SSR 09-1p: Title XVI: Determining Childhood Disability Under the Functional Equivalence Rule — The “Whole Child” Approach

Effective Date: March 19, 2009 Publication

Date: February 17, 2009 Federal Register Vol. 74, No. 30, page

7527

POLICY INTERPRETATION RULING

Purpose:

This SSR provides policy interpretations and consolidates

information from our regulations, training materials, and question-and-answer

documents about our “whole child” approach for determining

whether a child's impairment(s) functionally equals the listings.

Citations:

Sections 1614(a)(3) , 1614(a)(4) ,

and 1614(c) of the Social Security Act, as amended; Regulations No. 4, subpart P,

appendix 1 ; and

Regulations No. 16, subpart I, sections 416.902 , 416.906 , 416.909 , 416.923 , 416.924 , 416.924a , 416.924b , 416.925 , 416.926 , 416.926a , and 416.994a .

Introduction:

A child [1] who applies for Supplemental Security Income

(SSI) [2] is “disabled”

if the child is not engaged in substantial gainful activity and has

a medically determinable physical or mental impairment or combination

of impairments [3] that results in "marked and severe functional limitations." [4] 20 CFR 416.906 . This

means that the impairment(s) must meet or

medically equal a listing in the Listing of Impairments (the

listings), [5] or functionally equal the listings (also referred to as

“functional equivalence”). 20 CFR 416.924 and 416.926a .

To functionally equal the listings , an impairment(s) must be of

listing-level severity; that is, it must result in “marked”

limitations in two domains of functioning or an “extreme”

limitation in one domain. [6] 20 CFR 416.926a(a) .

Domains are broad areas of functioning intended to

capture all of what a child can or cannot do. We use the following six

domains:

(1) Acquiring and using information,

(2) Attending and completing tasks,

(3) Interacting and relating with others,

(4) Moving about and manipulating objects,

(5) Caring for yourself, and

oning or an “extreme”

limitation in one domain. [6] 20 CFR 416.926a(a) .

Domains are broad areas of functioning intended to

capture all of what a child can or cannot do. We use the following six

domains:

(1) Acquiring and using information,

(2) Attending and completing tasks,

(3) Interacting and relating with others,

(4) Moving about and manipulating objects,

(5) Caring for yourself, and

(6) Health and physical well-being.

20 CFR 416.926a(b)(1) . [7]

Our rules provide that we start our evaluation of functional

equivalence by considering the child's functioning without considering

the domains or individual impairments. They provide that “[w]hen

we evaluate your functioning and decide which domains may be affected

by your impairment(s), we will look first at your activities and

limitations and restrictions.” [8] 20 CFR 416.926a(c) (emphasis

added). Our rules also provide that we:

20 CFR 416.926a(b) (emphasis

added).

After we identify which of a child's activities are

limited, we determine which domains are involved in those activities.

We then determine whether the child's impairment(s) could affect

those domains and account for the limitations. This is because:

20 CFR 416.926a(c) .

We then rate the severity of the limitations in each affected domain.

This technique "

for determining functional equivalence accounts for all of the effects

of a child's impairments singly and in combination—the interactive

and cumulative effects of the impairments—because it starts

with a consideration of actual functioning in all settings. We have

long called this technique our “whole child” approach.

Policy Interpretation

I. General

each affected domain.

This technique "

for determining functional equivalence accounts for all of the effects

of a child's impairments singly and in combination—the interactive

and cumulative effects of the impairments—because it starts

with a consideration of actual functioning in all settings. We have

long called this technique our “whole child” approach.

Policy Interpretation

I. General

We always evaluate

the “whole child” when we make a finding regarding functional

equivalence, unless we can make a fully favorable determination or

decision without having to do so. The functional equivalence rules

require us to begin by considering how the child functions every

day and in all settings compared to other children the same age

who do not have impairments. After we determine how the child functions

in all settings, we use the domains to create a picture of how, and

the extent to which, the child is limited by identifying the abilities

that are used to do each activity, and assigning each activity to

any and all of the domains involved in doing it. We then determine

whether the child's medically determinable impairment(s) accounts

for the limitations we have identified. Finally, we rate the overall

severity of limitation in each domain to determine whether the child

is “disabled” as defined in the Act.

More specifically, we consider the following questions.

- How does the child function? “Functioning” refers

to a child's activities; that is, everything a child does throughout

the day at home, at school, and in the community, such as getting

dressed for school, cooperating with caregivers, playing with friends,

and doing class assignments

her the child

is “disabled” as defined in the Act.

More specifically, we consider the following questions.

- How does the child function? “Functioning” refers

to a child's activities; that is, everything a child does throughout

the day at home, at school, and in the community, such as getting

dressed for school, cooperating with caregivers, playing with friends,

and doing class assignments. We consider: What activities the child is able to perform, What activities the child is not able to perform, Which of the child's activities are limited or restricted, Where the child has difficulty with activities—at home,

in childcare, at school, or in the community, Whether the child has difficulty independently initiating, sustaining,

or completing activities, The kind of help, and how much help the child needs to do activities,

and how often the child needs it, and Whether the child needs a structured or supportive setting, what

type of structure or support the child needs, and how often the child

needs it. 20 CFR 416.926a(b)(2) .

- Which domains are involved in performing the activities? We assign each activity to any and all of the domains involved in performing

it. Many activities require more than one of the abilities described

by the first five domains and may also be affected by problems that

we evaluate in the sixth domain.

- Could the child's medically determinable impairment(s) account

for limitations in the child's activities? If it could, and there

is no evidence to the contrary, we conclude that the impairment(s)

causes the activity limitations we have identified in each domain.

e of the abilities described

by the first five domains and may also be affected by problems that

we evaluate in the sixth domain.

