Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-2_06-cv-02043/USCOURTS-arwd-2_06-cv-02043-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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Linda S. McMahon became the Social Security Commissioner on January 20, 2007. 1

Pursuant to Rule 25(d)(1) of the Federal Rules of Civil Procedure, Linda S. McMahon has been

substituted for acting Commissioner Jo Anne B. Barnhart as the defendant in this suit.

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FORT SMITH DIVISION

DAVID W. DRAPER PLAINTIFF

VS. CIVIL NO. 06-2043

LINDA S. MCMAHON, ACTING COMMISSIONER,

SOCIAL SECURITY ADMINISTRATION DEFENDANT 1

MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

Plaintiff, David Draper, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial

review of a decision of the Commissioner of the Social Security Administration (“Commissioner”)

denying his claim for disability insurance benefits (“DIB”) under the provisions of Title XVI of the

Social Security Act (“Act”). 

Procedural Background:

The application for DIB now before this court was filed on October 9, 2003, alleging an

amended onset date of February 27, 2003, due to mental retardation, anxiety, and pain. (Tr. 12, 46,

70). An administrative hearing was held on September 2, 2004. (Tr. 177-197). Plaintiff was present

and represented by counsel.

At the time of the administrative hearing, plaintiff was forty-two years old and possessed a

high school education. (Tr. 12, 47, 64). However, plaintiff was enrolled in special education classes

in high school. The record also reveals that he had past relevant work (“PRW”) experience as a

sawmill stamper. (Tr. 12, 59). 

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On June 22, 2005, the Administrative Law Judge (“ALJ”), issued a written decision finding

that plaintiff’s mental retardation, pain and anxiety were “severe” impairments within the meaning

of the Act. (Tr. 17). However, he concluded that these impairments did not meet or equal the

criteria of any of the impairments listed in Appendix 1, Subpart P, Regulations No. 4. After

discrediting plaintiff’s subjective allegations, the ALJ determined that plaintiff retained the residual

functional capacity (“RFC”) to perform work activity at all exertional levels. Due to plaintiff’s

mental limitations, he also concluded that plaintiff would be limited to performing work where the

interpersonal contact required was incidental to the work performed; the complexity of tasks was

learned and performed by rote with few variables; the tasks required little judgment; and, the

supervision required was simple, direct and concrete. (Tr. 19). With the assistance of a vocational

expert (“VE”), the ALJ determined that plaintiff could perform his PRW as a sawmill stamper. (Tr.

20). 

On March 25, 2006, the Appeals Council declined to review this decision. (Tr. 3-5).

Subsequently, plaintiff filed this action. (Doc. # 1). This case is before the undersigned for report

and recommendation. Both parties have filed appeal briefs, and the case is now ready for decision.

(Doc. # 8, 9). 

Applicable Law:

This court’s role is to determine whether the Commissioner’s findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir. 2002).

Substantial evidence is less than a preponderance but it is enough that a reasonable mind would find

it adequate to support the Commissioner’s decision. The ALJ’s decision must be affirmed if the record

contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d 964, 966 (8th Cir. 2003).

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As long as there is substantial evidence in the record that supports the Commissioner’s decision, the

court may not reverse it simply because substantial evidence exists in the record that would have

supported a contrary outcome, or because the court would have decided the case differently. Haley

v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other words, if after reviewing the record it is

possible to draw two inconsistent positions from the evidence and one of those positions represents

the findings of the ALJ, the decision of the ALJ must be affirmed. Young v. Apfel, 221 F.3d 1065,

1068 (8th Cir. 2000).

It is well-established that a claimant for Social Security disability benefits has the burden of

proving his disability by establishing a physical or mental disability that has lasted at least one year and

that prevents his from engaging in any substantial gainful activity. Pearsall v. Massanari, 274 F.3d

1211, 1217 (8th Cir.2001); see also 42 U.S.C. § § 423(d)(1)(A), 1382c(a)(3)(A). The Act defines

“physical or mental impairment” as “an impairment that results from anatomical, physiological, or

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A plaintiff must show that his disability,

not simply his impairment, has lasted for at least twelve consecutive months.

