Social Security Ruling, SSR 09-6p.; Title XVI: Determining Childhood Disability-The Functional Equivalence Domain of “Moving About and Manipulating Objects”, 7518-7521 [E9-3383]
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Federal Register / Vol. 74, No. 30 / Tuesday, February 17, 2009 / Notices
• Communicates wishes or needs,
first with gestures and later with words
that can be understood most of the time
by people who know the child best.
3. Preschool Children (Age 3 to
Attainment of Age 6)
• Socializes with children and adults.
• Begins to prefer and develops
friendships with playmates the same
age.
• Relates to caregivers with
increasing independence.
• Uses words instead of actions to
express self.
• Is better able to share, show
affection, and offer help.
• Understands and obeys simple rules
most of the time, and sometimes asks
permission.
• Chooses own friends and plays
cooperatively without continual adult
supervision.
• Initiates and participates in
conversations with familiar and
unfamiliar listeners, using increasingly
complex vocabulary and grammar.
• Speaks clearly enough to be
understood by familiar and unfamiliar
listeners most of the time.
4. School-Age Children (Age 6 to
Attainment of Age 12)
• Develops more lasting friendships
with same-age children.
• Increasingly understands how to
work in groups to create projects and
solve problems.
• Increasingly understands another’s
point of view and tolerates differences
(for example, playing with children
from diverse backgrounds).
• Attaches to adults other than
parents (for example, teachers or club
leaders), and may want to please them
to gain attention.
• Shares ideas, tells stories, and
speaks in a manner that can be readily
understood by familiar and unfamiliar
listeners.
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5. Adolescents (Age 12 to Attainment of
Age 18)
• Initiates and develops friendships
with children of the same age.
• Relates appropriately to children of
all ages and adults, both individually
and in groups.
• Increasingly able to resolve
conflicts between self and family
members, peers, and others outside of
family.
• Recognizes that there are different
social rules for dealing with other
children than with adults (for example,
behaving casually with friends, but
more formally with people in authority).
• Describes feelings, seeks
information, relates events, and tells
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stories in all kinds of environments (for
example, at home or in school) and with
all kinds of people (for example,
parents, siblings, friends, or classmates).
• Develops increasing desire for
privacy.
• Focuses less attention on parents
and more on relationships with peers.
Examples of Limitations in the Domain
of ‘‘Interacting and Relating With
Others’’
To further assist adjudicators in
evaluating a child’s impairment-related
limitations in the domain of ‘‘Interacting
and relating with others,’’ 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 may be appropriately
fearful of meeting new people, but a
teenager would be expected to interact
with strangers more readily. 16
• Does not reach out to be picked up,
touched, and held by a caregiver.
• Has no close friends, or has friends
who are older or younger.
• Avoids or withdraws from people
he or she knows.
• Is overly anxious or fearful of
meeting new people or trying new
experiences.
• Has difficulty cooperating with
others.
• Has difficulty playing games or
sports with rules.
• Has difficulty communicating with
others (for example, does not speak
intelligibly or use appropriate nonverbal
cues when carrying on a conversation).
DATES: Effective date: This SSR is
effective on March 19, 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 09–4p, Title
XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Attending and Completing
Tasks’’; SSR 09–6p, Title XVI:
Determining Childhood Disability—The
16 See
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20 CFR 416.924b.
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Fmt 4703
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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’’; 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.
[FR Doc. E9–3382 Filed 2–13–09; 8:45 am]
BILLING CODE 4191–02–P
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA–2008–0062]
Social Security Ruling, SSR 09–6p.;
Title XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Moving About and
Manipulating Objects’’
Social Security Administration.
Notice of Social Security Ruling
AGENCY:
ACTION:
(SSR).
SUMMARY: We are giving notice of SSR
09–6p. This SSR consolidates
information from our regulations,
training materials, and question-andanswer documents about the functional
equivalence domain of ‘‘Moving about
and manipulating objects.’’ It also
explains our policy about that domain.