- Could the child's medically determinable impairment(s) account

for limitations in the child's activities? If it could, and there

is no evidence to the contrary, we conclude that the impairment(s)

causes the activity limitations we have identified in each domain.

- To what degree does the impairment(s) limit the child's ability

to function age-appropriately in each domain? We consider how well

the child can initiate, sustain, and complete activities, including

the kind, extent, and frequency of help or adaptations the child

needs, the effects of structured or supportive settings on the child's

functioning, where the child has difficulties (at home, at school,

and in the community), and all other factors that are relevant to

the determination of the degree of limitation. 20 CFR 416.924a .

How does the child function? “Functioning” refers

to a child's activities; that is, everything a child does throughout

the day at home, at school, and in the community, such as getting

dressed for school, cooperating with caregivers, playing with friends,

and doing class assignments. We consider:

- What activities the child is able to perform,

- What activities the child is not able to perform,

- Which of the child's activities are limited or restricted,

- Where the child has difficulty with activities—at home,

in childcare, at school, or in the community,

- Whether the child has difficulty independently initiating, sustaining,

or completing activities,

- The kind of help, and how much help the child needs to do activities,

and how often the child needs it, and

- Whether the child needs a structured or supportive setting, what

type of structure or support the child needs, and how often the child

needs it.

What activities the child is able to perform,

What activities the child is not able to perform,

Which of the child's activities are limited or restricted,

, and how much help the child needs to do activities,

and how often the child needs it, and

- Whether the child needs a structured or supportive setting, what

type of structure or support the child needs, and how often the child

needs it.

What activities the child is able to perform,

What activities the child is not able to perform,

Which of the child's activities are limited or restricted,

Where the child has difficulty with activities—at home,

in childcare, at school, or in the community,

Whether the child has difficulty independently initiating, sustaining,

or completing activities,

The kind of help, and how much help the child needs to do activities,

and how often the child needs it, and

Whether the child needs a structured or supportive setting, what

type of structure or support the child needs, and how often the child

needs it.

20 CFR 416.926a(b)(2) .

Which domains are involved in performing the activities? We assign each activity to any and all of the domains involved in performing

it. Many activities require more than one of the abilities described

by the first five domains and may also be affected by problems that

we evaluate in the sixth domain.

Could the child's medically determinable impairment(s) account

for limitations in the child's activities? If it could, and there

is no evidence to the contrary, we conclude that the impairment(s)

causes the activity limitations we have identified in each domain.

To what degree does the impairment(s) limit the child's ability

to function age-appropriately in each domain? We consider how well

the child can initiate, sustain, and complete activities, including

the kind, extent, and frequency of help or adaptations the child

needs, the effects of structured or supportive settings on the child's

functioning, where the child has difficulties (at home, at school,

and in the community), and all other factors that are relevant to

the determination of the degree of limitation. 20 CFR 416.924a .

ld can initiate, sustain, and complete activities, including

the kind, extent, and frequency of help or adaptations the child

needs, the effects of structured or supportive settings on the child's

functioning, where the child has difficulties (at home, at school,

and in the community), and all other factors that are relevant to

the determination of the degree of limitation. 20 CFR 416.924a .

This technique of looking first at the child's actual functioning

in all activities and settings and considering all domains that are

involved in doing those activities, accounts for the interactive

and cumulative effects of the child's impairment(s), including any

impairments that are not “severe.” This is because limitations

in a child's activities will generally be the manifestation of any

difficulties that result from the impairments both individually

and in combination. [9]

In sections II, III, and IV, we provide

more detail about the technique for determining functional equivalence.

However, we do not require our adjudicators to discuss all of the

considerations in the sections below in their determinations and

decisions, only to provide sufficient detail so that any subsequent

reviewers can understand how they made their findings.

II. Determining which domains are involved in doing activities.

A. General.

The “whole child” approach recognizes

that many activities require the use of more than one of the abilities

described in the first five domains, and that they may also be affected

by a problem that we consider in the sixth domain. A single impairment,

as well as a combination of impairments, may result in limitations

that require evaluation in more than one domain. [10] Conversely, a combination

of impairments, as well as a single impairment, may result in limitations

that we rate in only one domain.

scribed in the first five domains, and that they may also be affected

by a problem that we consider in the sixth domain. A single impairment,

as well as a combination of impairments, may result in limitations

that require evaluation in more than one domain. [10] Conversely, a combination

of impairments, as well as a single impairment, may result in limitations

that we rate in only one domain.

Therefore, it is incorrect

to assume that the effects of a particular medical impairment must

be rated in only one domain or that a combination of impairments

must always be rated in several. Rather, adjudicators must consider

the particular effects of a child's impairment(s) on the child's

activities in any and all of the domains that the child uses to do

those activities, based on the evidence in the case record. [11]

In

the sections that follow, we provide examples to illustrate how we

apply these principles. These examples do not indicate whether a

child is disabled, only how we assign limitations in a child's activities

to a domain or domains. The rating of severity—determining

whether the child is disabled—comes later. See sections III

and IV below.

B. Examples of activities that typically require two or more

abilities.

