Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-06-03640/USCOURTS-ca8-06-03640-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 

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The Honorable Henry L. Jones, Jr., United States Magistrate Judge for the

Eastern District of Arkansas, to whom the case was referred for final disposition by

consent of the parties pursuant to 28 U.S.C. § 636(c).

United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 06-3640

___________

Lisa Cox, *

*

Appellant, *

* Appeal from the United States

v. * District Court for the

* Eastern District of Arkansas.

Michael J. Astrue, Commissioner *

of Social Security, *

*

Appellee. *

___________

Submitted: April 13, 2007

Filed: July 26, 2007

___________

Before WOLLMAN, BEAM, and COLLOTON, Circuit Judges.

___________

WOLLMAN, Circuit Judge.

Lisa Cox appeals the district court’s1

 order upholding the Social Security

Commissioner’s denial of her application for disability insurance benefits. Cox argues

that as a result of procedural errors and ambiguous medical evidence, the

administrative law judge’s (ALJ) determination that she was not disabled was not

premised on substantial evidence. We affirm.

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I.

Cox contends that she has been qualified for disability benefits since December

11, 2002, because anxiety, mental retardation, and a respiratory impairment prevent

her from working. At the time of the ALJ’s decision, Cox was thirty-seven years old.

According to her Social Security Administration disability form and testimony, she

reported having received a tenth grade education and having attended special

education classes. She attempted to receive a GED, but was unsuccessful. She also

asserted that she had worked full time, on and off, as a certified nurse’s aide (CNA)

from 1994 to 1996, although she acknowledges that she never received special job

training or attended a trade or vocational school, and had reported earnings averaging

approximately $2000 a year during that period.

Cox has had a chronically tumultuous home life. She testified that she was

molested by her father from the age of nine to sixteen, and as a result has difficulty

concentrating, handling stress, and dealing with people. She has three children, and

she still lives with and takes care of her sixteen-year-old daughter, who suffers from

severe mental impairments. She informed a psychiatrist that she had been married

three times to abusive men, that she receives no child support from her children’s

father, and that she has had to care for various other family members.

In April 2002, Angela McKinness, an advanced practice nurse, diagnosed Cox

with insomnia and generalized anxiety disorder. Nurse McKinness prescribed

medication to help Cox with these issues. On May 8, 2003, Dr. Mary Ellen Ziolko

performed a consultative psychological evaluation. Dr. Ziolko described Cox’s affect

and mood as depressed and anxious. An administration of the Wechsler Adult

Intelligence Scale indicated that Cox had full scale, verbal, and performance IQ scores

in the mid- to upper-sixties. These results were considered valid. Dr. Ziolko’s

summary report and diagnosis, however, made facially conflicting statements

concerning Cox’s status. Although she reported that Cox’s intellectual functioning

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The mild retardation conclusion appears in the diagnosis section of the report.

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Specifically, the ALJ noted that Cox’s IQ scores are inconsistent with her

ability to do the following: work as a nursing assistant for over two years, care for

children, shop for groceries and clothes, pay bills, count change, cook, and drive.

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falls in the “mild” retardation range,2

 she also indicated in her evaluation of adaptive

functioning that there “did not appear to be significant limitations in two or more areas

of adaptive behavior. Adaptive behavior appeared more consistent with ‘borderline’

intellectual functioning than mental retardation.” 

Cox was subsequently treated by Dr. Mohammed Al-Taher for her depression,

anxiety, and insomnia. Dr. Al-Taher periodically adjusted Cox’s medication in

response to her needs. At various points, Dr. Al-Taher noted that the treatment

appeared to be yielding positive results, but Cox’s tumultuous family life and

manipulative daughter often resulted in the return of depressive episodes. The record

indicates that Dr. Al-Taher diagnosed Cox with mild depression and dependent

personality traits. Cox testified that she suffers from anxiety attacks two to three times

a week, does not have her anxiety and depression completely under control even with

medication, and would cry if criticized in a work environment. She stated that she is

routinely subject to crying spells and constantly thinks of her experience as a victim

of molestation. Nevertheless, she acknowledged that she was not plagued by most of

these problems when she worked as a CNA at a nursing home and her children were

younger. She left that job in order to take care of her children.

