Introduction

Young adults tend to present with their first symptoms of mental illnesses between ages 18–25 [1, 2]. In recent years, the shifting demographics of students matriculating into post-secondary educational settings have resulted in an increasing number of students with serious mental illness beginning college [3]. In addition to biological factors driving age of onset for mental illnesses, there is a range of psychological factors and social stressors—i.e., increased academic pressure, separation from family, and demands of those balancing school, jobs, and familial demands that can present significant challenges for individuals as they matriculate into college [2].

This paper focuses on disability in the post-secondary environment, which is defined by legal mandates from the Americans with Disabilities Act (1990 and amended in 2008).

While disability in the post-secondary setting is related to mental health disability in primary and secondary education, accommodations in these two settings are allowable through two different mandates (K-12 education accommodations via the Individuals with Disabilities Education Act, IDEA). As such, accommodations made available in K-12 settings may be different from those available/mandated in the post-secondary educational environment (see Table 1, Key terminology).

Table 1 Key terminology
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Not all post-secondary students with mental illness have a disability as a result. However, many college students’ reported symptoms are concerning for impairment and disability. In recent surveys, two in five college students report trouble functioning due to low mood and nearly half (46.8%) report difficulty managing academics as a result of their mental health symptoms. Counseling center directors surveyed (n = 621) in 2017 reported that over a quarter of all students sought their services for suicidal ideation and that 16.2% of students seeking their services reported having a history of extensive mental health treatment [4]. Hopelessness and suicidal thoughts are signs of severe depression, the leading cause worldwide of disability [1].

According to national data, a growing number of post-secondary students are making use of available legislation for mental health disability accommodation [5, 6]. At one large mid-western public university, between 2012 and 2017, the number of students registered at the SSD office for a mental health-related disability increased from 438 to 770, a 57% increase in 6 years.

Providers may not be aware of relevant legislation and resources to address the complex needs surrounding students and mental health disability. Given all that is at stake and the complexity of this issue, it is essential for psychiatrists to be knowledgeable about how college student’s psychiatric symptoms can lead to academic impairments.

Evaluation resources in the post-secondary settings can be scarce, and regardless, many students disabled by mental health concerns choose not to seek accommodation. Students may not always seek accommodations for many reasons including privacy concerns, lack of knowledge about available accommodations, stigma, and lack of resources [7, 8••]. The decision for a disabled individual not to seek accommodations can have a far-reaching impact. Graduation rates for un-accommodated individuals are lower than for accommodated peers. Post-secondary education completion is a key determinant for future employment success as well as health outcomes [3, 9••].

Unfortunately, when students do seek accommodations, psychiatrists are often not comfortable assessing disability and staff in disability services offices are not always informed about assessing disability or knowing which accommodations are reasonable [10]. Given all that is at stake for these individuals, and considering that this is an expanding problem, the need for attention and resource allocation to mental health disability is apparent.

Academic Accommodations in the Post-secondary Environment

The goal of this section is to enhance mental health care professionals understanding of legislation relevant to academic accommodation in the post-secondary environment (classroom and high stakes testing: SAT, ACT, GRE, LSAT, Medical College Admission Test (MCAT), GMAT).

Two federal civil rights laws bear on students with disabilities in the post-secondary and high-stakes testing environments—the Vocational Rehabilitation Act of 1973—Section #504 and the American with Disabilities Act—Amended Act (ADA-AA) of 2008 [11, 12]. The goal of these laws is to ensure that students have equal access to all components of their academic programs (both cognitive/intellectual and physical access).

It is important to recognize that these civil rights laws are far different from the federal special education law (IDEA), which is an entitlement act and only covers students from prekindergarten to 12th grade [13]. The main difference between IDEA and #504/ADA-AA is that intervention and remediation are the goals of IDEA, not just equal access. There are fewer accommodations and services available under the civil rights laws, and the individual bears far greater responsibility in the accommodation process.