DATES: Effective Date: March 19, 2009.
FOR FURTHER INFORMATION CONTACT:
Janet Truhe, Office of Disability
Programs, Social Security
Administration, 6401 Security
Boulevard, Baltimore, MD 21235–6401,
(410) 965–1020.
SUPPLEMENTARY INFORMATION: Although
5 U.S.C. 552(a)(1) and (a)(2) do not
require us to publish this SSR, we are
doing so under 20 CFR 402.35(b)(1).
SSRs make available to the public
precedential decisions relating to the
Federal old-age, survivors, disability,
supplemental security income, special
veterans benefits, and black lung
benefits programs. SSRs may be based
on determinations or decisions made at
all levels of administrative adjudication,
Federal court decisions, Commissioner’s
decisions, opinions of the Office of the
General Counsel, or other
interpretations of the law and
regulations.
Although SSRs do not have the same
force and effect as statutes or
E:\FR\FM\17FEN1.SGM
17FEN1
Federal Register / Vol. 74, No. 30 / Tuesday, February 17, 2009 / Notices
regulations, they are binding on all
components of the Social Security
Administration. 20 CFR 402.35(b)(1).
This SSR will be in effect until we
publish a notice in the Federal Register
that rescinds it, or publish a new SSR
that replaces or modifies it.
(Catalog of Federal Domestic Assistance,
Program No. 96.006 Supplemental Security
Income.)
Dated: February 9, 2009.
Michael J. Astrue,
Commissioner of Social Security.
Policy Interpretation Ruling
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Title XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Moving About and
Manipulating Objects’’
Purpose: This SSR consolidates
information from our regulations,
training materials, and question-andanswer documents about the functional
equivalence domain of ‘‘Moving about
and manipulating objects.’’ 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
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.
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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
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
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. 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 ImpairmentRelated 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 WellBeing.’’
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7519
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 ‘‘Moving about and
manipulating objects,’’ we consider the
physical ability to move one’s body
from one place to another, and to move
and manipulate things. These activities
may require gross or fine motor skills,
or a combination of both.
Moving one’s body includes several
kinds of actions, such as:
• Rolling,
• Rising or pulling up from a sitting
position,
• Raising the head, arms, and legs,
• Twisting the hands and feet,
• Shifting weight while sitting or
standing,
• Transferring from one surface to
another,
• Lowering down to the floor, as
when bending, kneeling, stooping, or
crouching, and
• Moving forward and backward as
when crawling, walking, running, and
negotiating different terrains (for
example, curbs, steps, and hills).
Moving and manipulating objects
includes several kinds of actions, such
as:
• Engaging the upper and lower body
to push, pull, lift, or carry objects from
one place to another,
• Controlling the shoulders, arms,
and hands to hold or transfer objects,
and
• Coordinating the eyes and hands to
manipulate small objects or parts of
objects.
All of these physical actions require
children to exhibit varying degrees of
strength, coordination, dexterity, and
pace to accomplish a given task or
activity (for example, getting dressed).
They also require children to have a
sense of where their bodies are in
relation to the environment and an
understanding of how their bodies move
in space (for example, jumping rope). In
addition, gross and fine motor skills
require the integration of sensory input
with motor output (for example, seeing
a ball and catching it). Those skills also
require the capacity for motor planning
and motor memory, that is, the ability
to plan, remember, and execute
controlled movement (for example,
riding a bicycle).
9 See 20 CFR 416.926a(e) for definitions of the
terms ‘‘marked’’ and ‘‘extreme.’’
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Both physical and mental
impairments can affect a child’s ability
to move about and manipulate objects.
For example:
• A child with a benign brain tumor
may have difficulty with balance.
• A child with rheumatoid arthritis
may have difficulty writing.
• A child with a developmental
coordination disorder may be clumsy or
have slow eye-hand coordination.
Some somatoform disorders can also
have effects in this domain.
Some medications can affect a child’s
ability to move about and manipulate
objects. For example, some
antidepressant medications may cause
hand tremors that interfere with fine
motor skills. If these effects persist over
time, we consider them in this domain.