After reviewing the entirety of the record, the ALJ found that although Cox’s

IQ scores were within the range of mild mental retardation, because of both her ability

to perform a wide variety of daily activities and Dr. Ziolko’s conclusion that her

adaptive functioning was more consistent with borderline intellectual functioning, Cox

did not have an impairment listed in, or medically equal to, those set forth in the

Federal Regulations.3

 Furthermore, the ALJ found that her subjective complaints

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were not borne out by the record and were not fully credible. After the ALJ

determined Cox’s residual functional capacity (RFC), he posed hypotheticals to the

vocational expert (VE) consistent with Cox’s RFC. The VE indicated that an

individual with Cox’s RFC who can perform functionally light work could work as

a bench assembler or small products assembler. Accordingly, the ALJ concluded that

Cox lacked a cognizable disability as defined in the Social Security Act.

On appeal, Cox contends that the ALJ erred by (1) not seeking clarification

from Dr. Ziolko, whose report contradicted itself by indicating that Cox had mild

retardation while simultaneously concluding that she had borderline intellectual

functioning inconsistent with mild retardation; (2) failing to recontact Dr. Al-Taher

and Nurse McKinness to determine how they believed her depression and anxiety

affect her ability to work; and (3) asking the vocational expert hypothetical questions

that did not include all of the relevant details of Cox’s residual functional capacity,

thereby rendering the answers unreliable.

II.

“It is not the role of this court to reweigh the evidence presented to the ALJ or

to try the issue in this case de novo.” Loving v. Dep’t of Health & Human Servs., 16

F.3d 967, 969 (8th Cir. 1994). Instead, we review the ALJ’s decision to determine

whether it is supported by substantial evidence on the record as a whole. Id.

“Substantial evidence is less than a preponderance, but enough that a reasonable mind

might accept it as adequate to support a decision.” Cox v. Apfel, 160 F.3d 1203,

1206-07 (8th Cir. 1998). Our review extends beyond examining the record to find

substantial evidence in support of the ALJ’s decision; we also consider evidence in

the record that fairly detracts from that decision. Id. at 1207. If, after conducting this

review, we find that “‘it is possible to draw two inconsistent positions from the

evidence and one of those positions represents the [Secretary’s] findings, we must

affirm the decision’ of the Secretary.” Siemers v. Shalala, 47 F.3d 299, 301 (8th Cir.

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1995) (alteration in original) (quoting Robinson v. Sullivan, 956 F.2d 836, 838 (8th

Cir. 1992)). 

The ALJ considered Cox’s impairment by conducting the familiar five-step

evaluation set forth in 20 C.F.R. § 404.1520(a)-(g) (2004). Under the regulations, the

ALJ determines: (1) whether the claimant is currently engaged in substantial gainful

activity; (2) whether the claimant’s impairments are so severe that they significantly

limit the claimant’s physical or mental ability to perform basic work activities; (3)

whether the claimant has impairments that meet or equal a presumptively disabling

impairment specified in the regulations; (4) whether the claimant’s RFC is sufficient

for her to perform her past work; and finally, if the claimant cannot perform her past

work, the burden shifts to the Commissioner to prove that (5) there are other jobs in

the national economy that the claimant can perform given the claimant’s RFC, age,

education and work experience. See Cox v. Apfel, 160 F.3d at 1207. Cox’s claims

of error relate to steps three and five.