The Commissioner’s regulations require her to apply a five-step sequential evaluation process

to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful

activity since filing his claim; (2) whether the claimant has a severe physical and/or mental impairment

or combination of impairments; (3) whether the impairment(s) meet or equal an impairment in the

listings; (4) whether the impairment(s) prevent the claimant from doing past relevant work; and, (5)

whether the claimant is able to perform other work in the national economy given his age, education,

and experience. See 20 C.F.R. §§ 404.1520(a)- (f)(2003), 416.920. Only if the final stage is reached

does the fact finder consider the plaintiff’s age, education, and work experience in light of his or her

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We do note, however, that plaintiff had continued to be employed following his father’s 2

death, until his employer went out of business. (Tr. 171, 188). His brother testified that plaintiff

had been employed by a family friend. (Tr. 171, 187). Further, the brother indicated that he

checked in on plaintiff while he was working because plaintiff’s anxiety made it difficult for him

to work around others and stay focused. (Tr. 171, 188). 

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residual functional capacity. See McCoy v. Schwieker, 683 F.2d 1138, 1141-42 (8th Cir. 1982); 20 C

.F.R. §§ 404.1520, 416.920 (2003).

Discussion:

Because a social security hearing is a non-adversarial proceeding, the ALJ has a duty to fully

develop the record regarding the claimant’s impairments. See Stormo v. Barnhart, 377 F.3d 801,

806 (8th Cir. 2004). That duty includes seeking clarification from treating physicians if a crucial

issue is undeveloped or underdeveloped. Id. The ALJ is also required to recontact medical sources

and may order consultative evaluations when the available evidence does not provide an adequate

basis for determining the merits of the disability claim. See 20 C.F.R. §§ 416.912(e), 416.919a(b).

In the present case, the pertinent evidence reveals as follows. On October 23, 2003, Dr. W.

R. Young indicated that plaintiff was not prone to physical illness. (Tr. 127). However, he noted

that plaintiff did have cerebral palsy with questionable additional genetic problems, microcephalic

features, and mental retardation. Dr. Young stated that plaintiff had worked at minial tasks when

his father was alive to be his mentor and guide. Since his father’s death, he indicated that plaintiff

had basically been unemployable. Dr. Young noted that plaintiff had difficulty with short-term 2

memory and significant deficits in his fund of knowledge, ability to reason, and ability to organize

thoughts. These, he opined, were characteristic of his mental retardation. It was Dr. Young’s

opinion that plaintiff’s mental problems would preclude him from being gainfully employed. He

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Klinefelter syndrome is a term used to describe males who have an extra X chromosome 3

in most of their cells. See National Institute of Child Health and Human Development,

Klinefelter Syndrome, at www.nlm.nih.gov/medlineplus. Instead of having the usual XY

chromosome pattern that most males have, these men have an XXY pattern. Id. 

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also indicated that plaintiff would not be a candidate for rehabilitation because he was permanently

disabled and depended on others to maintain his finances and business affairs. (Tr. 127).

On January 7, 2004, Dr. Keith Norway performed an intellectual assessment and evaluation

of plaintiff’s adaptive functioning. (Tr. 131-134). Testing revealed that plaintiff had a full scale IQ

of sixty-nine, indicative of mild mental retardation. (Tr. 132). Dr. Norway noted that plaintiff lived

with his mother, got along with others, and communicated effectively. Although he concluded that

plaintiff could respond appropriately to supervisors and co-workers in a low skilled job position, he

indicated that plaintiff had only a fair ability to carry out instructions and was a slow learner. (Tr.

133-134). He also found that plaintiff met the definition of mental retardation because he had

significant limitations in two or more areas of adaptive functioning. (Tr. 133). As such, Dr. Norway

was of the opinion that plaintiff would have difficulty working at most jobs within the national

economy. (Tr. 134).

This same date, plaintiff underwent a general physical examination with Dr. Gordon

McCraw. (Tr. 135-141). Dr. McCraw found no physical impairments or abnormalities. (Tr. 238).

