Download Documentation Guidelines - Mental Health

C A L I F O R N I A S T A T E P O L Y T E C H N I C U N I V E R S I T Y, P O M O N A
Disability Resource Center
Guidelines for Documenting Mental Health Disabilities
The following guidelines describe the necessary components of acceptable documentation for students
requesting academic accommodation(s) based on a disabling mental health condition. Students are encouraged
to share these guidelines with their mental health treatment provider or other appropriate professional. The
cost of obtaining disability documentation is the responsibility of the student. Please note: The Disability
Resource Center is responsible for making the final determination regarding what accommodations are
reasonable or appropriate to the learning environment at Cal Poly Pomona.
Definitions
The Americans with Disabilities Act, as amended (ADAAA) and Section 504 of the Rehabilitation Act define a
disability as a physical or mental condition that substantially limits a major life activity, such as learning, working
and communicating, among others. Mental health disabilities refers here to a broad range of mental and
emotional conditions, and is different from other covered mental impairments such as intellectual disability,
organic brain damage, and learning disabilities. The irregular nature of mental illness may create problems in
establishing or maintaining consistent work or school patterns. Some individuals may need time off for medical
appointments or to recuperate. The irregular nature of mental illness might also impair an individual’s
performance. Persons with mental health disabilities may experience difficulties with remembering, learning,
reading, concentrating and/or thinking, socially interacting and/or communicating, which may interfere directly
with their ability to function in a university setting.
The source for understanding the diagnostic criteria of these conditions is typically the most recent version of
the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases:
Classification of Mental and Behavioural Disorders (ICD). However, not all clinical diagnoses included in the DSM
and/or ICD are included in the legal definition of a disability. For example, Substance-Related Disorders, when it
involves the current or ongoing use of illegal drugs, is specifically excluded from the definition of a disability.
Some clinical diagnoses that the ADA recognizes as potentially disabling include, but are not limited to:
Obsessive-Compulsive, Bipolar, Generalized Anxiety, Mood, and Post-Traumatic Stress Disorders.
A Qualified Professional Must Conduct the Evaluation
Qualified evaluators are defined as those licensed individuals who are have the education and training to
evaluate and diagnose mental health disorders, and have relevant expertise in differential diagnosis of mental
health disorders. These may include: licensed social workers, professional counselors, psychologists,
psychiatrists, neurologists, or other mental health specialists with experience and expertise in the area for which
accommodations are being requested. The name, title, and professional credentials of the evaluator should be
clearly stated in the documentation. It is not considered appropriate for professionals to evaluate members of
their family.
3801 West Temple Avenue, Pomona, CA 91768 Telephone (909) 863-3333 • (909) 869-3269 V/TDD • Fax (909) 869-3271
T H E C A L I F O R N I A S T A T E U N I V E R S I T Y Bakersfield, Channel Islands, Chico, Dominguez Hills, Fresno, Fullerton, Hayward, Humboldt, Long Beach, Los Angles,
Maritime Academy, Monterey Bay, Northridge, Pomona, Sacramento, San Bernardino, San Diego, San Francisco, San Jose, San Luis Obispo, San Marcos, Sonoma,
Stanislaus
Updated 1/25/2016. Guidelines adapted from Educational Testing Services (2012). Guidelines for Documentation of Psychiatric Disabilities in Adolescents and Adults, 2nd Ed.
C A L I F O R N I A S T A T E P O L Y T E C H N I C U N I V E R S I T Y, P O M O N A
Disability Resource Center
Documentation to Support the Diagnosis and Accommodations Must be Recent
Due to the changing nature of mental health conditions, an individual’s presentation and functional impacts of
the diagnosis may vary over time even if the diagnosis remains the same. It is difficult to provide hard-and-fast
rules regarding the currency of psychiatric documentation, but the DRC endeavors to be reasonable when
reviewing the totality of information provided. In most instances, we require that an evaluation has been
conducted within one year of the requested accommodations. However, there is room for flexibility, depending
on the following variables: nature and type of disability, including its stated or implied course; severity of the
disability; history of onset and/or duration of the disability; treatment status; and stability of functioning.
Documentation to Support the Diagnosis and Accommodations Must be Comprehensive
A school plan such as an IEP is insufficient documentation by itself, but can be included as part of a more
comprehensive report. In most cases, documentation should be based on a comprehensive diagnostic/clinical
evaluation and include the following components:
A
Clear Statement of the Diagnosis
A specific diagnosis must be based on current DSM or ICD diagnostic criteria. Citing the specific objective
measures used to help substantiate the diagnosis, along with scores, can be quite helpful in
documenting a reasonable need for accommodations. The evaluator should use definitive language in
the diagnosis of a psychiatric disorder, avoiding such wording as “is consistent with,” “has problems
with,” or “may indicate emotional problems.” Given that many individuals benefit from prescribed
medications and therapies, a positive response to medication in and of itself does not confirm a
diagnosis, nor does the use of medication in and of itself either support or negate the need for
accommodations.
