Setting the Stage

In his scathing examination of the Canadian motor-vehicle accident benefits system, psychiatrist Andrew Malleson (2002) documents how having a disability secondary to an otherwise minor motor vehicle accident had become a cottage industry in some provinces, offering secondary gain potential not only to the victims themselves, but also to the physicians and other allied health professionals who assessed and treated these ‘useful’ illnesses. The idea that illnesses could be ‘useful’ seemed counterintuitive, given that illnesses or chronic injuries are usually associated only with unpleasant consequences. However, Malleson suggested that there existed a ‘whiplash industry’ in Canada. Victims of minor accidents received not only accident benefits and paid sick leave, but also unfettered access to allied health care services, sometimes for years. Some physicians and other allied health care professionals generated a continuous source of revenue by both diagnosing and treating these victims using funds provided by either universal health care or insurance reimbursement. Lawyers obtained a steady stream of paying clients to help defer ongoing office and practice expenses. Malleson suggests that some physicians and lawyers promoted these disabilities to build up the need for their services. As Malleson (2002) noted:

Just as the lumber industry depends on trees for its existence, so the healthcare industry depends upon illness. The lumber industry worries about a shortage of trees, but the healthcare industry is confronted by an even bigger problem. Never before…. have there been so many healthcare practitioners in search of work. Doctors and other healthcare professionals, and many lawyers and businessmen who depend upon the health industry for their livelihoods are entrepreneurs. When illnesses are in short supply, they create new ones. Increasingly expensive investigational techniques are deployed in the unending search for illnesses to treat (p. 3).

The resulting symbiotic diagnosis and victimhood system, he suggested, was a win–win situation for all but the insurance industry and the Canadian tax-payers.

Malleson showed convincingly that the rise in the base rate of whiplash and other subjectively diagnosed conditions depended mainly on there being a tangible benefit involved in having the condition of interest. For example, in countries and jurisdictions that did not offer compensation for whiplash, the most severe cases of post-accident impairment typically lasted no more than a few weeks and resulted in full recovery. In addition, he showed that when funding for assessment and treatment of these conditions became limited in both time and money available, the rates of long-term illness and ongoing medical treatment for whiplash plummeted in those jurisdictions.

Such tangible benefits must accrue not only to the patient but also to all who diagnose, treat, and work with the victims. However, benefits are only part of the equation. One also needs to have a disorder or group of disorders that are diagnosed subjectively, include a host of vague symptoms commonly reported by many people at some time, and a condition that cannot be confirmed independently by lab tests or other objective methods. In other words, as game theory predicts, people will lie and take advantage of a system when the payoffs increase and the chance of being caught is low (see Kajackaite & Gneezy, 2017). Furthermore, as behavioral economics demonstrates, humans will change their behaviors when there are tangible rewards for the behavior in question with no immediate negative consequences, and cease behaving in such a manner when the rewards are removed (see Vlaev et al., 2019).

The book concludes by recommending that we stop incentivising being injured or disabled and instead provide honest and accurate feedback to patients about their actual skills, abilities, and expected health outcomes, celebrating the fact that they are (or can again become) normal. Malleson thought that these actions would be more ethical and reduce the harm to both the individual and society that had arisen secondary to reinforcing an illness identity.

Where Are We Now?

Sadly, 20 years later, it seems that the same problem of incentivized diagnosis that Malleson documented for whiplash has now emerged in the form of disability assessment and academic accommodation in the postsecondary sector. As the articles in this special issue all illustrate, an industry has now sprung up that appears to overpathologize normal behavioral variability, frequently diagnosing otherwise normal young adults with a non-visible disability that can grant them access a host of academic, financial, and social benefits. To be clear, there are individuals who have legitimate learning disabilities (LD), attention deficit hyperactivity disorder (ADHD), or severe mental health conditions. However, the problem is that research shows that rates of non-visible disability diagnoses such as LD and ADHD have skyrocketed over the past 20 years (Freedman, 2006; Houtrow et al., 2014; Xu et al., 2018), with the increases occurring mainly in affluent communities, whereas rates of physical disabilities have remained constant regardless of privilege (Belkin et al., 2019; Goldstein & Patel, 2019; Lester & Kellman, 1997). In addition, while rates of physical disabilities in children and adolescents have remained stable or decreased over the past decade, the number of children and teens diagnosed with non-visible disabilities has increased dramatically, primarily in households with the highest incomes (Houtrow et al., 2014).

