Opinion ID: 785992
Heading Depth: 3
Heading Rank: 2

Heading: Marked Impairment

Text: 35 As noted above, the second prong of the medical equivalency test of listing 112.04 requires marked impairment in two of four functional categories. These categories are: 36 a. Marked impairment in age-appropriate cognitive/communicative function, documented by medical findings (including consideration of historical and other information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, the results of appropriate standardized psychological tests ...; or 37 b. Marked impairment in age-appropriate social functioning, documented by history and medical findings (including consideration of information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, the results of appropriate standardized tests; or 38 c. Marked impairment in age-appropriate personal functioning, documented by history and medical findings (including consideration of information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, appropriate standardized tests; or 39 d. Marked difficulties in maintaining concentration, persistence, or pace. 40 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 112.02(B)(2), cross-referenced by id. Pt. 404, Subpt. P, App. 1, § 112.04(B). 41 Similarly, to be found to be disabled by virtue of suffering from a functionally equal impairment, a claimant Myron's age must show marked impairment in at least two functional categories. 2 Prior to the effective date of the final rules, personal functioning and social functioning appeared in both the meet or medically equal provisions and in the functionally equivalent provisions of the interim final rules. Compare id. § 416.926a(c)(4)(i)-(iii), (v)-(vi) (2000) (functional equivalence domains for children age three to age eighteen under interim rules were: cognition/communication, motor, social, personal, and concentration, persistence, or pace), with id. Pt. 404, Subpt. P, App. 1, § 112.02(B)(2)(a)-(c) (meet or medically equal domains included: cognitive/communicative function, social functioning, personal functioning). However, the final rules, which apply in this appeal, see supra, extensively reorganized and revised 20 C.F.R. § 416.926a, the section that governs the functional equivalence of children. 65 Fed.Reg. 54,752 (Sept. 11, 2000). Under the final rules, the broad areas of functioning pertaining to the functionally equivalent route of establishing disability are: (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 C.F.R. § 416.926a(g)-(1) (2003). 42 Our ability to review the Commissioner's final decision regarding functional equivalency is severely curtailed by the fact that the ALJ's decision was made under the interim rules, and this difficulty is compounded by the Social Security Appeals Council's cursory review of Myron's case. The Social Security Appeals Council merely stated that it had considered the final rules but found that the new final rules did not provide a basis to change the ALJ's decision. 3 (Admin. Tr. at 7.) 43 The parties in this case did not address the personal and social functioning domains with regard to the changes that the final rules made in § 416.926a. Even though these domains no longer appear in both § 416.926a and in the meet or medically equal provisions of the final rules, for purposes of this appeal we will treat the final rules'interacting and relating with others, 20 C.F.R. § 416.926a(i), and caring for yourself, id. § 416.926a(k), functional domains as analogous to the social and personal functioning domains, respectively. 44 Under the final rules as expressed in § 416.926a, a child will be found to have a marked limitation when the impairment interferes seriously with the child's ability to independently initiate, sustain, or complete activities. Id. § 416.926a(e)(2). Further, `[m]arked' limitation also means a limitation that is `more than moderate' but `less than extreme.' Id. For purposes of comparison, a child will be found to have an extreme limitation when the impairment interferes very seriously with [the child's] ability to independently initiate, sustain, or complete activities. Id. § 416.926a(e)(3). 45 Similarly, the regulations pertaining to meeting or medically equaling a listed impairment define marked as more than moderate but less than extreme. Id. Pt. 404, Subpt. P., App.1 § 112.00(C). The rules provide: [a] marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with the ability to function (based upon age-appropriate expectations) independently, appropriately, effectively, and on a sustained basis. Id. 46 We agree that substantial evidence in the record supports the ALJ's determination that Myron's impairments do not result in marked limitations in the areas of cognition/communication, motor, and concentration, persistence, or pace. Myron does not challenge these findings on appeal. Instead, he argues that he meets listing 112.04, or at least his limitations are functionally equivalent to a listed impairment, because he has marked impairment in social functioning and in personal functioning. The ALJ concluded that Myron had marked limitations of functioning in only one domain — social. 47 The principal issue on appeal is whether the ALJ adequately considered Myron's suicide attempts in the domain of personal functioning and, consequently, whether substantial evidence supports his finding that Myron had only slight limitations in this area. According to the appellant, the ALJ's analysis in finding that Myron only had slight limitation of functioning in personal development demonstrates that the ALJ failed to adequately consider the gravity and impact of Myron's suicide attempts on his ability to care for himself. 