- Tying shoes. Tying shoes typically requires abilities in

at least four domains: Learning and remembering the sequence for tying (Acquiring and

using information), Focusing on the task (Attending and completing tasks), Using the fingers and hands to do the task (Moving about and

manipulating objects), and Taking responsibility for dressing and appearance (Caring for

yourself). Therefore, depending on the nature and effects of the impairment(s),

a child who has difficulty tying his shoes may have limitations in

one, two, three, or even all of these domains

ocusing on the task (Attending and completing tasks), Using the fingers and hands to do the task (Moving about and

manipulating objects), and Taking responsibility for dressing and appearance (Caring for

yourself). Therefore, depending on the nature and effects of the impairment(s),

a child who has difficulty tying his shoes may have limitations in

one, two, three, or even all of these domains. For example, if a

child has a deformity of the hands and fingers that affects only

manipulation, the only domain that might be affected is “Moving

about and manipulating objects.” However, if the child has

pain or other symptoms, there might also be a problem in concentration,

which we would also evaluate in the domain of “Attending and

completing tasks.” There might also be limitations in other

domains. [12]

- Riding a public bus. Taking a public bus independently typically

requires the abilities in the first five domains: Knowing how, where, and when to catch the bus, which bus to ride,

the amount of the fare and how to pay it, and how and where to get

off, as well as properly accomplishing these tasks (Acquiring and

using information, Attending and completing tasks). Relating appropriately to the driver and other passengers (Interacting

and relating with others), Being physically able to get on and off the bus (Moving about

and manipulating objects), and Following safety rules (Caring for yourself).

Tying shoes. Tying shoes typically requires abilities in

at least four domains:

- Learning and remembering the sequence for tying (Acquiring and

using information),

- Focusing on the task (Attending and completing tasks),

- Using the fingers and hands to do the task (Moving about and

manipulating objects), and

- Taking responsibility for dressing and appearance (Caring for

yourself).

Learning and remembering the sequence for tying (Acquiring and

using information),

Focusing on the task (Attending and completing tasks),

quiring and

using information),

- Focusing on the task (Attending and completing tasks),

- Using the fingers and hands to do the task (Moving about and

manipulating objects), and

- Taking responsibility for dressing and appearance (Caring for

yourself).

Learning and remembering the sequence for tying (Acquiring and

using information),

Focusing on the task (Attending and completing tasks),

Using the fingers and hands to do the task (Moving about and

manipulating objects), and

Taking responsibility for dressing and appearance (Caring for

yourself).

Therefore, depending on the nature and effects of the impairment(s),

a child who has difficulty tying his shoes may have limitations in

one, two, three, or even all of these domains. For example, if a

child has a deformity of the hands and fingers that affects only

manipulation, the only domain that might be affected is “Moving

about and manipulating objects.” However, if the child has

pain or other symptoms, there might also be a problem in concentration,

which we would also evaluate in the domain of “Attending and

completing tasks.” There might also be limitations in other

domains. [12]

Riding a public bus. Taking a public bus independently typically

requires the abilities in the first five domains:

- Knowing how, where, and when to catch the bus, which bus to ride,

the amount of the fare and how to pay it, and how and where to get

off, as well as properly accomplishing these tasks (Acquiring and

using information, Attending and completing tasks).

- Relating appropriately to the driver and other passengers (Interacting

and relating with others),

- Being physically able to get on and off the bus (Moving about

and manipulating objects), and

- Following safety rules (Caring for yourself).

pay it, and how and where to get

off, as well as properly accomplishing these tasks (Acquiring and

using information, Attending and completing tasks).

- Relating appropriately to the driver and other passengers (Interacting

and relating with others),

- Being physically able to get on and off the bus (Moving about

and manipulating objects), and

- Following safety rules (Caring for yourself).

Knowing how, where, and when to catch the bus, which bus to ride,

the amount of the fare and how to pay it, and how and where to get

off, as well as properly accomplishing these tasks (Acquiring and

using information, Attending and completing tasks).

Relating appropriately to the driver and other passengers (Interacting

and relating with others),

Being physically able to get on and off the bus (Moving about

and manipulating objects), and

Following safety rules (Caring for yourself).

Again, depending on the nature and particular effects of

the impairment(s), a child who has difficulty riding a public bus

may have limitations in any one, two, several, or even all of these

domains.

C. Example of a child with a single impairment that

is rated in more than one domain.

A boy in elementary school

with attention-deficit/hyperactivity disorder (AD/HD) has trouble

with all of the following activities.

- Reading class assignments. The child repeatedly misreads words

by impulsively guessing what they are based on the first letters

or the shapes of the words, and he is not keeping up with the rest

of his class. His ability to learn and think about information in

school is at least partly dependent on how well he can read. These

difficulties indicate a limitation in the domain of “Acquiring

and using information.”

ments. The child repeatedly misreads words

by impulsively guessing what they are based on the first letters

or the shapes of the words, and he is not keeping up with the rest

of his class. His ability to learn and think about information in

school is at least partly dependent on how well he can read. These

difficulties indicate a limitation in the domain of “Acquiring

and using information.”

- Following classroom instructions. The child generally carries

out only the first part of three-part instructions. Being unable

to sustain focus, he quickly goes on to unrelated activities. He

also makes mistakes in carrying out the instructions on which he

does try to focus. He needs controlled, directed attention to carry

out instructions correctly. These difficulties indicate a limitation

in the domain of “Attending and completing tasks.”

- Playing with others. The child will typically approach a group

of children, interrupt whoever is talking, and begin telling his

own story, leading to conflicts with the other children. To successfully

interact and relate with peers, the child must understand the social

situation and use appropriate behaviors to approach other children.

These difficulties indicate a limitation in the domain of “Interacting

and relating with others.”

- Avoiding danger. The child often impulsively dashes out into

the street without looking for cars and considering his safety. Being

responsible for his own safety requires the child to stop moving

and to be cautious before stepping into the street. These difficulties

in self-related activities indicate a limitation in the domain of

“Caring for yourself.”

eracting

and relating with others.”

- Avoiding danger. The child often impulsively dashes out into

the street without looking for cars and considering his safety. Being

responsible for his own safety requires the child to stop moving

and to be cautious before stepping into the street. These difficulties

in self-related activities indicate a limitation in the domain of

“Caring for yourself.”

Reading class assignments. The child repeatedly misreads words

by impulsively guessing what they are based on the first letters

or the shapes of the words, and he is not keeping up with the rest

of his class. His ability to learn and think about information in

school is at least partly dependent on how well he can read. These

difficulties indicate a limitation in the domain of “Acquiring

and using information.”