A national survey conducted over 20 years ago estimated that about 7% of the total enrollment in Canadian postsecondary institutions had some type of identified disability (Hubka & Killean, 1999), with similar numbers reported in the USA (Brown et al., 2020). Data collected from various Canadian sources between 2005 and 2011 indicated that about 11% of community college students were receiving disability-related services compared with about 5% of all university students (McCloy & DeClou, 2013). Current reports, however, suggest that the number of students registered at postsecondary Disability Services Offices (DSOs) has increased even further, with up to 30% of students at private high schools and up to 25% of all postsecondary students registering with a postsecondary DSO (Belkin et al., 2019; Brown et al., 2020).

Rates of Non-visible Disabilities Are Rising Mainly in the Well-to-do

Many have suggested that the sharp rise in non-visible disability diagnoses given to the children from well-off families reflects the increase in tangible benefits associated with having a disability label (e.g., Abrams, 2005; Belkin et al., 2019; Tapper et al., 2006). For instance, there has been a steep rise over the past decade in the number of young adults with non-visible disabilities seeking accommodations on high-stakes tests and licensing exams (e.g., Lauth et al., 2017; Yellin, 2017). A number of authors (e.g., Abrams, 2005; Belkin et al., 2019; Goldstein & Patel, 2019) have documented that this increase has been fueled mainly by students from higher socio-economic backgrounds. Recent high-profile investigations such as the US College Admissions Scandal demonstrated how easily the accommodation and disability diagnosis system could be manipulated by privileged families for personal gain (see Escobar & Ahmed, 2019).

In the first article of this special issue, Weis and Bittner (2022, this issue) address this social problem. Conducting a broad audit of disability determination and accommodation granting over the past 12 years at both public and elite private postsecondary institutions in the USA, they demonstrate that the increase in students enrolling in DSOs over time is driven largely by students attending the most selective and expensive private schools. In fact, these schools have experienced a 117% increase in access rates since 2009. By contrast, over this same time period, access to disability-related accommodations increased only 31% at public (and less selective) 2-year colleges, the very institutions where one might predict that students with non-visible disabilities would typically enroll (e.g.. McCloy & DeClou, 2013). Data provided by the authors show that access to accommodations is also tied closely to both economic factors and evidence of financial privilege: enrollment with DSOs increased 124% at the most expensive schools, whereas it increased only 37% at the least expensive schools. Further, access to accommodations increased quadratically at the most selective private schools that have high admissions standards and a low acceptance rate, whereas DSO registration increased negligibly at open enrollment schools. These authors note that at some of the most selective private colleges in America, the base rate of reported disability ranges between 17 and 27% of the entire student population, something the authors feel is difficult to justify given that these have historically been the institutions with the most academically capable students. Weis and Bittner conclude that the current academic accommodation system is inequitable, favoring students from privileged backgrounds and disadvantaging those whose families lack the knowledge, understanding, or funds to obtain the supports that they or their children may need. To combat this, Weis and Bittner make a number of recommendations, some of which would remove the need for expensive (and perhaps biased) psychoeducational assessments as the gateway to receiving accommodations. If reports from psychologists continue to be required in order to access academic accommodations, Weis and Bittner call for clinicians to be held more accountable for their opinions, demonstrate objectively that the reported test scores are valid and credible, and call for postsecondary institutions to start critically evaluating the disability documentation they receive.

Clinicians in Need of a Reliable Income Source

Malleson (2002) noted that the rise in the whiplash industry occurred in part because there was an increase in the number of medical and allied health professionals who needed a reliable source of revenue within a background of a healthier population who had a declining need for such expensive services. Malleson pointed to the resulting insidious efforts of various medical specialists to legitimize subjectively diagnosed conditions and to create an epidemic by taking advantage of people’s suggestible nature.

