtests on the WAIS-IV.

Address the Applicant’s Academic History

Because learning disabilities begin during school-age years, school records from elementary, secondary, and post-secondary school should be reviewed by the evaluator and discussed in the report whenever possible. Such records can corroborate the functional limitations experienced by the applicant and help support the requested accommodations. Relevant information from these records should be summarized by the evaluator in the report and/or included as an attachment.

Interpret and Discuss the Diagnostic Findings

A well-written interpretation of findings is extremely helpful. Assessment instruments provide important data that must be synthesized by the evaluator with background information, historical information, clinical observations of the applicant during testing, and other information relating to the applicant’s current functioning.

Include a Specific Diagnosis

The documentation must include a specific diagnosis based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 or DSM-IV, depending upon when the documentation was prepared). The documentation should specify all academic domains and subskills that are impaired and specify the current severity of the applicant’s learning difficulties (mild, moderate, severe).

When discussing the applicant’s functional limitations, the applicant’s ability to perform a given activity should be compared to the ability of most people in the general population to perform the same activity.   

Each Recommended Accommodation Must Include a Rationale

If the documentation recommends specific accommodations, it should explain the need for each recommended accommodation with reference to specific functional limitations that have been established through the evaluation process.

Documentation Must Be Current

The provision of reasonable accommodations is based upon the current impact of the disability on a major life activity that affects the applicant’s ability to take the MPRE under standard conditions. Although learning disorders are lifelong impairments, changes in manifestation of symptoms can occur with age. In most cases, the documentation should reflect an evaluation done within the past five years.

Documentation that is more than five years old may be considered if the applicant was age 17 or older at the time of the assessment and the applicant has an established history of persistent learning difficulties. If documentation is inadequate in scope or content or does not address the applicant’s current level of functioning and need for accommodations in a standardized testing context, reevaluation may be necessary.

Summary of Information that Should be Included in Documentation of a Learning Disability

  • A comprehensive diagnostic interview that summarizes the applicant’s academic history and learning processes in elementary, secondary, and post-secondary education, as well as other relevant developmental, medical, family, psychosocial, and employment history
  • A neuropsychological, psychological, or psychoeducational assessment consisting of a comprehensive battery of tests that addresses aptitude, achievement, and relevant aspects of cognitive function and information processing
    • The battery must include current levels of academic functioning in reading (decoding and comprehension)
    • If extended time is requested, it is useful to include a timed reading measure that has been normed on adults and allows for both extended and regular administration
    • Because the MPRE is a reading-based test, cognitive measures that relate to the processing of words and sentences presented visually are most relevant
    • If informal assessment procedures are used to determine performance across domains, establish a differential diagnosis, or support a specific accommodation, those procedures should be described in reasonable detail
    • A qualitative description of behavioral observations should be provided
    • Age-based standard scores should be provided for all normed measures
  • A discussion of any factors influencing the validity of the assessment scores
  • A rule-out of alternative diagnoses or explanations
  • A clear diagnostic statement
  • A summary of academic records reviewed by the evaluator
  • An interpretation and discussion of diagnostic findings
  • A rationale for each requested accommodation that is correlated with specific functional limitations established through the evaluation process from test results and clinical observations
  • A discussion of prior accommodations used and the extent to which those accommodations met the applicant’s needs