Following classroom instructions. The child generally carries

out only the first part of three-part instructions. Being unable

to sustain focus, he quickly goes on to unrelated activities. He

also makes mistakes in carrying out the instructions on which he

does try to focus. He needs controlled, directed attention to carry

out instructions correctly. These difficulties indicate a limitation

in the domain of “Attending and completing tasks.”

Playing with others. The child will typically approach a group

of children, interrupt whoever is talking, and begin telling his

own story, leading to conflicts with the other children. To successfully

interact and relate with peers, the child must understand the social

situation and use appropriate behaviors to approach other children.

These difficulties indicate a limitation in the domain of “Interacting

and relating with others.”

ally approach a group

of children, interrupt whoever is talking, and begin telling his

own story, leading to conflicts with the other children. To successfully

interact and relate with peers, the child must understand the social

situation and use appropriate behaviors to approach other children.

These difficulties indicate a limitation in the domain of “Interacting

and relating with others.”

Avoiding danger. The child often impulsively dashes out into

the street without looking for cars and considering his safety. Being

responsible for his own safety requires the child to stop moving

and to be cautious before stepping into the street. These difficulties

in self-related activities indicate a limitation in the domain of

“Caring for yourself.”

Therefore, even though attentional difficulties and hyperactivity

are hallmarks of AD/HD, in this case it would be incorrect to assume

that this child's AD/HD causes limitations only in the domain of

“Attending and completing tasks.” This child's activities

demonstrate that his single impairment causes limitations that we

must rate in four domains.

D. Example of a child with a combination

of impairments that is rated in only one domain.

A girl

in middle school has a mild hearing disorder that affects both her

hearing and speech. She also has a repaired complete cleft lip and

palate that affects her speech as well as her appearance. She has

difficulty hearing other children, especially on the playground during

games, and they have difficulty understanding what she says. The

other children do not approach her, and they also make fun of her

because of her appearance and speech difficulties. Consequently,

she has difficulty forming friendships with her classmates. She tends

to stay to herself during recess and lunchtime and plays alone when

at home. [13]

children, especially on the playground during

games, and they have difficulty understanding what she says. The

other children do not approach her, and they also make fun of her

because of her appearance and speech difficulties. Consequently,

she has difficulty forming friendships with her classmates. She tends

to stay to herself during recess and lunchtime and plays alone when

at home. [13]

However, she does not have any difficulty learning.

She completes all her schoolwork and chores on time, appropriately,

and without unusual assistance, is well-behaved and otherwise cares

for herself age-appropriately. She also has no motor difficulties.

In this example, the evidence shows that the child has only social

limitations at school and in her neighborhood, and that the limitations

in her activities are the result of her difficulty communicating

effectively with other children because of her hearing and speech

problems and appearance. Therefore, the combination of this child's

two impairments causes limitations only in the domain of “Interacting

and relating with others.”

It is unnecessary to evaluate

the effects of each of the child's impairments separately and then

to determine their combined effects. Since we start by evaluating

her functioning (in this case, her social limitations), the limitations

in interacting and relating with others established by the evidence

in the case record reflect the combined effects of her impairments.

E. Example of a child with a combination of impairments that is rated

in more than one domain.

ments separately and then

to determine their combined effects. Since we start by evaluating

her functioning (in this case, her social limitations), the limitations

in interacting and relating with others established by the evidence

in the case record reflect the combined effects of her impairments.

E. Example of a child with a combination of impairments that is rated

in more than one domain.

An adolescent has a diagnosis of

borderline intellectual functioning (BIF) and has been a “slow

learner” throughout school. She also has recently been diagnosed

with depression. She has received special education services throughout

her school years and is now in the 11th grade. She has attended special

classes for all of her academic subjects, but has been mainstreamed

for some elective courses and extracurricular activities. Her teacher

reports that she performed satisfactorily in most of her classes

in previous years, but for the past two semesters has become inattentive

in class, has failed three academic subjects because of inattention

and failure to complete her assignments, and has frequently refused

to go to school. Her mother reports that at home the child cries

a lot, sleeps as long as 12 hours every night, eats irregularly,

complains of headaches, and is irritable, uncooperative, and angry

more often than not. Despite many attempts, the parent has been unable

to engage her daughter in talking about what is wrong and how she

might help.

The student's difficulty with activities at school

and at home involves three, and possibly four, domains:

- Her many years of placement in special education classes for

all academic work indicate a limitation that we would rate in the

domain of “Acquiring and using information.”

- Her inattention in class and current failure in three academic

subjects as a consequence indicate that there is also a limitation

in the domain of “Attending and completing tasks.”

es three, and possibly four, domains:

- Her many years of placement in special education classes for

all academic work indicate a limitation that we would rate in the

domain of “Acquiring and using information.”

- Her inattention in class and current failure in three academic

subjects as a consequence indicate that there is also a limitation

in the domain of “Attending and completing tasks.”

- Her mother's description of some of the child's difficulties

at home (for example, crying, oversleeping, physical complaints,

and irritability) and the child's avoidance of dealing with them

indicate a limitation in the domain of “Caring for yourself.”

- In addition, if her refusal to talk with her mother and her anger

and uncooperativeness exceed what would be expected of adolescents

of the same age who do not have an impairments, this would indicate

a limitation in the domain of “Interacting and relating with

others.”

Her many years of placement in special education classes for

all academic work indicate a limitation that we would rate in the

domain of “Acquiring and using information.”

Her inattention in class and current failure in three academic

subjects as a consequence indicate that there is also a limitation

in the domain of “Attending and completing tasks.”

