Revised Medical Criteria for Evaluating Mental Disorders, 66137-66178 [2016-22908]

Agencies

• Social Security Administration

[Federal Register Volume 81, Number 186 (Monday, September 26, 2016)]
[Rules and Regulations]
[Pages 66137-66178]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-22908]



[[Page 66137]]

Vol. 81

Monday,

No. 186

September 26, 2016

Part II





Social Security Administration





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20 CFR Parts 404 and 416





Revised Medical Criteria for Evaluating Mental Disorders; Final Rule

Federal Register / Vol. 81 , No. 186 / Monday, September 26, 2016 / 
Rules and Regulations

[[Page 66138]]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

[Docket No. SSA-2007-0101]
RIN 0960-AF69


Revised Medical Criteria for Evaluating Mental Disorders

AGENCY: Social Security Administration.

ACTION: Final rules.

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SUMMARY: We are revising the criteria in the Listing of Impairments 
(listings) that we use to evaluate claims involving mental disorders in 
adults and children under titles II and XVI of the Social Security Act 
(Act). The revisions reflect our program experience, advances in 
medical knowledge, recommendations from a commissioned report, and 
public comments we received in response to a Notice of Proposed 
Rulemaking (NPRM).

DATES: These rules are effective January 17, 2017.

FOR FURTHER INFORMATION CONTACT: Cheryl A. Williams, Office of Medical 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, Maryland 21235-6401, (410) 965-1020. For information on 
eligibility or filing for benefits, call our national toll-free number, 
1-800-772-1213, or TTY 1-800-325-0778, or visit our Internet site, 
Social Security Online, at https://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

Background

    We are revising and making final the rules for evaluating mental 
disorders we proposed in an NPRM published in the Federal Register on 
August 19, 2010 (75 FR 51336). Even though these rules will not go into 
effect until January 17, 2017 for clarity, we refer to them in this 
preamble as the ``final'' rules. We refer to the rules in effect prior 
to that time as the ``prior'' rules.
    In the preamble to the NPRM, we discussed the revisions we proposed 
for the mental disorders body system. To the extent that we are 
adopting those revisions as we proposed them, we are not repeating that 
information here. Interested readers may refer to the preamble to the 
NPRM, available at https://www.regulations.gov under docket number SSA-
2007-0101.
    We are making several changes in these final rules from the NPRM 
based upon some of the public comments we received. We explain those 
changes in later sections of this preamble. We are also making minor 
editorial changes throughout these final rules. We are making final the 
non-substantive editorial changes, the conforming changes in other body 
systems, and the changes we proposed in 114.00.

Why are we revising the listings for evaluating mental disorders?

    We developed these final rules as part of our ongoing review of the 
listings. We are revising the listings to update the medical criteria, 
provide more information on how we evaluate mental disorders, reflect 
our program experience, and address adjudicator questions. The 
revisions also reflect comments we received from medical experts and 
the public at an outreach policy conference, in response to an Advance 
Notice of Proposed Rulemaking (ANPRM) published on March 17, 2003 (68 
FR 12639), and in response to the NPRM.

When will we begin to use these final rules?

    As we noted in the dates section of this preamble, these final 
rules will be effective on January 17, 2017. We delayed the effective 
date of the rules to give us time to update our systems, provide 
training and guidance to all of our adjudicators, and revise our 
internal forms and notices before we implement the final rules. The 
prior rules will continue to apply until the effective date of these 
final rules. When the final rules become effective, we will apply them 
to new applications filed on or after the effective date of the rules, 
and to claims that are pending on or after the effective date.\1\
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    \1\ This means that we will use these final rules on and after 
their effective date, in any case in which we make a determination 
or decision. We expect that Federal courts will review our final 
decisions using the rules that were in effect at the time we issued 
the decisions. If a court reverses our final decision and remands a 
case for further administrative proceedings after the effective date 
of these final rules, we will apply these final rules to the entire 
period at issue in the decision we make after the court's remand.
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Public Comments on the NPRM

    In the NPRM, we provided the public with a 90-day comment period 
that ended on November 17, 2010. We received 2,245 public comments 
during this comment period. The commenters included national medical 
organizations, advocacy groups, legal services organizations, national 
groups representing claimants' representatives, a national group 
representing disability examiners in the State agencies that make 
disability determinations for us, individual State agencies, and other 
members of the public. A number of the letters provided identical 
comments and recommendations.
    We published a notice that reopened the NPRM comment period for 15 
days on November 24, 2010 (75 FR 71632). We reopened the comment period 
to clarify and seek additional public comment about an aspect of the 
proposed definitions of the terms ``marked'' and ``extreme'' in 
sections 12.00 and 112.00 of our listings. We received 156 additional 
comments during the reopened comment period, for a total of 2,401 total 
public comments.
    We considered all of the significant comments relevant to this 
rulemaking. We condensed and summarized the comments below. We have 
tried to present the commenters' concerns and suggestions accurately 
and completely, and we have responded to all significant issues that 
were within the scope of these rules. We provide our reasons for 
adopting or not adopting the recommendations in our responses below.
    We also received comments supporting our proposed changes. We 
appreciate those comments; however, we did not include them. Finally, 
some of the comments were outside the scope of the rulemaking. In a few 
cases, we summarized and responded to such comments because they raised 
public concerns that we thought were important to address in this 
preamble. For example, we received comments about the statutory 
policies regarding how we evaluate substance use disorders. We thought 
that it was important to explain how we follow the requirements of the 
statute for claims in which a substance use disorder is involved. 
However, in most cases, we did not summarize or respond to comments 
that were outside the scope of our rulemaking. As one example, several 
commenters asked us to give equal weight to evidence that we receive 
from all medical sources and to consider that evidence separately from 
the other information collected from non-medical sources. We will 
retain these types of comments and consider them if they are 
appropriate for other rulemaking actions.

General Comments

    Comment: One commenter, a clinical psychologist, did not recommend 
eliminating the paragraph A criteria from the prior listings because 
the criteria provide a basis for comparing and assessing the severity 
of different disorders, such as dysthymic disorder compared with a 
major depressive disorder. The commenter also noted that ``it may be 
premature to implement significant modification [to the] rules without 
having the benefit of the newest

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edition of the Diagnostic and Statistical Manual being available.''
    Response: We agreed with the commenter and adopted the 
recommendations. The paragraph A criteria provide important medical 
information that we consider when we make disability determinations. 
The criteria also identify mental disorders that are significant and 
that we should consider at the ``listings step'' of the sequential 
evaluation process. For these reasons, we retained the paragraph A 
criteria in each listing. We revised most of the paragraph A criteria 
using the diagnostic features for the corresponding categories of 
mental disorders in the Diagnostic and Statistical Manual of Mental 
Disorders, Fifth Edition \2\ (DSM-5).
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    \2\ American Psychiatric Association: Diagnostic and Statistical 
Manual of Mental Disorders, Fifth Edition. Arlington, VA, American 
Psychiatric Association, 2013.
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    Comment: A commenter suggested that we use the terms ``health'' or 
``healthcare'' instead of ``medical,'' where appropriate.
    Response: We adopted the comment and used the recommended terms 
where appropriate.
    Comment: The spokesperson for an organization strongly recommended 
that SSA reviewers who possess child and adolescent health backgrounds 
review the applications of children to ensure the most accurate 
evaluation of the unique mental health considerations of the pediatric 
population.
    Response: This comment is outside the scope of the NPRM, and we did 
not make any changes in these final rules in response to it. Section 
221(h) of the Act requires us to make every reasonable effort to ensure 
that a qualified psychiatrist or psychologist has evaluated the case if 
the evidence indicates the existence of a mental impairment and we find 
that the person is not under a disability (see also Sec. Sec.  
404.1615(d) and 416.903(e)). After we published the NPRM, Congress 
passed the Bipartisan Budget Act of 2015 (BBA), Public Law 114-74. 129 
Stat. 584. For determinations made on or after November 2, 2016, 
section 832 of the BBA requires us to make reasonable efforts to ensure 
that a qualified physician (in cases involving a physical impairment) 
or a qualified psychiatrist or psychologist (in cases involving a 
mental impairment) has completed the medical review of the case and any 
applicable residual functional capacity assessment. We will address the 
requirements of section 832 of the BBA in a separate rulemaking.

Sections 404.1520a and 416.920a--Evaluation of Mental Impairments

    Comment: Some commenters objected to the proposal to remove 
Sec. Sec.  404.1520a and 416.920a. These regulations contain guidance 
about the ``special technique'' that we use to evaluate the severity of 
mental impairments for adults, known as the ``psychiatric review 
technique.'' One commenter stated that the technique is a decision-
making tool that is useful for our medical consultants and 
adjudicators. Another commenter indicated that the psychiatric review 
technique increases consistency in case outcomes.
    Response: We adopted the comments because we agree with the reasons 
that the commenters provided. The final rules keep the special 
technique described in Sec. Sec.  404.1520a and 416.920a and make the 
conforming changes necessary to implement these rules.

Sections 12.00A and 112.00A--How are the listings for mental disorders 
arranged, and what do they require?

    Comment: After we published the NPRM, the American Psychiatric 
Association (APA) made the public aware that it was developing the DSM-
5. Several commenters stated that it might be premature to implement 
significant modification to SSA's rules on mental disorders without the 
benefit of the DSM-5 being available. Some commenters recommended 
postponing these final rules until after the APA published the DSM-5 so 
these rules could include the updates in medical understanding 
reflected in the DSM-5.
    Response: The APA published the DSM-5 in May 2013. We adopted the 
recommendation to include updates in medical knowledge in these final 
rules, where appropriate. For example, we:
     Revised the titles of most of the listings to reflect the 
terminology that the DSM-5 uses to describe categories of mental 
disorders;
     added a new listing for trauma- and stressor-related 
disorders that is separate from the listing for anxiety disorders;
     consulted the descriptions of mental disorders in the DSM-
5 when we described the mental disorders that we evaluate under each 
listing; and
     consulted the diagnostic criteria in the DSM-5 when we 
revised the criteria for each listing.
    Comment: A commenter recommended that we group listings 12.02, 
12.05, and 12.11 under a heading separate from functional psychiatric 
disturbances because ``intellectual disabilities and psychiatric 
disturbances are qualitatively different from each other and require 
different methods of determination.''
    Response: Although we acknowledge the distinction made by the 
commenter, we did not adopt the comment. We decided to continue the 
prior structure of headings, which lists each category of mental 
disorder as a separate listing, similar to the separate chapters of 
mental disorders in the DSM-5. Although the listings for cognitive 
disorders and psychiatric impairments appear next to each other in the 
ordering of the listings, and occasionally alternate within the 
ordering of the listings, they have separate titles, separate 
identifying numbers, and separate medical criteria. This format 
provides a clear distinction among the types of mental disorders. 
Additionally, given the relatively small number of mental disorders 
listings, grouping listings 12.02, 12.05, and 12.11 under separate 
headings would complicate the listings at a time when we are trying to 
simplify them. We maintained the ordering and numbering of the listings 
from our prior rules to ease the transition to these final rules, when 
possible.
    Comment: One commenter suggested that the listings should consider 
combined disability for schizophrenia (12.03) and cognitive disorder 
(12.02), and for mood disorder (12.04) and cognitive disorder, because 
co-morbidity between these disorders ``is the rule rather than the 
exception. The listings should expect this, and allow for this.'' 
Another commenter stated that it is important to ``acknowledge the 
impact that dual diagnoses may have on an individual's functioning.''
    Response: We did not adopt the comment. Although we appreciate the 
issues raised by the commenters, it is not necessary or practical to 
provide listings that combine mental disorder categories for four 
reasons. First, Sec. Sec.  404.1523 and 416.923 require us to consider 
the combined effect of all of a person's impairments in our disability 
determination processes. Second, when we determine whether a person's 
mental disorder is disabling under the law, it does not matter whether 
the person has a diagnosis or a combination of diagnoses. The 
controlling issue is whether the medically determinable mental 
impairment(s) result(s) in limitations in functioning that prevent the 
person from working. Third, given the numerous examples of co-morbid 
mental disorders, we do not think it is feasible to provide listings 
for all possible co-morbidities. Fourth, the listing criteria allow us 
to evaluate the range of effects of any combination of mental disorders 
on functioning

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independently, appropriately, effectively, and on a sustained basis.

Sections 12.00B and 112.00B--Which mental disorders do we evaluate 
under each listing category?

