Forum Spring 2019


Test Accommodations

Candidates who request test accommodations are treated on a case-by-case basis to determine what adjustments, if any, are necessitated by their situation. FSBPT is committed to providing full access to the NPTE to individuals with documented disabilities. FSBPT is also committed to ensuring that the security, integrity, and validity of the examination are not compromised. In order to ensure a fair and consistent process, Paradigm Testing, experts in the field of accessibility and disability services, has been contracted by FSBPT to review accommodations requests and supporting evidence, and to provide accommodations recommendations to FSBPT. This article is based on a presentation by John A. Hosterman, PhD, Chief of Accessibility & Disability Services, Paradigm Testing, at the 2018 FSBPT Annual Meeting.

What is a Disability?

The Americans with Disabilities Act (ADA) was enacted in 1990. It was amended in 2008 to become broader and more inclusive. However, the definition of a disability has not changed and it is similar to the definition of a disability in Canada, the United Kingdom, Ireland, and Australia.

 A physical or mental impairment that substantially limits one or more major life activities, compared to most people in the general population.

The ADA has helped protect millions of Americans from unnecessary discrimination. In fact, many people who are protected from discrimination do not even consider themselves to be disabled—they are just “differently-abled.”

Some individuals who are protected by the ADA have a condition that is readily apparent—vision loss, deafness, mobility impairments. When individuals with these conditions seek accommodations in school, on tests, or at work, obtaining appropriate documentation of their condition and substantiating a need for accommodations should be a simple, straightforward process, and many such accommodations can even be anticipated in advance.

However, other individuals who may be protected by the ADA have conditions that are less obvious, such as people with diabetes, Attention-Deficit/Hyperactivity Disorder (ADHD), learning disorders (LD), or cancer. Some of these conditions can easily be documented, such as medical conditions. Other conditions such as LD or ADHD are not diagnosed using blood tests or x-rays, but are evaluated in more subjective ways that may vary from one evaluator to the next. This makes the process of documenting the disorder more ambiguous and the need for accommodations even more subjective and speculative.

In order to be disabled under the ADA, there has to be actual impairment. It is important to note that a relative weakness is not the same thing as an impairment. Many psychologists, for example, diagnose learning disorders on the basis of a discrepancy between an individual’s relative strengths and relative weaknesses. While this intra-individual “discrepancy model” approach may be appropriate for diagnosing a particular condition such as a learning disorder, it is not appropriate for determining actual functional impairment. To determine disability, there must be functional impairment relative to most people in the general population—not relative to the individual’s own strengths. In the field of physical therapy, we see many very high-functioning individuals who are not quite as strong in one area as in other areas, or who are in a doctoral program and wonder why their grades are not as good as they were in high school. This is not necessarily an indication of a disability. Keep in mind that it is called the Americans with Disabilities Act, not the “Americans with Disorders Act” or the “Americans with Discrepancies Act.”

    • In order to have a disability, there first must be evidence of a disorder or condition, properly diagnosed using criteria from DSM-5 or ICD-9 (10).
    • Not all diagnosed conditions will rise to the level of a disability.
    • Many psychologists (incorrectly) believe that simply diagnosing someone with a condition automatically entitles the person to accommodations.

Many people have been diagnosed with some sort of condition—everything from acid reflux disease to high blood pressure to obesity. While these conditions may have been appropriately and accurately diagnosed, not every diagnosed condition will necessarily rise to the level of a disability.

In order to be disabled under the ADA, a person has to establish actual functional impairment, as described above, and also must demonstrate that this impairment substantially limits a major life activity. Major life activities are central to daily life, such as seeing, hearing, walking, breathing, reading, learning, concentrating, and working. For example, a person who has acid reflux disease may take medication for this condition, and they may have to adjust their diet to avoid certain kinds of spicy foods. While this may be annoying and aggravating, it does not substantially limit any major life activities. If you know somebody who has a disability, such as a person who is deaf or blind, you know that their condition impacts almost every aspect of their life.

The ADA defines what are major life activities, but what are not major life activities? Major life activities are broad, and they are central to daily life. Activities and skills that are not central to daily life are not major life activities, such as one’s ability to recall math facts, spelling skills, handwriting legibility, or having reading comprehension skills that are not up to par with one’s IQ.

What Accommodations Are Appropriate?

Beyond the question of establishing that a person’s condition rises to the level of a disability, there is the question of what accommodations, if any, are appropriate. This entails consideration of the person’s unique strengths and challenges, the setting, and the tasks at hand. It is unlikely that the same accommodations that are appropriate for one type of task, in a particular setting, would be appropriate on all other tasks and in all other types of settings. For example, a person who is a wheelchair rider may be impaired in the major life activity of walking. It might be appropriate for this person to have a handicap-accessible parking placard and to have other mobility-related accommodations. However, it is not necessarily the case that this person needs “extra time” for cognitive tasks, such as reading. Likewise, while it might be appropriate for a nursing student with a reading disorder to have extra time on classroom-based tests, it might not be appropriate to have extra time accommodations in hospital-related or practical-skills settings. Again, it is critical to consider the person, the task, and the setting in order to determine what accommodations, if any, might be appropriate.