As with limitations in any domain,
we do not consider a limitation in the
domain of ‘‘Moving about and
manipulating objects’’ unless it results
from a medically determinable
impairment(s). However, while it is
common for some children (especially
younger children) to experience some
difficulty in this area 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.
The Difference Between the Domains of
‘‘Moving About and Manipulating
Objects’’ and ‘‘Health and Physical
Well-Being’’
In the domain of ‘‘Moving about and
manipulating objects,’’ we consider how
well children are able to move their own
bodies and handle things. We evaluate
limitations of fine and gross motor
movements caused by musculoskeletal
and neurological impairments, by other
impairments (including mental
disorders) that may result in motor
limitations, and by medications or other
treatments that cause such limitations.
In the domain of ‘‘Health and physical
well-being,’’ we consider the cumulative
physical effects of physical and mental
impairments and their associated
treatments or therapies not addressed in
the domain of ‘‘Moving about and
manipulating objects.’’ We evaluate the
problems of children who are physically
ill or who manifest physical effects of
mental impairments (except for effects
on motor functioning). Physical effects,
such as pain, weakness, dizziness,
nausea, reduced stamina, or recurrent
infections, may result from the
impairment(s) itself, from medications
or other treatment, or from chronic
illness. These effects can determine
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whether a child feels well enough and
has sufficient energy to engage in ageappropriate activities, either alone or
with other children.10
In fact, an impairment(s) or its
treatment may have effects in both
domains when it affects fine or gross
motor functioning and the child’s
general physical state. For example,
some medications used to treat
impairments that affect motor
functioning may have physical effects
(such as nausea, headaches, allergic
reactions, or insomnia) that sap a child’s
energy or make the child feel ill. We
evaluate these generalized, cumulative
effects on the child’s overall physical
functioning in the domain of ‘‘Health
and physical well-being.’’ We evaluate
any limitations in fine or gross motor
functioning in the domain of ‘‘Moving
about and manipulating objects.’’
Effects in Other Domains
Impairments that affect motor
functioning and their associated
treatments can have effects in other
domains as well. For example,
generalized or localized pain that results
from an impairment(s) may interfere
with a child’s ability to concentrate, an
effect that we evaluate in the domain of
‘‘Attending and completing tasks’’ and
often in the domain of ‘‘Acquiring and
using information.’’ Pain may also cause
a child to be less active socially, an
effect that we evaluate in the domain of
‘‘Interacting and relating with others.’’
Some medications for physical
impairments may cause restlessness,
agitation, or anxiety that may affect a
child’s social functioning (which we
evaluate in the domain of ‘‘Interacting
and relating with others’’) or emotional
well-being (which we evaluate in the
domain of ‘‘Caring for yourself’’).11
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
10 For more information about the domain of
‘‘Health and physical well-being,’’ see SSR 09–8p,
Title XVI: Determining Childhood Disability: The
Functional Equivalence Domain of ‘‘Health and
Physical Well-Being.’’
11 Further, a child may also have social
difficulties because of a device used for treatment
or assistance in functioning, such as a prosthesis for
a missing limb or other adaptive equipment, that
results in social stigma.
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involved in the child’s limited
activities.12
Examples of Typical Functioning in the
Domain of ‘‘Moving About and
Manipulating Objects’’
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 ‘‘Moving about and
manipulating objects,’’ 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 the development and use of
gross and fine motor skills.
1. Newborns and young infants (birth
to attainment of age 1)
• Explores immediate environment
by moving body and using limbs.
• Learns to hold head up, sit, crawl,
and stand.
• Tries to hold onto a stable object
and stand actively for brief periods.
• Begins to practice developing eyehand control by reaching for objects or
picking up small objects and dropping
them into containers.
2. Older infants and toddlers (age 1 to
attainment of age 3)
• Explores a wider area of the
physical environment with steadily
increasing body control and
independence from others.
