SSR 09-4p: Title XVI: Determining Childhood Disability – The Functional Equivalence Domain of “Attending and Completing Tasks”

Effective Date: March 20, 2009 Publication Date:

February 18, 2009 Federal Register Vol. 74, No. 31, page 7630

POLICY INTERPRETATION RULING

Purpose:

This SSR consolidates information from our regulations, training

materials, and question-and-answer documents about the functional

equivalence domain of “Attending and completing tasks.” It

also explains our policy about that domain.

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 .

As we explain in greater detail in SSR 09-1p , we always evaluate the

“whole child” when we make a finding regarding functional

equivalence, unless we can otherwise make a fully favorable

determination or decision. [6] We focus first on the child’s activities, and evaluate how

appropriately, effectively, and independently the child functions

compared to children of the same age who do not have impairments. 20 CFR 416.926a(b) and (c) . We consider what

activities the child cannot do, has difficulty doing, needs help doing,

or is restricted from doing because of the impairment(s). 20 CFR 416.926a(a) . Activities are everything a child does at home, at school, and in

the community, 24 hours a day, 7 days a week. [7]

e child functions

compared to children of the same age who do not have impairments. 20 CFR 416.926a(b) and (c) . We consider what

activities the child cannot do, has difficulty doing, needs help doing,

or is restricted from doing because of the impairment(s). 20 CFR 416.926a(a) . Activities are everything a child does at home, at school, and in

the community, 24 hours a day, 7 days a week. [7]

We next evaluate the effects of a child’s impairment(s) by

rating the degree to which the impairment(s) limits functioning in six

“domains.” 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) . [8]

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. [9] 20 CFR 416.926a(a) .

Policy Interpretation

General

In the domain of “Attending and completing tasks,” we

consider a child’s ability to focus and maintain attention, and

to begin, carry through, and finish activities or tasks. We consider

the child’s ability to initiate and maintain attention, including

the child’s alertness and ability to focus on an activity or task

despite distractions, and to perform tasks at an appropriate pace. We

also consider the child’s ability to change focus after

completing a task and to avoid impulsive thinking and acting. Finally,

we evaluate a child’s ability to organize, plan ahead, prioritize

competing tasks, and manage time. [10]

ntain attention, including

the child’s alertness and ability to focus on an activity or task

despite distractions, and to perform tasks at an appropriate pace. We

also consider the child’s ability to change focus after

completing a task and to avoid impulsive thinking and acting. Finally,

we evaluate a child’s ability to organize, plan ahead, prioritize

competing tasks, and manage time. [10]

The ability to attend and to complete tasks develops throughout

childhood, evolving from an infant’s earliest response to

stimuli, such as light, sound, and movement, to an adolescent’s

completion of academic requirements. Over time, this evolution can be

seen in the steady development of a child’s ability to attend and

to complete increasingly complex tasks. For example:

- Newborns or young infants gaze at human faces or moving objects,

and listen in the direction of a human voice.

- Toddlers engage in activities that interest them, such as listening

to a story.

- Preschool children engage in uninterrupted periods of play, such as

putting a puzzle together.

- School-age children focus long enough to do classwork and

homework.

- Adolescents may perform part-time work requiring sustained

attention to assigned duties that must be completed on time.

As in any domain, when we evaluate a child’s limitations in

the domain of “Attending and completing tasks,” we consider

how appropriately, effectively, and independently the child functions

compared to children of the same age who do not have impairments. For

example, a teacher may report that a child “pays attention well

with frequent prompting.” The need for frequent prompting

demonstrates that the child is not paying attention as appropriately,

effectively, or independently as children of the same age who do not

have impairments. Despite the fact that the child is paying attention

with prompting, this child is not functioning well in this domain.

ample, a teacher may report that a child “pays attention well

with frequent prompting.” The need for frequent prompting

demonstrates that the child is not paying attention as appropriately,

effectively, or independently as children of the same age who do not

have impairments. Despite the fact that the child is paying attention

with prompting, this child is not functioning well in this domain.

The domain of “Attending and completing tasks” covers

only the mental aspects of task completion; such as the mental pace

that a child can maintain to complete a task. [11] Therefore, limitations in the domain

of “Attending and completing tasks” are most often seen in

children with mental disorders. For example, in school:

- Children with attention-deficit/hyperactivity disorder (AD/HD)

whose primary difficulty is inattention may be easily distracted

or have difficulty focusing on what is important and staying on task.

