THE NATIONAL ASSOCIATION 
OF SCHOOL NURSES
1416 Park Street, Suite A  
Castle Rock, CO  80414

THE NATIONAL ASSOCIATION OF SCHOOL NURSES
COMMENTS IN RESPONSE TO 
SOCIAL SECURITY ADMINISTRATION'S
ADVANCE NOTICE OF PROPOSED RULEMAKING 
ON CRITERIA FOR EVALUATING MENTAL DISORDERS
As Requested in the Federal Register, March 17, 2003

The National Association of School Nurses is the professional nursing organization of over 11,000 nurses throughout the United Sates and supports the health and safety of children in our nation's schools.  These comments are submitted in response to the notice of March 17, 2003 regarding SSA's intention to revise the criteria for evaluating mental impairments under federal disability programs.  

I.	Introduction to Mental Disorders Listings:  Section 12.00

1.	Evidence issues
SSA should provide clear guidance to adjudicators in the Introduction section of the Listings and in separate regulations regarding the importance of evidence from all health care professionals in assessing the limitations imposed by mental impairments.

The fact that SSA has established a distinction between "medical" and "non-medical" evidence that allows adjudicators to consider non-physician evidence, even though provided by licensed health professionals, to be less important.  As a result, adjudicators give it less weight than it deserves, despite the fact that it is key information needed to establish the individual's functional limitations.  School nurses work with disabled children every day and can provide key information that must be given equal weight.

Evidence from an "acceptable medical source" is necessary to establish the existence of a "medically determinable impairment" under the Social Security Act.  However, once a "medically determinable impairment" is established, evidence from "other sources" is obtained to show the severity of the impairment and the limitations it imposes.  These "other sources" include many of the primary sources of health care treatment for individuals with mental impairments, e.g., nurse practitioners including school nurses, physicians' assistants, therapists, psychiatric social workers, and educational personnel.  Evidence from professional school nurses regarding the severity of the impairment should not be treated differently when provided by these licensed health professionals than when given by a psychiatrist or psychologist.

The organization of community mental health programs is such that an individual may see the psychiatrist rarely, and only to evaluate medications during a very brief visit.  The people most familiar with the case and the individual claimant's functional limitations include professional school nurses who see the child on a daily or weekly basis.  Current regulations do not treat evidence from such sources as "medical evidence of record," even though it is prepared by a professional, included in the psychiatric case file and an integral part of a physician supervised treatment team.  Often the adjudicator of the claim will give more weight to consultative examiners who see the individual only once or to non-examining state agency physicians who only review the file. 

SSA should treat such information as medical evidence when it comes from a licensed clinic or is part of a medically supervised treatment plan.  To do otherwise is to treat low income claimants unfairly merely because they cannot afford treatment in a setting where most of the work is done by physicians.  For many children, school nurses provide the only health care these children receive.  

2.	Documentation

A discussion about school attendance and vocational training should be added to the Introduction to provide guidance for evaluating cases of young adults for whom such evidence is particularly relevant.  School nurse input into the record can be vital and weighed accordingly.

II.	Records of School-Based Testing 

When children have Individualized Education Programs (IEPs) in their school files, it is quite likely that the school also has records of testing done to assess the student for the school system.  We recommend that SSA routinely request these test results as part of the applicant's file.  

III.	New listings needed

Several new listings should be added because of the prevalence of these disorders. 

1.	Post-Traumatic Stress Disorder (PTSD) to 12.06 and 112.06

PTSD, a condition found in adults who have been members of the armed forces and other victims of terrorism, violence, or traumatic events, including children exposed to violence in the home or community.  Currently it is buried in section 12.06 of the Adult Listings, where it is hard to find, in part because it is never named.  Children are suffering more traumatic events today and should be included.  A separate Listing for PTSD should be included in both the Adult and the Children's Listings.

2.	Eating Disorders 12.13 & 112.13

The Eating Disorders Anorexia Nervosa, Bulimia, and Other Types should be added as a new Listing.

V.	Administrative Process

The SSDI and SSI application processes can be both lengthy and complex.  Often, families with children with mental impairments have difficulty even applying for benefits at a crowded SSA field office, unless they are provided with assistance.  While a significant percentage of claimants are granted benefits by ALJs, many claimants (families with children with mental impairments) are unable to file appeals, and thus they never have this additional opportunity to demonstrate their disability.  

1. SSA should refer all children's SSI applicants not already receiving Medicaid coverage to state Medicaid and CHIP enrollment offices, so that those who are eligible can receive these critical health care benefits.
	
2. SSA should require state DDS agencies to have specialized adjudicators to handle 
children's SSI claims.  

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