Of interest, the rise in the number of students and young adults diagnosed with non-visible disorders has paralleled the rise in private practice psychological professionals. Historically, the vast majority of these professionals were employed by government-funded agencies rather than working in private practice (Vanden Bos & Stapp, 1983). When employed by an agency, these professionals were guaranteed an income regardless of number of referrals or, for the most part, satisfaction ratings from clients. They received a regular salary, a pension, medical benefits, and paid holidays. They did not have to recruit new clients and likely did not feel obliged to provide clients with their preferred diagnosis or any diagnosis at all if one was not warranted. Similarly, 40 years ago, the majority of people undergoing psychoeducational assessments, or parents whose children were being assessed, did not want to discover that they or their children had a disability. Relatively speaking, there were no advantages to be gained from a disability label, and most grieved when confronted with the news that they or their child had a disability for which treatments may or may not have existed (e.g., see Waisbren, 1980).

However, as early as 1995, concerns were raised regarding cuts to government-funded psychology positions. Dobson (1995) found that budget cuts in the traditional settings that employed psychologists (e.g., hospitals and schools) had resulted in psychology positions being scaled back or eliminated from these public institutions, leading psychologists to seek alternative sources of revenue. A 2005 survey of neuropsychologists in the USA and Canada found that 63.3% were in private practice, and 70.7% said that their most frequent referral question was determination of a diagnosis (Rabin et al., 2005). By 2015, nearly half (44.8%) of the psychologists surveyed by the American Psychological Association (APA) were in private practice, and only 2% were paid for their work by school boards. These findings are similar to the demographic changes for psychologists in Canada (Peachey et al., 2013).

Given the aforementioned changes in employment, private practice psychologists now needed to generate a regular revenue stream. Although there were people in need of treatment for anxiety and depression, most improved and graduated from treatment relatively quickly. Psychologists in private practice needed a more reliable and constant source of guaranteed income. Serendipitously, in the late 1990s, just at the time that the majority of psychologists were moving to private practice, students who had benefitted from legislation mandating special education services in elementary and high school system were now graduating from high school more frequently and seeking to pursue postsecondary studies (Nichols et al., 2002). Although these students may have been assessed in elementary school by a school psychologist, the colleges and universities to which they matriculated did not have a system in place to determine academic accommodation needs. It was also at about this time that high stakes testing agencies stopped “flagging” accommodated test scores, leading to a sharp increase in students requesting disability-related accommodations on timed college entrance exams (Abrams, 2005; Freedman, 2006; Mapou, 2022, this issue). Accommodation requests for tests like the SAT needed to be accompanied by an up-to-date psychoeducational or neuropsychological assessment. Hence, there was a new niche ready to be filled, namely psychoeducational/neuropsychological assessments conducted by private practice psychologists to verify the need for disability-related accommodations. At first, these were conducted mainly by professionals who had left hospital or school positions and were well versed in proper assessment practices. However, very soon, others realized the potential of an ongoing source of revenue for a relatively short investment of time (i.e., a psychoeducational assessment that lasts a few hours). While such assessments used to be relatively inexpensive, they now cost anywhere from $5000 to $10,000, depending on location (Belkin et al., 2019). At that price, one suspects that the clinician might be motivated to provide the client with a diagnosis that is wanted rather than warranted.

Malleson suggested that the steep increase in whiplash cases arose in part because some professionals were able to create an epidemic; they were willing to exploit people’s suggestible nature, encouraging people to be assessed for, and then blame all their troubles and difficulties on a useful illness (like whiplash) rather than take personal responsibility for their problems or working to remediate or eliminate the cause of their issues. The article by Suhr and Johnson (2022, in this special issue) addresses these issues directly. They document the marked increase in the number of postsecondary students currently receiving academic accommodations and the growing disparity in the types of students receiving these accommodations. These authors raise concerns about clinicians overpathologizing everyday behaviors and experiences, creating a manufactured epidemic and encouraging the adoption of an illness identity by these otherwise normal students.