• Begins to walk and run without
assistance, and climbs with increasing
skill.
• Tries frequently to manipulate
small objects and to use hands to do or
get something wanted or needed.
• Uses improving motor skills to play
with small blocks, scribble with
crayons, and feed self.
3. Preschool children (age 3 to
attainment of age 6)
• Walks and runs with ease.
• Climbs stairs and playground
equipment with little supervision.
• Plays more independently (for
example, rides a tricycle, swings self).
• Completes puzzles easily, strings
beads, and builds with assortment of
blocks.
• Uses crayons, markers, and small
game pieces with increasing control.
• Cuts with scissors independently.
• Manipulates buttons and other
fasteners.
12 For more information about how we rate
limitations, including their interactive and
cumulative effects, see SSR 09–1p.
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4. School-age children (age 6 to
attainment of age 12)
• Uses developing gross motor skills
to move at an efficient pace at home, at
school, and in the neighborhood.
• Uses increasing strength and
coordination to participate in a variety
of physical activities (for example,
running, jumping, and throwing,
kicking, catching and hitting balls).
• Applies developing fine motor
skills to use many kitchen and
household tools independently (for
example, scissors).
• Writes with a pen or pencil.
5. Adolescents (age 12 to attainment
of age 18)
• Uses motor skills to move easily
and freely at home, at school, and in the
community.
• Participates in a full range of
individual and group physical fitness
activities.
• Shows mature skills in activities
requiring eye-hand coordination.
• Possesses the fine motor skills to
write efficiently or type on a keyboard.
sroberts on PROD1PC70 with NOTICES
Examples of Limitations in the Domain
of ‘‘Moving About and Manipulating
Objects’’
To further assist adjudicators in
evaluating a child’s impairment-related
limitations in the domain of ‘‘Moving
about and manipulating objects,’’ 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 teenager would be expected
to run without difficulty, but a toddler
would not.13
• Has muscle weakness, joint
stiffness, or sensory loss that interferes
with motor activities (for example,
unintentionally drops things).
• Has trouble climbing up and down
stairs, or has jerky or disorganized
locomotion, or difficulty with balance.
• Has trouble coordinating gross
motor movements (for example,
bending, kneeling, crawling, running,
jumping rope, or riding a bicycle).
• Has difficulty with sequencing
hand or finger movements (for example,
using utensils or manipulating buttons).
• Has difficulty with fine motor
movements (for example, gripping and
grasping objects).
13 See
20 CFR 416.924b.
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• Has poor eye-hand coordination
when using a pencil or scissors.
DATES: Effective date: This SSR is
effective on March 19, 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 09–4p, Title
XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Attending and Completing
Tasks’’; SSR 09–5p, Title XVI:
Determining Childhood Disability—The
Functional Equivalence Domain of
‘‘Interacting and Relating with Others’’;
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’’; 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.
[FR Doc. E9–3383 Filed 2–13–09; 8:45 am]
BILLING CODE 4191–02–P
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA–2008–0062; Social
Security Ruling, SSR 09–7p.]
Title XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Caring for Yourself’’
Social Security Administration.
Notice of Social Security Ruling
AGENCY:
ACTION:
(SSR).
SUMMARY: We are giving notice of SSR
09–7p. This SSR consolidates
information from our regulations,
training materials, and question-andanswer documents about the functional
equivalence domain of ‘‘Caring for
yourself.’’ It also explains our policy
about that domain.
DATES: Effective Date: March 19, 2009.
FOR FURTHER INFORMATION CONTACT:
Janet Truhe, Office of Disability
Programs, Social Security
Administration, 6401 Security
Boulevard, Baltimore, MD 21235–6401,
(410) 965–1020.
SUPPLEMENTARY INFORMATION: Although
5 U.S.C. 552(a)(1) and (a)(2) do not
require us to publish this SSR, we are
doing so under 20 CFR 402.35(b)(1).