Prior Accommodations Approvals

Some people (incorrectly) believe that having a history of receiving accommodations—for a particular setting and type of task—necessarily entitles them to the same accommodations for all future tasks and settings. Instead, the individual with the disability and the people they are working with (school officials, employers, etc.) need to work together in an interactive process to determine what accommodations, if any, are appropriate. For example, many colleges and universities are exceptionally generous in the types and amount of support services and accommodations they offer to their students, disabled or not. Schools are usually eager to provide accommodations and support services to their students in order to boost retention rates, graduation rates, and general student “happiness.” However, this precedent does not necessarily obligate future academic institutions, licensing boards, or employers to provide these same exact support services and accommodations for different tasks and different settings that have different purposes. Each organization has a responsibility to make its own determination based on the evidence. It is helpful to see what other institutions have determined, but it’s certainly not determinative for all future situations.

Test Security

Test-takers with disabilities should have full access to tests. At the same time, concerns arise with requests for accommodations that could seriously compromise the integrity and security of the tests.

Test security is vitally important to FSBPT and other high-stakes testing organizations. Licensure exams may take a year or more to develop, including item-writing, psychometric validation, content review, fairness (bias) review, and field testing. This lengthy process often requires the expertise of dozens (if not hundreds) of professionals, at a cost that can easily run into the millions of dollars. Maintaining the security and integrity of the test is paramount. Many testing organizations have had incidents of cheating as well as theft of content (“item harvesting”). Some such scandals have recently been widely publicized in the news media.

At the same time, many test-takers with disabilities are asking for accommodations that include personal devices, software applications, and other types of technology—any of which could pose challenges with maintaining the security of the test content and reducing the risk of cheating. For example, a common screen-magnification software program is widely used by individuals with low vision. However, this software includes a “Help” menu that allows the user access to the internet, which opens a host of risks for cheating. Likewise, some newer technology for people with diabetes—continuous glucose monitors and insulin pumps—rely on a person’s smartphone to monitor and treat the diabetes. Thus, the smartphone has become “medically necessary,” and may need to travel with the person into the test center and be with them during the exam, which again poses significant security challenges both in terms of cheating as well as theft of content (with the phone’s camera).

Ensuring Test Validity and Access

Testing organizations must simultaneously balance both the goal of providing access to their test for candidates with disabilities and the measurement goal of eliciting valid test scores that can be accurately interpreted by licensing boards and future employers. For candidates with disabilities, this means that the accommodation should eliminate some particular impediment faced by the examinee, so that the accommodated administration of the exam is statistically equivalent to a standard administration of that test in all other respects. In other words, the candidate with the disability should receive an accommodation that ensures access to the test, so the test measures what it purports to measure.

Accommodations are meant to ensure equal access—not to increase the likelihood of any particular outcome, such as “finishing the test,” “passing,” or “reaching one’s potential.” Sometimes, test candidates and their doctors request accommodations that are clearly designed to ensure a particular outcome. For example, asking for “unlimited time” on a timed licensure exam does not serve to “level the playing field”—it serves to change the playing field completely, by guaranteeing a specific outcome (finishing the test) that is not guaranteed for any other licensure candidate, tipping the proverbial “playing field” in favor of the person with the disability. Thus, the predictive validity—the usefulness of the test scores to licensure boards and employers—would be undermined and the resulting score would be meaningless.

Some accommodations can reasonably be said to approximate a valid test administration, by “leveling the playing field.” For example, a person with a Specific Learning Disorder (SLD) may have slow processing speed, leading to slow reading rate and slow rate of comprehension. Based on that person’s modestly below-average performance on standardized measures of processing speed and timed reading comprehension, it might be reasonable to permit her to have 25 percent or 50 percent extra time on a timed test that is reading-based. The intended net effect is to level the playing field so that, with this additional time, the test is as speeded for the candidate with SLD as it is for non-disabled candidates. As discussed above, the purpose of accommodations is to allow for an equal opportunity to participate, not to ensure any particular outcome.


There are many factors that must be considered when evaluating requests for accommodations, either for licensure exams or the workplace. Such factors include the unique needs and challenges of the individual with a disability, as well as the unique factors of the task and setting for which accommodations are requested. What may have been appropriate in a classroom setting may no longer be appropriate on a licensure exam or in the workplace. The security of the licensure test content is important, as is the goal of delivering a meaningful, fair, and valid test to all candidates.

Having an individualized approach to carefully reviewing accommodations requests is complicated and may take more time than a “rubber-stamp” approach. This individualized model also requires that all parties—test-sponsor staff, contracted disability experts, test-delivery vendors, and candidates with disabilities—be willing to collaborate in an interactive process. It is possible that not everyone will be pleased with the outcome. Nevertheless, this individualized and collaborative approach is more defensible and ultimately fairer to all candidates.

John A. Hosterman, PhD

Chief of Accessibility & Disability Services, Paradigm Testing

Dr. John Hosterman is Chief of Accessibility & Disability Services at Paradigm Testing, where he oversees a team of experts who review accommodations requests and provide guidance to testing organizations. Prior to Paradigm, John worked for several large multinational testing programs, including the MCAT and GED programs. John did his undergraduate work at the College of William and Mary in Virginia and completed his PhD from Northwestern University. He is also fluent in ASL and active in the deaf community.


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