Documenting Hidden Disabilities in Higher Education

Abstract

Once students with disabilities leave high school, they must take proactive steps to document their disabilities to educational institutions or employers when requesting accommodations. The Association on Higher Education and Disability (AHEAD) has been the principal organization offering suggestions on documentation requirements, and AHEAD’s recently revised guidance involves radical changes to the suggested requirements. AHEAD now recommends that students’ self-reports and disability services professionals’ impressions take precedence over external, objective records. This article reviews the relevant research to evaluate the evidence base for the revised guidance, finding it lacking in important ways as it applies to hidden disabilities (learning, cognitive, and psychiatric disabilities). The evidence supporting various sources of disability documentation is reviewed, and implications for policy and practice are discussed.

Keywords

accommodations ADA transition self-advocacy policy

When students with disabilities transition into postsecondary education settings, they enter a legal and regulatory framework that is substantially different from that found in their K-12 schools. K-12 schools are charged with actively seeking out students who might have disabilities, evaluating these students and designing a package of special education and related services tailored to each student’s educational needs, consistent with the provisions of the Individuals With Disabilities Education Act (IDEA, 2004). In contrast, postsecondary educational agencies follow the Americans With Disabilities Act (ADA) of 1990, and their students must self-identify their disability status and request particular accommodations, which may or may not be granted, depending on the accommodations’ reasonableness and the burden that they place on the educational agency.

IDEA and ADA, then, are different in a variety of ways. In general, ADA has more rigorous standards for determining who qualifies for the law’s protections, and its protections are fewer, guaranteeing reasonable accommodations but not special education services. IDEA is designed to increase academic success in students with special needs, whereas ADA is designed to increase access, regardless of whether the student’s ultimate academic outcome is success or failure. In addition, students can receive services under IDEA so long as they have a disability condition that fits into at least 1 of 13 categories and their disability adversely affects their educational experience. In contrast, to be considered “disabled” under ADA, a disability condition must cause substantial limitations in one or more major life activities, compared with most people in the general population.

A more specific, concrete consequence of the transition from IDEA to ADA is that students’ special education documentation from their K-12 schooling may not be sufficient to obtain accommodations in college, where different kinds of documentation may be required (J. H. Lindstrom & Lindstrom, 2011). One step toward addressing this “documentation disconnect” involves standardizing the documentation requirements across different colleges and universities, so that those requirements can then be communicated to transitioning high school students. These requirements can also be provided to adults being diagnosed with a disability for the first time. Without question, the organization that has done the most to help standardize documentation requirements is the Association on Higher Education and Disability (AHEAD). AHEAD’s position papers on documenting disabilities have been extremely influential, in that countless colleges and universities reproduce its documentation recommendations in their own policies for students seeking accommodations (e.g., Ashford University, 2013; Humboldt State University, n.d.). As Gomez (2012) recently noted, following AHEAD’s position papers has also “long been seen as a way to . . . avoid Office for Civil Rights complaints” of disability discrimination (p. 4). Being the only professional organization devoted to postsecondary disability issues, AHEAD has substantial influence and its position papers are understandably taken to reflect the collective wisdom of student support professionals who specialize in services for postsecondary students with disabilities. It is, therefore, important that AHEAD’s positions be scrutinized externally to ensure that they are consistent with relevant research and that they will lead to appropriate, ethical service delivery.

AHEAD’s efforts toward training college administrators to support students with disabilities date back to the 1970s, but initially, there were few concerns over documentation. In the mid-1990s, AHEAD appointed ad hoc committees to develop specific “guidelines” for documenting learning disabilities (LDs) and attention-deficit/hyperactivity disorder (ADHD) in adolescents and adults (AHEAD, 1997, 1998, reprinted in Gordon & Keiser, 2000). These guideline sets are comprehensive and quite specific. For instance, the LD guidelines specify the various information that an LD evaluation report must contain and go so far as to list particular diagnostic tests that are or are not appropriate.

In 2004, AHEAD replaced these guidelines with a more general “framework” of “best practices” for documentation. Although this framework was far less directive, and emphasized the importance of flexibility in accepting different kinds of documentation, it nonetheless included a list of seven “essential elements of quality disability documentation.” These elements described the importance of a properly credentialed evaluator, formal disability diagnoses that are made explicitly, and descriptions of evidence (such as test scores) used to arrive at the diagnoses. Thus, the 2004 framework clearly advocated the use of comprehensive reports from objective, external evaluations by credentialed experts when documenting disabilities.

