Guidelines for Writing Diagnostic Reports

These guidelines go over the essential components of a comprehensive psychoeducational or neuropsychological report. They will be useful to evaluators who write diagnostic reports for individuals with disabilities who are planning to take one of ETS's graduate or professional licensing examinations. Evaluators can also help prevent unnecessary delays in processing by reviewing ETS's Documentation Guidelines for specific disabilities.
 

The documentation should be typed or printed on letterhead, dated and signed. It should include the name, title and professional credentials of the evaluator. Evaluators must ensure that the documentation is legible.
 

The recency of documentation is critical to the establishment of the test taker's current functional limitations. Most testing agencies, including ETS, have guidelines regarding the duration for which documentation is deemed acceptable. As a general rule, learning disabilities (LD), ADHD or autism spectrum disorder (ASD) documentation needs to be written within the past five years.

Objective evidence regarding psychiatric disabilities, traumatic brain injury (TBI) and other disabilities that are more changeable or modifiable with medication or other treatments should be updated every 12 months. If a test taker has sustained a head injury or has had brain surgery in the past 12 months, recovery may be still taking place, and documentation needs to be updated more frequently. However, if a head injury or brain surgery took place more than 2 or 3 years ago, then the 5-year rule may apply for substantiating evidence of a functional impairment. If the disability is a permanent health or sensory impairment (e.g., blindness or cerebral palsy), documentation does not have to be as recent, but the rationale for the accommodations requested should be provided by a qualified professional.

For test takers with LD and/or dual diagnoses of LD/ADHD, a complete and comprehensive reevaluation is no longer necessary for basic accommodations (i.e., time-and-one-half and rest breaks). Instead, a documentation update may be sufficient if all three of the following conditions are met:

1. The test taker has a longstanding learning disability or LD/ADHD.
2. The original diagnostic evaluation was performed using adult measures in both the ability and achievement domains (e.g., WAIS-IV, Woodcock-Johnson III, or WIAT-III) in accordance with ETS documentation criteria.
3. The test taker has received accommodations through the Disability Services office on campus or on the job through their employer's HR office.

Individuals with a longstanding learning disability or dual diagnoses of LD/ADHD who are requesting more extensive accommodations (e.g., double time, reader, scribe, separate room, calculator, etc.) are required to send their documentation along with an update (if documentation is more than five years old). The update should demonstrate the ongoing impact of the disability on academic performance. Since intellectual functioning is typically stable in adulthood, another WAIS-IV is not required if one was conducted in the testing covered by the initial report. For these individuals, a comprehensive update should include:

1. a historical review of earlier testing, and
2. recent achievement and/or cognitive measures which demonstrate the ongoing impact of the disability on academic performance.

This change in policy reflects ETS's concerns about the increasing cost of neuropsychological or psychoeducational testing that many young adults with disabilities may have to bear.
 

There should always be a detailed history that supports the reason for referral. This may include failed courses, multiple incompletes in coursework, slow reading or an uneven job history. The reason for referral should be clearly stated by the evaluator. Whenever possible, the evaluator should present corroborative data from school records. If accommodations are needed in the testing situation but not in other circumstances, the report will need to justify this distinction. In most cases, if the test taker has a disability in learning or attention that is substantially limiting to a major life activity, then it will spill over into areas other than test taking.
 

It’s important that all evaluation measures used in the report are reliable, valid and age-appropriate and that the most recent edition of each diagnostic measure is used. When an evaluator uses a diagnostic instrument that isn’t age-appropriate, that should be noted and the rationale for the instrument's use should be provided. Similarly, if an evaluator re-administers a test too frequently within a 2- or 3-year period, they should acknowledge that there may be a practice effect operating that can bias the scores. Evaluators need to find a balance between testing too much and not enough. If the initial battery is too limited, then costly retesting may be required by the testing agency. For example, a screening measure such as the WRAT-III should never be used as the exclusive measure of achievement, but it should be used to complement additional diagnostic measures. The testing should be complete and comprehensive enough that the evaluator can arrive at a DSM-5 or ICD-9 diagnosis.

Scores should be reported as standard or scaled scores, as applicable, and/or as percentiles. Age- and grade-equivalent scores aren’t particularly helpful when reviewing psychometric evidence on adults and young adults. If any test protocol is altered during the test administration, that fact should be reported, as should score comparisons based on a non-standard administration.

Some tests, such as the WIAT-III, provide norms for age-equivalent scores as well as norms based on college students. The latter is preferred when reporting scores for college students. It’s important to report all test and subtest scores. If the test provides index scores and cluster scores, as far as possible, all these scores should be reported. While qualitative categorizations such as "average" and "below average" are helpful, actual score data are needed. It’s particularly important that the evaluator not base the entire diagnosis of the disability on a single subtest or a single discrepancy measure. Objective evidence of the functional limitations should be supported across several tests within the diagnostic battery. Refer to the ETS Guidelines for Documentation of a Learning Disability in Adolescents and Adults and the ETS Guidelines for Documentation of Attention-Deficit/Hyperactivity Disorder in Adolescents and Adults.
 