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7521
SSRs make available to the public
precedential decisions relating to the
Federal old-age, survivors, disability,
supplemental security income, special
veterans benefits, and black lung
benefits programs. SSRs may be based
on determinations or decisions made at
all levels of administrative adjudication,
Federal court decisions, Commissioner’s
decisions, opinions of the Office of the
General Counsel, or other
interpretations of the law and
regulations.
Although SSRs do not have the same
force and effect as statutes or
regulations, they are binding on all
components of the Social Security
Administration. 20 CFR 402.35(b)(1).
This SSR will be in effect until we
publish a notice in the Federal Register
that rescinds it, or publish a new SSR
that replaces or modifies it.
(Catalog of Federal Domestic Assistance,
Program No. 96.006 Supplemental Security
Income.)
Dated: February 9, 2009.
Michael J. Astrue,
Commissioner of Social Security.
Policy Interpretation Ruling
Title XVI: Determining Childhood
Disability—The Functional Equivalence
Domain of ‘‘Caring for Yourself’’
Purpose: This SSR consolidates
information from our regulations,
training materials, and question-andanswer documents about the functional
equivalence domain of ‘‘Caring for
yourself.’’ 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, 416.930, 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
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.
E:\FR\FM\17FEN1.SGM
17FEN1
]]>Agencies
[Federal Register Volume 74, Number 30 (Tuesday, February 17, 2009)]
[Notices]
[Pages 7518-7521]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-3383]
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SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA-2008-0062]
Social Security Ruling, SSR 09-6p.; Title XVI: Determining
Childhood Disability--The Functional Equivalence Domain of ``Moving
About and Manipulating Objects''
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling (SSR).
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SUMMARY: We are giving notice of SSR 09-6p. This SSR consolidates
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of ``Moving
about and manipulating objects.'' It also explains our policy about
that domain.
DATES: Effective Date: March 19, 2009.
FOR FURTHER INFORMATION CONTACT: Janet Truhe, Office of Disability
Programs, Social Security Administration, 6401 Security Boulevard,
Baltimore, MD 21235-6401, (410) 965-1020.
SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do
not require us to publish this SSR, we are doing so under 20 CFR
402.35(b)(1).
SSRs make available to the public precedential decisions relating
to the Federal old-age, survivors, disability, supplemental security
income, special veterans benefits, and black lung benefits programs.
SSRs may be based on determinations or decisions made at all levels of
administrative adjudication, Federal court decisions, Commissioner's
decisions, opinions of the Office of the General Counsel, or other
interpretations of the law and regulations.
Although SSRs do not have the same force and effect as statutes or
[[Page 7519]]
regulations, they are binding on all components of the Social Security
Administration. 20 CFR 402.35(b)(1).
This SSR will be in effect until we publish a notice in the Federal
Register that rescinds it, or publish a new SSR that replaces or
modifies it.
(Catalog of Federal Domestic Assistance, Program No. 96.006
Supplemental Security Income.)
Dated: February 9, 2009.
Michael J. Astrue,
Commissioner of Social Security.
Policy Interpretation Ruling
Title XVI: Determining Childhood Disability--The Functional Equivalence
Domain of ``Moving About and Manipulating Objects''
Purpose: This SSR consolidates information from our regulations,
training materials, and question-and-answer documents about the
functional equivalence domain of ``Moving about and manipulating
objects.'' 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.
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\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.
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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\
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\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. 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.
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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\
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\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.''
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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).
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\9\ See 20 CFR 416.926a(e) for definitions of the terms
``marked'' and ``extreme.''
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Policy Interpretation
General
In the domain of ``Moving about and manipulating objects,'' we
consider the physical ability to move one's body from one place to
another, and to move and manipulate things. These activities may
require gross or fine motor skills, or a combination of both.
Moving one's body includes several kinds of actions, such as:
Rolling,
Rising or pulling up from a sitting position,
Raising the head, arms, and legs,
Twisting the hands and feet,
Shifting weight while sitting or standing,
Transferring from one surface to another,
Lowering down to the floor, as when bending, kneeling,
stooping, or crouching, and
Moving forward and backward as when crawling, walking,
running, and negotiating different terrains (for example, curbs, steps,
and hills).