    Comment: One commenter noted that the guidance to adjudicators in 
paragraph ``c'' of all the 12.00B sections says, ``. . . examples of 
disorders in this category include . . . , '' without clarifying that 
the list of examples is not exhaustive. The commenter recommended that 
we make clear the non-exhaustive nature of the list of examples of 
mental disorders in each listing category by adding, ``may include, but 
are not limited to.''
    Response: We did not adopt the comment. Several sections of the 
introductory text have lists that are not exhaustive. It would make the 
listings more difficult to use if we included repeated statements of 
``may include, but are not limited to'' in every place in the listings 
where there is a list. The words ``examples'' and ``include'' 
sufficiently indicate that the lists are not exhaustive.
    Comment: One commenter noted that in proposed 12.00B1, which is the 
description of listing 12.02, we provided a cross-reference to the 
documentation and evaluation guidance in 11.00F for traumatic brain 
injury (TBI) only. The commenter recommended that the entire ``Dementia 
category'' be cross-referenced so that ``adjudicators give full 
consideration to both the neurological and mental limitations'' 
associated with all the disorders evaluated under listing 12.02.
    Response: We adopted this suggestion and ended final 12.00B1b with 
a parenthetical statement explaining that we evaluate neurological 
disorders under that body system (see 11.00). We evaluate cognitive 
impairments that result from neurological disorders under 12.02 if they 
do not satisfy the requirements in 11.00.
    Comment: One commenter was concerned that the description of 
listing 12.02 did not appear to include the effects of head injuries 
that do not rise to the level of TBI. For example, adults with mental 
disorders who are homeless or incarcerated may have histories of 
physical abuse including blows to the head, fights or falls involving 
episodes of unconsciousness, or as pedestrian victims of vehicular 
accidents. These brain injuries, which can result from recurring, less 
traumatic assaults rather than from one or more traumatic injuries, can 
nevertheless add up to impaired cognitive functioning. The commenter 
urged us to include some direction to adjudicators in the listing about 
how to evaluate such histories.
    Response: We did not adopt the comments. We agree that it is 
important for adjudicators to understand the differing impacts of TBI 
and a history of concussive injuries, as well as the lasting effects of 
substance use on the brain. However, the list of symptoms and signs and 
the examples of disorders in this listing category are not limited to 
those presented in 12.00B1a. Furthermore, they would readily include a 
history of concussive injuries resulting in brain damage. We believe 
that the list of symptoms and signs is sufficiently descriptive of the 
brain damage a person may incur after several such injuries that it is 
not necessary to expand it at this time.
    Comment: A few commenters stated that it is difficult to determine 
whether listing 12.02 would apply in circumstances when cognitive 
limitations have resulted from the impact of substance use. To address 
this, a commenter recommended ``some expansion of the symptoms or some 
addition to the overarching cognitive difficulties in this category.''
    Response: We adopted this comment. We included substance-induced 
cognitive disorder associated with drugs of abuse, medications, or 
toxins among the examples of disorders in this category in 12.00B1b.
    Comment: Some commenters stated that the descriptions in 112.00B of 
two listing categories, proposed listing 112.02 (dementia and amnestic 
and other cognitive disorders) and proposed listing 112.11 (other 
disorders usually first diagnosed in childhood or adolescence) were 
``incompletely specified.'' The commenters noted that listing 112.02 
includes TBI, but that there are many other types of childhood brain 
insult, including those related to tumors, epilepsy, cancer treatment, 
genetic disorders, exposure to toxins, and perinatal brain insults. The 
commenters observed that children with these conditions ``fall more 
clearly in the first [listing] . . . than in the second. Unfortunately, 
which category encompasses these conditions is unclear from the 
descriptions of these two categories.''
    Response: We partially adopted these recommendations. We included 
mental impairments resulting from vascular malformation or progressive 
brain tumor in final 112.00B1b, where we list examples of disorders 
that we evaluate under listing 112.02. We did not include all of the 
examples that the commenters recommended because the lists of example 
disorders in 112.00B are not exhaustive. The examples include the 
impairments that we see most often in child claimants seeking benefits 
under our program. We may find that other disorders not included in the 
examples may meet or medically equal the respective listings, depending 
on the facts of each case.
    We also added an explanation to final 112.00B1b that we evaluate 
neurological disorders under that body system (see 111.00). We evaluate 
cognitive impairments that result from neurological disorders under 
112.02 if they do not satisfy the requirements in 111.00. We evaluate 
catastrophic genetic disorders under the listings in 110.00, 111.00, or 
112.00, as appropriate. We evaluate genetic disorders that are not 
catastrophic under the affected body system(s).
    In addition, to respond to this comment, we updated the title of 
listing 112.11 to ``neurodevelopmental disorders,'' which is the term 
used in the DSM-5 for these types of impairments, to better distinguish 
the applicability of listings 112.02 and 112.11. Another intended 
distinction between these two listings is that of knowing, compared 
with not knowing, the cause of a child's mental impairment. If we know 
that the mental impairment has an organic cause, we will evaluate the 
impairment under listing 112.02; if the cause is not known, we will 
evaluate the impairment under listing 112.11.
    Comment: The spokesperson for a professional organization 
recommended that we add language to proposed 112.00B7, where we 
describe personality disorders in our childhood listings, to indicate 
that personality disorders ``typically have an onset in adolescence or 
early adulthood.'' The commenter stated that this characterization is 
consistent with information in the Diagnostic and Statistical Manual of 
Mental Disorders, Fourth Edition, Text Revision \3\ (DSM-IV-TR).
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    \3\ American Psychiatric Association: Diagnostic and Statistical 
Manual of Mental Disorders, Fourth Edition, Text Revision. 
Washington, DC, American Psychiatric Association, 2000.
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    Response: We adopted the comment because the DSM-5 also indicates 
that personality disorders have an onset in adolescence or early 
adulthood. Final 112.00B7a includes the sentence, ``Onset may occur in 
childhood but more typically occurs in adolescence or young 
adulthood.''
    Comment: A commenter noted that intermittent explosive disorder is 
``a diagnosis for which there is remaining confusion . . . [but which 
is] the most serious form of unclassified disorders of

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impulse control.'' The proposed guidelines for children are ``very 
clear that problems of self-regulation and impulsivity may potentially 
be [the] bases for [a finding of] `marked' [or extreme] functional 
limitation.'' However, in the absence of other specific mental 
disorders, this disorder does not seem to fit a clear category, and 
adjudicators could overlook it in a disability determination. The 
commenter recommended that we state clearly that the diagnosis can 
apply to both children and adults.
    Response: We adopted the comment. We are aware that the DSM-5 
includes this diagnosis under the category of disruptive, impulse-
control, and conduct disorders. In response to this comment, we added 
``intermittent explosive disorder'' to the lists of example disorders 
that we evaluate in final 12.00B7b and 112.00B7b. We also revised the 
titles and the criteria for listings 12.08 and 112.08 to include 
impulse-control disorders. The new paragraph B4 criterion for adults 
and for children age 3 to age 18, adapt or manage oneself, also 
provides for consideration of problems of self-regulation and impulse 
control.
    Comment: One commenter had several suggestions about proposed 
12.00B8. First, the commenter recommended that we wait until the expert 
panel that was revising the DSM-IV completed its work before we 
proposed a definition for autism spectrum disorder (ASD). The commenter 
raised concern that failing to consider a new DSM-5 definition of these 
disorders could foster confusion among professionals, parents, and 
consumers, and could breed inconsistent definitions of ASD that might 
hinder the rights of children and adults to secure important benefits. 
Second, the commenters recommended that we should conduct in-depth 
research, expert consultation, and study to ensure that any proposed 
revision in the definition of ASD is warranted and correct. Third, the 
commenter stated that our proposed definition and criteria did not 
recognize that the core nature of ASD is not an intellectual impairment 
but a social and behavioral disability. Therefore, the commenter 
thought that the use of the paragraph B1 criteria (understand, 
remember, or apply information) and B3 criteria (concentrate, persist, 
or maintain pace) pointed to our lack of understanding of ASD.
    Response: We did not adopt the comments, although we appreciated 
them, particularly given the intense concern and dialogue currently 
focused on ASD among medical professionals, educators, and parents. The 
APA ``defines'' or characterizes mental disorders based on research, 
consultation, and study in its diagnostic and statistical manual. The 
discussion of ASD in final 12.00B8a and 112.00B8a is not a ``proposed 
definition''; it is the characterization of this disorder found in the 
DSM-IV-TR and DSM-5. We understand that ASD is a highly complex 
disorder that interferes with a person's functioning in many ways, 
especially communication and social interaction. Therefore, the 
description of ASD in 12.00B8b begins with a discussion of social 
interaction and communication skills to reflect the emphasis in the 
DSM-5 on these two aspects of functioning.
    Although some people with ASD do not have cognitive limitations, 
some do. Any method of evaluation intended to apply to everyone with 
ASD must provide criteria for assessing the range of possible 
limitations that individuals with the disorder may experience. For this 
reason, we apply all four of the paragraph B criteria, including 
paragraphs B1, understand, remember, or apply information, and B3, 
concentrate, persist, or maintain pace, to ASD.
    Comment: A commenter recommended that if the APA removed 
``Asperger's disorder'' as a separate diagnosis in the DSM-5, then 
these final rules should be consistent with that change.
    Response: We adopted the comment, and we removed the references to 
Asperger's disorder in final 12.00B8b and 112.00B8b.
    Comment: Some commenters suggested including specific mention of 
conduct disorder and oppositional defiant disorder in proposed 
112.00B9c, where we listed examples of disorders we would evaluate 
under listing 112.11 (other disorders usually first diagnosed in 
childhood or adolescence). One of the commenters explained that these 
disorders are included in a similar chapter of the DSM-IV and are 
common diagnoses in childhood and adolescence.
    Response: We did not adopt the comment. In the DSM-5, these 
disorders are now included in their own category of ``disruptive, 
impulse-control, and conduct disorders.'' To be consistent with the 
DSM-5, final listing 112.08, personality and impulse-control disorders, 
now includes aspects of ``disruptive, impulse-control, and conduct 
disorders.'' For example, final 112.00B7a includes impulsive anger and 
behavioral expression ``grossly out of proportion to any external 
provocation or psychosocial stressors.'' As another example, final 
112.00B7b lists intermittent explosive disorder as one of examples of 
disorders we evaluate under listing 112.08. Additionally, the paragraph 
A criteria for final listing 112.08 includes ``recurrent, impulsive, 
aggressive behavioral outbursts.''
    We did not include conduct disorder or oppositional defiant 
disorder in the list of examples of disorders that we evaluate under 
listing 112.08 because, in our programmatic experience, these 
impairments do not typically result in marked limitation in two of the 
``paragraph B'' criteria, or extreme limitation in one of the criteria. 
However, the list of examples in final 12.00B7b is not exclusive. 
Either or both of these impairments may meet or medically equal the 
criteria in listing 112.08, depending on the facts of the individual 
case.

Sections 12.00C and 112.00C--What evidence do we need to evaluate your 
mental disorder? (Proposed 12.00G and 112.00G)

    Comment: Several commenters requested that we include language in 
12.00G2 that ``requires adjudicators to consider the factors in the 
regulations for weighing medical opinions.''
    Response: We partially adopted this comment. We typically do not 
repeat guidance that we provide elsewhere in our regulations. However, 
in response to this comment, we added a reference to our regulations on 
evaluating opinion evidence in 12.00C1 and 112.00C1.
    Comment: We received various comments regarding our reference to 
health care providers, such as physician assistants, nurses, licensed 
clinical social workers, and therapists, as medical sources whose 
evidence we will consider when evaluating a person's mental disorder 
and the resulting limitations in the person's functioning. Some 
organizations and individual commenters strongly supported our 
inclusion of these professionals, because they may be most familiar 
with a person's limitations in functioning. However, a professional 
medical organization opposed characterizing the reports of non-
physician mental health professionals as ``evidence from medical 
sources,'' unless the work of the practitioner is recognized as medical 
in scope. The spokesperson maintained that any reference to ``medical 
sources'' of information should be limited to medical professionals 
such as medical doctors (MDs) or doctors of osteopathy (DOs). Other 
professional organizations said that our reference to ``physician'' and 
``psychologist'' should be more specific, and should include references

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to psychiatrists and clinical neuropsychiatrists.
    Response: We did not adopt the recommendations. Our recognition of 
non-physician health care providers as other medical sources of 
evidence is not a new rule; see Sec. Sec.  404.1513(d) and 416.913(d). 
The list of these other medical sources in our regulations is not all-
inclusive, and our mention of licensed clinical social workers and 
clinical mental health counselors in final 12.00C2 is appropriate, 
given their roles in the treatment of people with mental disorders in 
both private and public settings. We believe that these other medical 
professionals--because they typically see patients regularly--are 
important sources of the evidence we need to assess the severity of a 
person's mental disorder and the resulting limitations in the person's 
functioning.
    Comment: The spokesperson for an organization questioned why we 
``separated'' therapists and licensed clinical social workers (LCSW) in 
proposed 12.00G2, because LCSWs are therapists. This person noted that 
because the scope of social work is so broad, some people may be 
confused about the specific expertise of LCSWs, which is the largest 
group of therapists in the country.
    Response: We adopted this comment. We replaced the example of 
``therapists'' with that of ``clinical mental health counselors'' in 
final 12.00C2 for accuracy and completeness.
    Comment: The spokesperson for an organization requested that we add 
case managers and similar staff as examples of non-medical sources of 
evidence.
    Response: We adopted the comment. We added the examples of 
community support and outreach workers and case managers in final 
12.00C3 and 12.00C5b where we discuss evidence from third parties and 
non-medical sources of longitudinal evidence.
    Comment: While commenting on proposed 12.00D and expressing 
concerns about standardized testing, one person said that because 
mental disorders are not amenable to testing and are different for 
every individual, we should evaluate each person on a case-by-case 
basis, using the best sources of information about the person's 
condition. Some health care professionals, while acknowledging our need 
to make the determination of disability as ``efficient'' and 
``objective'' as possible, urged us to recognize the importance of 
clinicians' observations, interpretations, and evaluations of their 
patients' mental disorders. Many direct service providers stressed the 
importance of obtaining information from people who, because they know 
and spend time with the person with a mental disorder, are in the best 
position to tell us how the person functions.
    Response: We adopted the comments. We removed the provision in 
proposed 12.00D regarding standardized testing from these final rules. 
We discuss that change and our reasons for making it below, where we 
explain our responses to public comments about sections 12.00F and 
112.00F.
    Regarding the commenters' suggestions about sources of evidence and 
our evaluation of mental disorders, we appreciate the views and 
recommendations, and the NPRM and the final rules reflect them. For 
example, in final 12.00C2, we explain how we consider evidence from 
medical sources. We state that we consider all relevant medical 
evidence, including the results of physical or mental status 
examinations, structured clinical interviews, psychiatric or 
psychological rating scales, measures of adaptive functioning, and 
observations and descriptions of how a claimant functions during 
examinations or therapy. As another example, in final 12.00C3, we state 
that we consider evidence from third parties who can provide 
information about a claimant's mental disorder, including a claimant's 
symptoms, daily functioning, and medical treatment. We added to the 
list examples of people who can provide us with this evidence. The list 
of examples includes family, caregivers, friends, neighbors, clergy, 
social workers, shelter staff, or other community support and outreach 
workers.
    Regarding the suggestion for a case-by-case assessment of each 
claimant, our longstanding principle has been to evaluate each person 
who files a disability claim on an individualized basis. We understand 
that no mental disorder affects all individuals in the same way; 
rather, mental disorders affect each person uniquely in every aspect of 
his or her life. Our process of evaluating four criteria that reflect a 
person's functional abilities and rating the person's limitations for 
each criterion is just one example of our commitment to individualized, 
case-by-case assessments.
    Comment: One commenter recommended that we recognize the unique 
circumstances of people who are experiencing homelessness, and permit 
longitudinal evidence of their mental disorders from social workers.
    Response: We adopted this comment. In final 12.00C5b, we included 
``chronic homelessness'' as an example of a situation that may make it 
difficult to provide longitudinal medical evidence. This section also 
lists social workers as a source of longitudinal evidence of a person's 
mental disorder.
    Comment: Some commenters recommended that we emphasize the value 
and importance of using standardized assessment instruments 
specifically developed for use with children. The commenter suggested 
that, for example, additional language could be included in proposed 
112.00G5 to ensure that tests used are appropriate to the age and 
condition of the child.
    Response: Although we appreciate the concern raised by the 
commenter, we did not adopt the comment. We cannot control what 
standardized instruments medical and educational providers use when 
evaluating children. We consider all relevant evidence that we receive. 
If we receive the results from standardized assessment instruments not 
specifically developed for use with children, or that were not 
appropriate to the age and condition of the child, those are important 
facts that we will consider when we evaluate the evidence.
    To the extent that the comments pertained to our policies for 
ordering standardized assessment instruments when we purchase 
psychological consultative examinations for children, the comment would 
be outside of the scope of the proposed rulemaking. Our policies 
regarding consultative examinations for children are in Sec. Sec.  
416.917-416.919t.
    Comment: Spokespersons for two professional organizations expressed 
concern about the absence of specific reference to neuropsychological 
testing and its application in the evaluation of claims of both adults 
and children with mental disorders. One spokesperson said that 
neuropsychological examinations are particularly relevant when 
neurodevelopmental or acquired brain dysfunction forms the basis of a 
person's category of disability. Another spokesperson said that proper 
evaluation of childhood brain insults requires comprehensive 
neuropsychological assessments because, ``proper evaluation of these 
disorders requires assessments of specific skill domains such as would 
be provided in comprehensive neuropsychological assessments.''
    Response: We did not adopt these comments. We do not believe that 
it is necessary to refer to both psychological and neuropsychological 
testing because neuropsychological testing is a subset of psychological 
testing, and the same broad principles apply to our evaluation of these 
tests. In addition, neuropsychological test batteries, while useful in 
clinical and research settings,