In April 2012, this framework was overhauled completely, when AHEAD released an entirely new set of documentation “guidance.” Although the guidance is lengthy and was supplemented in September 2012 with a question-and-answer section, we summarize its most salient features in the following four points with key quotations:

The guidance questions the need for documentation at all, noting that “no legislation or regulations require that documentation be requested or obtained in order to . . . seek reasonable accommodations.” This implies that it is reasonable for an educational institution to grant accommodations without any documentation of disability status.

In contrast to the apparent lack of concern with undocumented disabilities (see Point 1), the guidance expresses great concern regarding overly rigorous documentation policies: “requiring extensive medical and scientific evidence perpetuates a deviance model of disability, undervalues the individual’s history and experience with disability and is inappropriate and burdensome.” Indeed, educational institutions are told that they “cannot” use documentation policies that “have the effect of discouraging students from seeking protections and accommodations to which they are entitled.”

A student’s report of his or her own disability constitutes the “primary documentation” format that “may be sufficient for establishing disability and a need for accommodation” all on its own. Next to this, “impressions and conclusions formed by higher education disability professionals” when interacting with students and considering their benefit from past accommodations constitute the “secondary documentation” format.

In contrast to students’ self-reports and disability services office (DSO) staff members’ impressions, objective external documentation (such as diagnostic evaluation reports containing test score data) constitutes “tertiary documentation” that a DSO “may need to request” in the case that “the student is unable to clearly describe how the disability is connected to a barrier and how the accommodation would provide access.”

Obviously, these changes represent a radical shift in thinking; and if higher education institutions base their policies on the new guidance, it will be a radical shift in practice as well. Of course, it could be argued that this shift represents progress. Certainly, it appears to reduce logistical barriers for those students applying for accommodations. Moreover, it also might reduce the workload of DSO staff if more students can be given accommodations without needing documentation reviewed. In the preface to the guidance, AHEAD (2012) claims an additional benefit: that the changes are “necessitated by changes in society’s understanding of disability, the 2008 amendments to the Americans with Disabilities Act, and the updated regulations and guidance to Titles II and III of the ADA.”

Even if these purported benefits are, in fact, present, they should be balanced against limitations of the new guidance. For instance, with relaxed standards for eligibility, the new guidance may increase the workload of DSOs significantly because more students may be determined eligible for academic accommodations and be in need of DSO personnel to aid in the provision of these services. In addition, as Adele (2013) worried, if standards are relaxed too much, college and university faculty may lose trust in the judgments of DSO personnel, with the office losing credibility on campus. Finally, recent empirical research studies, especially those on the identification and accommodation of high-incidence disability conditions, question several elements of the new guidance. These studies are the focus of the present article.

Before we proceed, one disclaimer is in order: We primarily discuss research relevant to learning, cognitive, and psychiatric disabilities (the “hidden disabilities”), which comprise the majority of disability conditions seen in higher education settings (Raue, Lewis, & Coopersmith, 2011). The empirical research on these disabilities presents a strong challenge to the revised AHEAD guidance. In contrast, physical and sensory disabilities present very different issues in which the differentiation between disabled and nondisabled groups is clearer, functional deficits are more obvious, and a need for accommodations is clearer. Indeed, interpreted with regard to physical and sensory disabilities, the AHEAD guidance has much common sense to offer. However, hidden disabilities are the more common ones, and as the empirical literature shows, documenting these disabilities requires a more thorough process than the guidance recommends.

The Accuracy of Self-Reports

The AHEAD guidance strongly implies that self-reported disability-related information is accurate. Such information is considered “primary documentation,” and may be all that is needed, according to the guidance, to justify providing accommodations. The guidance never acknowledges the possibility that self-reported information may be inaccurate, but a considerable body of research suggests that it often is inaccurate. Before even examining this research, though, consider precisely what a student requesting accommodations is expected to report. First, ADA requires that there be a discrete disability condition present. Students will often misunderstand or misremember the details of their diagnostic history. For instance, an elementary schoolteacher’s informal reference to “reading difficulties” may be recalled as a formal identification of a “reading disability,” or a child’s positive response to an informal trial of stimulant medication may be misunderstood as showing a formal diagnosis of ADHD. It is often difficult to recall which professionals made the diagnoses (if any), when such diagnoses were made and confirmed, and what evidence was used to establish the diagnoses.