The goal of the disability office in post-secondary environments is to guarantee access to, not success in, the institution. In contrast, under IDEA, success is a much bigger part of the calculus. Students and their families may be surprised to learn that they are not entitled to the same accommodations that they received in secondary school and recommendations made by a health care provider may not be realistically implemented within the framework of the legal mandates.

One of the many challenging tasks for evaluators is to know what accommodations are legally mandated and how to document the assessment according to these mandates. In order to achieve this, one must understand that the core component of the federal government’s definition of a disability is that an individual has a substantial limitation (i.e., impairment) in a major life activity. Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. Thus, the main point that providers need to know is that a diagnosis alone does not get students accommodations.

The entities responsible for administering high-stakes testing must comply with federal law while also maintaining the integrity of their tests. They must work to avoid fundamentally altering the process of measurement of the skills or knowledge the examination is intended to test. When applying for accommodations on such tests, students will typically need to produce evidence of their disability including data that is sufficiently current (e.g., psychological testing results from the last 3 years, or psychiatric assessment results from the past 6 months). The websites for many of the standardized tests offer guidance to health professionals about the information that is required, sometimes including specific suggestions for opinion formulation. For example, the MCAT website asks that evaluators address having ruled out alternative explanations for a student’s difficulties when differentiating between learning disabilities, ADHD, and psychiatric disabilities [14].

Mental Health Disability Evaluation in the Post-secondary Environment

Like any non-clinical assessment, evaluations of students to determine whether they have disabilities requiring academic accommodations must begin with an understanding of the underlying conceptual and legal framework. Without this, the evaluation may neither accurately nor adequately address questions about diagnosis, impairment, need for accommodations, or the justification for particular accommodations. Evaluators bear considerable responsibility in this endeavor, since U.S. Department of Justice regulations suggest that higher education institutional disability specialists accept the recommendations of “qualified professionals” who have performed an “individualized evaluation” of students, so long as their documentation demonstrates a “consistent history of a diagnosis of a disability” [15].

There is a two-step process for determining the need for accommodations: step one: does the person have a diagnosable condition recognized in the diagnostic nomenclature? (i.e., DSM or IDCM) and step two: are they substantially limited (impaired) by that condition?

The goal of accommodation is to address the area of impairment in order to help ameliorate the effect of the impairment. Providing sufficient documentation allows for appropriate accommodations in college or high stakes testing. Both qualitative and quantitative reports that address the student’s condition and what specific accommodations may be useful in allowing the student equal access to the test or program are required for a student to receive accommodations. Evaluating providers must document substantial impairment in some part of the learning process. Just as this process can be confusing to students and their families, health care providers may not understand this requirement and providing sufficient information to attest to the above is usually where they fall short.

There are limitations regarding what accommodations are legally required, and students are often denied accommodations if there is no clear evidence that the student is impaired relative to the requested accommodation. If a treating clinician provides only a diagnosis and a generic list of symptoms and recommendations related to the student’s condition, it will not likely be sufficient for the institution or agency’s needs. Additionally, both #504 and ADA-AA require students to meet the standards of the program in which they are participating. They also require that there are no fundamental alterations to the program as a result of any accommodation. These factors may pose challenges to receiving requested accommodations. Furthermore, if a program leads to certification or license in a profession, no modification of those requirements is necessary.

With all of these considerations in mind, evaluators should focus on eliciting a careful clinical history yielding sufficient information to make a diagnosis. Whenever possible, past clinical records should be reviewed, including diagnostic evaluations and records from primary and secondary school such as IDEA documents (Individualized Education Program, or IEP and 504 Plan records) as they may include descriptions of the student’s impairments related to their disorder, as well as response to various accommodations. Beyond symptoms and diagnosis, assessment of functional impairment is required, particularly aspects germane to participation in educational requirements. Evaluators should consider collateral interviews and psychological testing, as these sources can provide valuable additional information.