[[Page 66143]]

have limited applicability in the disability program. This is because 
such batteries generally contain a number of subtests that focus on 
small units of behavior. These types of clinical measures often have 
little direct relevance to functional behavior as we assess it under 
the disability program. We will consider the results from 
neuropsychological assessments when they are a part of the evidence in 
the case record. We will not purchase formal neuropsychological test 
batteries, such as the Halstead-Reitan Neuropsychological Test Battery. 
We may purchase a neuropsychological test to assess specific 
neurocognitive deficits if the case evidence is insufficient to 
evaluate the claim, or to obtain evidence needed to resolve a conflict, 
inconsistency, or ambiguity in the evidence.
    Comment: Spokespersons for some professional organizations 
recommended that we use symptom validity testing (SVT) to enhance 
validity of psychological consultative examinations (PCE) and to 
identify malingering. The commenters said that using SVT in disability 
evaluations is one method of enhancing validity, and they made two 
related recommendations. First, the commenter suggested that we consult 
with the American Academy of Clinical Neuropsychology and related 
organizations to take advantage of their expertise in revising and 
expanding provisions addressing symptom validity in the regulations. 
Second, the commenter suggested that we promote training in SVT methods 
or encourage change in PCE practice to include routine use of SVT to 
evaluate response bias, effort, and malingering during psychological 
examinations.
    Response: We did not adopt the comment. Inaccurate self-report of 
symptoms and behavior occurs when individuals, because of psychiatric 
disorders or personality traits, over- or under-report the nature, 
range, and severity of symptoms. Inaccuracy in self-report does not 
necessarily mean there is no medically determinable impairment that 
imposes real limitations. Since we do not adjudicate a claim based on 
symptoms alone, objective observation and description of the person's 
behavior must support any conclusions based on a test(s) of 
malingering. Additionally, the conclusions must be consistent with 
other evidence.

Sections 12.00D and 112.00D--How do we consider psychosocial supports, 
structured settings, living arrangements, and treatment? (Proposed 
12.00F and 112.00F)

    Comment: Several commenters asked that we make clear that the list 
of psychosocial supports and structured settings and living 
arrangements does not include all possible supports a person with 
mental disorder may receive, or in which he or she may be involved.
    Response: We adopted the comment. We did not intend the list of 
supports in proposed 12.00F2 be inclusive of everything that we would 
consider when we evaluate a person's particular circumstances. We 
intended that the list only include examples of such supports and 
settings. In response to the comments, we added a phrase to final 
12.00D1 indicating that the types of supports listed in that section 
are ``some examples of the supports'' that a person ``may'' receive.
    Comment: Several commenters requested that we add supported housing 
with wrap-around services as an example of psychosocial supports and 
highly structured settings in proposed 12.00F2.
    Response: We adopted the comment. We included reference to `` `24/7 
wrap-around' mental health services'' to the examples of possible 
supports and structured settings and living arrangements in final 
12.00D1d.
    Comment: One commenter recommended that we expand the list of 
psychosocial supports and highly structured settings to include 
examples relevant to people whose impairments have contributed to 
homelessness and infrequent access to supports. The commenter said that 
the list of psychosocial supports, structured settings, and treatment 
presumes that a person has a regular and stable place to live, has 
social connections with family and friends, and has connections with 
treatment and services. However, clients of health care services for 
homeless people are often socially isolated, disconnected from 
services, and do not have a place to live, or live in residential 
facilities for homeless people.
    Response: We adopted the comment. We added an example in final 
12.00D1f to include the situation of people who receive assistance from 
a crisis response team, social workers, or community mental health 
workers who help them meet their needs and who may also represent them 
in matters with government or community social services.

Sections 12.00E and 112.00E--What are the paragraph B criteria? 
(Proposed 12.00C and 112.00C)

    Comment: We received comments presenting several different reasons 
for retaining the prior paragraph B1 criterion, activities of daily 
living (ADL). The spokesperson for an organization was concerned that 
the proposed change to paragraph B1 will hinder accurate disability 
determinations for people with severe disabilities who do not regularly 
engage in work or treatment. This commenter said that the category of 
ADL is easily understandable to providers and that important 
information and significant details will be lost if this category is 
eliminated. Two commenters remarked that it is easier to document 
limitations in ADL than the proposed paragraph B1 criterion, 
particularly with respect to adults with mental disorders who are 
homeless and unable to access or attend consistent treatment. Another 
commenter said that if a person cannot adequately manage his or her 
ADL, it is reasonable to assume that working at substantial gainful 
activity levels would be extremely unlikely. One commenter said that 
removing ADL as a criterion partly ignores the basic self-reported 
information we have about what a person actually is doing while not in 
a work setting. Another commenter said that ``as a non-clinician,'' it 
is easier to see how someone is having a difficult time completing ADL 
than to give examples of when he or she does or does not ``understand'' 
things or ``apply information.''
    Response: We did not adopt these comments. However, we will 
continue to consider how a person performs ADL when we evaluate the 
effects of a mental disorder on the person's functioning and ability to 
work. ADL information will continue to be central to our documentation 
of a person's mental disorder, because knowing how the mental disorder 
affects the person's day-to-day functioning can help us evaluate how it 
would affect the person's functioning in a work setting.
    The final rules will use information about a person's ADL as a 
principal source of information, rather than as a criterion of 
disability. This change is congruent with the focus of the paragraph B 
criteria on the mental abilities a person uses to perform work 
activities. The principle is that any given activity, including ADL, 
may involve the simultaneous use of the paragraph B areas of mental 
functioning. For example, with respect to the same activity, one person 
may have trouble understanding and remembering what

[[Page 66144]]

to do, while another person may understand the activity but have 
trouble concentrating and staying on task to do it. Still another 
person may understand the activity but be unable to engage in it with 
other people, or may feel such frustration in doing it that he loses 
self-control in the situation. Rather than ADL being one separate area 
in which we evaluate a person's functioning, ADL are now a source of 
information about all four of the paragraph B areas of mental 
functioning. We will focus on this aspect of the final rules in our 
formal training of adjudicators.
    Comment: A commenter stated that the ADL information solicited from 
a person experiencing homelessness, along with third party evidence, is 
crucial to providing adjudicators with an accurate portrayal of 
limitations in daily functioning. A spokesperson for a professional 
organization raised concern that increased documentation requirements 
would disproportionately affect homeless people with mental illness, 
because they do not have access to transportation to appointments, and 
face significant challenges in seeking treatment, attending 
appointments, and obtaining documentation. The spokesperson indicated 
that although homelessness is not an indication of functional 
limitation under the paragraph B criteria, a prolonged period of 
homelessness reflects significant barriers, such as a disabling 
condition, in obtaining and maintaining housing and health stability. 
The commenter suggested that it would be an oversight to ignore the 
most significant factor of a person's ADL (homelessness). A related 
comment was that it would be helpful to claimants and adjudicators if 
we provided examples of evidence we need from the person filing for 
disability benefits and from people who know him or her.
    Response: We did not adopt the comments. As we explained in 
response to a previous comment, ADL information continues to be central 
to how we document a person's mental disorder and its effects on a 
person's daily functioning. Under these rules, we will use ADL as a 
source of information about all four of the paragraph B areas of mental 
functioning. We appreciate the unique difficulties that homeless people 
have with respect to access to transportation to appointments, and 
their significant challenges in seeking treatment, attending 
appointments, and obtaining documentation. We have special case 
processing and development guidance for homeless claimants in our field 
offices and our State agency partners in our sub-regulatory policies. 
Furthermore, we do not agree that these final rules increase 
documentation requirements. However, in final 12.00C5b, we included 
chronic homelessness as an example of a situation that may make it 
difficult to obtain longitudinal medical evidence.
    Comment: The spokesperson for one organization said that it might 
be difficult to identify and distinguish sufficient information to 
satisfy the criteria in paragraphs B1 and B3, because the categories 
appear to be redundant. While proposed paragraph B1 (understand, 
remember, and apply information) involves a person's cognitive 
abilities, proposed paragraph B3 (concentrate, persist, and maintain 
pace) involves attention. However, these two criteria have 
``significant overlap.'' Medical records already lack sufficient 
functional information for disability determination, and moving to a 
more work-centered approach (using those criteria) may exclude some 
people.
    Response: We did not make any changes to the final rules in 
response to these comments. We agree that there is ``overlap'' between 
the abilities to understand, remember, or apply information, and to 
concentrate, persist, or maintain pace--given the need to pay attention 
when using both abilities. It is also true that approaches to 
categorizing human abilities and functioning--in other contexts and for 
other reasons--use different categories to describe mental abilities. 
However, the Mental Cognitive Demands Subcommittee of the Occupational 
Information Development Advisory Panel (OIDAP) (referenced in the 
preamble to the NPRM) recommended separate categories and descriptions 
for ``neurocognitive functioning,'' and ``initiative and persistence,'' 
\4\ which generally parallel the final paragraphs 12.00E1 and 12.00E3 
criteria, respectively.
---------------------------------------------------------------------------

    \4\ Occupational Information Development Advisory Panel (OIDAP) 
under the Federal Advisory Committee Act. Mental-Cognitive 
Subcommittee Content Model and Classification Recommendations. 
Report of the Mental-Cognitive Subcommittee, Appendix C, C-15 and C-
16. September 2009. https://www.ssa.gov/oidap/Documents/AppendixC.pdf.
---------------------------------------------------------------------------

    In our prior rules on evaluating mental disorders, there is 
precedent for using the two separate paragraph B criteria to evaluate a 
person's functioning. Since 1990, in the rules for evaluating mental 
disorders in children, we have used separate criteria for assessing a 
child's cognitive functioning and the child's concentration, 
persistence, and pace (see 112.00). Since 1991, the rules for assessing 
a claimant's mental residual functional capacity (MRFC) have 
specifically addressed non-exertional limitations, including 
limitations in the person's ability to understand or remember 
instructions and to maintain attention or concentration (see Sec. Sec.  
404.1569a(c) and 416.969a(c)). Our programmatic experience has been 
that when a person's difficulties with the abilities described in 
paragraphs B1 and B3 rise to the level of marked limitation, the 
medical and non-medical evidence in the record is typically sufficient 
to distinguish the person's limitations in those abilities.
    Comment: Many commenters were concerned that our use of ``and'' in 
proposed paragraph B1 (understand, remember, and apply information) and 
proposed paragraph B3 (concentrate, persist, and maintain pace) could 
be misinterpreted as a change in policy that would set a higher 
standard for a person's mental disorder satisfying those criteria. The 
misinterpretation would be that a claimant would have to demonstrate 
limitation in each of the three parts of B1 and B3 rather than in only 
one part. The commenters recommended that we change the word ``and'' to 
``or'' in B1 and B3 for all of the listings. They also recommended that 
we make clear in the 12.00 Introduction that if a person has 
``extreme'' or ``marked'' limitation in any single part of the B1 or B3 
areas of mental functioning, the person has that degree of limitation 
for that whole paragraph B criterion.
    Response: We agree with the commenters and the reasons they 
provided. Therefore, we adopted these recommendations. To ensure that 
adjudicators apply these criteria properly, we explain in new sections, 
final 12.00F3f and 112.00F3e, that for paragraphs B1, B3, and B4, the 
greatest degree of limitation of any single part of the area of mental 
functioning will direct the rating of limitation for that whole area of 
functioning.
    Comment: Several commenters expressed concern about the new 
paragraph B4 criterion, manage oneself. Two commenters said that the 
criterion is ``vague and very difficult to document . . . and open to 
extremely subjective interpretation.'' They further commented that the 
proposed criterion of ``manage oneself in a work environment'' is 
``undefined and very subjective.'' Another commenter said, ``self-
management and skills for independence encompass more than the 
workplace and this should not be the requirement.'' The spokesperson 
for an organization questioned the usefulness of ``managing oneself in 
a work environment'' as a separate paragraph B criterion because this 
``appears to be the

[[Page 66145]]

overarching question when evaluating functional limitations; this is 
precisely what the four functional areas attempt to assess.''
    Response: We partially adopted the comments. In these final rules, 
we made changes to paragraph B4 to clarify the abilities and behaviors 
that the criterion ``managing oneself'' encompasses. We added more 
examples of ``managing oneself'' in the workplace in final 12.00E4, 
such as distinguishing between acceptable and unacceptable work 
performance, setting realistic goals, and making plans independently of 
others. Another change we made was adding that a person's ability to 
maintain personal hygiene and attire should be appropriate to a work 
setting. After making these revisions, we changed the title to include 
the word ``adapt'' to reflect the abilities and behaviors that we 
consider for this criterion.
    Additionally, we note that the content of the B4 criterion is not 
new or different from what adjudicators are already accustomed to 
evaluating and documenting. Our adjudicators already consider a 
person's ability to respond appropriately to work pressures when they 
assess the nature and extent of a person's mental limitations and 
determine the person's residual functional capacity for work activity 
(see Sec. Sec.  404.1545(c) and 416.945(c)).
    With respect to the comment that self-management and skills for 
independence encompass more than the workplace, we agree that the 
ability and skills we address in paragraph B4 are important in daily 
life as well as the workplace. The statutory definition of disability 
for adults limits our determination to whether a person is able to work 
(and, therefore, function in the workplace). However, we use all the 
information available to us about how a person functions, including how 
the person manages him- or herself from day-to-day at home and in the 
community, to make this determination.
    Comment: A spokesperson for an organization expressed concern that 
eliminating ``repeated episodes of decompensation'' from the paragraph 
B criteria would reduce our ability to measure the chronic nature and 
impact of a mental illness. The commenter noted that evaluating a 
person's decompensation patterns over time is crucial for determining 
the full impact of a mental disorder. The commenter also said that 
current medical records, particularly those for people with transient 
treatment, provide only a momentary snapshot of the illness.
    Response: We did not adopt these comments. We do not agree that 
eliminating ``episodes of decompensation'' from the paragraph B 
criteria will reduce our ability to measure the chronic nature and 
impact of a mental illness. To address the chronic nature of a mental 
disorder, we provide guidelines in several sections of the final rules: 
Final 12.00C5, concerning the need for longitudinal evidence; final 
12.00F4, concerning how we evaluate disorders involving exacerbations 
and remissions; and final 12.00G and the paragraph C criteria, which 
address ``serious and persistent'' mental disorders.
    Comment: One commenter found the proposed definitions of the B 
criteria lacking in detail and examples to guide adjudicators and 
advocates, particularly when compared to our prior rules. Another 
commenter said that the proposed B2 criterion for interacting with 
others was too broad, and difficult to assess and use in determining a 
person's mental status. The commenter said it would be more helpful if 
we were to provide examples of more specific interpersonal behaviors 
that reflect how one handles conflicts in adaptive, compared with 
maladaptive and impaired, ways.
    Response: We adopted these comments. We included more examples of 
each of the criteria in final 12.00E to provide adjudicators a more 
detailed understanding of the four paragraph B criteria in these final 
rules. We included the example of ``keeping social interactions free of 
excessive irritability, sensitivity, argumentativeness, or 
suspiciousness'' in our explanation of paragraph B2 to describe an 
adaptive way to interact socially in the context of maladaptive 
examples of social interactions.