Her mother's description of some of the child's difficulties

at home (for example, crying, oversleeping, physical complaints,

and irritability) and the child's avoidance of dealing with them

indicate a limitation in the domain of “Caring for yourself.”

In addition, if her refusal to talk with her mother and her anger

and uncooperativeness exceed what would be expected of adolescents

of the same age who do not have an impairments, this would indicate

a limitation in the domain of “Interacting and relating with

others.”

III. Rating severity

A. General.

dance of dealing with them

indicate a limitation in the domain of “Caring for yourself.”

In addition, if her refusal to talk with her mother and her anger

and uncooperativeness exceed what would be expected of adolescents

of the same age who do not have an impairments, this would indicate

a limitation in the domain of “Interacting and relating with

others.”

III. Rating severity

A. General.

Once we

have determined which of a child's activities are limited, which

domain or domains are involved, and that the limitations are the

result of a medically determinable impairment(s), we rate the severity

of the limitations and determine whether the impairment(s) functionally

equals the listings. We consider all relevant evidence in the case

record, including objective medical and other evidence, and all

of the relevant factors discussed in 20 CFR 416.924a . [14]

It is important to determine the extent to which an impairment(s)

compromises a child's ability to independently initiate, sustain, and complete

activities. To do so, we consider the kinds of help or support the

child needs in order to function. See 20 CFR 416.924a(b) .

In general, if a child needs a person, medication, treatment, device,

or structured, supportive setting to make his functioning possible

or to improve the functioning, the child will not be as independent

as same-age peers who do not have impairments. Such a child will

have a limitation, even if he is functioning well with the help

or support.

The more help or support of any kind that a child

receives beyond what would be expected for children the same age

without impairments, the less independent the child is in functioning,

and the more severe we will find the limitation to be. For example:

as same-age peers who do not have impairments. Such a child will

have a limitation, even if he is functioning well with the help

or support.

The more help or support of any kind that a child

receives beyond what would be expected for children the same age

without impairments, the less independent the child is in functioning,

and the more severe we will find the limitation to be. For example:

- A 10-year-old child who is dressed appropriately may appear not

to be limited in this activity. However, if the evidence in the case

record shows that the child needs significant help from her parents

with the basics of dressing every day (for example, putting on and

buttoning shirts), the child will have a limitation of that

activity. [15]

- A 14-year-old child who has a serious emotional disturbance may

be given “wrap-around services” that include the services

of an adult who supervises the child at school. With these services,

the child attends school, participates in activities with other children,

and does not take any actions that endanger himself or others. However,

the degree of “extra help” [16] the child needs to function

demonstrates a limitation in at least the domains of “Interacting

and relating with others” and “Caring for

yourself.”

A 10-year-old child who is dressed appropriately may appear not

to be limited in this activity. However, if the evidence in the case

record shows that the child needs significant help from her parents

with the basics of dressing every day (for example, putting on and

buttoning shirts), the child will have a limitation of that

activity. [15]

relating with others” and “Caring for

yourself.”

A 10-year-old child who is dressed appropriately may appear not

to be limited in this activity. However, if the evidence in the case

record shows that the child needs significant help from her parents

with the basics of dressing every day (for example, putting on and

buttoning shirts), the child will have a limitation of that

activity. [15]

A 14-year-old child who has a serious emotional disturbance may

be given “wrap-around services” that include the services

of an adult who supervises the child at school. With these services,

the child attends school, participates in activities with other children,

and does not take any actions that endanger himself or others. However,

the degree of “extra help” [16] the child needs to function

demonstrates a limitation in at least the domains of “Interacting

and relating with others” and “Caring for

yourself.”

B. Rating the severity of limitations in the domains.

When we determine the degree to which the child's impairment(s) limits

each affected domain, we use the definitions of “marked”

or “extreme” in our regulations.

See 20 CFR 416.926a(e) .

The following discussion provides further guidance

about how to apply those definitions.

To determine whether there

is a “marked” or an “extreme” limitation

in a domain, we use a picture constructed of the child's functioning

in each domain. This last step in the “whole child” approach

summarizes everything we know about a child's limited activities.

The rating of limitation in a domain is then based on the answers

to these questions:

- How many of the child's activities in the domain are limited

(for example, one, few, several, many, or all)?

- How important are the limited activities to the child's age-appropriate

functioning (for example, basic, marginally important, or essential)?

- How frequently do the activities occur and how frequently are

they limited (for example, daily, once a week, or only occasionally)?

ions:

- How many of the child's activities in the domain are limited

(for example, one, few, several, many, or all)?

- How important are the limited activities to the child's age-appropriate

functioning (for example, basic, marginally important, or essential)?

- How frequently do the activities occur and how frequently are

they limited (for example, daily, once a week, or only occasionally)?

- Where do the limitations occur (for example, only at home or

in all settings)?

- What factors are involved in the limited activities (for example,

does the child receive support from a person, medication, treatment,

device, or structured/supportive setting)?

How many of the child's activities in the domain are limited

(for example, one, few, several, many, or all)?

How important are the limited activities to the child's age-appropriate

functioning (for example, basic, marginally important, or essential)?

How frequently do the activities occur and how frequently are

they limited (for example, daily, once a week, or only occasionally)?

Where do the limitations occur (for example, only at home or

in all settings)?

What factors are involved in the limited activities (for example,

does the child receive support from a person, medication, treatment,

device, or structured/supportive setting)?

There is no set formula for applying these considerations

in each case. A child's day-to-day functioning may be seriously or

very seriously limited whether an impairment(s) limits only one activity

or whether it limits several. See 20 CFR 416.926a(e)(2) and (e)(3) .

Also, we may find that a child has a “marked” or

“extreme” limitation of a domain even though the child

does not have serious or very serious limitations every day. As in

any case, we must consider the effects of the impairment(s) longitudinally

(that is, over time) when we evaluate the severity of the child's

limitations

or whether it limits several. See 20 CFR 416.926a(e)(2) and (e)(3) .