However, he diagnosed plaintiff with Klinefelter’s syndrome and mental retardation. (Tr. 141, 142).

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Although he did not state plaintiff’s specific limitations, he did indicate that plaintiff’s impairments

were severely limiting. (Tr. 142). 

On December 9, 2004,. Dr. Douglas Brown conducted a complete battery of psychological

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tests on plaintiff. (Tr. 163-167). He noted that plaintiff had a deformed head and facial features.

Dr. Brown described plaintiff as looking like an adult premature baby. He also noted that plaintiff

had worked in the past but had either worked for a family business or for a close family friend.

Although Dr. Brown could not explain why his test results were so markedly different from Dr.

Norway’s, he indicated that intellectual testing had revealed that plaintiff had an IQ of ninety, which

placed him in the average range of intellect. (Tr. 164). However, Dr. Brown found that plaintiff had

suppressed verbal skills and was extremely slow and an extremely slow learner. As such, plaintiff

was diagnosed with dysthymia with a significant impairment in mental speed. (Tr. 164). 

Dr. Brown rated plaintiff’s ability to deal with the public, deal with work stresses, function

independently of others, maintain attention for extended periods of time, and maintain personal

appearance as only fair. (Tr. 166-167). Further, Dr. Brown stated that plaintiff had moderate

limitations with regard to understand, remembering, and carrying out complex job instructions. He

was of the opinion that plaintiff would experience difficulties with employment due to his

“slowness.” (Tr. 167). 

On February 17, 2005, Dr. Patricia Walz conducted a psychological evaluation of plaintiff.

(Tr. 169-174). She examined plaintiff and reviewed Dr. Brown’s report. Dr. Walz noted that

plaintiff’s appearance made it obvious that he did have some genetic or developmental

abnormalities. (Tr. 172). She also indicated that plaintiff seemed to over-estimate his actual abilities

when compared to his abilities as described by his brother. Although Dr. Walz did not conduct IQ

testing, she stated that she would not have expected plaintiff’s IQ to fall within the low average to

average range of intellect, as found by Dr. Brown, because plaintiff was quite slow to respond and

appeared to have limitations in concept formation, social judgment, and cognitive speed. (Tr. 173).

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We also note that the ALJ failed to address this inconsistency in his opinion. 4

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She noted that, while plaintiff described his functioning as quite independent, he actually relied on

others to direct him in nearly all aspects of his life. Further, the mere fact that he did perform a few

chores around the house did not convince her that he had the skills necessary to independently

determine when tasks needed to be done. As such, Dr. Walz diagnosed him with dysthymia and

cognitive disorder with significant mental slowing. (Tr. 174). 

Dr. Walz also completed a mental RFC assessment. (Tr. 175-176). She rated plaintiff’s

ability to deal with work stresses; function independently; and, understand, remember, and carry out

complex job instructions as poor. In addition, his ability to relate to co-workers, deal with the public,

and maintain attention and concentration was said to be fair to poor. Dr. Walz determined that

plaintiff had only a fair ability to use judgment; understand, remember, and carry out detailed

instructions; behave in an emotionally stable manner; and, relate predictably in social situations. In

addition, plaintiff’s ability to interact with supervisors was rated as good to fair. Dr. Walz noted that

plaintiff would likely function well in a sheltered workshop type of setting. (Tr. 176).

After reviewing the evidence of record, the undersigned is of the opinion that the case should

be remanded to the ALJ for further development of the record concerning plaintiff’s mental abilities

and limitations. The record reveals that Drs. Norway, Young, and McCraw diagnosed plaintiff with

mental retardation. We note, however, that Dr. Brown also evaluated plaintiff and obtained an IQ

score that was drastically inconsistent with the findings of Dr. Norway. Dr. Brown was unable to

explain the reasoning behind this discrepancy. In fact, after conducting her own evaluation of 4

plaintiff, Dr. Walz stated that she was surprised by Dr. Brown’s findings. Given this inconsistency

and the lack of evidence to explain it, we believe that the ALJ should have requested clarification

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concerning plaintiff’s intellectual and academic abilities prior to rendering his decision. Clearly,

plaintiff’s IQ has an impact on his RFC and the types of positions he is capable of performing. 