Sections 12.00F and 112.00F--How do we use the paragraph B criteria to 
evaluate your mental disorder? (Proposed 12.00D and 112.00D)

    Comment: Many commenters representing various organizations, health 
care professionals, families of people with mental disorders, and 
others opposed the language in proposed 12.00D regarding using 
standardized test results to inform our assessment of whether a 
claimant's impairment results in marked or extreme limitations of his 
or her mental abilities. Commenters expressed a wide array of opinions 
and recommendations; the most frequently made public comment was, ``the 
proposed use of standardized tests to measure the functioning of people 
with serious mental illnesses is a flawed approach, with no scientific 
basis.''
    Response: In response to these comments, we removed this provision 
in the final rule. We had included the language in proposed 12.00D 
based on comments that we received in response to the ANPRM. In the 
ANPRM, we invited the public to send us comments and suggestions for 
updating and revising the mental disorders listings. In response to the 
ANPRM, two major organizations representing people with cognitive and 
other mental disorders advised that, in revising rules for mental 
disorders in adults, we should incorporate the definitions of 
``marked'' and ``extreme'' limitations based on standardized test 
results that we have in the childhood disability regulations in Sec.  
416.926a(e) of this chapter. In response to that recommendation, and as 
explained in the NPRM, we included these provisions from the childhood 
rules in proposed 12.00D (75 FR 51341-42). However, in their comments 
on the 2010 NPRM, those same organizations, and many other commenters, 
presented the objections summarized above about using the childhood 
regulatory definitions of ``marked'' and ``extreme'' based on the 
results of standardized testing.
    In these final rules, we removed the provisions and explanations 
that were in proposed 12.00D. We provide guidance that is different 
from what we proposed in 12.00D in final 12.00F (How do we use the 
paragraph B criteria to evaluate your mental disorder?). Final 12.00F 
explains how we rate the degree of a person's limitations when using 
the four paragraph B areas of mental functioning. For example, we 
provide a five-point rating scale, with definitions of each point on 
the scale that are unrelated to standardized test results. We explain 
how we use the paragraph B criteria and the rating scale to evaluate a 
person's ability to function independently, appropriately, and 
effectively, on a sustained basis.
    Comment: A spokesperson for an organization stated that 
psychometric tests should not be the sole determinant of ``marked'' and 
``extreme'' limitation for children. The commenter said that we should 
base our determination of the level of a child's limitation on the 
overall clinical assessment of the child, with equal emphasis placed on 
both testing and clinical assessment.
    Response: We do not rely on test scores alone when we decide 
whether a child is disabled. As explained in Sec.  416.924a, when we 
determine disability, we consider all of the relevant information in a 
child's case record. We do not consider any single piece of evidence, 
including test scores, in isolation. The medical evidence we consider 
includes clinical observations from, for example, a child's physician,

[[Page 66146]]

psychiatrist, psychologist, or speech-language pathologist, and from 
other medical sources such as physical, occupational, and 
rehabilitation therapists. These sources of evidence may provide us 
their clinical assessments of a child's impairment(s) and its effects 
on the child's functioning. Professional sources such as teachers and 
school counselors, as well as the child's caregivers and others who 
know the child, also provide information important to any disability 
determination.
    Comment: Many commenters recommended that we use a 5-point or 6-
point scale to evaluate impairment severity. Some commenters supported 
use of a 5-point scale ``to assist disability examiners to anchor the 
standards of `marked' or `extreme' limitations in functioning.'' Others 
submitted a rationale for using a 6-point scale, saying that a 5-point 
scale defined by ``no'' limitation at one end and ``extreme''--but not 
total--limitation at the other is confusing and misleading. They 
recommended that, to provide more clarification to adjudicators and 
medical sources, we should use a 6-point scale consisting of: No 
limitation; slight limitation; moderate limitation; marked limitation; 
extreme limitation; and total limitation.
    Response: We adopted the recommendation to retain the 5-point 
rating scale from our prior rules to assess impairment severity for 
adults. We agree that the use of this scale will help ``anchor'' the 
standards of ``marked'' and ``extreme.'' We provide definitions for 
each of the points of the scale in final 12.00F2. With respect to the 
recommendation that we use a six-point scale to evaluate impairment 
severity (that is, the addition of a sixth point at the ``severe'' end 
of the 5-point scale), we disagree that such a scale ``would provide 
more clarification to adjudicators and medical sources.'' ``Extreme'' 
is the rating we give to the worst limitations; however, it does not 
mean a total lack or loss of ability to function. A sixth rating point 
of ``total limitation'' would not serve any useful function in the 
disability program.
    Comment: The spokesperson for an organization recommended that we 
use the term ``mild'' to describe the second point on the five-point 
scale for assessing the degree of a person's limitations. The commenter 
objected to the term ``slight,'' as suggested in proposed 12.00D. The 
commenter stated that professionals use the term ``mild'' when rating 
and ranking human behavior.
    Response: We adopted the comment. As discussed above, because we 
are retaining our prior policies pertaining to the use of a five-point 
scale in these final rules, we will continue to use the word ``mild'' 
to describe the second point on the scale. By using the same words to 
describe the same policies, we hope to prevent any confusion that would 
result from using a new and different word.
    Comment: The spokesperson for an organization requested 
``additional clarification that it is not the role of the adjudicator 
to evaluate a claimant's ability to function in the workplace based on 
his or her own conclusions drawn from a single observation of the 
claimant.''
    Response: We did not adopt the comment. We do not believe the 
additional clarification that the commenter requested is necessary in 
these final rules. The introductory text states in multiple places that 
we will consider all relevant evidence when we evaluate a person's 
ability to function in the workplace. Final section 12.00F3a states 
that we will use all of the relevant medical and non-medical evidence 
in the case record to evaluate a person's mental disorder. In final 
section 12.00F3c, we indicate that we will consider all evidence about 
a person's mental disorder and daily functioning before we reach a 
conclusion about his or her ability to work. In final 12.00F3d, we 
state that no single piece of information can establish the degree of 
limitation of a paragraph B area of mental functioning. We do not 
believe the additional statement requested by the commenter is 
necessary in light of the other guidance throughout final 12.00F.
    Comment: Several commenters suggested that we consider homelessness 
(along with a diagnosis of mental illness) as an indicator of 
functional impairment. The commenters also proposed that we could 
establish a period of homelessness that we would consider an indicator 
of functional difficulty.
    Response: We did not adopt the comment. When we evaluate a person's 
mental disorder(s), we consider all the information available to us 
that could indicate limitations in the person's functioning. If the 
person is homeless, we consider that fact, including how long he or she 
has been homeless. As stated in final 12.00C5b, we try to learn about 
how a person functions day-to-day from the people who spend time with 
him or her. However, it would not be appropriate to establish a 
specific period of homelessness as an indicator of limited functioning, 
because we do not believe there is a measurable correlation between the 
severity of a person's mental disorder and the length of time the 
person has been homeless.
    Comment: A commenter requested that we place a greater emphasis on 
a claimant's ability to sustain work activity for 8 hours per day, five 
days per week, on a regular and continuing basis.
    Response: We adopted the comment. In final 12.00F4a, where we 
discuss how we evaluate mental disorders involving exacerbations and 
remissions, we explain that we will consider whether a person can use 
his or her areas of mental functioning on a regular and continuing 
basis (8 hours a day, 5 days a week, or an equivalent work schedule).
    Comment: The spokesperson for an organization recommended that we 
change our policies so that a ``moderate'' degree of impairment in 
three or more areas of functioning demonstrates an individual's 
inability to work.
    Response: We did not adopt the comment. It has been our 
longstanding policy to require that a claimant have ``marked'' 
limitation in two areas of functioning or ``extreme'' limitation in one 
area of functioning to be found disabled at the third step of the 
sequential evaluation process. At this step, we consider whether the 
person's impairment meets or equals a listed impairment.\5\ In other 
words, the impairment must be ``severe enough to prevent an individual 
from doing any gainful activity, regardless of his or her age, 
education, or work experience'' (or, for a child under age 18 for title 
XVI eligibility, the impairment causes ``marked and severe functional 
limitations'').\6\ Our programmatic experience includes the use of a 
standard based on moderate limitations in three domains in the title 
XVI childhood disability program from February 11, 1991 through August 
21, 1996.\7\ We used this standard at a fourth step of the childhood 
sequential evaluation process, not at the third step.\8\ In our 
experience with this standard, the spectrum of limitation that may 
constitute ``moderate'' limitation ranges from limitations that may be 
close to ``marked'' in severity to limitations that may be close to the 
``mild'' level. Thus, people who have

[[Page 66147]]

moderate limitation in three or more functional areas do not always 
meet our definition of disability. We assess these types of claims most 
accurately at the fourth step of the sequential evaluation process, 
where we consider a claimant's residual functional capacity and work 
experience, and the fifth step of the sequential evaluation process, 
where we also consider a claimant's age and education.
---------------------------------------------------------------------------

    \5\ Sec. Sec.  404.1520, 416.920, and 416.924.
    \6\ Sec. Sec.  404.1525(a) and 416.925(a).
    \7\ See 56 FR 5560 for the regulation in effect from February 
11, 1991, through September 8, 1993, and 58 FR 47584 for the 
regulation in effect from September 9, 1993, through August 21, 
1996.
    \8\ The Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 eliminated this standard and the fourth 
step of the childhood sequential evaluation process (Pub. L. 104-
193).
---------------------------------------------------------------------------

    Comment: Several commenters were concerned that a clinician's use 
of the term ``mild'' or ``moderate'' in diagnosing the stage or level 
of a person's mental disorder (for example, as in a diagnosis of 
Alzheimer's disease) might be misconstrued as a description of the 
person's level of functioning with respect to the paragraph B or C 
criteria. They suggested that we include language in 12.00 to preclude 
any misunderstanding of how medical providers use these terms in 
medical records. Presenting the opposite viewpoint, one commenter 
recommended that we incorporate the DSM-IV-TR definitions for ``mild,'' 
``moderate,'' and ``severe'' in these rules as our program definitions 
for ``mild,'' ``marked,'' and ``extreme.''
    Response: We adopted the first comment for the reason the 
commenters provided. We added the recommended language to final 
12.00F3a. We did not adopt the second comment for three reasons. First, 
the definitions of the terms ``mild,'' ``moderate,'' and ``severe'' in 
the updated DSM-5 are different depending on the type of mental 
impairment the words are describing. For example, the DSM-5 definition 
of ``mild'' to describe major neurocognitive disorder is different from 
the definition of ``mild'' to describe major depressive disorder, and 
different from the definition of ``mild'' to describe intellectual 
disability. The different definitions of these terms in the DSM-5 serve 
the needs of trained medical and psychological specialists. However, 
they would be confusing and burdensome for our adjudicators to use.
    Second and related to the first point above, the DSM-5 does not use 
the terms ``mild,'' ``moderate,'' and ``severe'' consistently for all 
of the types of mental disorders. For example, the DSM-5 does not use 
the words ``mild,'' ``moderate,'' or ``severe'' to describe anxiety 
disorders. In addition to these three words, the DSM-5 also uses the 
word ``profound'' to describe some cases of intellectual disability. As 
a result, if we were to rely on the DSM-5 definitions of these terms, 
we would not have definitions for all types of impairments. The DSM-5 
definitions are not comprehensive enough for our program purposes.
    Third, we have used the words ``mild,'' ``moderate,'' ``marked,'' 
and ``extreme'' under our prior rules for many years. Although we did 
not provide definitions for most of these terms until now, the 
definitions in final 12.00F are consistent with how our adjudicators 
have understood and used those words in our program since we first 
introduced the rating scale in 1985. As a result, the definitions we 
provide in these rules do not represent a departure from prior policy. 
However, the DSM-5 definitions for these terms are not consistent with 
how we have used these words in our program in the past. For example, a 
claimant who has ``mild'' intellectual disability according to the DSM-
5 may have ``moderate'' or ``marked'' limitation in understanding, 
remembering, or applying information, depending on the facts of the 
case. We believe that using familiar definitions and concepts to define 
familiar terms will be easier for the public and adjudicators, rather 
than describing familiar terms in changed and unfamiliar ways.
    For these three reasons, we did not adopt the second 
recommendation.
    Comment: A commenter recommended that we add language to proposed 
12.00F and 112.00F to explain how adjudicators assess claims involving 
psychosocial supports and highly structured settings.
    Response: We adopted the comment. We added final sections 12.00F3e 
and 112.00F3d to explain how we consider the effects of support, 
supervision, and structure when we rate the degree of limitation that a 
person has. We explain that the more extensive the support the person 
needs from others, or the more structured the setting the person needs 
in order to function, the more limited we will find him or her to be.