Also, we may find that a child has a “marked” or

“extreme” limitation of a domain even though the child

does not have serious or very serious limitations every day. As in

any case, we must consider the effects of the impairment(s) longitudinally

(that is, over time) when we evaluate the severity of the child's

limitations. [17] The judgment about whether there is a “marked”

or “extreme” limitation of a domain depends on the importance

and frequency of the limited activities and the relative weight of

the other considerations described above.

Adjudicators must

also be alert to the possibility that limitation of several seemingly

minor activities may point to a larger problem that requires further

evaluation. For example, a young child may have serious difficulty

with common childhood activities such as scribbling, using scissors,

or copying shapes, which in themselves may not appear to be important

to age-appropriate functioning. It would be unlikely, however, that

a young child would have serious difficulty with those common activities

but have no trouble with other activities, such as buttoning a shirt

or printing letters, that also involve fine motor or perceptual-motor

ability. Such additional difficulties would indicate that the child

has more significant problems with age-appropriate functioning than

just scribbling, using scissors, or copying shapes alone might suggest.

serious difficulty with those common activities

but have no trouble with other activities, such as buttoning a shirt

or printing letters, that also involve fine motor or perceptual-motor

ability. Such additional difficulties would indicate that the child

has more significant problems with age-appropriate functioning than

just scribbling, using scissors, or copying shapes alone might suggest.

Finally, the rating of limitation of a domain is not an “average”

of what activities the child can and cannot do. When evaluating whether

a child's functioning is age-appropriate, adjudicators must consider

evidence about all of the child's activities. We do not “average”

all of the findings in the evidence about a child's activities to

come up with a rating for the domain as a whole. The fact that a

child can do a particular activity or set of activities relatively

well does not negate the difficulties the child has in doing other

activities.

IV. Example of a functional equivalence analysis

In this section, we provide an example of how we would consider a

child's activities at the functional equivalence step. In this example,

we provide only partial evidence to illustrate how we consider activities

and sort them into the domains. We do not rate the severity of the

limitations because we are not providing complete evidence and because

rating severity based on a specific set of case facts would not

be useful in other cases.

Example: A parent files a claim on

behalf of her 8-year-old son, alleging that anxiety keeps him from

living normally, going to school regularly, and playing with other

children. The evidence establishes that the child has a generalized

anxiety disorder (GAD) that is “severe” but that does

not meet or medically equal listing 112.06.

A. How does the child function?

be useful in other cases.

Example: A parent files a claim on

behalf of her 8-year-old son, alleging that anxiety keeps him from

living normally, going to school regularly, and playing with other

children. The evidence establishes that the child has a generalized

anxiety disorder (GAD) that is “severe” but that does

not meet or medically equal listing 112.06.

A. How does the child function?

The child says that he cannot sleep because

he is afraid of the dark and the noises he hears outside, and that

he needs to be awake and keep his eyes open as long as possible in

case anything happens. His mother reports that he refuses to go to

bed, must be coaxed into his room, frequently will not stay there,

and gets up and watches television until he falls asleep in front

of it. He does not sleep well at night and in the daytime is often

irritable. Sometimes, he is combative. He cries when he has to leave

for school, and his mother must sometimes ride with him on the school

bus. His teacher reports a reduction in his energy and attention

in school, that he has trouble focusing in class and does little

work at school or at home, and that he may not be promoted at the

end of the year because he has fallen behind in his learning. She

also reports that he sometimes refuses to leave the classroom for

recess or activities anywhere else in the school building or playground,

and that an aide must stay with him when he does. She says that the

child seems suspicious of other children in his class because he

frequently reports things they do and say that worry and frighten

him.

The child is seen regularly by a clinical psychologist.

Results of formal evaluation, including an anxiety scale and a depression

inventory, contribute to a profile of GAD. His pediatrician prescribed

two kinds of medications, but both had unacceptable side effects,

so the child does not take them. He is in play therapy.

B. Which domains are involved in the child's limited activities?

him.

The child is seen regularly by a clinical psychologist.

Results of formal evaluation, including an anxiety scale and a depression

inventory, contribute to a profile of GAD. His pediatrician prescribed

two kinds of medications, but both had unacceptable side effects,

so the child does not take them. He is in play therapy.

B. Which domains are involved in the child's limited activities?

The following chart [18] provides a picture of the child's functioning, including

information about several factors that are relevant to determining

the severity of his limitations; for example, help from a parent

and school aide, medications, and play therapy. As shown in the chart,

the descriptions from the evidence about how the child functions

must be specific, not general. For example, “the child is anxious”

is a general conclusion, while the notes in the chart below state

specifically what the child does and how he does it, based on his

own words and the observations of the medical sources and adults

who know him and spend the most time with him.

C. Could the child's medically determinable impairment(s)

limit any of his activities?

In the example described above,

the medically determinable impairment of GAD clearly accounts for

the child's problems, and there is no evidence to the

contrary. [19] Therefore, it is appropriate to conclude that the child's GAD results

in limitations that are evaluated in five of the six domains, as

indicated in the chart above.

V. Responsibility for determining functional equivalence

The responsibility for making functional

equivalence determinations depends on the level of the administrative

review process.

- For initial and reconsideration determinations, the State agency

medical or psychological consultant has the overall responsibility

for determining functional equivalence.

, as

indicated in the chart above.

V. Responsibility for determining functional equivalence

The responsibility for making functional

equivalence determinations depends on the level of the administrative

review process.

- For initial and reconsideration determinations, the State agency

medical or psychological consultant has the overall responsibility

for determining functional equivalence.

- When an SSI recipient has requested a hearing before a disability

hearing officer at the reconsideration level, the disability hearing

officer determines functional equivalence.