A. Mental Retardation

The ALJ found that substantial evidence supported the conclusion that Cox’s

mental impairments did not meet or equal the listed requirements for mental

retardation. We agree. For Cox’s purposes, to qualify as presumptively disabled due

to mental retardation, substantial evidence must support the presence of a “valid

verbal, performance, or full scale IQ of 60 through 70” and “a physical or other mental

impairment imposing an additional and significant work-related limitation of

function,” whose onset had occurred by age twenty-two. 20 C.F.R. Pt. 404, Subpt. P,

App. 1, § 12.05(c); Maresh v. Barnhart, 438 F.3d 897, 899 (8th Cir. 2006) (describing

the § 12.05(c) requirements).

Generally, social security hearings are non-adversarial. Snead v. Barnhart, 360

F.3d 834, 838 (8th Cir. 2004). An ALJ bears a responsibility to “develop the record

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We note that the medical standard for mental retardation is not identical to the

legal standard. Maresh v. Barnhart, 438 F.3d 897, 899 (8th Cir. 2006). Here,

however, the medical definition is relevant for purposes of interpreting what was

stated in a medical document.

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fairly and fully, independent of the claimant’s burden to press his case.” Id. Cox

contends, then, that because Dr. Ziolko’s medical report at least appeared to diagnose

her with mental retardation, the ALJ should not have relied on contradictory language

indicating that her adaptive function was more in line with borderline functioning than

mental retardation to support its determination that Cox was not mentally retarded.

Instead, the ALJ should have determined that Cox was mentally retarded or else

consulted Dr. Ziolko for further clarification of the report’s discrepancy. See Snead,

360 F.3d at 839 (“Because [the] evidence might have altered the outcome of the

disability determination, the ALJ’s failure to elicit it prejudiced [the claimant] in his

pursuit of benefits.”). 

It is clear that Dr. Ziolko did not intend to ultimately diagnose Cox with mental

retardation, however. The totality of the clinical record supports the ALJ’s conclusion

and was not ignored. Dr. Ziolko’s report recounts Cox’s ability to effectively

communicate, her generally successful social relationships as exemplified by her

relationships with her children, the many ways in which Cox has exhibited selfsufficient behavior, her lack of physical problems, and the lack of any limitations in

her concentration, persistence, or pace. Each of these categories is a relevant adaptive

functioning skill area. Dr. Ziolko concluded from these findings that Cox’s adaptive

behavior is more consistent with “borderline intellectual functioning” than mental

retardation, and noted that there did not appear to be limitations in two or more areas

of adaptive behavior – a medical prerequisite for the mental retardation classification.4

Her discussion and conclusion, in fact, directly parallel the analytical considerations

considered essential for the determination of mental retardation as enumerated in the

American Psychiatric Association, Diagnostic and Statistical Manual of Mental

Disorders 41 (4th ed. text revision 2000) (hereinafter “DSM-IV”), which states that

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“[t]he essential feature of Mental Retardation is significantly subaverage general

intellectual functioning . . . accompanied by significant limitations in adaptive

functioning in at least two [enumerated] skill areas . . . .”

In light of this direct, precise, and extensive discussion in Dr. Ziolko’s report,

which supports and culminates in an effective diagnosis of borderline intellectual

functioning, we conclude that her remark indicating a contrary diagnosis of mild

mental retardation was the result of inadvertence or imprecision. To hold otherwise

would require the improbable conclusion that Dr. Ziolko had intended to offer a

cursory diagnosis in direct contradiction to the careful findings and conclusions she

thoroughly recounted and characterized on prior pages, and in direct contradiction to

the defining diagnostic characteristics of mental retardation as identified by the DSMIV that her analysis explicitly addressed. The ALJ’s treatment of her report here, then,

does not involve his substituting judicial conjecture for ambiguous medical opinion,

but instead involves recognizing what amounts to an obvious medical opinion

inopportunely attended by superficially distracting or misleading language. In these

circumstances, there is no need for further clarification. See 20 C.F.R. § 416.912(e)

(2006) (requiring the recontacting of a treating physician only if evidence from that

physician is inadequate to determine disability).