Moving and manipulating objects includes several kinds of actions,
such as:
Engaging the upper and lower body to push, pull, lift, or
carry objects from one place to another,
Controlling the shoulders, arms, and hands to hold or
transfer objects, and
Coordinating the eyes and hands to manipulate small
objects or parts of objects.
All of these physical actions require children to exhibit varying
degrees of strength, coordination, dexterity, and pace to accomplish a
given task or activity (for example, getting dressed). They also
require children to have a sense of where their bodies are in relation
to the environment and an understanding of how their bodies move in
space (for example, jumping rope). In addition, gross and fine motor
skills require the integration of sensory input with motor output (for
example, seeing a ball and catching it). Those skills also require the
capacity for motor planning and motor memory, that is, the ability to
plan, remember, and execute controlled movement (for example, riding a
bicycle).
[[Page 7520]]
Both physical and mental impairments can affect a child's ability
to move about and manipulate objects. For example:
A child with a benign brain tumor may have difficulty with
balance.
A child with rheumatoid arthritis may have difficulty
writing.
A child with a developmental coordination disorder may be
clumsy or have slow eye-hand coordination.
Some somatoform disorders can also have effects in this domain.
Some medications can affect a child's ability to move about and
manipulate objects. For example, some antidepressant medications may
cause hand tremors that interfere with fine motor skills. If these
effects persist over time, we consider them in this domain.
As with limitations in any domain, we do not consider a limitation
in the domain of ``Moving about and manipulating objects'' unless it
results from a medically determinable impairment(s). However, while it
is common for some children (especially younger children) to experience
some difficulty in this area 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.
The Difference Between the Domains of ``Moving About and Manipulating
Objects'' and ``Health and Physical Well-Being''
In the domain of ``Moving about and manipulating objects,'' we
consider how well children are able to move their own bodies and handle
things. We evaluate limitations of fine and gross motor movements
caused by musculoskeletal and neurological impairments, by other
impairments (including mental disorders) that may result in motor
limitations, and by medications or other treatments that cause such
limitations.
In the domain of ``Health and physical well-being,'' we consider
the cumulative physical effects of physical and mental impairments and
their associated treatments or therapies not addressed in the domain of
``Moving about and manipulating objects.'' We evaluate the problems of
children who are physically ill or who manifest physical effects of
mental impairments (except for effects on motor functioning). Physical
effects, such as pain, weakness, dizziness, nausea, reduced stamina, or
recurrent infections, may result from the impairment(s) itself, from
medications or other treatment, or from chronic illness. These effects
can determine whether a child feels well enough and has sufficient
energy to engage in age-appropriate activities, either alone or with
other children.\10\
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\10\ For more information about the domain of ``Health and
physical well-being,'' see SSR 09-8p, Title XVI: Determining
Childhood Disability: The Functional Equivalence Domain of ``Health
and Physical Well-Being.''
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In fact, an impairment(s) or its treatment may have effects in both
domains when it affects fine or gross motor functioning and the child's
general physical state. For example, some medications used to treat
impairments that affect motor functioning may have physical effects
(such as nausea, headaches, allergic reactions, or insomnia) that sap a
child's energy or make the child feel ill. We evaluate these
generalized, cumulative effects on the child's overall physical
functioning in the domain of ``Health and physical well-being.'' We
evaluate any limitations in fine or gross motor functioning in the
domain of ``Moving about and manipulating objects.''