Sections 12.00G and 112.00G--What are the paragraph C criteria, and how 
do we use them to evaluate your mental disorder? (Proposed 12.00E and 
112.00E)

    Comment: We received various comments regarding our proposal to use 
the term ``deterioration'' rather than ``decompensation'' in the 
paragraph C criteria of the listings. Commenters who opposed the change 
cited confusion and negative connotations associated with the word 
``deterioration.'' Commenters who agreed with the change stated that 
``decompensation'' refers to a state of extreme deterioration often 
leading to hospitalization. They further noted that a person with a 
serious and persistent mental illness does not need to be in a state of 
full-blown decompensation to have serious deficits in daily activities 
and in social or occupational functioning. Another commenter 
recommended that we keep some of the examples in prior 12.00C4 to 
explain what we mean by ``deterioration''; for example, increase or 
change in medication, more help from others to support the person's 
functioning, or the need to live in a controlled environment.
    Response: We did not adopt the suggestion to use the term 
``decompensation.'' We agree with the majority of comments that we 
received in response to the NPRM supporting our proposal to use 
``deterioration.'' As we noted in the NPRM,\9\ ``decompensation . . . 
refers to a state of extreme deterioration, often leading to 
hospitalization.'' It also suggests that the person is a danger to him- 
or herself or others. That degree of impairment exceeds what we 
generally intend in the paragraph C criteria when we refer to the 
``marginal adjustment'' that makes a person vulnerable to deterioration 
in functioning. Furthermore, we also believe that continuing to use 
``decompensation'' may result in confusion between the prior rules and 
these final rules. In these final rules, we no longer require 
``repeated episodes of decompensation, each of extended duration.'' 
\10\ We agree with the comment that some of the examples in prior 
12.00C4 help explain what we mean by ``deterioration.'' We adopted that 
comment, and we included examples in final 12.00G2c.
---------------------------------------------------------------------------

    \9\ See 75 FR 51338.
    \10\ In our prior rules, this requirement was in the B4 
criterion in all of the listings except 12.05. In prior 12.05, the 
requirement was in the D4 criterion. It was also in the C1 criterion 
in prior 12.02, 12.03, and 12.04.
---------------------------------------------------------------------------

    Comment: One commenter was concerned that the emphasis in proposed 
12.00E2b on continued treatment or highly structured settings would not 
be flexible enough to evaluate certain phobic conditions, such as 
agoraphobia, the symptoms of which often preclude such treatment. The 
commenter suggested that proposed 12.00F2 should state that the 
circumstances in paragraph C1 are not exhaustive, and that we consider 
other types of supportive services, including in the home.
    Response: We adopted the comment. We added language to final 
12.00D1 to indicate that the list of psychosocial supports, structured 
settings, and living arrangements are only examples of supports that a 
person may receive. Both proposed 12.00F2 and final 12.00D1 include the 
home of a person

[[Page 66148]]

who lives alone and has eliminated all but minimally necessary contact 
with the outside world as an example of a ``highly structured 
environment.'' We intended this example to apply to persons with phobic 
conditions, such as agoraphobia.
    Comment: One commenter was concerned that the paragraph C criteria, 
and the description of the criteria in proposed 12.00E, did not account 
for a claimant's lack of insight or awareness about his or her mental 
disorder. The commenter stated that many people with mental disorders 
lack awareness about their mental disorders and therefore refuse 
treatment. The commenter recommended that the policies should not place 
at a disadvantage those claimants whose mental disorders cause them to 
refuse to attend or follow up with treatment.
    Response: We agree with the commenter's reasoning, and we adopted 
the recommendation. We added language in final 12.00G2b stating that we 
will consider periods of inconsistent treatment or lack of compliance 
with treatment that may result from a claimant's mental disorder. The 
section explains that if the evidence indicates that the claimant's 
inconsistent treatment or lack of compliance is a feature of his or her 
mental disorder, and it has led to an exacerbation of his or her 
symptoms and signs, we will not use it as evidence to support a finding 
that the claimant has not received ongoing medical treatment.

Sections 12.00H and 112.00H--How do we document and evaluate 
intellectual disorder under 12.05 (112.05)?

    Comment: Several commenters were concerned that proposed 12.00D4 
would allow disability decision-makers to reject standardized test 
scores based on their subjective opinions of a person's day-to-day 
functioning. The commenters also stated that the language in this 
section would give an inappropriate amount of discretion to the 
adjudicators, who do not have the expertise of the test administrators. 
They cited two examples of possible rejection of ``valid test scores'': 
When a person's daily functioning is actually very basic or supported 
by others; or when a person's strengths in one area are used to find 
that the person's test results or limitations in another area are ``not 
credible.'' These commenters asked us to state clearly that 
interpretation of a test is primarily the responsibility of the 
professional who administered the test, and that adjudicators cannot 
override the validity of a medical professional's interpretation of 
test results.
    Response: We adopted most of these comments by making several 
changes in the final rules. First, we removed the discussion of 
evaluating test scores from final 12.00F, which replaces proposed 
12.00D. Like proposed 12.00D, final 12.00F provides guidance to 
adjudicators about how to evaluate a claimant's functioning using the 
``paragraph B'' areas of mental functioning. However, final 12.00F does 
not include a discussion of standardized test scores. Second, we added 
a new section, final 12.00H, to organize and expand the guidance to 
adjudicators about how to evaluate a cognitive impairment under listing 
12.05. We moved the discussion about standardized test scores into 
final 12.00H2 because only listing 12.05B requires standardized test 
scores.
    Third, we revised the guidance to indicate that only qualified 
specialists, Federal and State agency medical and psychological 
consultants, and other contracted medical and psychological experts, 
may conclude that an obtained IQ score(s) is not an accurate reflection 
of a claimant's general intellectual functioning. This change serves 
several purposes. It responds to the commenters' concern that proposed 
12.00D gave an inappropriate amount of discretion to the adjudicators 
who do not have the expertise of the test administrators by permitting 
only the individuals who do have the expertise of test administrators 
to make conclusions about IQ scores. However, it also allows our 
agency's medical and psychological experts to reach different 
conclusions than those reached by the individual test administrator, 
when appropriate. This option is important because during our case 
development, we often receive a more complete picture of a claimant's 
functioning from a variety of sources of information other than the 
test administrator(s).
    Comment: Some commenters said that the proposed rules were ``weak 
with respect to specifying the standard of practice in psychometric 
evaluations.'' The commenters recommended stronger language calling for 
the use of standardized instruments ``with comprehensive and 
representative norms, for which there is empirical evidence for 
construct and criterion validity in the demographic and diagnostic 
groups in which they are used.''
    Response: We partially adopted the comments. The proposed rules 
removed the detailed information on psychological testing in prior 
12.00D5 through D9 because, as we explained in the NPRM, most of the 
information is educational and procedural, and tests are regularly 
revised and updated. However, in these final rules, we added section 
12.00H2 to explain the evidence that we require from standardized 
intelligence testing under final listing 12.05B. In this section, we 
included the information from prior 12.00D5 and D6 that applies to 
intelligence tests. In addition, we expect to provide formal and 
accessible guidance to adjudicators about intelligence testing and 
final listings 12.05 and 112.05. We discuss why we do not require 
standardized assessments of adaptive behavior in our response to 
another comment below.
    Comment: A commenter stated that sometimes people with intellectual 
disability are not properly identified because they ``appear more 
functional than they are,'' particularly in work settings. The 
commenter requested that we consider ``on the job difficulties'' as 
part of our analysis of a person's adaptive functioning.
    Response: We adopted the comment. As discussed above, we added 
final 12.00H to expand the guidance to adjudicators about how to 
evaluate a cognitive impairment under listing 12.05. That section 
includes a sub-section about how we consider a claimant's work activity 
when we evaluate his or her functional abilities. We state that we will 
consider all factors involved in a claimant's work history, including 
whether the work was in a supported setting, whether the claimant 
required additional supervision, how much time it took the claimant to 
learn the job duties, and the reason the work ended, if applicable.
    Comment: The spokespersons for several organizations recommended 
that we further clarify how adjudicators will evaluate deficits in 
adaptive functioning. One commenter suggested that we mention 
standardized tests as a valuable source of evidence. Another commenter 
recommended that we evaluate and rate deficits in adaptive functioning 
in terms of scores that are two or more standard deviations below the 
mean. The commenter asserted that this measurement would be 
``consistent with the drafted criteria for Intellectual Disability 
under DSM-5 and would better reflect the desired increase in focus on 
adaptive behaviors consistent with current trends set by the American 
Association on Intellectual and Developmental Disabilities [AAIDD].'' 
The commenter also thought that use of standard scores to evaluate 
adaptive functioning would simplify listing 12.05.
    Response: We adopted the suggestion to provide more clarification 
about how adjudicators will evaluate deficits in adaptive functioning. 
As we discussed

[[Page 66149]]

earlier in this preamble, the reorganized criteria in final listings 
12.05A and 12.05B describe the evidence that we require to establish 
significant deficits in adaptive functioning for each listing. Final 
12.05A2 requires dependence upon others for personal needs (for 
example, toileting, eating, dressing, or bathing) to establish 
significant deficits in adaptive functioning. Alternatively, final 
12.05B2 requires extreme limitation of one, or marked limitation of 
two, of the ``paragraph B'' areas of mental functioning. The revised 
organization of final listings 12.05A and 12.05B enabled us to provide 
these specific, concrete criteria. We then added final section 12.00H3 
to provide more guidance about adaptive functioning generally, and 
adaptive functioning in specific situations, such as when a claimant 
with intellectual disability has a work history. Furthermore, we 
included ``standardized tests of adaptive functioning'' as an example 
of evidence we may receive and consider about a claimant's adaptive 
functioning in final 12.00H3b.
    We did not adopt the suggestion to evaluate and rate deficits in 
adaptive functioning in terms of scores that are two or more standard 
deviations below the mean. We are aware that for the AAIDD, ``. . . 
significant limitations in adaptive behavior are operationally defined 
as performance that is two standard deviations below the mean of either 
(a) one of the following three types of adaptive behavior: conceptual, 
social, or practical, or (b) an overall score on a standardized measure 
of conceptual, social, and practical skills.'' \11\ The AAIDD also 
provides guidelines concerning technical standards for adaptive 
behavior assessment instruments and for selecting an adaptive behavior 
assessment instrument.
---------------------------------------------------------------------------

    \11\ American Association on Intellectual and Developmental 
Disabilities: Intellectual Disability: Definition, Classification, 
and Systems of Supports, 11th Edition, Washington, DC, 2010, page 
43.
---------------------------------------------------------------------------

    However, the use of standard deviations as a required measure of 
deficits in adaptive functioning under listing 12.05 is not feasible or 
necessary in our program. The suggestion is not feasible because 
inclusion of such criteria in the listing would mean that we would have 
to require the results of a standardized test of adaptive functioning 
in every case evaluated under that listing. Although we can agree with 
the recommendation in principle, the medical evidence of record for 
claims that we would evaluate under listing 12.05 do not always contain 
adaptive functioning test results. Financial constraints within the 
disability program preclude our purchasing such testing in every case 
lacking such results.
    Additionally, the suggestion is unnecessary because the areas of 
mental functioning described in the 12.00 ``paragraph B'' criteria 
capture both the spirit and intent of the AAIDD's descriptions and 
understanding of the elements of adaptive functioning. For that reason, 
as for all other mental disorders, we use the paragraph B areas of 
mental functioning to evaluate the limitations in a person's adaptive 
functioning under listing 12.05. We explain in final 12.00H3 that if a 
person's case record includes the results of a standardized test of 
adaptive functioning, we will consider the test results along with all 
other relevant evidence. However, to evaluate and determine the 
severity of those deficits, we will use the guidelines in final 12.00E, 
F, and H.

Sections 12.00I and 112.00J--How do we evaluate substance use 
disorders? (Proposed 12.00H and 112.00H)

    Comment: Several commenters requested that we more clearly define 
the criteria and guidelines for determining the nature and effects of 
substance use on a person's functional capacity.
    Response: This request is outside the scope of the notice of 
proposed rulemaking, and we did not adopt this comment in these final 
rules. However, we appreciate the importance of clear guidance for 
implementing the statutory drug addiction and alcoholism (DAA) policy. 
Therefore, we published a Social Security Ruling (SSR) titled, ``Social 
Security Ruling, SSR 13-2p.; Titles II and XVI: Evaluating Cases 
Involving Drug Addiction and Alcoholism (DAA))'' on February 20, 
2013.\12\ We based the SSR on information we obtained from individual 
medical and legal experts, the Substance Abuse and Mental Health 
Services Administration in the U.S. Department of Health and Human 
Services, and our adjudicative experience. The SSR provides detailed 
guidance for adjudicators at all administrative levels. It consolidates 
information from our regulations, training materials, and question-and-
answer responses to explain our DAA policy.
---------------------------------------------------------------------------

    \12\ See 78 FR 11939. Available at: https://www.gpo.gov/fdsys/pkg/FR-2013-02-20/pdf/2013-03751.pdf.
---------------------------------------------------------------------------

    In cases of alleged mental impairment in which a substance use 
disorder is involved, we will evaluate the person's mental impairment, 
as appropriate, under the mental disorder listing for the involved 
condition (for example, depressive, bipolar and related disorders; 
schizophrenia spectrum and other psychotic disorders), and according to 
the guidelines in SSR 13-2p.