They may fail to pay close attention to details and make careless

mistakes in schoolwork, avoid projects that require sustained attention,

or lose things needed for school or other activities beyond what is

expected of children their age who do not have impairments.

- Children with AD/HD whose primary difficulty is hyperactivity and impulsivity may fidget with objects instead of paying

attention, talk instead of listening to instructions, or get up from

their desks and wander around the classroom beyond what is expected of

children their age who do not have impairments. [12]

ities beyond what is

expected of children their age who do not have impairments.

- Children with AD/HD whose primary difficulty is hyperactivity and impulsivity may fidget with objects instead of paying

attention, talk instead of listening to instructions, or get up from

their desks and wander around the classroom beyond what is expected of

children their age who do not have impairments. [12]

Although we more often see limitations in this domain in connection

with mental disorders, a physical impairment(s) can also affect a

child’s mental ability to attend and to complete tasks. For

example, pain caused by a musculoskeletal disorder can distract a child

and interfere with the child’s ability to concentrate and to

complete assignments on time. Medications that affect concentration or

interfere with other mental processes, such as some medications for

seizure disorders, may also affect a child’s ability to attend

and to complete tasks.

Some children with impairments can attend to some tasks, but not to

all tasks in all settings. Such children may exhibit

“hyperfocus,” an intense focus on things that interest them,

such as video games, but be limited in their ability to focus on other

tasks. These kinds of limitations in the domain of “Attending

and completing tasks” are common in children with AD/HD and

autistic spectrum disorders (ASD). For example, some children with ASD

may be distracted by, or become fixated on, everyday sounds (such as

the hum of an air conditioner) that children without impairments can

easily ignore. Children with autism may become fixated on parts of an

object (such as the wheels on a toy truck) rather than on the more

obvious and primary use of the object. Children with Asperger’s

disorder (one type of ASD), may hyperfocus on a single area of interest

and have difficulty discussing or paying attention to any other

subject

onditioner) that children without impairments can

easily ignore. Children with autism may become fixated on parts of an

object (such as the wheels on a toy truck) rather than on the more

obvious and primary use of the object. Children with Asperger’s

disorder (one type of ASD), may hyperfocus on a single area of interest

and have difficulty discussing or paying attention to any other

subject. These children may appear to function well, or even better

than other children, in the area of hyperfocus, but may be very limited

in some other tasks and settings.

As with limitations in any domain, we do not consider a limitation in

the domain of “Attending and completing tasks” unless it

results from a medically determinable impairment(s). However, while it

is common for all children to experience some difficulty attending and

completing tasks from time to time, a child who has significant but

unexplained problems in this domain may have an impairment(s) that was

not alleged or has not yet been diagnosed. In such cases, adjudicators

should pursue any indications that an impairment(s) may be present.

Effects in other domains

In the domain of “Attending and completing tasks,” we

consider the mental aspects of a child’s ability to focus,

maintain attention, and complete age-appropriate tasks throughout the

day. In addition, because the ability to attend and to complete tasks

is involved in nearly everything a child does, an impairment(s) that

affects this ability may cause limitations in other domains.

her domains

In the domain of “Attending and completing tasks,” we

consider the mental aspects of a child’s ability to focus,

maintain attention, and complete age-appropriate tasks throughout the

day. In addition, because the ability to attend and to complete tasks

is involved in nearly everything a child does, an impairment(s) that

affects this ability may cause limitations in other domains.

For example, school-age children with AD/HD may have limitations in

multiple domains. The effects of inattention and hyperactivity can

impede the learning process and affect competence in many areas of

life. These effects can result in limitations in the domain of

“Acquiring and using information”; for example, by

undermining academic performance. They may also have effects in the

domain of “Interacting and relating with others”; for

example, children with AD/HD may interrupt others in conversation or

have difficulty taking turns during play activities. They may also

cause limitations in the domain of “Caring for yourself”;

for example, when a child risks personal safety by not stopping and

thinking before doing something.