Even if a student accurately recalls a particular diagnosis being made, this is not enough. As was noted above, the ADA also requires (and proper accommodations planning demands) that the student have substantial limitations in one or more major life activities—limitations that place their abilities and skills below average for the general population. For instance, a student with a formal diagnosis of a LD in reading who is requesting audiotaped versions of his or her textbooks must also be substantially limited in his or her ability to read, relative to most people. Importantly, formal diagnoses are not equivalent to deficits, especially in postsecondary student populations, who tend to be at the high-functioning end of many disability groups. For instance, college students with LDs typically have academic skills in the average range (Sparks & Lovett, 2009), but their skills are lower than those of nondisabled college students, and so they may report deficits due to upward peer comparisons.

This distinction between a diagnosis and relevant deficits is problematic, because often, students would not know where their abilities fall, relative to general population norms. Most of the recent research on this topic has focused on self-ratings of intelligence, which are quite inaccurate (correlations with tested IQ range from .20 to .35; for reviews, see DeYoung, 2011; Furnham, 2000). Earlier research showed that people’s estimates of specific skills (such as scholastic, clerical, and mechanical skills) are no more accurate; a meta-analysis of the extant literature by Mabe and West (1982) found an average accuracy (correlation with objective measures) of .29. It appears to be a substantial burden to ask students to make accurate judgments of their own abilities.

Even when describing psychiatric symptoms, self-reports often show only modest relationships with reports from informants, whether the informants are family members or trained clinicians. Achenbach, Krukowski, Dumenci, and Ivanova (2005) reviewed results from more than 100 studies on adult psychopathology in which “cross-informant agreement” could be calculated. These scholars found that, with the exception of substance abuse, the average correlation between self-reports and informant reports of psychiatric symptoms was .45, which certainly represents a relationship but one modest enough to allow for frequent sizable discrepancies between people’s views of themselves and others’ views of them, even when the “other” is an expert professional.

At times these discrepancies occur when students believe that they are reporting pathological symptoms or problematic deficits, but their reports are instead of normal experiences. This happens especially with ADHD symptoms, which students often report. Lewandowski, Lovett, Codding, and Gordon (2008) asked college students with and without ADHD diagnoses to report whether they experienced each of the 18 symptoms of ADHD; more than half of the students without diagnoses reported being easily distracted and fidgeting/squirming. Lewandowski et al. also surveyed students about academic concerns—concerns that are often cited by students seeking accommodations for learning, cognitive, and psychiatric disabilities. More than half of students without ADHD diagnoses reported having to “read material over and over again to understand it,” and almost half (47.5%) reported needing to “work harder than other people to get good grades” (Lewandowski et al., 2008, p. 159). Therefore, if students’ self-reports are to be taken as “primary documentation,” DSO staff must somehow determine whether reports of deficits genuinely signal accommodation needs or whether they are instead perfectly normal, common everyday concerns.

Even when students report high levels of impairment relative to other students, these reports may actually signal emotional distress, rather than genuine functional impairment. A recent study by Miller and colleagues (2013) examined correlates of self-reports of impairment in more than 2,000 individuals who had completed neuropsychological assessments for various reasons (e.g., mental health evaluations; traumatic brain injury evaluations, etc.). In addition to the neuropsychological assessment battery, all individuals completed the Patient Competency Rating Scale (PCRS; a 30-item scale measuring self-reported impairment in various life activities) and the Symptom Checklist 90–Revised (the SCL-90-R, a 90-item scale measuring psychological distress). Participants’ self-reported impairment was far more strongly related to SCL-90-R scores (r = −.62) than to objective neuropsychological test performance (r = .18). As Miller et al. concluded, self-reports of impairment “are more strongly related to one’s current emotional status . . . than actual impairment” (p. 184), and contra AHEAD, “self-report . . . clearly should not be used as the sole means of identifying impairment” (p. 185).

That distress is a source of self-reports of impairment has important implications for disability services provision. Students often seek accommodations after they are doing poorly in classes or experiencing other kinds of trouble, and so their distress can lead to inaccurate reports of deficits. It is easy to understand how students experiencing anxiety, stress, or sad mood would report having more deficits; as cognitive theory predicts (e.g., Beck, 1976), these emotional states lead people to view their experiences through a negative lens in which they have a negative bias toward perceiving, remembering, and interpreting their own skills and abilities (for a review of relevant research, see Mathews & MacLeod, 2005).