Listings 12.05 and 112.05--Intellectual Disorder

    Comment: We received many comments on the proposed change in the 
name of listing 12.05 to ``intellectual disability/mental retardation 
(ID/MR).'' Most commenters requested that we use only ``intellectual 
disability,'' given the adoption of that name in other governmental and 
non-governmental contexts. Some commenters were satisfied with the 
combination of terms during a transitional period, given our rationale 
in the NPRM for using both terms until the public and our adjudicators 
become accustomed to ``intellectual disability'' alone. One commenter, 
acknowledging a minority opinion, argued that we ought not to eliminate 
use of the prior title at any time. Several other commenters, while 
favoring the idea of changing the name of the listing, did not endorse 
the term proposed in the NPRM. Instead, they recommended the term, 
``intellectual disorder,'' because use of the word ``disability'' in 
the name of a listing would be confusing to claimants and to our 
adjudicators.
    Response: We adopted the last suggestion. After the NPRM published 
in 2010, Congress passed Public Law 111-256, which changed historically 
used terms in certain Federal laws to their updated counterparts, such 
as ``intellectual disability'' and ``an individual with an intellectual 
disability.'' The Federal law ordering this change did not apply to 
titles II and XVI of the Act, and therefore, did not require us to make 
any changes to our regulations. However, in response to public requests 
and in the spirit of the new law, we published another NPRM on January 
28, 2013 (78 FR 5755). The NPRM proposed to replace the historically 
used term with ``intellectual disability'' in our prior listings and in 
other appropriate sections of our rules. Public comments in response to 
the 2013 NPRM generally supported the change in terminology, and the 
proposed change became a final rule on August 1, 2013 (78 FR 46499).
    However, we are unlike other Federal agencies that have adopted the 
new terminology ``intellectual disability'' because we must comply with 
a legal definition of the word ``disability.'' As a result, a person 
who has a cognitive

[[Page 66150]]

impairment, including intellectual disability, does not have a 
``disability'' within the meaning of the Act until we have determined 
that the impairment satisfies all of the statutory and regulatory 
requirements for establishing disability.
    Although we carefully considered all of the comments we received in 
response to the 2010 NPRM, we ultimately agreed with those commenters 
who, while favoring the idea of changing the name of the listing, 
recommended the name ``intellectual disorder'' for listings 12.05 and 
112.05. We agree with their perspective and their recommendation, and 
we have adopted their proposed name change.
    Comment: Some commenters, including the spokesperson for a national 
organization, recommended that we make changes to listing 12.05. 
Commenters criticized the listing structure proposed in the NPRM as 
``inconsistent, redundant and unnecessary.'' One commenter stated, 
``the severity of intellectual disability is written into the diagnosis 
itself.'' Another commenter criticized proposed listing 12.05B as being 
both unclear and ``not needed.'' Some commenters said that proposed 
listing 12.05C is ``unnecessary.'' The commenters recommended that 
listing 12.05 guide adjudicators on the process of establishing 
intellectual disability with the assessment of both intellectual 
functioning and adaptive behaviors.
    Response: We adopted the comments. We reorganized the requirements 
of listing 12.05 to reflect the three diagnostic criteria for 
intellectual disability from the DSM-5 and the AAIDD. Listing 12.05 now 
has two paragraphs: 12.05A for claimants whose cognitive limitations 
prevent them from being able to take a standardized intelligence test 
and 12.05B for claimants who are able to take a standardized 
intelligence test. Paragraphs 12.05A and 12.05B each have three 
criteria that match the diagnostic criteria for intellectual disability 
and that describe the evidence that we need to satisfy the criteria. A 
claimant's impairment must satisfy the three criteria in either 
paragraph 12.05A or 12.05B, not both. We provide additional explanation 
about the revisions to listing 12.05 later in this preamble.
    Comment: Several commenters thought that proposed 12.00B4d would 
give ``excessive and largely unbridled leeway to the adjudicator to 
override valid test findings.'' The language they objected to was, ``We 
consider your IQ [intelligence quotient] score to be `valid' when it is 
supported by the other evidence, including objective clinical findings, 
other clinical observations, and evidence of your day-to-day 
functioning that is consistent with the [intelligence] test score.'' 
The commenters said that ``. . . the proposed rule seems to create a 
third prong to establish the diagnosis'' of intellectual disability. 
They identified the third ``prong'' as ``evidence of your day-to-day 
functioning that is consistent with the test score.'' The commenters 
urged us to ensure that adjudicators respect ``a valid diagnosis of 
`intellectual disability''' made by professionals and not allow 
adjudicators to dismiss a valid diagnosis.
    Other commenters thought that proposed 12.00B4d would allow 
adjudicators to use ``virtually . . . anything as evidence of a level 
of functioning that is inconsistent with'' intellectual disability. An 
attorney who represents disability claimants indicated that 
adjudicators cite ``high adaptive scores, or virtually anything in the 
record, as evidence of a level of functioning that is inconsistent'' 
with intellectual disability.
    Response: We made several changes in these final rules in response 
to these comments. First, as we mention in our response to an earlier 
comment, we revised the criteria in listings 12.05A and 12.05B. The 
changes clarify that there are three criteria that must be satisfied in 
order for an impairment to meet one of these listings. The three 
criteria, restated here, are: 1. significantly subaverage general 
intellectual functioning, 2. significant deficits in adaptive 
functioning, and 3. evidence demonstrating or supporting the conclusion 
that the disorder began prior to age 22. For claimants who are able to 
take a standardized intelligence test, the listing criteria about daily 
functioning requires that the claimant's impairment result in 
significant deficits in adaptive functioning, evidenced by extreme 
limitation in one, or marked limitation in two, of the four paragraph B 
areas of mental functioning (see final 12.05B2). This new organization 
of the listing criteria makes clear that there is no criterion or 
``prong'' requiring ``evidence of your day-to-day functioning that is 
consistent with the [intelligence] test score'' to establish 
disability. We discuss the revisions we made to listing 12.05 in detail 
in a later section of this preamble.
    Second, we removed proposed 12.00B4d, and we added final 12.00H to 
expand and organize the guidance for documenting and considering 
evidence under final listing 12.05. In final 12.00H2, we state that we 
will find standardized intelligence test results usable when a 
qualified specialist has individually administered the test. We 
indicate that only qualified specialists, Federal and State agency 
medical and psychological consultants, and other contracted medical and 
psychological experts may conclude that an obtained IQ score(s) is not 
an accurate reflection of a person's general intellectual functioning. 
The conclusion of the qualified specialist, or medical or psychological 
consultant or expert, about the accuracy of the obtained IQ score(s) 
determines whether the person's cognitive impairment satisfies the IQ 
score criterion.
    Third, in response to concerns that an adjudicator might 
misinterpret information about a person's daily functioning, we 
included guidance in three sections of the final rules to ensure proper 
evaluation of that information. In final 12.00D3, which applies to all 
of the mental disorders listings, we explain how we consider the 
complete picture of the person's day-to-day functioning, including the 
kinds, extent, and frequency of help and support received. In final 
12.00H3d, which applies to final listing 12.05B, we discuss how we 
consider evidence that a person engages in commonplace everyday 
activities when we evaluate his or her adaptive functioning. We state 
that a person may demonstrate both strengths and deficits in adaptive 
functioning, and we cite examples of the kinds of commonplace 
activities that a person might engage in. In final 12.00H3e, which also 
applies to final listing 12.05B, we discuss how we consider evidence 
that a person engaged in work when we evaluate his or her adaptive 
functioning. We describe special circumstances that may have made it 
possible for the person to work. In these two sections, we explain that 
we will not assume that doing some commonplace activities or work 
activity demonstrates that the person's impairment does not satisfy the 
criteria in 12.05B.
    Regarding the request to ensure that adjudicators respect ``a valid 
diagnosis of `intellectual disability,' '' we did not adopt this 
comment. It has been our experience that there can be considerable 
variability in the quality of reports of psychological examinations and 
intelligence testing. Moreover, our mental disorders listings are 
function-driven, not diagnosis-driven. To address this situation, and 
for the reasons explained in other sections of the preamble, we believe 
that the revision to listing 12.05 is a simpler, more effective 
approach to evaluating intellectual disability. The three elements that 
define ``intellectual disability'' are the three criteria in listing 
12.05. We do not

[[Page 66151]]

use the word ``diagnosis'' in the rules related to the listing.
    Comment: The spokesperson for an organization recommended that we 
change the term ``mental incapacity'' to ``intellectual incapacity'' in 
proposed 12.05A. The commenter suggested this change to be consistent 
with the reference to ``intellectual functioning'' later in proposed 
12.05A.
    Response: We adopted the comment, in part. We removed the term 
``mental incapacity'' from final 12.05A, as suggested. However, as part 
of the overall reorganization of listing 12.05, we replaced ``mental 
incapacity'' with the phrase ``significantly subaverage general 
intellectual functioning.'' We use this phrase to describe the first 
criteria in both listings 12.05A and 12.05B because it is a more 
accurate description of the first element of the medical definition of 
intellectual disability as defined in the DSM-5 and by the AAIDD, 
discussed above.
    Comment: We received differing public comments regarding the 
appropriate IQ score we should use for determining whether a person has 
significantly subaverage general intellectual functioning. Some 
commenters supported the continued use of the lowest IQ score (such as 
a part score, or component score) on a test that provides more than one 
score. Others questioned why we would use a part score rather than the 
full scale IQ score. The spokesperson for a professional organization 
noted, ``the Full Scale IQ is a widely understood and useful summary 
measure of intellectual functioning.'' Another commenter said that use 
of the lowest part score is inconsistent with other accepted 
definitions of intellectual disability, including that of the AAIDD and 
that of the DSM-IV-TR. These definitions call for the use of the full 
scale IQ score, except in limited circumstances. The commenter also 
noted that use of a part score could result in an outcome inconsistent 
with the definition of the disorder, which requires proof of 
``significantly subaverage general intellectual functioning [emphasis 
in original].'' Other commenters questioned why we did not adopt the 
2002 recommendation of the National Research Council to generally use 
the full scale IQ score, and to use certain part scores in limited 
circumstances.
    Response: We partially adopted these comments. We agreed with the 
reasons provided by the commenters who suggested that we use a full 
scale IQ score to determine whether a person's cognitive impairment 
satisfies the criteria in final listings 12.05B and 112.05B. In our 
experience, full scale IQ scores are the most reliable evidence that a 
person has intellectual disability and not another impairment that 
affects cognition.
    Additionally, in 2000, we commissioned a report from the National 
Research Council (NRC) about intellectual disability and determining 
eligibility for social security benefits, published in 2002.\13\ The 
primary focus of the report was people who have intellectual disability 
in what was called the ``mild'' range in the DSM-IV-TR, which means 
having IQ scores from 50-55 to approximately 70. In its report, the NRC 
concluded that for purposes of assessing impairment in people with 
intellectual disability, full scale IQ scores are generally better 
representations of general intelligence than are part scores because 
they combine a person's various skills and abilities to better reflect 
overall cognitive functioning. The NRC further noted that ``[t]he 
intelligence test total score is also the single overall fairest 
predictor [of general intelligence] for individuals of differing ages, 
genders, races, and ethnic backgrounds. . . .''
---------------------------------------------------------------------------

    \13\ National Research Council: Mental Retardation: Determining 
Eligibility for Social Security Benefits, National Academy Press, 
Washington, DC (2002) (available at: https://www.nap.edu/catalog/10295/mental-retardation-determining-eligibility-for-social-security-benefits).
---------------------------------------------------------------------------

    Despite this recommendation, the NRC noted that in some instances 
when a person obtains a full scale IQ score from 71 through 75, it can 
be appropriate to use certain part scores (verbal or performance IQ 
scores) that are 70 or below to establish that the person has 
significant limitations in general intellectual functioning. We largely 
adopted this recommendation for final listings 12.05B and 112.05B. We 
may find that a person's impairment satisfies the criteria in final 
12.05B1 and 112.05B1 if the person has either: a full scale IQ score of 
70 or below, or a full scale IQ score of 71-75 accompanied by either a 
verbal or performance IQ score of 70 or below.
    Comment: Some commenters recommended that we provide guidance to 
adjudicators about how to consider the ``standard error of 
measurement'' and other similar aspects of IQ testing in this 
regulation. Several commenters recommended that we ``give claimants the 
benefit of the doubt and include those individuals whose IQ scores 
place them within the standard error of measurement on standardized 
tests.''
    Response: We partially adopted the recommendations. The medical 
community recognizes measurement error for IQ scores (for example, the 
standard error of measurement). Test publishers often provide a range 
of scores around a person's obtained score that may also accurately 
represent a person's intellectual functioning. Similarly, as discussed 
above, one of the NRC's recommendations was to consider a range of full 
scale IQ scores from 71-75 in some instances.
    In these final rules, we addressed these aspects of IQ testing by 
largely adopting the NRC recommendation. We added an alternative option 
for establishing that a person has significantly subaverage general 
intellectual functioning in final 12.05B1 and 112.05B1, as described in 
the response to the previous comment. This alternative enables some 
people with significantly subaverage general intellectual functioning 
and full scale IQ scores that fall within a range of 71-75 to satisfy 
the IQ score requirement in final listings 12.05 and 112.05. 
Additionally, we expect to provide formal and accessible guidance to 
adjudicators about intelligence testing and final listings 12.05 and 
112.05.
    Comment: A commenter recommended that we use IQ scores from the 
2008 Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV), 
General Ability Index (GAI) rather than the WAIS-IV full scale IQ 
score. The commenter asserted that the full scale IQ score can be 
artificially inflated in the newer Wechsler scale test editions, 
relative to older Wechsler tests. The commenter said that the fourth 
edition gives higher weights to subtests within the Working Memory 
Index (WMI) and Processing Speed Index (PSI). The commenter explained 
that because of the highly concrete nature of their tasks, the WMI and 
PSI scores can be relatively higher among intellectually disabled 
claimants and thus do not reflect deeper learning potential or problem-
solving ability. The commenter believes that the GAI is a better 
summary measure of working memory and processing speed in the 
calculation of overall intelligence because it does not include WMI and 
PSI subtests.
    Response: We did not adopt the comment. The restructuring of the 
WAIS and the resulting changes in scoring have raised questions for 
many people regarding the use of the full scale IQ score and the GAI. 
We appreciate the commenter's observations about differences between 
the two scores. However, the full scale IQ score contains more subtests 
(10) than the GAI (6), and therefore the full scale IQ score has higher 
and more stable reliability and validity coefficients. Furthermore, the 
four subtests used for the WMI and PSI were a part of the full scale IQ 
score

[[Page 66152]]

calculations in the earlier editions of the WAIS and continue to be 
included in the full scale IQ score calculation in the WAIS-IV. For 
these reasons, we do not agree with the recommendation to encourage 
adjudicators to use the GAI rather than the full scale IQ score as a 
summary measure of intelligence for listing 12.05.
    Comment: Some commenters recommended that we add a provision to 
listings 12.05D and 112.05D to indicate that a person's impairment will 
satisfy the listing requirements if the impairment results in 
``extreme'' limitation of one of the functional criteria categories.
    Response: We adopted the comment. As explained earlier in this 
preamble, the final rules reorganize listings 12.05 and 112.05. Final 
listings 12.05B and 112.05B include the provision that the commenters 
recommended.