Suhr and Johnson also cite research showing how self-reported symptoms can be manipulated by the students being assessed (consciously or unconsciously), and that giving inaccurate feedback about the meaning of otherwise normal symptoms can actually increase the later development of non-credible symptoms reported by such students (see also Privitera et al., 2015, for an excellent example of this phenomenon in the context of ADHD symptom reporting). The Suhr and Johnson article underscores the harm that such overpathologizing can and is doing and contrasts it with the moral imperative that clinicians have to ‘first do no harm’.

One Hand Washes the Other

Just as whiplash industry mills sprang up due to an exaggeration of an existing need, so too have psychological and medical clinics appeared in every city in North America, claiming to provide specialized assessments for young adults needing proof of their disability in order to obtain academic accommodations in school and/or on high stakes exams (e.g., Anderson, 2019; Belkin et al., 2019). In some cases, clinicians collaborate with DSOs at a local college or university, who in turn ensure that the student gains access to the federal or provincial grants that will underwrite the cost of the assessment (see, for example, Fanshaw College, 2018; Fovet, 2018). Staff at DSOs want to help and support students who claim to have problems and so seek out sympathetic clinicians whom they know will assist their students. We know that more than half of clinicians who author assessment reports for non-visible disabilities incorrectly believe that the purpose of a psychoeducational assessment is to secure accommodations for their client (Harrison et al., 2013), so their goal is to provide their client with this product (e.g., accommodations). Perhaps this explains why studies have shown that the majority of the time these same clinicians will provide a diagnosis even if the assessment data do not support published guidelines (see Harrison, 2017 for a review), or why 14% admitted that they would lie or bend the rules to secure accommodations for their clients (Harrison et al., 2013).

The resulting assessment and accommodation system provides benefits to all involved. The student receives a diagnosis that opens the doors to many financial, social, and academic benefits, the clinician has a paying customer (because the bill is paid for by the government disability funding grant that the DSO staff approved), and the DSO staff feel virtuous because they “helped” a student who claimed to be in need. Moreover, the more students with diagnosed disabilities who require services at a DSO, the greater the pressure on DSOs to hire more advisors to support these students. The DSO then grows and expands, and in turn, must continue generating clients to justify their existence. Since the gateway to receiving disability funding and academic accommodations is registration with the DSO, the number of people employed in these offices has also grown steadily since the 1990s (Evans et al., 2017). In 2008, most DSOs employed only two staff on average, while by 2018, this had swelled to an average of 13 full time staff, almost all of whom had permanent positions with pension and benefits (Scott, 2019; Seifert et al., 2011).

Malleson (2002) observed that patients “are capable of putting illness to good use” (p. 3), and that “victimhood can bring much gratification” (p. 330). Currently, young adults now diagnosed with a learning, attention, or mental health disability can enjoy not only extra time accommodations in school and on high-stakes exams, but in Canada they can also obtain up to $24,000/year in disability-related grants (not loans) from the provincial and federal government, receive a $2000/year tuition rebate, and obtain a disability tax credit. Even more, any time that they have trouble in school or in the workplace, they can claim that they were victims of discrimination due to lack of appropriate support or accommodation for their disability. Since they can obtain free legal representation when they file a complaint with their provincial Human Rights Office (similar to the Department of Justice in the USA), it costs the complainant nothing to file a complaint anytime they feel that they have been wronged or disadvantaged. Fearful of a drawn out and expensive legal battle and negative coverage in the press, many high-stakes testing agencies and postsecondary intuitions simply accede to the wishes of the complainant, providing whatever is requested without question. Hence, as noted in the whiplash industry, the non-visible disability diagnostic system can continue to grow without opposition, as there is little chance that either the student or the assessor will be called on to defend the disability diagnosis or need for accommodations.

Advocacy versus Objectivity

As Malleson predicted, the rise in the victimhood industry requires more than just tangible rewards for the assessors, care providers, and clients. It also requires a number of other conditions, many of which are discussed in the articles featured in this special issue. First and foremost, a victimhood industry requires conditions that are diagnosed subjectively using vague or contested criteria, and clinicians who are willing to bend (or ignore) the diagnostic criteria, and turn a blind eye to exaggeration or findings that do not meet criteria for a disability in order to advocate for their client. Like Malleson’s description of whiplash, clinicians must profess trust in their patients and, at the same time, ignore any signs that suggest the self-reported symptoms are implausible.