- For cases at the Administrative Law Judge (ALJ) and Appeals Council

(AC) levels (when the AC makes a decision), the ALJ or AC determines

functional equivalence. 20 CFR 416.926a(n) .

For initial and reconsideration determinations, the State agency

medical or psychological consultant has the overall responsibility

for determining functional equivalence.

When an SSI recipient has requested a hearing before a disability

hearing officer at the reconsideration level, the disability hearing

officer determines functional equivalence.

For cases at the Administrative Law Judge (ALJ) and Appeals Council

(AC) levels (when the AC makes a decision), the ALJ or AC determines

functional equivalence. 20 CFR 416.926a(n) .

While SSR 96-6p [20] requires that an ALJ or the

AC must obtain an updated medical expert opinion before making a decision

of disability based on medical equivalence, there is no such requirement

for decisions of disability based on functional equivalence. Therefore,

ALJs and the AC (when the AC makes a decision) are not required to

obtain updated medical expert opinions when they determine that a

child's impairment(s) functionally equals the

listings. [21]

Effective date:

This SSR is effective on March 19, 2009.

Cross-References:

medical equivalence, there is no such requirement

for decisions of disability based on functional equivalence. Therefore,

ALJs and the AC (when the AC makes a decision) are not required to

obtain updated medical expert opinions when they determine that a

child's impairment(s) functionally equals the

listings. [21]

Effective date:

This SSR is effective on March 19, 2009.

Cross-References:

SSR 09-2p ,

Title: Determining Childhood Disability

— Documenting a Child's Impairment-Related Limitations; SSR 09-3p ,

Title XVI: Determining Childhood Disability — The

Functional Equivalence Domain of “Acquiring and Using Information”; SSR 09-4p ,

Title XVI: Determining Childhood Disability —

The Functional Equivalence Domain of “Attending and Completing

Tasks”; SSR 09-5p , Title XVI:

Determining Childhood

Disability — “Interacting and Relating with Others”; SSR 09-6p , Title XVI:

Determining Childhood Disability —

The Functional Equivalence Domain of “Moving About and Manipulating

Objects”; SSR 09-7p , Title XVI:

Determining Childhood

Disability — The Functional Equivalence Domain of “Caring

for Yourself”; SSR 09-8p , Title XVI:

Determining Childhood

Disability — The Functional Equivalence Domain of “Health

and Physical Well-Being”; SSR 98-1p , Title XVI: Determining

Medical Equivalence in Childhood Disability Claims When a Child

Has Marked Limitations in Cognition and Speech; SSR 96-6p , Titles II and XVI:

Consideration of Administrative Findings of Fact

by State Agency Medical and Psychological Consultants and Other Program

Physicians and Psychologists at the Administrative Law Judge and

Appeals Council Levels of Administrative Review; Medical Equivalence;

and Program Operations Manual System (POMS) DI 25225.030, DI 25225.035,

DI 25225.040, DI 25225.045, DI 25225.050, and DI 25225.055.

XVI:

Consideration of Administrative Findings of Fact

by State Agency Medical and Psychological Consultants and Other Program

Physicians and Psychologists at the Administrative Law Judge and

Appeals Council Levels of Administrative Review; Medical Equivalence;

and Program Operations Manual System (POMS) DI 25225.030, DI 25225.035,

DI 25225.040, DI 25225.045, DI 25225.050, and DI 25225.055.

[1] The definition of disability in section 1614(a)(3)(C) of the

Social Security Act (the Act) applies to any “individual”

who has not attained age 18. In this SSR, we use the word "child"

to refer to any such person, regardless of whether the person is

considered a "child" for purposes of the SSI program under section 1614(c) of the Act.

[2] For simplicity, we refer in this SSR only

to initial claims for benefits. However, the policy interpretations

in this SSR also apply to continuing disability reviews of children

under section 1614(a)(4) of the Act and 20 CFR 416.994a .

[3] We use the term “impairment(s)” in this SSR to refer to

an “impairment or a combination of impairments.”

[4] The impairment(s) must also satisfy the duration requirement in section 1614(a)(3)(A) of the Act;

that is, it must be expected to result in death,

or must have lasted or be expected to last for a continuous period

of not less than 12 months.

[5] For each major body system, the listings describe impairments we consider

severe enough to cause “marked and severe functional limitations.” 20 CFR 416.925(a) ; 20 CFR part 404, subpart P,

appendix 1 .

[6] See 20 CFR 416.926a(e) for definitions of the terms “marked”

and “extreme.”

in death,

or must have lasted or be expected to last for a continuous period

of not less than 12 months.

[5] For each major body system, the listings describe impairments we consider

severe enough to cause “marked and severe functional limitations.” 20 CFR 416.925(a) ; 20 CFR part 404, subpart P,

appendix 1 .

[6] See 20 CFR 416.926a(e) for definitions of the terms “marked”

and “extreme.”

[7] For the first five domains, we describe

typical development and functioning using five age categories: Newborns

and young infants (birth to attainment of age 1); older infants and

toddlers (age 1 to attainment of age 3); preschool children (age

3 to attainment of age 6); school-age children (age 6 to attainment

of age 12); and adolescents (age 12 to attainment of age 18). We

do not use age categories in the sixth domain because that domain

does not address typical development and functioning, as we explain

in SSR 09-8p Title XVI: Determining Childhood Disability — The Functional

Equivalence Domain of “Health and Physical Well-Being.”

[8] In the preamble to the final childhood disability regulations

we published in 2000, we noted that this approach assumes that at

this step in the sequential evaluation process for children we have

already established the existence of at least one medically determinable

impairment that is “severe.” Therefore, * * * we are

looking primarily at the extent of the limitation of the child's

functioning. We look at all of the child's activities to determine

the child's limitations or restrictions and then decide which domains

to use. 65 FR 54747, 54757 (2000).