Effects in Other Domains
Impairments that affect motor functioning and their associated
treatments can have effects in other domains as well. For example,
generalized or localized pain that results from an impairment(s) may
interfere with a child's ability to concentrate, an effect that we
evaluate in the domain of ``Attending and completing tasks'' and often
in the domain of ``Acquiring and using information.'' Pain may also
cause a child to be less active socially, an effect that we evaluate in
the domain of ``Interacting and relating with others.'' Some
medications for physical impairments may cause restlessness, agitation,
or anxiety that may affect a child's social functioning (which we
evaluate in the domain of ``Interacting and relating with others'') or
emotional well-being (which we evaluate in the domain of ``Caring for
yourself'').\11\
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\11\ Further, a child may also have social difficulties because
of a device used for treatment or assistance in functioning, such as
a prosthesis for a missing limb or other adaptive equipment, that
results in social stigma.
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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.\12\
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\12\ For more information about how we rate limitations,
including their interactive and cumulative effects, see SSR 09-1p.
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Examples of Typical Functioning in the Domain of ``Moving About and
Manipulating Objects''
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
``Moving about and manipulating objects,'' 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 the development
and use of gross and fine motor skills.
1. Newborns and young infants (birth to attainment of age 1)
Explores immediate environment by moving body and using
limbs.
Learns to hold head up, sit, crawl, and stand.
Tries to hold onto a stable object and stand actively for
brief periods.
Begins to practice developing eye-hand control by reaching
for objects or picking up small objects and dropping them into
containers.
2. Older infants and toddlers (age 1 to attainment of age 3)
Explores a wider area of the physical environment with
steadily increasing body control and independence from others.
Begins to walk and run without assistance, and climbs with
increasing skill.
Tries frequently to manipulate small objects and to use
hands to do or get something wanted or needed.
Uses improving motor skills to play with small blocks,
scribble with crayons, and feed self.
3. Preschool children (age 3 to attainment of age 6)
Walks and runs with ease.
Climbs stairs and playground equipment with little
supervision.
Plays more independently (for example, rides a tricycle,
swings self).
Completes puzzles easily, strings beads, and builds with
assortment of blocks.
Uses crayons, markers, and small game pieces with
increasing control.
Cuts with scissors independently.
Manipulates buttons and other fasteners.
[[Page 7521]]
4. School-age children (age 6 to attainment of age 12)
Uses developing gross motor skills to move at an efficient
pace at home, at school, and in the neighborhood.
Uses increasing strength and coordination to participate
in a variety of physical activities (for example, running, jumping, and
throwing, kicking, catching and hitting balls).
Applies developing fine motor skills to use many kitchen
and household tools independently (for example, scissors).
Writes with a pen or pencil.
5. Adolescents (age 12 to attainment of age 18)
Uses motor skills to move easily and freely at home, at
school, and in the community.
Participates in a full range of individual and group
physical fitness activities.
Shows mature skills in activities requiring eye-hand
coordination.
Possesses the fine motor skills to write efficiently or
type on a keyboard.
Examples of Limitations in the Domain of ``Moving About and
Manipulating Objects''
To further assist adjudicators in evaluating a child's impairment-
related limitations in the domain of ``Moving about and manipulating
objects,'' 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 teenager would be expected to run without difficulty,
but a toddler would not.\13\
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\13\ See 20 CFR 416.924b.
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Has muscle weakness, joint stiffness, or sensory loss that
interferes with motor activities (for example, unintentionally drops
things).
Has trouble climbing up and down stairs, or has jerky or
disorganized locomotion, or difficulty with balance.
Has trouble coordinating gross motor movements (for
example, bending, kneeling, crawling, running, jumping rope, or riding
a bicycle).
Has difficulty with sequencing hand or finger movements
(for example, using utensils or manipulating buttons).
Has difficulty with fine motor movements (for example,
gripping and grasping objects).
Has poor eye-hand coordination when using a pencil or
scissors.
DATES: Effective date: This SSR is effective on March 19, 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 09-4p, Title XVI:
Determining Childhood Disability--The Functional Equivalence Domain of
``Attending and Completing Tasks''; SSR 09-5p, Title XVI: Determining
Childhood Disability--The Functional Equivalence Domain of
``Interacting and Relating with Others''; 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''; 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.
[FR Doc. E9-3383 Filed 2-13-09; 8:45 am]
BILLING CODE 4191-02-P