Because the ALJ failed to seek clarification regarding this issue, the undersigned finds that the case

should be remanded to the ALJ for clarification and further development of the record concerning

plaintiff’s IQ. 

In addition, we also take issue with the ALJ’s RFC assessment. RFC is the most a person

can do despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). A disability claimant has the

burden of establishing his or her RFC. See Masterson v. Barnhart, 363 F.3d 731, 737 (8th Cir.2004).

“The ALJ determines a claimant’s RFC based on all relevant evidence in the record, including

medical records, observations of treating physicians and others, and the claimant’s own descriptions

of his or her limitations.” Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004); Guilliams

v. Barnhart, 393 F.3d 798, 801 (8th Cir. 2005). Limitations resulting from symptoms such as pain

are also factored into the assessment. 20 C.F.R. § 404.1545(a)(3). The United States Court of

Appeals for the Eighth Circuit has held that a “claimant’s residual functional capacity is a medical

question.” Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001). Therefore, an ALJ’s determination

concerning a claimant’s RFC must be supported by medical evidence that addresses the claimant’s

ability to function in the workplace.” Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). “Under

this step, the ALJ is required to set forth specifically a claimant’s limitations and to determine how

those limitations affect her RFC.” Id.

We note that the ALJ gave a great deal of attention to plaintiff’s ability to work with others,

understand instructions, and handle criticism. In so doing, he failed to appropriately consider the

impact that plaintiff’s mental “slowness” would have on his ability to perform work-related activities

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in the national economy. Several of the examining doctors indicated that plaintiff’s slow mental

speed would impact his ability to work. However, the ALJ merely concluded that plaintiff could

perform work where the interpersonal contact required was only incidental to the work performed,

the complexity of the tasks performed was learned and performed by rote with few variables and

little judgment, and the supervision required for the tasks was simple, direct, and concrete. Clearly,

this does not fully reflect plaintiff’s mental limitations. While, plaintiff may well be able to perform

these types of tasks, the record raises questions concerning plaintiff’s ability to perform these

activities on a daily basis at the level and/or pace expected of individuals working in the real world.

It is significant to note that individuals suffering from mental disorders often have their lives

structured to minimize stress and help control their symptoms, giving the appearance that they are

less impaired than they actually are. Hutsell v. Massanari, 259 F.3d 707, 711 (8th Cir. 2001); 20

C.F.R. Pt. 404, Subpt. P., App. 1, § 12.00(E) (1999). This limited tolerance for stress is particularly

relevant because a claimant’s residual functional capacity is based on their “ability to perform the

requisite physical acts day in and day out, in the sometimes competitive and stressful conditions in

which real people work in the real world.” McCoy v. Schweiker, 683 F.2d 1138, 1147 (8th Cir.

1982) (abrogated on other grounds). Given the fact that all of plaintiff’s PRW has been performed

under the guidance of either his father or his brother and the fact that plaintiff is mentally slow, we

believe that remand is necessary to allow the ALJ to reconsider plaintiff’s RFC. 

On remand, the ALJ is also directed to consider plaintiff’s IQ and mental slowness when

fashioning an appropriate hypothetical question for the vocational expert. See Grissom v. Barnhart,

416 F.3d 834, 837 (8th Cir. 2005) (holding that in fashioning an appropriate hypothetical question

for a vocational expert, the ALJ is required to include all of claimant’s impairments supported by

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substantial evidence in the record as a whole). In addition, the ALJ should make the VE aware of

the fact that plaintiff was given special accommodations with regard to his PRW.

Conclusion:

Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore recommend that the denial of benefits to the plaintiff be reversed and this matter be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

405(g). 

ENTERED this 8th day of February 2007.

/s/ J. Marschewski

HON. JAMES R. MARSCHEWSKI

UNITED STATES MAGISTRATE JUDGE 

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