Harrison and Sparks (2022, this issue) confront the erosion of diagnostic standards and the increase in reasoning errors currently found in many of the psychoeducational and neuropsychological reports written for young adults requesting test accommodations in postsecondary education or on high-stakes examinations. These authors examine empirical evidence relevant to each of the seven most common ‘sins’ they encounter in their clinical practices, namely bias and conflict of interest, naivety, base rate blindness, cherry-picking, counting apples as oranges, psychometric sleight of hand, and blissful ignorance. The numerous studies they review offer a compelling and disturbing picture demonstrating that serious thinking and reasoning errors occur frequently in psychoeducational assessments, eroding the clinical accuracy and reliability of reports diagnosing non-visible disabilities in young adults. These authors posit a number of possible reasons for the rise in these “sins”, including concept creep and the advent of critical disability theory, and conclude by warning that if clinicians do not adopt a more objective and unbiased perspective in their work, their role in the accommodations verification process may be removed permanently.

Lovett (2022, this issue) attempts to answer more directly the question of why such diagnostic ‘sins’ might be occurring. Using a metaphor of the Scout or Soldier mentality, he examines how these different mindsets can influence the clinical reasoning and decision-making tasks undertaken by clinicians. The Soldier mindset involves motivated reasoning. Soldiers have a mission or goal, and work to ensure that the goal is achieved, but in pursuit of this goal, they ignore any information that conflicts with their primary goal. By contrast, the Scout mindset involves honestly and accurately evaluating all relevant information, even if what has been discovered is unpleasant or inconvenient. This mindset involves objectively evaluating all relevant information and changing one’s assumptions, even if those assumptions proved to be wrong. Lovett argues that clinicians now face strong pressure to adopt the Soldier mindset, but its adoption can lead to unethical practices and ignoring of diagnostic standards. Moreover, if a clinician is operating under a Soldier mentality, financial interests can cloud their judgement and decision-making, thereby increasing the tendency to adopt an advocate role rather than being an objective reporter of fact(s). Conversely, the Scout mindset requires open-minded, critical evaluation of data obtained in an evaluation, a fair and even-handed consideration of the facts, and honest reporting of findings. Lovett argues that every effort must be made to train future psychologists to adopt a Scout mindset in their assessment practices and concludes that clinicians can be both an advocate for a client and also embrace the Scout mindset when undertaking diagnostic assessments for non-visible disabilities.

The Benefits of Extra Time

Why would having a non-visible disability be beneficial academically? As demonstrated in the recent US College Admissions Scandal, extra time can provide a substantial benefit when taking timed, high-stakes tests (Picchi, 2019). Extra time helps all students do better on timed tests, so a non-disabled individual (or an individual whose impairments do not interfere with test-taking speed) will enjoy a substantial benefit in terms of access to test questions if they can secure an extra time accommodation. This may help explain the skyrocketing increase in requests for extra time accommodations on high stakes and licensing exams (Abrams, 2005; Belkin et al., 2019; Picchi, 2019). As Bill Singer, the mastermind behind the US College Admissions Scandal, noted when speaking with a client:

Yeah, everywhere around the country. What happened is, all the wealthy families that figured out that if I get my kid tested and they get extended time, they can do better on the test. So most of these kids don’t even have issues, but they’re getting time. The playing field is not fair (from the criminal complaint, as cited in Escobar & Ahmed, 2019).

Singer also reassured one parent that the double time his daughter would receive on the SAT due to her fraudulent diagnosis would also be “a huge advantage” once she was in college (Escobar & Ahmed, 2019). Hence, getting access to extra time accommodations is viewed as a substantial benefit that can help improve academic performance for any student, and so provision of such accommodations needs to be regulated and determined objectively and fairly.