In addition to distress, another mechanism of exaggerated self-reports comes in the form of labeling effects. When students already have a formally diagnosed disorder, it is natural for them to think of themselves as having deficits that fit logically with the disorder. There are many pathways from a diagnosis to changes in how one expects oneself to think, feel, and behave; as Suhr and Wei (2013) noted, “when one is given diagnosis X and then reads about diagnosis X, hears about it on television, attends support groups for diagnosis X, and meets others with diagnosis X, etc., this can create response expectancy templates” (p. 189). Essentially, patients with a diagnosed disorder come to experience things that they now expect to experience, due to the formal diagnosis. Consistent with this hypothesis, reminding people of their diagnoses can affect their self-reports of symptoms/deficits (e.g., Ozen & Fernandes, 2011), and even telling people (inaccurately) that their scores on a clinical self-report measure are abnormal can lead them to give genuinely abnormal self-reports the next time that they complete the measure (Privitera, Agnello, Walters, & Bender, in press).

We should note that labeling effects may continue well after actual deficits are present. When students are diagnosed, as children, with problems such as a LD or ADHD, interventions and other environmental factors, as well as neurodevelopmental maturation, may lead deficits to attenuate, but the label—and the identity—remains. AHEAD’s guidance reinforces this effect when it claims that “disabilities are typically stable lifelong conditions.” This is an oversimplified claim regarding a complex issue. Although some disability conditions (e.g., blindness) are virtually always lifelong conditions, many of the most common disability conditions seen in higher education—learning, cognitive, and psychiatric disabilities—are not; at the very least, their presentation changes over time. For instance, between 30% and 50% of children with ADHD will no longer show impairing symptoms as adults (Antshel & Barkley, 2011). Whether the ADHD is actually still present is a metaphysical question (cf. Lovett & Hood, 2011), but clearly these individuals’ disability status (in terms of deficits causing substantial limitations in major life activities) has changed. As college students, however, these individuals may continue to perceive themselves as having deficits (as the ADHD label is rarely formally removed), leading to reports of deficits.

The Special Problem of Malingering

Uncritical trust of self-reported disabilities is also questionable because of the possibility of malingering. The term malingering refers to exaggeration or fabrication of physical or psychological symptoms when motivated by external incentive (American Psychiatric Association [APA], 2013). In contexts in which there is clear external benefit (e.g., medication access; educational accommodations) derived from obtaining a disability diagnosis, substantial prevalence rates of malingering have been found. The prevalence of malingering nearly quadruples in medical cases that potentially lead to financial compensation for the disability claimant (Mittenberg, Patton, Canyock, & Condit, 2002). In the medical/legal environment, malingering has been estimated to occur in up to 33% of disability claims (Samuel & Mittenberg, 2005).

Although malingering has been recognized most readily in the medical/legal context, increased attention has been given to its possibility in the determination of postsecondary disabilities. Many researchers have highlighted the external benefits (e.g., academic accommodations such as extended time on tests and note taking services) associated with postsecondary disabilities, benefits that may lead some students to feign disabilities as a way to gain a competitive edge over their classmates, or just to survive academically when the students are struggling (for representative studies, see, for example, Frazier, Frazier, Busch, Kerwood, & Demaree, 2008; Harrison, Rosenblum, & Currie, 2010; Sollman, Ranseen, & Berry, 2010; Suhr, Hammers, Dobbins-Buckland, Zimak, & Hughes, 2008; Sullivan, May, & Galbally, 2007). Within the current context of the underemployment or unemployment of approximately 50% of recent college graduates (Vedder, Denhart, & Robe, 2013), seeking a competitive edge to outperform peers and thus making oneself more attractive to future employers are likely on the minds of many college students.

Many college students are willing to engage in improper behaviors to meet the academic demands of college and to remain competitive with their classmates. Nearly 60% of students admit to cheating on quizzes, exams, or assignments at some point in their college career (Vandehey, Diekhoff, & LaBeff, 2007). This high rate of cheating has led some to speculate that otherwise honest students may feel compelled to cheat to remain competitive in an environment in which cheating is normal (Hughes & McCabe, 2006). A growing number of college students are also willing to illicitly take stimulant medications (McCabe, Knight, Teter, & Wechsler, 2005; Teter, McCabe, Boyd, & Guthrie, 2003). A primary motive for their illicit use is to improve concentration and increase alertness, presumably to enhance academic performance (Teter, McCabe, Cranford, Boyd, & Guthrie, 2005). These findings have led to speculation that college students may engage in other improper behaviors, such as feigning disabilities, as a way to gain a competitive edge (Harrison, 2006).