Taking into account the medical report and other evidence on the record

concerning Cox’s impairments, then, substantial evidence supports the ALJ’s

determination that Cox’s impairments neither meet nor equal those limitations

required for mental retardation. We reach this conclusion with full awareness of the

very real difficulties Cox appears to experience. The difficulties are not sufficient to

merit reversal, however, because “we will not reverse the decision even if substantial

evidence also supports a different outcome.” Stormo v. Barnhart, 377 F.3d 801, 805

(8th Cir. 2004) (citing Fredrickson v. Barnhart, 359 F.3d 972, 976 (8th Cir. 2004)).

On balance, we consider the ALJ’s determination to be supported by substantial

evidence – particularly in light of the activities Cox acknowledged she could perform,

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not least of which was her assertion that she previously worked as a CNA, a

semiskilled job, without experiencing difficulties for more than two years. Her

counsel contends that given Cox’s limited education, lack of specialized training, and

marginal income from the CNA work, the job title she provides is “probably” little

more than an attempt to put a positive spin on what amounts to a nurse’s helper

position. This is no more than speculation, however. We have not been made aware

of any evidence on record controverting her assertion that she worked as a CNA. 

B. The Residual Functional Capacity Determination

Cox next contends that the ALJ erroneously established Cox’s RFC in the

absence of any medical opinion by Nurse McKinness and Dr. Al-Taher directly

addressing how her depression and anxiety affect her ability to work. As a result, Cox

argues that the ALJ’s RFC determination amounted to no more than a “layman’s

guess” at the work-related restrictions imposed by Cox’s anxiety and depression.

Cox’s argument lacks merit because the medical evidence provided a sufficient basis

on which her RFC was determined. The ALJ determined that Cox had the residual

functional capacity to perform unskilled or semiskilled work and that Cox should have

only superficial incidental contact with the public and co-workers, experience few

changes in work setting, and perform only simple, routine, repetitive tasks involving

no more than limited decision making.

Because a claimant’s RFC is a medical question, an ALJ’s assessment of it must

be supported by some medical evidence of the claimant’s ability to function in the

workplace. Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001) (citing Nevland v.

Apfel, 204 F.3d 853, 858 (8th Cir. 2000)). Accordingly, the regulations provide that

treating physicians or psychologists will be recontacted by the Commissioner when

the medical evidence received from them is inadequate to determine a claimant’s

disability. 20 C.F.R. § 416.912(e). Nevertheless, in evaluating a claimant’s RFC, an

ALJ is not limited to considering medical evidence exclusively. Lauer, 245 F.3d at

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For added context, we note that a GAF score in the fifties may be associated

with a moderate impairment in occupational functioning, and a GAF score in the

forties may be associated with a serious impairment in occupational functioning.

American Psychiatric Association, Diagnostic and Statistical Manual of Mental

Disorders 34 (4th ed. text revision 2000). 

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704; Dykes v. Apfel, 223 F.3d 865, 866 (8th Cir. 2002) (per curiam) (“To the extent

[claimant] is arguing that residual functional capacity may be proved only by medical

evidence, we disagree.”). Even though the RFC assessment draws from medical

sources for support, it is ultimately an administrative determination reserved to the

Commissioner. 20 C.F.R. §§ 416.927(e)(2), 416.946 (2006).

The ALJ’s RFC determination with respect to the work-related effects of Cox’s

depression and anxiety was sufficiently supported by the medical evidence. The ALJ

considered Dr. Al-Taher’s examination in which Dr. Al-Taher assessed only a mild

depressive disorder. Dr. Al-Taher indicated that Cox’s depression was largely due to

her chaotic lifestyle and family-life. The record also indicates that Dr. Al-Taher

assigned Cox a Global Assessment of Functioning (GAF) score of sixty-five, which

indicates that even though she suffers from some mild symptoms such as depressed

mood and mild insomnia, or experiences some difficulty in social or occupational

functioning, she generally functions reasonably well and is capable of having

meaningful interpersonal relationships.5

 DMS-IV at 34. Furthermore, although Cox

reported intermittent depressive symptoms (usually spurred by a family crisis), Dr. AlTaher stated that they “partially improved fairly quickly.” Despite Cox’s ability to