Harrison et al. (2022, this issue) review the existing literature on extra time and offer readers some best practice guidelines for when this accommodation is reasonable and how much time should be offered to students with various non-visible disabilities. Historically, it was believed that extra test-taking time provided no benefit to nondisabled students, but provided a substantial boost only to those with non-visible disabilities (Lovett & Lewandowski, 2015). In practice, however, this has not proven to be the case. In fact, many studies have shown that providing extra test-taking time improves the scores of all individuals, especially when there is a speed component to the test (e.g., Lewandowski et al., 2013). For those with LD, Harrison et al. (2022, this issue) review research showing that anything more than 25% extra time confers greater access to test content relative to those writing in standard test conditions, and 100% extra time allows students with reading disabilities to access almost twice as many items as non-disabled students writing under standard time conditions. However, for other non-visible disabilities such as ADHD, anxiety, and depression, no objective data exists to support that such individuals require extra time due to disability-related impairment. In fact, extra time has been shown to provide a substantial advantage for such students in terms of access to test items (e.g. Harrison et al., 2020, 2022, this issue; Jansen et al., 2019; Miller et al., 2015; Pritchard et al., 2016). The guidelines provided in the contribution by Harrison et al. (2022, this issue) provide research-informed recommendations for how much extra time to award for which types of impairments in order to provide fair and equal test access.

Accommodations Arms Race and the Pressure to Diagnose

The articles discussed in this special issue so far outline the pressures currently placed on clinicians to diagnose a disability, and the incentives and benefits that lead individuals, families and even DSOs to seek a disability diagnosis. However, as shown above, families also feel that their children need access to extra time in order to keep up in the accommodations arms race (see also Belkin et al., 2019). The extent of the resulting duress on clinicians is evident in the final contribution to this special issue. Mapou (2022, this issue) outlines in detail why he no longer performs these types of assessments. The reader is taken on a journey through Dr. Mapou’s professional history as a psychologist specializing in diagnosis of non-visible disabilities, and the changes to both the diagnostic and legal systems over the past 20 years that have, in his opinion, watered down what it means to be disabled. Twenty years ago, he recalls assessing mainly individuals with genuine and demonstrable impairments, but gradually found that increasing numbers of his clients were otherwise normal individuals with only relative weaknesses who nevertheless wanted access to the benefits afforded by a disability diagnosis. In an accommodations arms race, wealthy parents sought a diagnosis for their child because all the other high-performing children in the class were being accommodated, and their child needed extra time so they could also improve their marks and remain academically competitive. Mapou cites this mounting pressures from (typically well-off) clients and their families to confirm a disability in an otherwise unimpaired person, and a loosening of the concept of what constitutes a disability (as defined by courts, the justice system, and even diagnostic codebooks), as reasons for his retirement from these types of assessments. When the reward for telling otherwise normal individuals that they are not disabled is anger, threats of litigation, and bad ratings on social media, whereas the positive benefits of providing a disability diagnosis is ‘likes’, positive ratings, and payment of a hefty fee, it may not be surprising that economic game theory (and the Solider mindset) trumps ethics and standards. When competent and ethical clinicians stop conducting these types of assessments due to mounting pressures to bend the rules and use flexible diagnostic criteria, the message is clear: we have a serious problem that needs to be addressed before the credibility of psychology as a profession is eroded and the concept of disability is undermined completely.

Conclusion: Where Do We Go from Here?

Ideally, we need a way to ensure that disability diagnoses and recommendations for accommodations are made using the Scout mindset, avoid bias and thinking errors, dis-incentivize illness identity and disability, and remove the tangible rewards given to otherwise normal individuals who receive a diagnosis. When determining functional impairment, Els et al. (2012) discuss the importance of objectively measuring impairment using well-established diagnostic standards. They also make a strong case for why opinions regarding level of impairment must come from an independent professional who has no duty to advocate for the patient. Unfortunately, the current system is not structured to allow for objective evaluations by impartial, unbiased third parties. Due to both economic pressures and the desire to advocate for clients, many clinicians adopt a role that conflicts with providing objective and impartial evidence for diagnosis of a disability and recommendations for accommodations. Unfortunately, turning to medical professionals to verify disability diagnoses is also fraught with difficulty. For instance, in Canada, medical specialists typically receive no training in how to objectively determine functional impairment in postsecondary-aged students, relying mainly on their clinical judgement, self-reports, or wishes of the clients (Harrison et al., 2018). Furthermore, medical doctors often see their role as being a patient advocate (Weinstein, 2001), making it virtually impossible for them to provide an independent, objective evaluation of a client’s disability status for legal purposes. Hence, asking medical doctors to verify a disability is also not an objective and reliable fix to the problem.