Among the disabilities served in postsecondary settings, the hidden disabilities are likely the easiest to feign, particularly if self-report is the primary means for determining disability. The symptoms for these disabilities are subjective, well known to the general public, and easily accessible via the Internet. Furthermore, little effort and only a superficial knowledge of symptoms are needed to feign some hidden disabilities on self-report measures. Fisher and Watkins (2008) found that up to 93% of college students endorsed the necessary symptomatology for ADHD after being directed to study the diagnostic criteria for 5 min and after a warning to not endorse all of the symptoms to avoid being detected for malingering. Similar results have been found in other studies investigating the ease of feigning ADHD on self-report measures (e.g., Harrison, Edwards, & Parker, 2007; Marshall et al., 2010). In addition, similar rates of successful faking on self-report measures have been found for other hidden disabilities such as major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder (Lees-Haley & Dunn, 1994).

Not only are hidden disabilities easy to fake on self-reports; several studies have indicated that the prevalence of actual malingering of hidden disabilities in postsecondary settings may be substantial. Researchers have estimated prevalence rates by calculating the percentage of students failing various tests designed to measure test-taking effort; these tests are very easy (so easy that even individuals with significant brain damage can obtain passing scores), so if a student fails even a part of the test, this suggests that the student may not be accurately portraying his or her symptoms. Of course, it does not require active, intentional deception to fail one of these effort tests; the person taking the test may simply put forth very little effort. In any case, empirical research has indicated that clinicians who assess college students for hidden disabilities must frequently deal with inaccurate portrayal of symptoms. Sullivan et al. (2007) found that 47.6%, 24.5%, and 15.4% of college students evaluated for ADHD only, ADHD/LD, and LD only, respectively, failed at least one part of an effort test. Similarly, Suhr et al. (2008) found a 31% failure rate on at least one part on an effort test with a sample of college students seeking evaluations for ADHD. Using more restrictive criteria of at least two effort test failures, Marshall et al. (2010) found 17% of college students evaluated for ADHD may have been malingering. Consistent with this finding, Harrison and Edwards (2010) found that 14.7% and 18.2% of college students seeking evaluations for LD and ADHD, respectively, failed an effort test. Collectively, these findings indicate that concerns regarding the possibility of malingering in those seeking evaluations for postsecondary accommodations for hidden disabilities are not trivial.

Several recommendations have been made in the empirical literature to protect against the possibility of malingering. First, reliance on self-report as a primary source of information is discouraged and, instead, it has been recommended that self-report should be regarded as only one source of information within a comprehensive multi-informant, multi-method approach (Fisher & Watkins, 2008; Marshall et al., 2010; Sollman et al., 2010; Quinn, 2003). Second, the inclusion of effort tests in assessments of those seeking academic accommodations has been highly recommended (Booksh, Pella, Singh, & Gouvier, 2010; Frazier et al., 2008; Marshall et al., 2010; Sollman et al., 2010). These tests have become standard practice in other settings in which a clear external incentive is present (Bush et al., 2005). Several effort tests have been shown to be effective in detecting malingered ADHD (Frazier et al., 2008; Marshall et al., 2010; Sollman et al., 2010) and LD (Frazier et al., 2008; Harrison, Edwards, Armstrong, & Parker, 2010; W. A. Lindstrom, Lindstrom, Coleman, Nelson, & Gregg, 2009), in that students who are asked to feign these disorders will often fail the tests, whereas students with genuine disorders (and nondisabled students putting forth full effort) will pass the tests. Thus, the tests are far more effective than clinical judgment (Booksh et al., 2010). Finally, postsecondary institutions have been encouraged to develop thorough documentation requirements for establishing disabilities, to protect against diagnoses made using procedures that are highly susceptible to malingering (Fisher & Watkins, 2008). These recommendations are striking when compared with AHEAD’s guidance to consider self-report as a primary form of documentation and to require limited, if any, external documentation to verify disabilities.

