Guide for Assessing Persons with Disabilities - How to determine and implement assessment accommodations - Chronic illnesses

What you need to know about chronic illnesses?

Chronic illnesses include, but are not limited to, long-term diseases such as:

• Cancer
• Crohn's disease
• Chronic pain
• Diabetes
• Epilepsy
• Fibromyalgia
• Lupus
• Multiple sclerosis
• Rheumatoid arthritis

While chronic illnesses are by definition long-term, they may be subject to fluctuations in severity and thus may affect the same individual in several different ways at different times. In addition, they are frequently exacerbated by stress, resulting in sudden flare-ups of the condition.

Here are some ways that a chronic illness can manifest itself which are relevant an assessment context:

Fatigue or limited physical tolerance
Some people can fatigue easily or have a low energy level for extended periods or during specific times of the day, due to fluctuations in the effects of the illness, or the presence of chronic pain. Those with limited physical tolerance may require frequent rests to compensate for the effects of everyday activities on their body. This need may be exacerbated by the added stress of undergoing an assessment such as a written examination or an interview.

Concentration and speed of information processing
A person's concentration and speed of information processing which are required for reading, writing, speaking, or decision-making, may be reduced due to the illness or to side effects of medication. Diminished concentration and a slower speed of information processing can also result from fatigue or can occur before medication has taken effect.

Motor coordination or mobility
Nerve damage, tremors, inflammation of the joints, stiffness, or pain may limit gross motor or fine motor coordination, as well as, lack of muscle strength may affect mobility.

Certain chronic illnesses may also affect other areas of functioning of the individual. For example, with Multiple Sclerosis, there may be cognitive impairments relating to short-term memory, perception or executive functions, as well as problems of vision or speech. For appropriate assessment accommodations for the illness, it will be useful to consult the sections on learning disabilities, visual disabilities, or others, depending on the areas affected. It is also recommended that a qualified professional, who is accredited by the appropriate regulated professional association, be consulted for assessment accommodations for individuals with illnesses such as Multiple Sclerosis, that can affect a number of areas of functioning.

What information or professional documentation is needed?

Applicants are the first source of information on how their chronic illness affects them and the accommodations which are useful to them, including any adaptive technology they may normally use. However, unless the functional limitations caused by a chronic illness are obvious, long-standing and stable, professional documentation in the form of a report of a medical assessment will be needed to determine appropriate accommodations.

A report from a medical specialist or family physician will help to clarify the nature and the extent of the functional limitations. The report may also take the form of an occupational health assessment or work capacity evaluation. Because a given chronic illness may be expressed differently from one person to another or fluctuate for one specific individual, it is essential to clearly understand the nature and extent of functional limitations for a particular person. A qualified professional will be in a position to complement the information already provided by the applicant, and give a more precise picture of his or her actual mode of functioning.

Professional documentation is expected to reflect the person's current level of functioning. Due to the fluctuating nature of some chronic illnesses, if a long period has elapsed since the report, or if the report suggests that the condition is not stable, an update may be required. For a more general discussion on professional documentation requirements and standards, refer to the section on Standards for professional documentation.

The medical report should describe:

• the nature and extent of the current functional limitations due to the illness;
• the current effects of any medication being taken, if applicable; and
• any accommodations the person is using, has used or could benefit from.

Having this information in the professional report or document allows for a description of the person's current strengths and limits with implications for assessment accommodations. Specific accommodations may be suggested in the assessment report. While suggested accommodations may not be directly transferable to the specific assessment situation, depending on the context for which they were intended, they may still provide useful information. When there is a difference between the professional's suggestions and the planned accommodations, it may be necessary to consult with the professional or another external expert familiar with both the applicant and the issues involved. The applicant must agree in writing to this further consultation (see step 3 of the section Determining and implementing assessment accommodations).

What are the key elements to consider?