Validity is a critical issue in these evaluations, given the high stakes—some accommodations (e.g., extended time on standardized tests) would be desirable for most students, and therefore, there is potential for these stakes to influence the self-report and presentation of the student–examinee. Surveys have found that many clinicians discount the possibility that students exaggerate symptoms in order to obtain a disability diagnosis [16] and believe that there is a low base rate for such exaggeration in psychoeducational assessments. While reviewing records and during the examination, the evaluator must probe for internal consistency in the examinee’s self-report of symptoms and seek to identify atypical symptoms or descriptions of atypically severe functional impairment. Psychometric testing is often indicated, including symptom validity tests and other measures that can identify indicators of distortion in the examinee’s presentation.

If the evaluator concludes that the student has a disability, they should recommend accommodations designed to reduce or eliminate the impact of the student’s impairment on a particular task. While this may sound straightforward, experts on the matter note that accommodations are frequently recommended indiscriminately, sometimes without any logical relationship between the disability and intervention, and there is even concern that some traditional accommodations could be counterproductive for students with specific disabilities [17••].

After completing the assessment, the evaluator submits a report to the educational institution outlining their diagnosis and recommendations. The report should list sources of information, and data were referenced with clear attribution throughout the report. The evaluator should apply a basic test to their work in a review of the report before submission, asking: “Have I provided supporting evidence for my opinions, addressed any areas of ambiguity or conflicting data, and do my recommendations for accommodations match with the impairments stemming from the student’s condition?”

Misconceptions About the Purpose of an Evaluation and Avoiding Conflict of Interest

Many evaluating psychiatrists may not appreciate that, whereas preK-12 educational regulations governing determinations about granting accommodations aspire to promote a particular outcome (e.g., the student achieving mandated standards), in post-secondary education, these determinations are guided by the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act [17••]. Under the ADA, persons with disabilities are granted reasonable accommodations in order to ensure access and opportunity equal to others, rather than a particular outcome or degree of success. Also, importantly, the ADA concept of disability requires a substantial limitation in a major life activity, which the Equal Employment Opportunity Commission (EEOC) has clarified as amounting to “a significant restriction when compared with the abilities of the average person” [18]. In post-secondary psychoeducational evaluations, the “average person” standard is not intended to refer to the individuals’ immediate peer group (e.g., medical students), but instead to the average person in the population at large. Despite this, one study found that 43% of clinicians conducting disability evaluations endorsed the practice of assessing impairment by comparing a student to others at “similar educational levels [19••].”

When a mental health practitioner elects to perform an evaluation of student disability and eligibility for academic accommodations, they are to proceed by striving for objectivity rather than advocacy. However, this can be difficult for clinicians to do, especially when they have a treatment relationship with the student. A 2016 American Psychiatric Association (APA) position paper on college mental health recognized this issue by explicitly stating, “A treating psychiatrist should not serve as a decision-maker regarding academic matters, including withdrawal from classes or school, due to the potential conflict of interest between the academic mission of the university and fidelity to the welfare of the student. A treating psychiatrist should serve in a consultative capacity in academic decisions, but the final decisions should rest with those not involved in the direct health care of students” https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2016-College-and-University-Mental-Health.pdf.

The following points relate to common misunderstandings among mental health practitioners in assessing students’ eligibility for accommodations. One study found that almost 30% of clinicians surveyed incorrectly stated that the purpose of such evaluations is to help students secure the desired accommodations [19••]. Another survey of clinicians preparing disability documentation supporting testing accommodations on the Law School Admissions Test found over 30% thought the purpose of the ADA was intended to increase academic performance and test scores of individuals with disabilities [19••]. There is a significant knowledge gap for professionals tasked with completing these evaluations.

Recommendations for Managing and Mitigating the Burden of Mental Health Diagnoses and Disability for Students

Before College

Since colleges vary in the availability of mental health, disability, and other support services, students and their families are well advised to research the range of support services available at colleges in which the student is interested. The campus disability office should be able to inform potential applicants or families about the ability to provide support and accommodations for students with serious mental illness, including relevant campus-wide statistics. Additionally, some colleges offer for-credit courses that support the mental health and well-being of their students—and this could be inquired about, as well [20, 21].