Therefore, as in any case, we evaluate the effects of a child’s

impairment(s), including the effects of medication or other treatment

and therapies, in all relevant domains. 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. [13]

Examples of typical functioning in the domain of

“Attending and completing tasks”

ins. 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. [13]

Examples of typical functioning in the domain of

“Attending and completing tasks”

While there is a wide range of normal development, most children

follow a typical course as they grow and mature. To assist

adjudicators in evaluating a child’s impairment-related

limitations in the domain of “Attending and completing

tasks,” we provide the following examples of typical functioning

drawn from our regulations, training, and case reviews. These examples

are not all-inclusive, and adjudicators are not required to develop

evidence about each of them. They are simply a frame of reference for

determining whether children are functioning typically for their age

with respect to attending and completing tasks.

1. Newborns and young infants (birth to attainment of

age 1)

- Shows sensitivity to environment by responding to various stimuli

(for example, light, touch, temperature, movement).

- Stops activity when voices or other sounds are heard.

- Begins to notice and gaze at various moving objects, including

people and toys.

- Listens to family conversations and plays with people and toys for

progressively longer periods of time.

- Wants to change activities frequently, but gradually expands

interest in continuing an interaction or a game.

2. Older infants and toddlers (age 1 to attainment of

age 3)

- Attends to things of interest (for example, looking at picture

books, listening to stories).

- Has adequate attention to complete some tasks independently (for

example, putting a toy away).

- Demonstrates sustained attention (for example, building with

blocks, helping to put on clothes).

3. Preschool children (age 3 to attainment of age 6)

- Pays attention when spoken to directly.

age 3)

- Attends to things of interest (for example, looking at picture

books, listening to stories).

- Has adequate attention to complete some tasks independently (for

example, putting a toy away).

- Demonstrates sustained attention (for example, building with

blocks, helping to put on clothes).

3. Preschool children (age 3 to attainment of age 6)

- Pays attention when spoken to directly.

- Sustains attention to play and learning activities.

- Concentrates on activities like putting puzzles together or

completing art projects.

- Focuses long enough to complete many activities independently (for

example, getting dressed, eating).

- Takes turns and changes activities when told by a caregiver or

teacher that it is time to do something else.

- Plays contentedly and independently without constant supervision.

4. School-age children (age 6 to attainment of age

12)

- Focuses attention in a variety of situations in order to follow

directions, completes school assignments, and remembers and organizes

school-related materials.

- Concentrates on details and avoids making careless

mistakes.

- Changes activities or routines without distracting self or

others.

- Sustains attention well enough to participate in group sports, read

alone, and complete family chores.

- Completes a transition task without extra reminders or supervision

(for example, changing clothes after gym or going to another classroom

at the end of a lesson).

5. Adolescents (age 12 to attainment of age

18)

- Pays attention to increasingly longer presentations and

discussions.

- Maintains concentration while reading textbooks.

- Plans and completes long-range academic projects

independently.

- Organizes materials and manages time in order to complete school

assignments.

- Maintains attention on tasks for extended periods of time, and is

not unduly distracted by or distracting to peers in a school or work

setting.

Examples of limitations in the domain of

“Attending and completing tasks”

while reading textbooks.

- Plans and completes long-range academic projects

independently.

- Organizes materials and manages time in order to complete school

assignments.

- Maintains attention on tasks for extended periods of time, and is

not unduly distracted by or distracting to peers in a school or work

setting.

Examples of limitations in the domain of

“Attending and completing tasks”

To further assist adjudicators in evaluating a child’s

impairment-related limitations in the domain of “Attending and

completing tasks,” we also provide the following examples of some

of the limitations we consider in this domain. These examples are

drawn from our regulations and training. They are not the only

examples of limitations in this domain, nor do they necessarily

describe a “marked” or an “extreme”

limitation.

In addition, the examples below may or may not describe limitations

depending on the expected level of functioning for a given child’s

age. For example, a toddler would not be expected to be able to play a

game or stay on another task for an hour, but a teenager would. [14]

- Is easily startled, distracted, or overreactive to everyday sounds.

- Is slow to focus on or fails to complete activities that interest

the child.

- Gives up easily on tasks that are within the child’s

capabilities.

- Repeatedly becomes sidetracked from activities or frequently

interrupts others.

- Needs extra supervision to stay on task.

- Cannot plan, manage time, or organize self in order to complete

assignments or chores.

Effective date:

This SSR is effective on March 20, 2009.

Cross-References:

vities that interest

the child.

- Gives up easily on tasks that are within the child’s

capabilities.

- Repeatedly becomes sidetracked from activities or frequently

interrupts others.