“Secondary Documentation”: Observations and Interviews

After self-reports, the AHEAD guidance suggests that disability services staff rely on “impressions” formed when interacting with students applying for accommodations. Interviews, conversations, and observations are mentioned as specific sources of interactions. However, do these information-gathering techniques lead to valid, appropriate accommodations in the case of the most common disabilities—learning, cognitive, and psychiatric disabilities? Consider a student who reports having dyslexia and requests that his tests be read to him, or a student who reports severe social anxiety and requests that she receive a single room without having to pay an additional cost. Are the students’ self-reports and the disability services staff’s impressions sufficient, by themselves, to determine whether the students are eligible for the requested accommodations?

Research suggests that subjective judgments by disability services professionals (DSP) are likely to be less accurate than objective information, such as external documentation. One body of relevant research has looked at the “clinical judgment” of other professionals, such as clinical psychologists, finding that these professionals’ intuitive judgments are often quite inaccurate, failing to even agree with the judgments of other (peer) professionals. In his review of this research, Garb (2005) considered clinicians’ judgments of personality traits, clinical diagnoses, and case formulations (i.e., identifying the causes of symptoms). Studies of these phenomena often showed low levels of agreement between professionals as well as a failure to consult relevant information when making decisions.

Clinical professionals’ accuracy increases substantially when they use semi-structured interviews and other standardized techniques (e.g., IQ tests) for decision making (as most do). In general, “actuarial” procedures that rely on standardized assessment tools and formulas to interpret results not only lead to more agreement between professionals but also increase the accuracy of predictions of behavior (for a meta-analysis on this point, see Grove, Zald, Lebow, Snitz, & Nelson, 2000). Therefore, if DSPs were to use validated standardized procedures (e.g., questionnaires that have been shown to be reliable and accurate) to make decisions, it is quite possible that this would be useful in determining specific accommodation needs, once disability status has been established. However, this procedure is quite different from relying on the subjective, intuitive “impressions” that the AHEAD guidance seems to endorse, supplemented only by self-report, as sufficient documentation of both eligibility and needs.

Another area of relevant research has explored why clinicians’ intuitive judgments are often inaccurate. Briefly, research shows that clinical professionals exhibit the same biases and errors in judgment that laypeople show (Ruscio, 2006). Space precludes a comprehensive treatment of these issues, but one bias is particularly relevant here: the confirmation bias. This is the tendency to seek information that confirms initial impressions and to interpret ambiguous information as confirming initial impressions. DSPs will only be meeting to observe and interact with students who are applying for accommodations, often mentioning a diagnosis or disability at the outset. Therefore, it is easy to inadvertently seek information (through leading questions and selective attention) that is consistent with the self-reported diagnosis/disability while paying less attention to other information. Similarly, it is easy to interpret any ambiguous information (e.g., self-reports of problems that are actually quite common in the general population) as diagnostic of a disability condition. Finally, it is easy to interpret a requested accommodation as being logically related to the student’s report of a disability condition, even when the connection is tenuous or unclear. Admittedly, there may be DSPs who show a bias against providing services, and this bias can easily manifest itself in the opposite direction in which skeptical questions are phrased and observations are made in such a way that very few students will appear to qualify for accommodations. This is, of course, equally unsatisfactory.

A final area of relevant research has examined the reliability of behavioral observations. In theory, there are some hidden disabilities where disability services staff’s observations would be relevant, such as noting distraction and poor concentration in someone reporting an ADHD diagnosis. However, research suggests that single, fairly brief observations in a single setting do not generalize well to other times and settings (e.g., Hintze & Matthews, 2004). There is a logical reason to expect this; as Rowley (1978) demonstrated, in the same way that longer tests will cover larger sampling of relevant material, longer observation periods, preferably broken up over different days, are necessary to capture a larger sample of relevant behavior. Therefore, if a disability services staff member were to meet many times with a student in each of several natural environments, each time using a standardized technique to assess behavior, and then combining the data across observational sessions, it is possible that the observations would be relevant, but this is unlikely to happen in most higher education settings.

Again, none of these areas of research provides dispositive proof against the value of disability services staff’s impressions with regard to students with learning/cognitive/psychiatric disabilities. Indeed, no studies have actually evaluated this specifically. However, we can infer fairly confidently that DSPs, like other professionals working in human services settings, often make poor judgments when unconstrained by standardized decision procedures, falling prey to cognitive biases and relying on unreliable observations made over brief periods in single settings. At the very least, this places the burden of proof on proponents of subjective impressions and observations to demonstrate their accuracy in the cases of accommodations for students reporting hidden disabilities.