As emphasized by Mapou (2022, this issue), there is no doubt that non-visible disabilities such as LD, ADHD and significant mental health disorders are real and can have significant real-world impact on both academic performance and other major life activities. However, as demonstrated clearly by Mapou, the past 20 years have seen a watering down of the concept of what a disability is, and relative weaknesses due to normal variability in skills is often all that is now needed to obtain academic accommodations and supports. We know that the diagnosis and accommodation system is broken and in need of a hard reset when having a disability is now seen as a right or even as a loophole to be exploited. If psychologists will not adhere to established standards for disability diagnosis that require the presence of functional impairment, then the first step in the reset may be removal of psychologists from the diagnostic verification process.

This culling of psychologists from the disability-verification process is already starting in the USA (see, for example, Axelrod et al., 2021). Indeed, as Mapou (2022, this issue) discusses, recommendations issued by the US Department of Justice in 2015 specify that verification by any qualified professional (such as family physicians) could be sufficient to support the need for academic accommodations, but other acceptable verification could include observations by educators, a history of prior accommodations, or even the student’s own self-report. Indeed, Axelrod et al. (2021) have suggested that postsecondary and high stakes systems may need to rethink what documentation (if any) is required to confirm the presence of functional impairment and suggests that such documentation could rely mainly on self-reports and the disability service provider’s impressions of the student’s narrative. In what should be a warning to psychologists, Axelrod et al. state that an “expert” is unnecessary for diagnosing a disability or recommending accommodations. In fact, a disability diagnosis may not be necessary if educational and testing agencies adopt a Universal Design for Learning approach (e.g., La et al., 2018) and accommodations can be provided automatically to all test-takers, not just those who know how to game the system. Freedman (2006) has suggested that offering accommodations to all students may help stem the tide of incentivized disability diagnoses, as it would remove one of the main benefits currently sought by students.

However, this solution, while attractive, may end up disadvantaging those who are truly disabled and who actually need very specific accommodations and supports in some situations in order to participate equally in education. If everyone can self-identify as disabled without needing proof of actual impairment, then everyone will feel pressured to enter the accommodations arms race so that they, too, can obtain the academic, financial and legal benefits offered to those deemed eligible. This, in turn, will erode further the notion of disability and impairment, undermine confidence in the existence of actual non-visible disabilities, and may place too heavy a burden on existing and needed disability resources. In effect, those who need disability supports most may be crowded out by all the others who want access to the “benefits” that an illness can now confer. This is an example of the resulting harm to society about which Suhr and Johnson (2022, this issue) warn.

The concerns raised in this special issue about the expanded concept of “disability” and the increase in the numbers of students diagnosed are reminiscent of the concerns voiced by Senf (2009) regarding the LD concept and its widespread growth and acceptance by psychologists, educators, and consumers over the past 30 years. He describes the LD label as a “sociologic sponge” designed to “wipe up regular education’s spills and cleanse its ills” (p. 289). He sees the label as a convenient sponge that can absorb any educational problems rather than dealing directly with the cause of the spill (a task that would require much more work to accomplish). It seems that the expansion of disability to encompass otherwise normal variations in cognitive and academic abilities and the widespread promotion of non-visible disabilities by clinicians, educators, and related helping professions is today’s “sociologic sponge”, wiping up life’s spills by diagnosis of a disability and attempting to cure its ills with accommodations. That many of those absorbed by the “disability” sponge are not actually impaired or in need of accommodations, and how those not soaked up by the sponge may be harmed, does not appear to be an open question.