The ADHD Evaluation Process (page 4)
Two important federal mandates protect the rights of eligible children with ADHD-the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). The regulations implementing these laws are 34 CFR sections 300 and 104, respectively, which require school districts to provide a "free appropriate public education" to students who meet their eligibility criteria. Although a child with ADHD may not be eligible for services under IDEA, he or she may meet the requirements of Section 504.
The requirements and qualifications for IDEA are more stringent than those of Section 504. IDEA provides funds to state education agencies for the purpose of providing special education and related services to children evaluated in accordance with IDEA and found to have at least one of the 13 specific categories of disabilities, and who thus need special education and related services. Attention Deficit Hyperactivity Disorder may be considered under the specific category of "Other Health Impairment" (OHI), if the disability results in limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment and that is due to chronic or acute health problems.
Under IDEA, each public agency-that is, each school district-shall ensure that a full and individual evaluation is conducted for each child being considered for special education and related services. The child's individualized education program (IEP) team uses the results of the evaluation to determine the educational needs of the child. The results of a medical doctor's, psychologist's, or other qualified professional's assessment indicating a diagnosis of ADHD may be an important evaluation result, but the diagnosis does not automatically mean that a child is eligible for special education and related services. A group of qualified professionals and the parent of the child determine whether the child is an eligible child with a disability according to IDEA. Children with ADHD also may be eligible for services under the "Specific Learning Disability," "Emotional Disturbance," or other relevant disability categories of IDEA if they have those disabilities in addition to ADHD.
After it has been determined that a child is eligible for special education and related services under IDEA, an IEP is developed that includes a statement of measurable annual goals, including benchmarks or short-term objectives that reflect the student's needs. The IEP goals are determined with input from the parents and cannot be changed without the parents' knowledge. Although children who are eligible under IDEA must have an IEP, students eligible under Section 504 are not required to have an IEP but must be provided regular or special education and related aids or services that are designed to meet their individual educational needs as adequately as the needs of nondisabled students are met.
Section 504 was established to ensure a free appropriate education for all children who have an impairment-physical or mental-that substantially limits one or more major life activities. If it can be demonstrated that a child's ADHD adversely affects his or her learning-a major life activity in the life of a child-the student may qualify for services under Section 504. To be considered eligible for Section 504, a student must be evaluated to ensure that the disability requires special education or related services or supplementary aids and services. Therefore, a child whose ADHD does not interfere with his or her learning process may not be eligible for special education and related services under IDEA or supplementary aids and services under Section 504.
IDEA and Section 504 require schools to provide special education or to make modifications or adaptations for students whose ADHD adversely affects their educational performance. Such adaptations may include curriculum adjustments, alternative classroom organization and management, specialized teaching techniques and study skills, use of behavior management, and increased parent/ teacher collaboration. Eligible children with ADHD must be placed in regular education classrooms, to the maximum extent appropriate to their educational needs, with the use of supplementary aids and services if necessary. Of course, the needs of some children with ADHD cannot be met solely within the confines of a regular education classroom, and they may need special education or related aids or services provided in other settings.
|Components of a Comprehensive Evaluation|
A diagnosis of ADHD is multifaceted and includes behavioral, medical, and educational data gathering. One component of the diagnosis includes an examination of the child's history through comprehensive interviews with parents, teachers, and health care professionals. Interviewing these individuals determines the child's specific behavior characteristics, when the behavior began, duration of symptoms, whether the child displays the behavior in various settings, and coexisting conditions. The American Academy of Pediatrics (AAP) stresses that since a variety of psychological and developmental disorders frequently coexist in children who are being evaluated for ADHD, a thorough examination for any such coexisting condition should be an integral part of any evaluation (AAP, 2000).