Listings 12.09 and 112.09--Removed

    Comment: Several commenters objected to the proposal to remove 
prior listing 12.09, substance addiction disorders from our rules. They 
provided various reasons in support of their position. For example, the 
spokesperson for an organization asked that we retain the listing to be 
consistent with the DSM-IV-TR and then-proposed DSM-5, because those 
publications have a category of impairment for ``Addiction and Related 
Disorders.'' As another example, some commenters acknowledged that 
although substance use disorders alone are not grounds for disability 
in the current regulations, other government agencies, such as the U.S. 
Department of Health and Human Services, have documented the impact 
that these disorders have on the health and functioning of disabled 
people. As a third example, a commenter stated that substance abuse is 
one of the behavior disorders that can seriously affect functional 
capacity. That commenter also noted that a large percentage of cases 
requiring medical expert testimony related to mental disorders involve 
substance abuse issues.
    Response: Although we appreciate the issues raised by the 
commenters, we did not adopt the recommendation to keep prior listing 
12.09. Our current policy regarding how we evaluate claims involving 
substance use disorders comes from sections 223(d)(2)(C) and 
1614(a)(3)(J) of the Act, which state that, ``[a]n individual shall not 
be considered to be disabled . . . if alcoholism or drug addiction 
would . . . be a contributing factor material to the Commissioner's 
determination that the individual is disabled.'' \14\ Under this 
provision of the Act, we cannot find that a person is disabled based on 
his or her substance use disorder alone. Furthermore, if a claimant's 
substance use is a medically determinable impairment and is material to 
a finding that the claimant is disabled, then we must find that the 
claimant is not disabled. (See our response to the prior comment that 
requested that we more clearly define the criteria and guidelines for 
determining the nature and effects of substance use on a person's 
functional capacity for more information about our guidance on how we 
assess of the impact of substance use disorders.)
---------------------------------------------------------------------------

    \14\ 42 U.S.C. 432(d)(2)(C), 1382c(a)(3)(J).
---------------------------------------------------------------------------

    These final rules remove prior listing 12.09 because we cannot use 
listing 12.09 alone to meet our definition of disability. In addition, 
listing 12.09 is a reference listing, which means that it only refers 
to medical criteria in other listings. As we revise the listings, we 
are also trying to eliminate reference listings. Finally, listing 12.09 
is redundant because we use other listings to evaluate the physical or 
mental effects of substance use (for example, liver damage, peripheral 
neuropathy, or dementia). For these reasons, we are removing the 
listing.

Listing 112.14--Developmental Disorders in Infants and Toddlers

    Comment: A commenter requested that we keep the name of prior 
listing 112.12, ``emotional and developmental disorders'' for listing 
112.14 for infants and toddlers. The commenter agreed with our decision 
to have a listing encompassing the period of birth to age 3 because 
this age group is better viewed as a continuum rather than as two 
distinct age groups, but disagreed with our removing the words, 
``emotional and,'' and naming the listing only, ``Developmental 
Disorders.'' The commenter explained that, because ``many [mental 
health] disorders are apparent prior to age three . . . and are 
distinct from developmental disorders . . ., eliminating emotional 
disorders will delay determination of eligibility for certain children 
for years.''
    Response: We did not adopt the comment. We appreciate that the 
inclusion of ``emotional'' in the name of prior listing 112.12 was an 
effective way to emphasize that children, even in the first year of 
life, can manifest emotional disturbance--a condition that has been 
identified, described, and increasingly studied by various early 
childhood authorities in the past 25 years. However, the term, 
``developmental disorders,'' in final listing 112.14 is sufficiently 
broad to encompass all of the myriad ways in which an infant or toddler 
can present delays or deficits in typical early childhood development, 
including emotional disturbance.
    Comment: The spokesperson for an organization suggested that we 
replace the proposed name of listing 112.14 with ``neurodevelopmental 
delay'' for children birth to 3 years.
    Response: We did not adopt the comment. We appreciate the basis for 
the recommendation of ``neurodevelopmental delay'' as the name for 
listing 112.14 because developmental problems in very young children 
are often attributable to known neurological factors. However, the DSM-
5 uses a very similar term, ``neurodevelopmental disorders,'' as the 
overall diagnostic category comprising disorders usually diagnosed in 
infancy, childhood, and adolescence. As a result, we are adopting the 
term ``neurodevelopmental disorders'' as the new title for listings 
12.11 and 112.11. To avoid confusion, we are keeping the titles of 
listings 112.11 and 112.14 as different as possible.
    Comment: The spokesperson for an organization recommended that we 
consider including fetal alcohol spectrum disorders as a ``potential 
listing'' in proposed listing 112.14, developmental disorders of 
infants and toddlers.
    Response: We did not adopt the comment. Each listing does not 
include separate listings within it. Final 112.00B11b cites examples of 
disorders that we evaluate under this listing. However, we make clear 
that the list of examples is not all-inclusive. Fetal alcohol spectrum 
disorders (FASD) are known to produce the kinds of delay or deficit in 
the development of age-appropriate skills involving motor planning and 
control, learning, relating and communicating, and self-regulating that 
we address in listing 112.14. As with any disorder, the effects and 
severity of FASD can be highly variable across individuals. If an 
infant or toddler manifests a medically determinable developmental 
disorder of the severity described in listing 112.14, we will find the 
child disabled.
    Comment: Some commenters recommended that we use age-related 
percentiles rather than fractions to assess developmental disorders in 
younger children. The commenters remarked that proposed listing 112.14 
provided for the use of non-standardized measures for assessing 
developmental disorders in younger children, and that such a practice 
is appropriate if well-developed measures with age-standardized scores 
are not

[[Page 66153]]

available. However, the commenters found our determination of 
impairment severity based on performance that is ``more than one-half, 
but not more than two-thirds of chronological age'' problematic given 
that standards based on fractions of what would be expected for 
chronological age have different meanings for children of different 
ages. The commenters illustrated the concern with the observations that 
performance of half of expected age in a 4-month-old infant represents 
a delay of only 2 months, while half of expected age for a 4-year-old 
child is a much more severe delay.
    Response: We did not adopt the comment for two reasons. First, 
proposed section 112.00I4 included the references to fractions that the 
commenters mention. However, proposed 112.00I4 restated our guidance 
about fractions from Sec.  416.926a(e). Rather than repeat guidance 
that we provide elsewhere in our regulations, in these final rules, we 
removed those provisions from 112.00I. Instead, we refer users to 
Sec. Sec.  416.925(b)(2)(ii) and 416.926a(e) to find that information. 
As a result, the final rules no longer include the language the 
commenter mentions.
    However, Sec.  416.926a(e) also uses language very similar to, 
``more than one-half, but not more than two-thirds of chronological 
age.'' We have used these fractions, and other similar ones, to 
determine disability in children since we published updated childhood 
disability regulations in 1991 (56 FR 5559). We use the fractions as an 
approximation when we do not have standardized test results in the case 
record. Our adjudicators are now very familiar with using these 
fractions in our program, and they find that the fractions are an 
accurate alternative and helpful when the case record does not have 
standardized test results.
    Second, with respect to the illustration involving a 4-year-old 
child, according to Sec.  416.926a(e), we use a fraction to assess a 
child's functioning only up to age 3, and only in the absence of 
standardized test results. Therefore, we do not use fractions to assess 
the functioning of 4-year-old children.
    Comment: A commenter recommended that we not defer disability 
determination for pre-term infants until attainment of corrected 
chronological age of 6 months. The commenter observed that adjustment 
of chronological age to account for a period of gestational prematurity 
is an accepted practice until a chronological age of 2 years, after 
which such adjustments are often not made. The commenter states, ``a 
problem in using corrected age is that it may delay services for 
children who need them most. It would thus be critical not to defer 
disability determination in these cases, as this could result in delay 
in services to children with severe neurodevelopmental disorders. . . . 
While it is clear that the proposed rule changes specify that 
adjudication `may' be deferred, rather than required, it would be 
important to emphasize in the rule changes that deferral of 
determination of age-expected development not be the default rule.''
    Response: We did not adopt the comment. We do not believe the final 
rule in 112.00I5 includes guidance that adjudicators could interpret as 
a ``default'' action. In 112.00I5a and b, we explain that we will defer 
determination until an infant is at least 6 months old (chronological 
or corrected chronological age) if the evidence is insufficient to make 
a determination. Similarly, adjudicators have the option to defer 
determination beyond a child's attainment of 6 months, if the available 
evidence warrants deferral. However, 112.00I5c states that we will not 
defer the determination if we have sufficient evidence to support a 
determination that a child is disabled under final listing 112.14 or 
any other listing.
    We also appreciate that whether a premature infant's chronological 
age should be corrected to adjust for prematurity can be a significant 
factor in decisions regarding the provision of intervention services. 
However, in determining whether the same infant meets our statutory 
definition of disability, the sole basis for our determination is how 
the infant's development compares to established developmental 
milestones, based on chronological age ranges. It is necessary, then, 
that we correct chronological age to adjust for prematurity in order to 
make a determination that is fair to the infant.
    Comment: A commenter recommended that we not defer disability 
determination for children born at extreme risk for ongoing 
developmental problems. This commenter said that ``it is unclear that 
deferring determination of disability . . . is justifiable in cases of 
more extreme disability. There would seem to be little reason to defer 
assessment of a child born at extreme risk for ongoing developmental 
problems, such as those with perinatal brain insults, including hypoxic 
ischemic encephalopathy with severe deficits in early neurodevelopment, 
extreme prematurity with severe early neurologic impairments and 
perinatal strokes.''
    Response: We did not adopt this comment. We acknowledge that some 
government programs establish eligibility for services based on a 
child's ``at risk'' status. However, the Act and our regulations do not 
permit us to evaluate ``risk'' factors as the commenter describes.\15\ 
We consider only the effects of medically determinable impairments 
established by ``medical evidence consisting of signs, symptoms, and 
laboratory findings'' (see Sec. Sec.  416.908 and 416.928). We do not 
require that the child's treating providers identify a specific 
diagnosis to describe the child's medical situation. However, there 
must be evidence of a medically determinable impairment that causes 
limitations in the child's functioning. Under our rules, we consider 
certain medical situations, such as low birth weight in infants and 
failure to thrive in children, as medically determinable impairments. 
These impairments may cause developmental delays or physical effects 
that meet our definition of childhood disability (see, for example, 
listings 100.04 and 100.05).
---------------------------------------------------------------------------

    \15\ For more information about why we do not evaluate risk 
factors, see the preamble to the 1991 final rule with request for 
comments on determining disability for a child under age 18 (56 FR 
5534, 5551).
---------------------------------------------------------------------------

    With respect to infants with perinatal brain insults, such as 
hypoxic ischemic encephalopathy and perinatal strokes, we cannot know 
immediately following the insult what the outcome will be with respect 
to the infant's developmental course. The provision for deferring 
adjudication until the infant is at least 6 months of age allows for 
the necessary documentation of the child's developmental patterns and 
functioning over time. However, we do not defer determinations when we 
have sufficient evidence that a child's impairment causes marked and 
severe functional limitations and can be expected to cause death, or 
has lasted or can be expected to last for a continuous period of not 
less than 12 months (see Sec.  416.906).
    Comment: The spokesperson for an organization stated that although 
the four paragraph B criteria for listing 112.14 reflect age-
appropriate expectations and activities, reliably measuring the 
criteria can be difficult. The commenter recommended that we allow 
``temporary access to [supplemental security income (SSI)] benefits, 
pending repeat and confirmatory testing of a child's disability 
severity to meet SSI standards.''
    Response: This comment is outside the scope of this rulemaking, 
therefore we did not make any changes in these final rules in response 
to it. Although

[[Page 66154]]

our program does not provide for ``temporary access to SSI benefits,'' 
we have rules providing for ``presumptive disability'' payments to 
claimants applying for SSI benefits. If the evidence available reflects 
a high degree of probability that the claimant meets our definition of 
disability, we may find initially that a claimant is ``presumptively 
disabled.'' This initial finding means that the claimant may receive 
benefits for up to 6 months before we make a formal determination about 
whether the claimant is disabled (see Sec. Sec.  416.931-416.934).
    Comment: A commenter advised us to identify the standardized 
developmental test instruments that the evidence should include so that 
adjudicators recognize ``current validated screening modalities and do 
not accept antiquated assessment tools or approaches.''
    Response: We did not adopt the comment. Although there are many 
developmental assessment instruments available from several publishers, 
we do not name individual tests in our regulations because we do not 
endorse proprietary (copyrighted) instruments. Additionally, tests are 
regularly developed or updated, and it would be impractical to attempt 
to maintain a current list of instruments in a regulation.

Summary of Revisions We Made in the Final Rules

    As we described in our responses to the public comments, we are 
making changes to some of the proposals in the NPRM because of public 
comments we received. Although we explain all of those changes in 
detail later in this preamble, we summarized some of the more 
significant changes here. These changes include:
     Updating the titles of most of the listings;
     Keeping the structure of the ``paragraph A'' criteria from 
our prior rules in all of the listings (except for 12.05 and 112.05), 
and updating the paragraph A criteria;
     Renaming the titles of paragraph B1 (understand, remember, 
or apply information) and B3 (concentrate, persist, or maintain pace) 
to be linked by ``or'' rather than ``and'';
     Removing all references to using standardized test scores 
for rating degrees of functional limitations for adults (except for 
listing 12.05);
     Indicating that the greatest degree of limitation in any 
part of a paragraph B1, B3, or B4 area of mental functioning will be 
the degree of limitation for that whole area of functioning;
     Retaining the 5-point rating scale that we used in our 
prior rules for rating degrees of functional limitations in adults;
     Reorganizing the listing criteria in listings 12.05 and 
112.05, intellectual disorder, to reflect the three diagnostic criteria 
for intellectual disability; and
     Creating new listings, 12.15 and 112.15, trauma- and 
stressor-related disorders, to reflect the updates in medical 
understanding reflected in the DSM-5.

Explanation of Listing 12.05, Intellectual Disorder

    Final listing 12.05 includes important changes that we explain 
here. We use listing 12.05 to evaluate claims involving intellectual 
disability. In the NPRM, we proposed mostly minor revisions to listing 
12.05. However, some of the public comments that we received about this 
listing recommended that we substantively reorganize and change the 
listing criteria. The commenters criticized the listing structure that 
we proposed as ``inconsistent, redundant and unnecessary.'' One 
commenter observed, ``the severity of intellectual disability is 
written into the diagnosis itself.'' The commenters recommended that we 
simplify the structure and the criteria for listing 12.05 so the 
listing would guide adjudicators through the process of identifying 
claimants who have intellectual disability.
    In response to these comments, we revised the criteria for listing 
12.05. We believe the revisions will continue to accurately and 
reliably identify claimants who have marked or extreme functional 
limitations due to intellectual disability. We also believe that the 
final listing will be clearer to adjudicators and the public. 
Furthermore, new listing 12.11 will identify claimants with cognitive 
impairments that result in marked or extreme functional limitations but 
do not satisfy the definition of intellectual disability. Our reasoning 
and explanation for those changes is below.

Intellectual Disability

    ``Intellectual disability'' is a diagnosis used by the medical 
community to identify and describe a certain type and degree of 
cognitive impairment. The American Psychiatric Association, the 
American Psychological Association, and the AAIDD are three leading 
experts within the medical community about what ``intellectual 
disability'' is. Those three organizations largely agree about what the 
three diagnostic criteria, or the three elements, are for intellectual 
disability. Those three elements, restated here, are: Significant 
limitations in general intellectual functioning, significant deficits 
in adaptive functioning, and evidence that the disorder began during 
the developmental period.