“Tertiary Documentation”: Information From External or Third Parties

As previously noted, information from external sources (e.g., health care providers, psychologists) is relegated to “tertiary” status in the AHEAD guidance. This is surprising because comprehensive reports from credentialed experts have historically served as the foundation for documenting hidden disabilities and were prominent in AHEAD’s own “best practices” guidance until 2012. The current AHEAD (2012) guidance emphasizes the intent to minimize the role of external documentation by stating that self-reports “may be sufficient for establishing a disability” and “no third party information may be necessary to confirm a disability or evaluate requests for accommodations when the condition and its impact are . . . comprehensively described.” Furthermore, self-report and observations are described as “important” data collection methods, while external documentation is described as varying in “relevance and value.” Finally, the acknowledgment that institutions may request reasonable documentation is followed by a warning that requiring too much of students (i.e., “extensive evidence”) is disrespectful (“devalues” a student’s experience and history), pejorative (i.e., propagates a “deviance” model of disability), and potentially illegal (i.e., “inappropriate and burdensome”). As a result, it would be reasonable to assume that many DSPs reading the AHEAD guidance would want to err on the side of caution, accepting virtually any form of documentation to avoid accusations of discrimination.

The denigration of external documentation is perhaps most surprising because it does not appear consistent with the regulations enforcing the ADA Amendments Act of 2008 (ADAAA). The only limitation placed by the ADAAA on external documentation is that it must be “reasonable and limited to the need for the modification, accommodation, or auxiliary aid or service requested” (U.S. Department of Justice [DOJ], 2010, p. 49). Whereas “reasonable” is an ambiguous term, clarifying examples are provided in the Title III guidance (DOJ, 2010). For example, institutions should not request information that is “impossible or extremely onerous to provide” (p. 151), and requests should not be so difficult that students abandon their attempt to seek services (DOJ, 2010). Based on extant literature (e.g., Madaus, Banerjee, & Hamblet, 2010), it appears unlikely that many institutions are currently requiring such evidence.

Not mentioned in the AHEAD guidance is that ADAAA regulations actually place great emphasis on independent evaluations conducted by qualified professionals when documenting the presence of a disability. According to Title I, the determination of whether an impairment substantially limits a major life activity requires an “individualized assessment” (Equal Employment Opportunity Commission, 2011, p. 110). According to an elaboration in the Title III guidance, the DOJ’s (2010) intention for using the term “individualized assessment” was to confirm that the documentation was provided by a qualified professional who had “individually and personally” conducted an evaluation for “diagnosis and treatment” (p. 153). Qualified professionals are defined as those “licensed or otherwise properly credentialed and possess expertise in the disability for which modifications or accommodations are sought” (DOJ, 2010, p. 152). Examples are listed, but DSPs are not included, likely because they are not recognized as a profession with the educational and training standards necessary for diagnosis and disability determination.

The shift of the AHEAD guidance away from external documentation marks a disregard for the role of the expert in the detection of hidden disabilities. The guidance fails to acknowledge the training necessary for the identification of hidden disabilities, the complicated nature of such determinations, and the vast empirical literature informing sound decision making. In contrast, the guidance encourages the use of significantly limited assessment approaches (e.g., self-report, observations) by professionals who vary in their level of assessment training (Madaus et al., 2010) while also discouraging requests for documentation from experts. Admittedly, external documentation is far from perfect; many external evaluators fail to understand the legal standards of disability (e.g., Gordon, Lewandowski, Murphy, & Dempsey, 2002), and hidden disabilities are often diagnosed using procedures other than research-based best practices (e.g., Handler & DuPaul, 2005). However, these issues should lead DSPs to review external documentation carefully and critically, not to reject it entirely.

Implications for Policy and Practice

As we have shown, at least in the case of hidden disabilities, there are good reasons to doubt the accuracy of self-reports and observations. Although external documentation is far from perfect, it remains superior in many ways to self-reports and can often verify or falsify self-reported information by providing more objective data. It is odd, then, that AHEAD’s guidance relegates external, objective information to the status of “tertiary documentation” and implies that it is only useful when it coincides with self-reported “primary documentation.”