When determining assessment accommodations for persons with chronic illness, the following three elements should be considered:

1. The nature and extent of the person's functional limitations must be clearly understood. The following questions may help to gather useful information:

• What are the functional areas affected by the person's illness: fatigue or limited tolerance, concentration, rate of information processing, motor coordination, mobility, or other areas of functioning?
• What is the extent of the limitations imposed by the illness (mild, moderate, severe), and whether symptoms are constant or tend to recur periodically?
• What are the current effects of medication?
• What are the practical requirements such as access to the test site and other facilities (for example: washroom, cafeteria), specific needs for food or beverages (for example, for a person with diabetes) or other medical requirements?
• What are the accommodations used by the person on the job to accomplish tasks similar to those of the assessment situation?

It is important to reiterate that persons with disabilities are the first source of information on the way their limitations affect them and on how to accommodate their specific needs. Consequently, this information is usually gathered through exchanges with the person. To help you to gather these details in a discussion, you may wish to refer to the questionnaire available in appendix 2.

However, as mentioned earlier, for person with chronic illness professional documentation may be required to complement the information already provided by the applicant. This documentation will ensure a precise understanding of complex functional limitations associated with the disability. For more information on professional documentation requirements please refer to Standards for professional documentation.

2. A thorough knowledge of the assessment tool to be used is required. Depending on the assessment tool's characteristics, accommodations which are necessary for one tool may be unnecessary for another. Here are some considerations to help you identify the characteristics of your assessment tool.

For an interview:

• Are written documents provided before or during the interview? If so, how much reading is involved?
• Is there time to prepare responses prior to the interview?
• What is the expected length of responses to be given orally?
• Is there a written component? If so, how much writing is involved?
• What is the time allotted?

For a written test:

• Is it an essay-style exam, short answers or a multiple choice test?
• Is it a case study, an in-basket exercise?
• Is it an open book test?
• How many questions are there?
• How much reading and writing are involved?
• What is the time allotted?
• Will the instructions be provided orally or in writing?

For an interactive situation:

• Is it a group setting? If so, how many participants are there? Is it advisable to inform other participants of the person's functional limitations? If so, who tells them, the person or the individual administering the interactive assessment session?
• Is written documentation provided before or during the situation? If so, how much reading is involved?
• What is the expected length of exercise to happen orally?
• Is there a written component? If so, how much writing is involved?
• What is the time allotted?

3. Knowledge of the qualification being assessed is essential. This information will help you ensure that accommodations do not modify the nature or level of the qualification being assessed. Considerations include:

• What qualification(s) is (are) assessed by the instrument? It is knowledge, abilities/skills, aptitude or personal suitability? How is it defined?
• Is there a speed requirement?
• Does the level of the qualification assessed reflect the job requirement?

Determining appropriate assessment accommodations necessarily requires research and analysis of all three elements above; of the impact they have one another, and the application of the Principles for assessment accommodations. This analysis is the foundation of the rationale for the accommodations. This rational has to explain how the accommodations are enabling the demonstration of the person's qualifications, preventing his or her functional limitations from being a disadvantage. It also has to explain how the person is not being given an advantage compared to others in the appointment process, therefore, that merit is preserved.

Examples of assessment accommodations and considerations

The following are examples and considerations that may be helpful in determining assessment accommodations. It also includes a number of specific examples of assessment accommodations relative to possible functional limitations.

While reviewing these examples, keep in mind that accommodations are determined on a case by case basis and their appropriateness will depend on the nature and extent of the individual's functional limitations, the assessment tool to be used and the qualification to be assessed. Also, accommodations must resemble, if possible, the usual way in which the person would perform the task requested as if he or she was on the job, and must not alter the nature or level of the qualification being assessed. For more details, please refer to Determining and implementing assessment accommodations.

Individual assessment session: Individual assessment sessions are required in all cases where test administration differs from standard procedures. As a means of reducing extraneous stimuli and enhancing concentration, individual session is especially important for persons who experience low energy levels or process information slowly.