- Needs extra supervision to stay on task.

- Cannot plan, manage time, or organize self in order to complete

assignments or chores.

Effective date:

This SSR is effective on March 20, 2009.

Cross-References:

SSR 09-1p , Title XVI:

Determining Childhood Disability Under the Functional Equivalence Rule

— The "Whole Child" Approach; 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 09-5p , 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; 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.

5.040, 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 SSR 09-1p , Title XVI: Determining

Childhood Disability Under the Functional Equivalence Rule – The

“Whole Child” Approach.

[7] However, some children

have chronic physical or mental impairments that are characterized by

episodes of exacerbation (worsening) and remission (improvement);

therefore, their level of functioning may vary considerably over time.

To properly evaluate the severity of a child’s limitations

in functioning, as described in the following paragraphs, we must

consider any variations in the child’s level of functioning to

determine the impact of the chronic illness on the child’s

ability to function longitudinally; that is, over time. For more

information about how we evaluate the severity of a child’s

limitations, see SSR 09-1p

operly evaluate the severity of a child’s limitations

in functioning, as described in the following paragraphs, we must

consider any variations in the child’s level of functioning to

determine the impact of the chronic illness on the child’s

ability to function longitudinally; that is, over time. For more

information about how we evaluate the severity of a child’s

limitations, see SSR 09-1p .

For a comprehensive discussion of how we document a child’s

functioning, including evidentiary sources, see SSR 09-2p , Title XVI: Determining

Childhood Disability – Documenting a Child’s

Impairment-Related Limitations.

[8] 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.”

[9] See 20 CFR 416.926a(e) for

definitions of the terms “marked” and “extreme.”

[10] In 20 CFR 416.924a(b)(5) ,

we provide that how independently a child can “initiate, sustain,

and complete” activities is a “factor” we consider

when evaluating a child’s functioning. The difference between

this “factor” and the domain of “Attending and

completing tasks” is that the factor addresses the issue of

independence in functioning at every step in the sequential evaluation

process and in all domains—the extent to which a child can begin,

carry out, and finish age-appropriate activities at an appropriate rate

and without needing extra help

g a child’s functioning. The difference between

this “factor” and the domain of “Attending and

completing tasks” is that the factor addresses the issue of

independence in functioning at every step in the sequential evaluation

process and in all domains—the extent to which a child can begin,

carry out, and finish age-appropriate activities at an appropriate rate

and without needing extra help. The child may receive help in a number

of ways: Personal service from another person; special equipment,

devices, or medications; adaptations (such as special appliances); and

structured or supportive settings, including the amount of help the

child needs to remain in a regular setting. The domain of “Attending and completing tasks” assesses

a child’s specific ability to focus and maintain

attention.

[11] We evaluate a

child’s physical ability to complete tasks in the domain of

“Moving about and manipulating objects,” or when

appropriate, “Health and physical well-being.” For example,

a child who has difficulty getting dressed at an age-appropriate pace

because of rheumatoid arthritis has a limitation that we evaluate in

the domain of “Moving about and manipulating objects” or

“Health and physical well-being” depending on the specific

physical reason for the limitation; for example, joint deformity

(Moving about and manipulating objects) or constitutional symptoms and

signs (Health and physical well-being). A physical impairment may have

effects that we evaluate in both the domains of “Moving about and

manipulating objects” and “Health and physical

well-being”; such as when a child has both a musculoskeletal

deformity and constitutional symptoms and signs because of systemic

sclerosis. In addition to the SSRs for the other domains cited at the

end of this SSR, see generally SSR 09-1p .

-being). A physical impairment may have

effects that we evaluate in both the domains of “Moving about and

manipulating objects” and “Health and physical

well-being”; such as when a child has both a musculoskeletal

deformity and constitutional symptoms and signs because of systemic

sclerosis. In addition to the SSRs for the other domains cited at the

end of this SSR, see generally SSR 09-1p .

[12] We provide a number

of examples involving AD/HD and autism spectrum disorders in this

SSR  because these impairments frequently occur in childhood SSI

cases. However, many other kinds of mental disorders can cause

limitations in the ability to attend and to complete tasks. For

example, mood disorders, such as depression, often cause difficulties in

concentration.

[13] For more

information about how we rate limitations, including their interactive

and cumulative effects, see SSR

09-1p .

[14] See 20 CFR 416.924b .