Therefore, one general implication is that DSPs in higher education or related settings (e.g., testing agencies) should not use the new AHEAD guidance when considering hidden disabilities. The guidance certainly has no legal force (AHEAD has no authority to set policies for educational institutions or other agencies that consider disability applications), and the guidance mentions explicitly that it “should not be considered legal advice.” Besides, as we have shown above, at some points, the guidance actually points in a direction opposite from that of recent legal regulations. Even so, because AHEAD has historically been so influential in affecting practice, we hope that the organization will consider revising its guidance in light of the research reviewed here.

This implication holds for hidden disabilities but not for sensory and physical disabilities. There, the AHEAD guidance makes far more sense. Most of the accommodations requested for sensory and physical disabilities are of little or no help to nondisabled individuals, taking away an incentive to malinger, and in any case, it would be substantially more difficult to malinger such conditions. Moreover, observations and interviews with the student are often the most valuable sources when planning accommodations for such students. For instance, consider a student who uses a wheelchair and is requesting that a special kind of desk be placed in each of the classrooms where he or she has classes. Interviews, conversations, and observations are generally the most efficient ways to determine how far off the ground the desk must be, and so interacting with the student is likely to be the most helpful source of information. However, as we have noted, it is hidden disabilities that account for the majority of disability conditions reported to DSOs in higher education, and so the AHEAD guidance should be designed to apply to such conditions.

If the new AHEAD guidance is inappropriate for hidden disabilities, what should higher education institutions use as a basis for designing documentation guidelines? A complete description of research-based guidelines is beyond the scope of the present article, but we recommend emphasizing a core principle: objective evidence of functional impairment. To be eligible for accommodations, postsecondary students must demonstrate substantial limitations in a major life activity and should show that their limitations keep them from accessing academic, residential, or other programs that their college or university provides. The evidence for this should come from objective sources, which, in the case of hidden disabilities, usually means impaired performance on standardized, norm-referenced diagnostic tests, unusually high levels of symptoms reported on standardized questionnaires completed by people other than the student, and formally recorded real-world consequences (as seen in report cards, job performance evaluations, and legal documents, among others). This type of objective evidence is often obtained, or at least reviewed, by diagnostic professionals, making formal diagnostic evaluation reports (external documentation) a very valuable source of evidence.

As a second implication, we would recommend that individual colleges consider the potential limitations to following the AHEAD guidance—limitations other than inaccurate decisions. As we noted earlier, one potential limitation is that a DSO may lose “respect and credibility if it has no standard documentation requirements and decisions about diagnosis are being made by staff members with no training in that area” (Adele, 2013, p. 7). In addition, although time spent reviewing external documentation may be saved, additional time may be needed to review, approve, and deliver requested accommodations to an increased number of students, who have learned that a mere self-report of a disability is sufficient evidence.

Yet another limitation to consider is the long-term effects of inappropriate identification of disabilities. The AHEAD guidance seems designed to eliminate all false negatives—denials of accommodations to students with genuine disabilities. This is an admirable goal, but it comes at the expense of raising the chance of false positives—provision of accommodations to students who do not need them and are not legally entitled to them. Under recent amendments to the ADA, prior provision of accommodations is to be given “substantial weight” in future decisions, and so colleges and universities who make false positive errors may be ensuring that those errors are set in stone, so to speak (see Lovett, in press), in future academic, testing, and employment situations. Due to this and other limitations, DSOs should conduct their own internal evaluations of their procedures to determine both the benefits and the costs of following the new guidance.

Because external documentation is crucial but fallible, a third implication is as follows: There is still very much a need for the careful judgments made by DSPs. Such professionals should not only request external documentation of hidden disabilities but also review the submitted documentation carefully, looking for evidence of ADA-level disability status: substantial limitations in one or more major life activities rather than just clinical diagnoses, which may or may not indicate a disability in a legal sense. As we have discussed, many clinicians are unfamiliar with the particulars of ADA regulations, and so external documentation from these clinicians is necessary but not sufficient to document most hidden disabilities.

In conclusion, empirical research suggests that, the AHEAD guidance notwithstanding, reviewing accommodation requests in higher education is a complex process usually requiring thoughtful consideration of external documentation, at least in the case of hidden disabilities. Neither self-reports nor casual observations are sufficient to determine which students are actually impaired by learning, cognitive, and psychiatric disabilities and therefore entitled to accommodations under disability laws. We hope that AHEAD will come to agree, and until then, we hope that colleges will continue to carefully review accommodation requests using all available data.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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