B
History of Present Illness
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C
Current symptoms, including level of severity
Onset and time course of the disorder, including previous episodes of mental illness, suicidality,
and/or aggressive behaviors
Treatment history (type, frequency, duration, adherence), including any previous psychiatric
hospitalizations and/or outpatient treatment and medication response/efficacy/side effects
Developmental, educational, and psychosocial history, including established eligibility for special
education, social services, and/or prior academic accommodations; coping strategies successfully
used; capacity to maintain interpersonal relationships; sociocultural supports
Dates and results of previous psychodiagnostic/psychoeducational/neuropsychological assessments,
including rule-outs of other potential diagnoses involving neurological and/or medical conditions
(including substance abuse), as well as educational, linguistic, and cross-cultural factors that may
result in symptoms
Current Level of Functioning
3801 West Temple Avenue, Pomona, CA 91768 Telephone (909) 863-3333 • (909) 869-3269 V/TDD • Fax (909) 869-3271
T H E C A L I F O R N I A S T A T E U N I V E R S I T Y Bakersfield, Channel Islands, Chico, Dominguez Hills, Fresno, Fullerton, Hayward, Humboldt, Long Beach, Los Angles,
Maritime Academy, Monterey Bay, Northridge, Pomona, Sacramento, San Bernardino, San Diego, San Francisco, San Jose, San Luis Obispo, San Marcos, Sonoma,
Stanislaus
Updated 1/25/2016. Guidelines adapted from Educational Testing Services (2012). Guidelines for Documentation of Psychiatric Disabilities in Adolescents and Adults, 2nd Ed.
C A L I F O R N I A S T A T E P O L Y T E C H N I C U N I V E R S I T Y, P O M O N A
Disability Resource Center
Reasonable accommodations are based upon the current impact of the disability, with the
understanding that a psychological disorder usually presents itself across a variety of settings beyond
the academic domain and its expression is often influenced by context-specific variables (e.g., schoolbased performance, work or job performance). The documentation must address:
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Present level of functioning across multiple settings, taking into account the impact of any
medication treatment regimen
Response to medication treatment (efficacy, side effects) and anticipated impact to functioning in
the academic setting
Expected progression or stability of the impact of the diagnosed condition over time
Note: Achievement measures that substantiate the ongoing impact of the disorder on postsecondary
academic performance may be necessary. If a formal psychological assessment is undertaken to help
document the presence of functional limitations, it is important that the test-taker undergo such clinical
testing while taking the medication. Although the ADAAA prevents considering a therapeutic response to
medication to deny the presence of a disabling condition, taking into account the impact of the
treatment regimen is relevant to the granting of appropriate accommodations for this population.
Provide Rationale for Each Requested Accommodation
Each accommodation recommended by the evaluator must include a rationale. A link must be established
between the requested accommodation(s) and the manifested symptomatology of the disorder that is pertinent
to the postsecondary education setting.
A diagnosis by itself does not automatically warrant accommodations. For example, “test anxiety” is not a
sufficient diagnosis and would not support a request for testing accommodations. Given that many individuals
may believe that they would benefit from extended time in testing situations, evaluators must provide specific
rationales and justifications for the recommended accommodation.
A prior history of accommodations, without demonstration of current need, does not in and of itself warrant the
provision of accommodations.
Accommodations can be provided only when a convincing rationale is made for their necessity to create a “level
playing field.” Documentation must support the need for reasonable accommodations that allow equal access to
the postsecondary academic environment without fundamentally altering essential curriculum or course
requirements.
Psychoeducational or neuropsychological testing is often necessary to support the need for academic
accommodations based on the potential for mental health disorders to interfere with cognitive performance.
Obtaining standardized measures of performance on a range of academically relevant tasks can guide the
accommodation-granting process by objectively demonstrating the need for accommodations and identifying
the type and extent of formal assistance that is likely to be effective.
3801 West Temple Avenue, Pomona, CA 91768 Telephone (909) 863-3333 • (909) 869-3269 V/TDD • Fax (909) 869-3271
T H E C A L I F O R N I A S T A T E U N I V E R S I T Y Bakersfield, Channel Islands, Chico, Dominguez Hills, Fresno, Fullerton, Hayward, Humboldt, Long Beach, Los Angles,
Maritime Academy, Monterey Bay, Northridge, Pomona, Sacramento, San Bernardino, San Diego, San Francisco, San Jose, San Luis Obispo, San Marcos, Sonoma,
Stanislaus
Updated 1/25/2016. Guidelines adapted from Educational Testing Services (2012). Guidelines for Documentation of Psychiatric Disabilities in Adolescents and Adults, 2nd Ed.