show some partial recovery from depressive episodes, Dr. Al-Taher acknowledged

that some socially avoidant symptoms remain. Finally, the ALJ found to be

significant Dr. Al-Taher’s observation that during her treatment, Cox was capable of

superficial social contact as evidenced by her ability to go Christmas shopping at a

shopping mall for a five-hour period without difficulty despite her alleged inability

to be around others and her proclivity to experience panic attacks. In light of these

facts, observations, and medical conclusions which bear directly on the extent of

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In support of her position, Cox cites a number of cases in which we reversed

and remanded with instructions to make a new determination after further

development of the record. The cases she cites, however, rely on inapposite fact

patterns or are otherwise distinguishable. For example, in Bowman v. Barnhart, 310

F.3d 1080 (8th Cir. 2002), we remanded because the doctor’s “somewhat cursory”

entries did not adequately assess how the claimant’s impairments limited her workrelated activities. Id. at 1084-85. Cox appears to believe that Bowman supports her

contention that the absence of any explicit reference to “work” in close proximity to

the description of her various medically evaluated limitations makes it impossible for

the ALJ to ascertain her work-related limitations from that evaluation. It does not.

Such explicit language is unnecessary here because Dr. Al-Taher’s evaluations

describe Cox’s functional limitations with sufficient generalized clarity to allow for

an understanding of how those limitations function in a work environment.

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Cox’s ability to function in a work environment, Dr. Al-Taher’s records persuade us

that the ALJ’s RFC assessment is supported by substantial medical evidence.6

C. The Hypothetical Questions

Finally, Cox contends that in step five of its analysis, the ALJ relied on the

vocational expert’s response to a hypothetical that did not include all of the limitations

contained in the RFC. Testimony from a vocational expert is substantial evidence

only when the testimony is based on a correctly phrased hypothetical question that

captures the concrete consequences of a claimant’s deficiencies. Porch v. Chater, 115

F.3d 567, 572 (8th Cir. 1997) (citing Pickney v. Chater, 96 F.3d 294, 297 (8th Cir.

1996)). Although the ALJ asked the vocational expert three hypotheticals, only the

first and third have bearing on our discussion of Cox’s claim. The relevant language

of each is as follows:

Assume . . . that this person has very limited reading and writing ability

at the elementary level, and very basic math ability. Assume further . . .

that this individual has a capacity for medium work, but with the

following additional limitations, the individual is limited to simple,

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repetitive, routine tasks, with low stress to be defined as limited decision

making required, and limited changes of the work setting, and that the

individual can only have incidental contact with the public and coworkers. Could such an individual perform the relevant work of Ms.

Cox?

. . . .

Assume, if you would, we have the same requirement for unskilled work

that I discussed with the limited decision-making and only incidental

contact with the public, but restricted to a light functional level. Would

there be any employment for such an individual?

Tr. 280-81.

Cox alleges that the third hypothetical fails to incorporate all of the material in

the first. Cox parses the language of the third hypothetical too finely, however, and

does not appreciate the full relevance of its surrounding context. Cox does not

contend that the first hypothetical fails to capture the concrete consequences of her

deficiencies. Furthermore, our plain reading of the third hypothetical comports with

the district court’s understanding of it – that is, one hearing it would assume from its

language that it incorporates the same limitations described in the first hypothetical

except for a change in the permissible exertion level from medium to light.

Accordingly, because the vocational expert, in response to a hypothetical that captures

the consequences of Cox’s deficiencies, described readily available occupations in

which she could engage, the Commissioner successfully demonstrated Cox’s ability

to perform work in the economy. See Reed v. Sullivan, 988 F.2d 812, 815-16 (8th

Cir. 1993) (describing the burden).

The judgment is affirmed.

______________________________

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