48 Personal functioning in adolescents pertains to self-care. 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 112.00(C)(4)(a). The focus of the personal functioning domain in adolescent children is on the adolescent's ability to take care of his or her own personal needs, health, and safety without assistance. Id. The analogous caring for yourself provision of § 416.926a of the final rules consider[s] how well you maintain a healthy emotional and physical state, including how well you get your physical and emotional wants and needs met in appropriate ways; how you cope with stress and changes in your environment; and whether you take care of your own health, possessions, and living area. Id. § 416.926a(k). 49 The regulations specifically address self-injurious actions, such as suicide attempts, in the domain of personal functioning and caring for oneself. For example, the regulations provide: Personal functioning in adolescents pertains to self-care.... Impaired ability in this area is manifested by failure to take care of these needs or by self-injurious actions.  Id. Pt. 404, Subpt. P, App. 1, § 112.00(C)(4)(a) (emphasis added). Section 416.926a lists examples of limited functioning in caring for oneself. One such example is, You engage in self-injurious behavior ( e.g., suicidal thoughts or actions, self-inflicted injury, or refusal to take your medication), or you ignore safety rules. Id. § 416.926a(k)(3)(iv). In addition, the regulations state that self-injurious behavior should not be considered in the social functioning domain: Impaired social functioning may be caused by inappropriate externalized actions (e.g., running away, physical aggression — but not self-injurious actions, which are evaluated in the personal area of functioning ), id. § 112.00(C)(2)(b) (discussing social function in preschool children) (emphasis added), and Note that self-injurious actions are evaluated in the personal area of functioning. Id. Part 404, Subpt. P, App. 1, § 112.00(C)(4) (discussing marked impairment in adolescents age 12 to eighteen). 50 Despite this clear direction to consider suicidal behavior in the area of personal functioning and not in the area of social functioning, the ALJ's opinion only briefly addresses suicide in personal functioning and arguably places a greater emphasis on it in considering Myron's social functioning. With regard to personal functioning, the ALJ found, 51 In the personal area of development, the claimant has slight limitation of functioning. From the testimony and written statements of the claimant's mother, he is quite capable of handling all his own personal needs, including household chores, when he wants to. When he does not want to, she has not pushed the matter. Obviously, limitations related to the claimant's lack of desire are not the result of a medically determinable impairment. The only medically determinable limitations documented in this area result on rare occasions when the claimant is severely depressed and fails to care for his own safety. At least one of these episodes has been clearly associated with non-compliance with medication. ( Exhibit 9F, page 9)[.] Considering the record as a whole, it is found that any limitations in this area are only slight, if the claimant adheres to proper treatment. 52 (Admin. Tr. at 21.) 53 Substantial evidence on the record as a whole does not support the ALJ's conclusion for several reasons. First, contrary to the ALJ's finding, the hospital records documenting Myron's March 1999 suicide attempt do not attribute Myron's actions to non-compliance with his medication regimen. Instead, they merely note that Myron had not been compliant: Myron Moore was admitted due to a suicide attempt (overdose). He was also non compliant with his medication. (Admin. Tr. at 256.) Thus, to the extent the ALJ found that Myron's non-compliance was the cause of his self-injurious behavior, substantial evidence does not support this conclusion. There is no indication that non-compliance was related to any of Myron's other attempted suicides. 54 Second, the record does not support the ALJ's conclusion that any limitations in this area [of personal development] are only slight, if the claimant adheres to proper treatment. (Admin. Tr. at 21.) Again, there is no evidence in the record that, prior to his other suicide attempts, Myron failed to adhere to his medication regimen. The only evidence in this regard relates to the single March 1999 hospitalization. As we noted above, the inference that the ALJ made from this evidence is tenuous and certainly does not amount to substantial evidence that all of Myron's suicide attempts were the result of his non-compliance with medication. 55 Moreover, we do not agree with the Commissioner's position that substantial evidence shows that Myron's depression is controlled. An impairment which can be controlled by treatment or medication is not considered disabling. Estes v. Barnhart, 275 F.3d 722, 725 (8th Cir.2002). The record evidence shows that, despite ongoing treatment and medication, Myron continues to suffer from episodic bouts of recurrent major depression. Medication helps to control Myron's condition, but it does not cure it. We know this to be true because Myron's condition improved after his hospitalization and treatment in December of 1998, for example, yet he attempted suicide three months later. And again, after having been counseled about the importance of taking his medications and undergoing treatment, Myron again attempted suicide and was hospitalized in August of 1999. Therefore, substantial evidence does not support the Commissioner's argument that Myron's depression is controlled by medication and treatment and that, consequently, he is not disabled. 