Applicants and families should examine college leave of absence policies to determine whether the college is flexible about allowing students to go out on leave when they have an exacerbation of their condition and return without undue administrative hurdles. It is also helpful to know whether the colleges offer tuition insurance and limits of coverage in the policy. Tuition insurance offers reimbursement for tuition if a student needs to leave school because of an urgent health problem, but different policies have differing thresholds for reimbursement—some require a psychiatric admission as a condition for tuition reimbursement for mental health-related leave.

College administrators and mental health professionals should be quick to refer students to resources such as Set to Go—The Jed Foundation, a recently developed online resource center focused on the emotional preparation for the transition to college and independent adult life [22]. This resource helps families and prospective students consider aspects of individual colleges that would be more or less compatible with their situation.

Once college plans are made, treating and evaluating mental health providers, in conjunction with other interested parties, should consider a plan for ongoing management and care. It is crucial for the student, family, and home-based treatment team to discuss how care will continue when the student transitions to college. Most colleges provide short-term or “primary care” health and mental health services. For example, if regular visits are necessary and the student is at a distance from the local/home based clinician(s), there may need to be a transfer of care to a clinician closer to campus who can handle care through the college years. It is important to note that for students with severe mental illness, campus services might not be able to provide adequate medication management as approximately 35% of campus services do not have medical staff who can prescribe psychiatric medications [4].

During College

After matriculation, providers and students need to be clear about who is the lead clinician. In many cases, while clinical care may primarily occur off campus, it is also helpful for a clinician (or case manager) at the campus counseling service to have some familiarity with the student to serve as an adviser or ombudsperson should the need for on-campus services or accommodations arise [23].

All involved should anticipate clinical setbacks or crises. The student, family, home-based clinicians, and local/campus-based clinicians should agree on plans for managing significant problems should they emerge. Discussions about triggers for contacting family and clinicians can be agreed upon ahead of time. This type of communication requires a significant degree of planning. Anticipating communication and intervention needs before an emergency arises is essential [24].

Also, there are some legal limits regarding communication between campus officials and family members. The Family Educational Rights and Privacy Act (FERPA) allows schools to release (without permission) educational records to “appropriate individuals in cases of health and safety emergencies.” The Health Insurance Portability and Accountability Act of 1996 (HIPAA) specifies that when a patient has released information or when the release of information is legally required, private “protected health information” can be shared.

After College

There is a paucity of literature exploring the emotional components and the mental health ramifications of the college to career transition. Recently, The Jed Foundation and the University of Massachusetts Transition to Adulthood Center for Research conducted a yet to be published literature review in partnership with Harris Poll that included a survey of over 400 college seniors, 1000 recent graduates, and approximately 500 employers to examine their expectations, attitudes, concerns, and experiences of transitioning from college to the workplace. It revealed that only 30% of graduating students with a mental health problem had set up a plan for continuing care by the time they had graduated and only 20% considered it necessary to consider access to care in considering their job and living settings. There are implications for mental health disability beyond the scope of this paper that could be expanded on in a future manuscript.

In order to address these challenges, it would be prudent for colleges to put more emphasis on building programs that help students develop life and social skills and to coordinate career counseling with mental health counseling services. Finally, it is essential that students with mental illness be encouraged to weigh their mental health care needs when they leave school and transition to work life.

Conclusion

Given the prevalence of mental illness and associated disabling symptoms, it is imperative that psychiatrists understand relevant legislation, best practices for evaluation, appropriate documentation to achieve accommodations, and resources available for managing transitions before, during, and after college.

The level of coordination required to appropriately evaluate, accommodate, and assist students with a mental health-related disability is extensive. Despite this, students suspected of having a mental health-related disability should be assessed by a mental health professional who is not their treating provider and who is familiar with evaluation of mental health disability, typical accommodations, and the available resources to support them. For a summary of “take-away points,” please refer to Table 2.

Table 2 Take-away points
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