Assessment stress as a factor with chronic illnesses: The test administrator or interviewer should be aware that the normal stress produced by assessment tends to have a disproportional effect on persons with limited physical tolerance. Allowing additional time and breaks may be helpful.

Additional time: Additional time may be required to compensate for lower energy levels, decreased concentration, or limitations to fine motor coordination affecting the person's ability to read or write. For a person with limited tolerance, it may allow her or him to work at a pace that will control the level of stress on his or her body caused by the assessment situation. The amount of time needs to be determined on a case-by-case basis, as individuals differ widely in the way a disease affects their capabilities and endurance.

Breaks: Breaks not included in the test administration time will frequently be necessary to allow the person to function effectively for the duration of the assessment session. This will be particularly true for those with fatigue or limited physical tolerance. A stopwatch should be used to keep track of the exact time spent on assessment and the time spent on breaks

Flexible scheduling of assessment sessions: Flexible scheduling of the assessment session is recommended to take into account the optimal time of day for assessing the person, given his or her illness and the timing of any medication which is being taken. Flexibility should be used to reschedule the assessment session of a person not well enough to participate at the scheduled time.

Adaptive technologies: Applicants using adaptive technologies may be provided with the devices or software that they use on a regular basis. Applicants' personal equipment may be brought into the assessment environment and used, or they may be tested in their office or at home. Use of applicants' own equipment has the advantage that it is configured appropriately for the individual, who is familiar with the settings, position of keys, etc. For listing and brief description of adaptive technologies commonly used, see the glossary of adaptive technology and services in appendix 4.

For fatigue or limited physical tolerance:

• Divide a lengthy examination into two or more parts, and administer each part in a separate session (e.g., a morning assessment session followed by an afternoon session, after a lengthy break, or test sessions scheduled on separate days).
• Use of a computer to provide answers may be beneficial for some persons with limited tolerance because less physical exertion is required. This may permit them to complete the assessment session more quickly and with less fatigue.
• Provide ergonomic seating (Obus chair, adjustable height table, etc.) as required.
• Schedule frequent breaks to allow the person to recoup enough energy to continue the assessment session:
  • In some cases, the person may require lengthy breaks and may benefit from a couch or comfortable chair on which to rest;
  • In other cases, the person may need frequent short breaks to change position, to rest muscles used for writing, or to get up and stretch to relieve discomfort or pain.

For difficulties of concentration or a slow rate of information processing:

• Individual assessment sessions to reduce distractions are desirable.
• Conduct interviews at a relaxed pace with breaks as required by the person.
• For interviews and interactive exercises the following may be used:
  • Give the person the interview questions in writing, immediately prior to the interview, and allow preparation time in a quiet room.
  • For interactive exercises, present the situation to the person in advance, preferably in writing, and allow time to prepare.
  • NOTE: If all applicants are to be given the questions or situations in advance, increase the time allowed for persons with difficulties of concentration or rate of information processing.

For mobility limitations

• Use of a computer or other adaptive device may be beneficial for persons with fine motor coordination difficulties. Be guided by devices the applicant normally employs in work or school.
• Refer to the section on mobility or agility disabilities for consideration and example of accommodations.

Specific medical requirements

Particular illnesses may entail specific medical requirements, which should be discussed with the person in advance. These requirements can generally be accommodated by simply scheduling the test session around the person's needs. However, for longer assessments occurring over the course of a day, it is important to build in time for the person's medical requirements. The following may serve as examples, but there are many other possible medical requirements:

• Persons with diabetes need to test their glucose level at specific times during the day, or they may need to inject insulin, for which they should have privacy (for example, a washroom).
• Persons with diabetes also need to eat at specific times, which should be taken into account in scheduling the assessment session. For a long assessment, allowing the person to bring in food and beverages is a possible option.
• Persons with conditions require frequent washroom breaks (for example, Crohn's disease or Irritable Bowel Syndrome), for which allowance must be made, both in terms of breaks and scheduling. For example, build in extra time in an assessment centre, where the person's time is typically scheduled to the minute.