Specific questionnaires and rating scales are used to review and quantify the behavioral characteristics of ADHD. The AAP has developed clinical practice guidelines for the diagnosis and evaluation of children with ADHD, and finds that such behavioral rating scales accurately distinguish between children with and without ADHD (AAP, 2000). Conversely, AAP recommends not using broadband rating scales or teacher global questionnaires in the diagnosis of children with ADHD. They suggest using ADHD-Specific rating scales including:
CPRS-R:L-ADHD Index(Conners Parent Rating Scale-1997
Revised Version: Long Form, ADHD Index Scale)
CTRS-R:L-ADHD Index(Conners Teacher Rating Scale-1997
Revised Version: Long Form, ADHD Index Scale)
CPRS-R:L-DSM-IV Symptoms(Conners Parent Rating Scale-1997
Revised Version: Long Form, DSM-IV Symptoms Scale)
CTRS-R:L-DSM-IV Symptoms(Conners Teacher Rating Scale-1997
Revised Version: Long Form, DSM-IV Symptoms Scale)
SSQ-O-1(Barkley's School Situations Questionnaire-Original Version, Number of Problem Settings Scale)
SSQ-O-II(Barkley's School Situations Questionnaire-Original Version, Mean Severity Scale)
(Taken from Green, Wong, Atkins, et al. (1999). Diagnosis of Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, as cited in AAP, 2000).
As with all psychological tests, child-rating scales have a range of measurement error. Appropriate scales have satisfactory norms for the child's chronological age and ability levels.
Collecting information about the child's ADHD symptoms from several different sources helps ensure that the information is accurate. Appropriate sources of information include the child's parents, teachers, other diagnosticians such as psychologists, occupational therapists, speech therapists, social workers, and physicians. It is also important to review both the child's previous medical history as well as his or her school records.
An educational evaluation assesses the extent to which a child's symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity.
|Behaviors targeted for classroom observation may include:|
Classroom observations are used to record how often the child exhibits various ADHD symptoms in the classroom. The frequency with which the child with ADHD exhibits these and other target behaviors are compared to norms for other children of the same age and gender. It is also important to compare the behavior of the child with ADHD to the behaviors of other children in his or her classroom.
It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes.
In order to receive special education and related services under Part B of IDEA, a child must be evaluated to determine (1) whether he or she has a disability and (2) whether he or she, because of the disability, needs special education and related services. The initial evaluation must be a full and individual evaluation that assesses the child in all areas related to the suspected disability and uses a variety of assessment tools and strategies. As discussed in the section on Legal Requirements (above), a child who has ADHD may be eligible for special education and related services because he or she also meets the criteria for at least one of the disability categories, such as specific learning disability or emotional disturbance. It is important to note that the assessment instruments and procedures used by educational personnel to evaluate other disabilities-such as learning disabilities-may not be appropriate for the evaluation of ADHD. A variety of assessment tools and strategies must be used to gather relevant functional and developmental information about the child.
An educational evaluation also includes an assessment of the child's productivity in completing classwork and other academic assignments. It is important to collect information about both the percentage of work completed as well as the accuracy of the work. The productivity of the child with ADHD can be compared to the productivity of other children in the class.
Once the observations and testing are complete, a group of qualified professionals and the parents of the child will review the results and determine if the child has a disability and whether the child needs special education and related services. Using this information, the child's IEP team, which includes the child's parents, will develop an individualized educational program that directly addresses the child's learning and behavior. If the child is recommended for evaluation and determined by the child's IEP team not to meet the eligibility requirements under IDEA, the child may be appropriate for evaluation under Section 504.
|A medical evaluation assesses whether the child is manifesting symptoms of ADHD, based on the following three objectives:|
Part B of IDEA does not necessarily require a school district to conduct a medical evaluation for the purpose of determining whether a child has ADHD. If a public agency believes that a medical evaluation by a licensed physician is needed as part of the evaluation to determine whether a child suspected of having ADHD meets the eligibility criteria of the OHI category, or any other disability category under Part B, the school district must ensure that this evaluation is conducted at no cost to the parents (OSEP Letter to Michel Williams, March 14, 1994, 21 IDELR 73).
In May 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with ADHD. The guideline, developed by a committee comprised of pediatricians and experts in the fields of neurology, psychology, child psychiatry, child development, and education, as well as experts in epidemiology and pediatrics, is intended for use by primary care clinicians who are involved in the identification and evaluation process. The recommendations are designed to provide a framework for diagnostic decisionmaking and include the following:
Medical evaluation for ADHD should be initiated by the primary care clinician. Questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physicians to possible ADHD.
In diagnosing ADHD, physicians should use DSM-IV criteria.
The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher or other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.
Evaluation of a child with ADHD should also include assessment of co-existing conditions such as learning and language problems, aggression, disruptive behavior, depression, or anxiety.
Reprinted with the permission of the U.S. Department of Education.
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