An early history of a disability can be a key factor in substantiating an ongoing disability. It’s often very important for evaluators to establish that the disability was identified early in the test taker's academic career, and if so, how it manifested itself. Did the test taker have trouble learning to read, write or do mathematical calculations in school? Was there attention or time-management issues, and if so, is there any record beyond the test taker's personal recollection? In some cases, there may be valid reasons why the test taker wasn’t identified previously (e.g., disability testing was not commonplace at that time). This should be addressed in the documentation. If there’s no historical evidence of a presumed disability and no explanation of why this is missing, it raises questions regarding the accommodations being requested.

In some instances, there may be diagnostic reports from previous years that can be cited to support the impact of the disability over time. Whenever possible, evaluators should corroborate the client's self-reports and obtain documentation, such as old report cards, standardized testing reports and relevant medical records. Medical histories shouldn’t be overlooked, as they’re often particularly relevant in cases involving test takers with attention disorders, seizures, traumatic brain injury or co-morbid psychiatric disorders. If a test taker is using any medication to alleviate the symptoms of the disabling condition, you need to include this in a report. The test taker's response to treatment also needs to be included in the report. It would be helpful if a rationale for the requested accommodations includes an explanation of why the test taker continues to need the accommodations if medication/treatment is producing favorable results.
 

A diagnosis should never be based solely on test results but should include a view of the whole person. The evaluator should comment on how the candidate approached learning tasks that required memory, attention, concentration and sustained attention. For some individuals, it may be particularly important to determine if there are "rule-outs" (other possible diagnoses that mimic the stated disability, such as depression or anxiety). By providing a thorough differential diagnosis, the evaluator can establish greater credibility. If the candidate is on medication at the time of testing, the evaluator should state this and discuss how this may affect performance on a high-stakes test.
 

Achievement testing, when viewed in light of the individual's intellectual and processing abilities, should reflect a substantial limitation to learning, not merely a relative weakness. Evaluators need to be sure the core battery they have selected is robust enough to address all the presenting problems that are currently impacting performance.

The report should clearly spell out the candidate's current level of achievement, so the severity and significance of the impact of the disability on test taking can be assessed. For example, information regarding a test taker's reading rate, decoding and comprehension should be discussed by the evaluator in situations in which reading and speed are important considerations.

It’s often helpful if the evaluator can provide information in the report about the effects of extended time on test performance by using both timed and extended-time measures in achievement to show the functional impact. For instance, a low information-processing-speed index score alone isn’t sufficient to justify the presence of an academic impairment. Mathematical functioning across both the computational and problem-solving domains should be addressed. Evaluators also need to keep in mind that one or two discrepant subtest scores in isolation are insufficient evidence to establish the presence of a learning, psychiatric or neurological disability.
 

A clinical summary that recaps the most salient points of the report and synthesizes the key findings is very helpful. This should reiterate evidence that the requested accommodations are grounded in objective diagnostic data, in addition to clinical observations and judgment. If the candidate used additional time during the diagnostic testing, then the evaluator should clearly state how this additional time was utilized (e.g., rereading materials or slow processing) to shed further light on the need for extended testing time. We suggest that evaluators not become overly reliant on a computerized printout of test scores but weigh in a variety of other factors, including the test taker's perspective, to create a more compelling document. Evaluators should reach conclusions that are logical and supported by the data, as well as by their clinical judgment.
 

Recommendations should be tailored to the individual, and each accommodation recommended by the evaluator should be tied to specific test results and clinical observations. You should avoid a "laundry list" of accommodations. If the test taker has received support services in college or on the job, it should be clearly stated whether these were informally granted or approved through the Disability Services Office on campus. If informal accommodations were granted by teachers in high school, then this could be helpful to include. Many evaluators falsely assume that if a test taker has a history of accommodations in school, a previous 504 plan or an IEP, these provide sufficient justification for a currently recommended accommodation. Have such accommodations actually been used in the past? Conversely, if a test taker has no history of accommodations in the past, but accommodations appear to be warranted now, the evaluator must develop a strong rationale for why the accommodations are necessary at this time.

If extended testing time is necessary, the evaluator should provide ETS with specific reasons based on the data as to how much additional time is necessary. It’s often helpful if evaluators can specify exactly how much additional time is needed (i.e., time-and-one-half or double time) based on qualitative and quantitative measures. If a reader, basic four-function calculator or separate room is requested, the documentation needs to specifically support this request. Evaluators should keep in mind that rest breaks are "off the clock" and don’t subtract from actual testing time. For some test takers, especially those with ADHD who may have difficulty sustaining attention for long periods of testing time, additional rest breaks may actually be more beneficial than more testing time.
 

Individuals who are deaf or hard of hearing are required to submit an audiogram or full audiometric report to ETS. It would also be helpful to include a cover letter addressing the current functional impact of the disability, indicating its unchanging nature and the rationale for each requested accommodation.

Information regarding the onset of the hearing loss, and related educational placement and progress, is helpful to include in a cover letter from the qualified professional. Information about the current functional impact of the hearing loss, including its permanent or fluctuating nature and the effectiveness of hearing aids, cochlear implants and/or other assistive devices, is also useful, as is a rationale for each requested accommodation.
 

Individuals who are blind or have low vision should submit Documentation of Blindness and Low Vision in Adolescents and Adults. The professional should refer to specific tests, clinical observations or other objective data. The functional impact of the visual impairment on processing speed, reading and/or test taking, as well as the candidate's current use of accommodations, corrective lenses and/or support services should be identified in this report.