[9] As noted in question no. 3 above, we would not make this assumption if there

is evidence indicating

that a child's limitations are not attributable to a medically determinable

impairment(s). However, in most cases, limitations that are of listing-level

severity will be associated with underlying physical or mental impairments.

then decide which domains

to use. 65 FR 54747, 54757 (2000).

[9] As noted in question no. 3 above, we would not make this assumption if there

is evidence indicating

that a child's limitations are not attributable to a medically determinable

impairment(s). However, in most cases, limitations that are of listing-level

severity will be associated with underlying physical or mental impairments.

[10] Rating the limitations caused by a child's impairment(s) in each

and every domain that is affected is not “double-weighting”

of either the impairment(s) or its effects. Rather, it recognizes

the particular effects of the child's impairment(s) in all domains

involved in the child's limited activities.

[11] By the time we reach the functional equivalence step, we will have already

determined that the child has at least one medically determinable impairment

that is “severe”; that is, it that causes more than minimal

functional limitations. 20 CFR 416.924 .

Therefore, the child must have a limitation in at least one domain.

[12] Children who have mental disorders will often have limitations that are

rated in more than one domain, but as we explain in the domain-specific

SSRs referenced at the end of this SSR, physical impairments can also

have effects that must be assigned to more than one domain.

[13] Even though this child's underlying ability to socialize may not be affected,

there is a limitation in her ability to interact and relate with

other children because of indirect effects of her impairments that

limit her opportunity to use the ability.

[14] As provided in 20 CFR 416.924a(b) ,

we consider these factors whenever we evaluate

functioning at any step of the sequential evaluation process for

children. We also use these factors to determine whether a child

has a limitation, not just the severity of the limitations.

with

other children because of indirect effects of her impairments that

limit her opportunity to use the ability.

[14] As provided in 20 CFR 416.924a(b) ,

we consider these factors whenever we evaluate

functioning at any step of the sequential evaluation process for

children. We also use these factors to determine whether a child

has a limitation, not just the severity of the limitations.

[15] The domain or domains in which we would rate the limitation would depend on

the reason(s) that the child needs the help. For example, the child

may have motor difficulties (Moving about and manipulating objects),

difficulties learning or remembering how to dress appropriately

(Acquiring and using information), difficulties with attention or

impulsivity (Attending and completing tasks), or a combination of

some or all of these problems. There may be limitations we would

evaluate in other domains as well.

[16] See 20 CFR 416.924a(b)(5) .

[17] For example, in 20 CFR 416.924a(b)(8) ,

we provide:

“If you have a chronic impairment(s) that is characterized

by episodes of exacerbation (worsening) and remission (improvement),

we will consider the frequency and severity of your episodes of exacerbation

as factors that may be limiting your functioning. Your level of functioning

may vary considerably over time. Proper evaluation of your ability

to function in any domain requires us to take into account any variations

in your level of functioning to determine the impact of your chronic

illness on your ability to function over time.” When we published

this rule in 2000, we explained that, while we adopted the language

from section 12.00D of the adult mental disorders listings, “[t]his

principle is equally applicable to children and adults, and to both

physical and mental impairments.” See 65 FR at 54754.

[18] This chart is for illustration only. We do not require our adjudicators

to develop or use such a chart.

r time.” When we published

this rule in 2000, we explained that, while we adopted the language

from section 12.00D of the adult mental disorders listings, “[t]his

principle is equally applicable to children and adults, and to both

physical and mental impairments.” See 65 FR at 54754.

[18] This chart is for illustration only. We do not require our adjudicators

to develop or use such a chart.

[19] With other facts, additional

development might be needed. For example, if the evidence in this

case showed that the child performed poorly in sports (which we mention

as a typical activity of children without impairments), we would

note that GAD would not be expected to affect the child's physical

ability to move about and manipulate objects. Therefore, poor performance

in sports in a child with GAD might be attributable to something

other than the mental disorder. There may not be a medical reason

at all: the child might do poorly because he does not like to play

any sport, is not good at sports, or is not interested in them.

On the other hand, there might be another impairment not yet documented

by evidence from an acceptable medical source that would limit motor

functioning and interfere with the child's day-to-day activities;

in such instances, additional development might be needed to complete

the evaluation of the child's functioning.

[20] See SSR 96-6p ,

Titles II and XVI: Consideration of Administrative Findings of Fact

by State Agency Medical and Psychological Consultants and Other Program

Physicians and Psychologists at the Administrative Law Judge and

Appeals Council Levels of Administrative Review; Medical Equivalence,

61 FR 34466 (1996), available at: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-06-di-01.html .

SSR 96-6p ,

Titles II and XVI: Consideration of Administrative Findings of Fact

by State Agency Medical and Psychological Consultants and Other Program

Physicians and Psychologists at the Administrative Law Judge and

Appeals Council Levels of Administrative Review; Medical Equivalence,

61 FR 34466 (1996), available at: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-06-di-01.html .

[21] For cases pending at the ALJ and AC levels from States

in the Ninth Circuit (Alaska, Arizona, California, Guam, Hawaii,

Idaho, Montana, Nevada, Northern Mariana Islands, Oregon, and Washington)

at the time of the ALJ or AC decision, see Acquiescence Ruling 04-1(9) , Howard on behalf of Wolff v. Barnhart , 341 F.3d 1006 (9th Cir.

2003)—Applicability of the Statutory Requirement for Pediatrician

Review in Childhood Disability Cases to the Hearings and Appeals

Levels of the Administrative Review Process—Title XVI of the

Social Security Act, 69 FR 22578 (2004), available at: http://www.socialsecurity.gov/OP_Home/rulings/ar/09/AR2004-01-ar-09.html .