56 Third, substantial evidence in the record as a whole does not support the ALJ's characterization of Myron's suicide attempts as rare. The undisputed evidence shows that Myron was hospitalized after attempting suicide on three separate occasions during a nine-month period. Moreover, the appellant claims there was a fourth attempted suicide that did not result in hospitalization. The ALJ only noted three suicide attempts in his analysis, and it is unclear whether he discredited the appellant's account of the undocumented attempted suicide or simply failed to address it. 57 Notwithstanding the foregoing, we do not find that Myron has marked limitation in the area of personal functioning. Indeed, we recognize that, when Myron is not experiencing an episodic bout of depression, he is capable of caring for his own needs, such as doing household chores and attending to his personal hygiene. However, we also do not find that substantial evidence in the record supports the ALJ's decision to discount Myron's suicide attempts in this area of functioning and to find that they were rare and resulted from Myron's failure to follow his prescribed course of treatment. On remand, the ALJ should evaluate whether Myron has marked limitations in personal functioning, giving proper weight to his serious history of self-injurious actions. 2. Social Functioning 58 The rules state that [s]ocial functioning refers to a child's capacity to form and maintain relationships with parents, other adults, and peers. Social functioning includes the ability to get along with others (e.g., family members, neighborhood friends, classmates, teachers). 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 112.00(C)(2)(b). The analogous interacting and relating with others provision of § 416.926a consider[s] how well [the child] initiate[s] and sustain[s] emotional connections with others, develop[s] and use[s] the language of [his or her] community, cooperate[s] with others, compl[ies] with rules, respond[s] to criticism, and respect[s] and take[s] care of the possessions of others. Id. § 416.926a(i). The regulations expect that adolescents, among other things, will be able to develop friendships with children their own age; relate appropriately to other children and to adults; solve problems; express feeling; and tell stories. Id. § 416.926a(i)(v). 59 In considering Myron's degree of impairment in social functioning, the ALJ reasoned, 60 In the social area of development, the claimant has marked limitation of functioning. Due to the claimant's attention deficit hyperactivity disorder and depression, his social [sic] the undersigned Administrative Law Judge concludes that he is markedly limited for significant periods of time. He has attempted suicide on three occasions and he has demonstrated temper outbursts that have resulted in serious disciplinary actions at school. However, much of the time the claimant is quite able to function in the social area. He has participated in team sports at school and, as noted by his resource teacher, he is generally quite capable of relating to classmates. (Exhibit 1E). In a structured setting the claimant has demonstrated the ability to improve his depression and anger control and has been quite pleased with his success (Exhibit 20F). 61 When the evidence, as developed at the hearing level, is considered in its entirety, the Administrative Law Judge finds that the claimant is more limited in his social abilities than was concluded by the State Agency physicians. Nonetheless, he does retain significant abilities in this area. Although his mother has asserted that the claimant only hangs around with children who are eight to ten years old, this is not consistent with his school records, the knee injury he received playing on the school basketball team or the claimant's own testimony. He stated that he liked to spend his free time at home by going to shoot baskets or skateboard with his friends. These activities are certainly consistent with the activities of someone the claimant's age. 62 (Admin. Tr. at 20-21.) 63 The Commissioner and the appellant agree that the ALJ improperly considered Myron's suicide attempts in the social functioning domain. The appellant urges us to sustain the ALJ's finding of marked impairment because, according to the appellant, there is more than sufficient evidence of marked impairment even in the absence of Myron's suicide attempts. We agree that much of the ALJ's analysis is unaffected by his consideration of Myron's self-injurious acts. For example, Myron has documented temper outbursts, has difficulty controlling his anger, cries easily, and has been suspended from school for fighting and for assaulting a teacher. Moreover, Myron's mother claims that his friends are significantly younger than he. However, it is impossible for us to determine the extent to which, if any, the ALJ's consideration of self-injurious acts in the area social functioning undermines his finding of marked limitation. Accordingly, we remand to give the ALJ an opportunity to re-evaluate Myron's degree of impairment in social functioning and, if appropriate, in the final rules' domain of interacting and relating with others.