Intellectual Disability Policies Proposed in the NPRM

    In the NPRM, we proposed to remove the capsule definitions in all 
of the prior mental disorders listings, including listing 12.05. Like 
prior listing 12.05, the version of listing 12.05 proposed in the NPRM 
had four paragraphs, paragraphs A-D. A person's impairment would meet 
the listing if it satisfied the criteria in any one of the four 
paragraphs. As in prior listing 12.05, we proposed to use paragraph A 
to evaluate claimants whose cognitive impairment prevented them from 
taking a standardized intelligence test. We proposed to use paragraph B 
to evaluate claimants who had an IQ score of 59 or lower. We proposed 
to use paragraph C to evaluate claimants with an IQ score of 60 through 
70 with another severe physical or mental impairment. We proposed to 
use paragraph D to evaluate claimants with an IQ score of 60 through 70 
and marked degree of limitation in two of the four proposed areas of 
mental functioning that were typically included in ``paragraph B'' of 
the other mental disorders listings.
    Although proposed listing 12.05 did not have a capsule definition 
like prior listing 12.05, the proposed listing required that a claimant 
have significantly subaverage general intellectual functioning, 
deficits in adaptive functioning, and evidence that the disorder 
initially manifested during the developmental period. The beginning of 
each lettered paragraph required that a claimant have intellectual 
disability ``as defined in [proposed] 12.00B4'' before stating the 
listing criteria specific to that paragraph. Proposed section 12.00B4a 
stated, ``This disorder is defined by significantly subaverage general 
intellectual functioning with significant deficits in adaptive 
functioning initially manifested before age 22.'' Therefore, the 
version of listing 12.05 proposed in the NPRM was similar to prior 
listing 12.05, but it did not include a capsule definition, and it 
moved the three elements of the medical definition of intellectual 
disability into the introductory text.

Intellectual Disability in Final Listing 12.05

    However, the public comments that we received in response to the 
NPRM, as described above, made clear to us that the reorganized 
criteria that we proposed in the NPRM was still

[[Page 66155]]

insufficient. In response to these comments, we reorganized the listing 
criteria in these final rules to reflect the three elements of the 
medical definition of intellectual disability.
    Final listing 12.05 does not include a capsule definition. The 
listing has only two paragraphs, and we will allow a claim under the 
listing when the criteria in either paragraph are satisfied. Each 
paragraph contains the three elements of the medical definition of 
intellectual disability. Therefore, the listing is now very similar to 
the DSM-5 and AAIDD definitions for intellectual disability.
    We will use final listing 12.05A to evaluate the claims of people 
whose cognitive impairment prevent them from taking a standardized 
intelligence test that would measure their general intellectual 
functioning. Listing 12.05A has three subparagraphs; there is one 
subparagraph for each element of the medical definition of intellectual 
disability. The first subparagraph requires that a claimant lack the 
cognitive ability to participate in standardized testing of 
intellectual functioning. Stated differently, if a claimant is not able 
to take an IQ test, this is sufficient evidence that the claimant has 
``significantly subaverage general intellectual functioning'' as 
required by the listing.
    The second subparagraph requires that a claimant be dependent on 
others to care for basic personal needs. If a claimant relies on others 
for such basic tasks, this is sufficient evidence that a claimant has 
``significant deficits in adaptive functioning'' as required by the 
listing.
    The last subparagraph requires evidence that demonstrates or 
supports the conclusion that the disorder began prior to age 22. For 
our program purposes, we use age 22 as the benchmark to establish that 
the disorder began during the developmental period.\16\ If a claimant's 
impairment satisfies the requirements in all three subparagraphs, we 
will find that the claimant's impairment meets the criteria for listing 
12.05A.
---------------------------------------------------------------------------

    \16\ Our use of age 22 in our program has a basis in clinical 
practice. Historically, the American Psychological Association used 
age 22 to identify people with ``intellectual disability'' 
(Jacobson, John W., and James A. Mulick, eds., Manual of Diagnosis 
and Professional Practice in Mental Retardation, American 
Psychological Association, Washington, DC (1996)) Today, in the 
disability insurance program, we use age 22 to identify claimants 
who may be eligible for benefits on the earnings record of an 
insured person who is entitled to old-age or disability benefits or 
who has died (20 CFR 404.350(a)). For these reasons, we continue to 
use age 22 as the benchmark to establish that intellectual 
disability began during the developmental period.
---------------------------------------------------------------------------

    We will use final listing 12.05B to evaluate the claims of people 
who are able to take a standardized intelligence test. Like final 
listing 12.05A, final listing 12.05B has three subparagraphs; there is 
one subparagraph for each element of the medical definition of 
intellectual disability. The first subparagraph requires a claimant to 
have obtained either: A full scale IQ score of 70 or below, or a full 
scale IQ score of 71 through 75 accompanied by a verbal or performance 
IQ score of 70 or below. Stated differently, if a claimant's IQ scores 
meet either of these requirements, there is sufficient evidence that 
the claimant has ``significantly subaverage general intellectual 
functioning'' as required by the listing.
    The second sub-paragraph requires that a claimant have extreme 
limitation of one, or marked limitation of two, of the four ``paragraph 
B'' areas of mental functioning (see 12.00E1, 2, 3, and 4). We use the 
same paragraph B criteria and severity ratings to evaluate a person's 
current adaptive functioning under listing 12.05 that we use to 
evaluate the functioning of a person using all of the other mental 
disorders listings in this body system. We use the paragraph B areas of 
mental functioning to evaluate a person's abilities to acquire and use 
conceptual, social, and practical skills.\17\ If a claimant has 
``extreme'' limitation of one, or ``marked'' limitation of two, of the 
paragraph B criteria, this is sufficient evidence that a claimant has 
``significant deficits in adaptive functioning'' as required by the 
listing.
---------------------------------------------------------------------------

    \17\ In its definitions of ``intellectual disability'' and 
discussions of adaptive behavior, the AAIDD refers to ``conceptual, 
social, and practical skills'' (Intellectual Disability: Definition, 
Classification, and Systems of Supports, 11th Edition, Chapter 5); 
the DSM-5 refers to ``conceptual, social, and practical domains.'' 
(American Psychiatric Association: Diagnostic and Statistical Manual 
of Mental Disorders, Fifth Edition, 33-41).
---------------------------------------------------------------------------

    The last sub-paragraph requires evidence that demonstrates or 
supports the conclusion that the disorder began prior to age 22. If a 
claimant's impairment satisfies the requirements in all three sub-
paragraphs, we will find that the claimant's impairment meets the 
criteria for listing 12.05B.
    The revised criteria in final listings 12.05A and B respond to the 
public comments that suggested that we simplify the listing structure 
by guiding adjudicators through the process of identifying claimants 
who have intellectual disability. Importantly, and as noted above, the 
mental disorders listings are function-driven, not diagnosis-driven, 
and the final listing criteria reflect this approach.

The Role of Listing 12.11

    Although prior listing 12.05 included a capsule definition that was 
very similar to the medical definition of intellectual disability, the 
capsule definition did not indicate how significant the claimant's 
subaverage general intellectual functioning and deficits in adaptive 
functioning had to be. For example, other mental impairments, such as 
specific learning disability and borderline intellectual functioning, 
can involve subaverage general intellectual functioning and deficits in 
adaptive functioning, as well as evidence that the disorder initially 
manifested during the developmental period. However, claimants with 
impairments such as specific learning disability and borderline 
intellectual functioning do not have the same nature or degree of 
subaverage intellectual functioning and deficits in adaptive 
functioning as people with intellectual disability.
    The reorganization of listing 12.05 will mean that cognitive 
impairments other than intellectual disability will not meet the 
listing criteria for 12.05. We will use final listing 12.11, 
neurodevelopmental disorders, to evaluate these impairments. Section 
12.00B9, which is the section of the introductory text that describes 
this listing, explains that we evaluate impairments such as specific 
learning disorder and borderline intellectual functioning under listing 
12.11. This listing furthers our goal to identify claimants with 
disabling impairments accurately, reliably, and as early in the 
sequential evaluation process as possible.

Other Significant Revisions Relating to Listing 12.05

    We made three other changes relating to listing 12.05 in response 
to public comments we received. First, as explained earlier in the 
preamble, we changed the title of the listing to ``intellectual 
disorder.'' Second, we changed our rules about standardized 
intelligence test results. Under the final rules, we use a full scale 
IQ score, or a combination of a full scale IQ score with either a 
verbal or performance IQ score, to determine if a claimant's disorder 
satisfies the criteria in listing 12.05. Commenters suggested that we 
make these two changes, and we agreed with them.
    Third, the nature and extent of the comments we received about 
listing 12.05 indicated that we needed to provide more guidance to 
adjudicators

[[Page 66156]]

at the regulatory level about how to apply the listing criteria. 
Therefore, we added final 12.00H to the introductory text to 
consolidate and clarify the guidance for listing 12.05.

Final 12.00--Introductory Text to the Adult Mental Disorders Listings

    The following is a description of the content and changes in each 
section of Part A, the adult mental disorders listings.

Final 12.00A: How are the listings for mental disorders arranged, and 
what do they require?

    Final 12.00A names the mental disorders listings, and it describes 
how we organized the listing criteria into either two or three lettered 
paragraphs for all listings (except 12.05). We explain that each 
lettered paragraph contains a specific type of listing criteria, and we 
state what criteria must be satisfied in order for us to find that a 
person's impairment meets the listing. This section also explains how 
we organized the criteria in final listing 12.05 differently from the 
other listings.
    In these final rules, we changed the title of final 12.00A from, 
``What are the listings, and what do they require?'' to, ``How are the 
listings for mental disorders arranged, and what do they require?'' for 
clarity.
    Final 12.00A2a reflects a change we made to the paragraph A 
criteria in these final rules. In the NPRM, we proposed that the 
paragraph A criteria would require a claimant to show that he or she 
had a medically determinable mental disorder in the listing category 
(for all listings except 12.05). However, these final rules keep 
paragraph A criteria in each listing that are similar to the criteria 
in our prior rules and include a list of medical criteria that must be 
present in a person's medical record. We made this change in response 
to a public comment raising concern that the paragraph A criteria in 
our prior rules served an important function by providing a basis for 
comparing and assessing the severity of different mental disorders. The 
commenter urged us to reconsider ``elimination'' of the paragraph A 
criteria. We summarized the comment and explained our reasons for 
adopting it earlier in this preamble. As a result, final 12.00A2 
explains that paragraph A of each listing (except 12.05) includes the 
medical criteria that must be present in a person's medical evidence.
    Final 12.00A2 also includes a change we made to the paragraph C 
criteria in these final rules. In the NPRM, we proposed to include 
paragraph C criteria in all listings (except 12.05). However, these 
final rules keep paragraph C criteria only in the final listings that 
correspond closely to the prior listings that included paragraph C 
criteria (final listings 12.02, 12.03, 12.04, 12.06, and 12.15). We 
made this change because our medical and psychological experts, and our 
adjudicative experience, indicate to us that the unique medical 
situation that we identify with the paragraph C criteria typically does 
not apply to the other disorders we evaluate under the remaining 
listings. As a result, final 12.00A2c explains that paragraph C of 
listings 12.02, 12.03, 12.04, 12.06, and 12.15 provides the criteria we 
use to evaluate ``serious and persistent mental disorders.''
    Final 12.00A3 reflects the way that these final rules revise the 
listing criteria for 12.05. We explain the changes to listing 12.05 and 
our reasons for making them earlier in this preamble.

Final 12.00B: Which mental disorders do we evaluate under each listing 
category?

    In these final rules, we changed the title of final 12.00B from, 
``How do we describe the mental disorders listing categories?'' to, 
``Which mental disorders do we evaluate under each listing category?'' 
for clarity. We removed the introductory paragraph in proposed 12.00B 
because the information was only descriptive or included elsewhere in 
the introductory text.
    Final 12.00B contains numbered sections that correspond to each 
listing. The numbered sections provide information about the types of 
mental disorders we evaluate under each listing. For example, final 
12.00B1 corresponds to listing 12.02 and provides information about 
neurocognitive disorders.
    In final 12.00B, each numbered section contains either two or three 
lettered paragraphs. The first lettered paragraph provides a 
description of the mental disorders included in each listing category, 
followed by examples of symptoms and signs commonly associated with 
those disorders. The second paragraph provides examples of disorders we 
evaluate under each listing. We updated these paragraphs with revised 
medical terms from the DSM-5. In sections that have a third paragraph, 
this paragraph lists examples of mental disorders that we do not 
evaluate under each listing.
    In final 12.00B4, which discusses listing 12.05, intellectual 
disorder, we removed proposed paragraphs 12.00B4c and B4d. These 
paragraphs discussed our requirements for documentation and 
standardized intelligence testing. We included this guidance in final 
12.00H, a new section that provides additional information about how to 
apply listing 12.05. We also removed proposed 12.00B4e from these final 
rules. That paragraph explained proposed listing 12.05C, and these 
final rules do not include a listing 12.05C, as we explained earlier in 
this preamble.
    We added final 12.00B11 to provide information about the types of 
mental disorders we evaluate under new listing 12.15, trauma- and 
stressor-related disorders.

Final 12.00C (Proposed 12.00G): What evidence do we need to evaluate 
your mental disorder?

    Final 12.00C describes the types of evidence that we need to 
evaluate a person's mental disorder. In these final rules, we moved 
this discussion from proposed 12.00G to final 12.00C to present the 
information earlier in the introductory text. This reorganization 
allows us to explain the evidence we need (in final 12.00C) and how we 
consider the supports a person receives (in final 12.00D) before we 
explain how we evaluate a person's mental disorder using the paragraph 
B criteria (in final 12.00E and final 12.00F).
    In final 12.00C2, we discuss and list examples of evidence from 
medical sources. We removed psychosocial supports or highly structured 
settings from the list (proposed 12.00C2k) because they are not 
examples of medical evidence, and because final 12.00D is devoted to 
those topics. We added psychiatric and psychological rating scales and 
measures of adaptive functioning to the list, and we removed the brief 
discussion about these topics from proposed 12.00G5.
    In final 12.00C3, we discuss non-medical sources of evidence, such 
as the claimant and people who are familiar with the claimant. We 
clarified that we will ask third parties for information about a 
claimant's impairments, but we must have the claimant's permission to 
do so. In response to public comments, we added social workers, shelter 
staff, and other community support and outreach workers to the list of 
examples of sources of evidence.
    In final 12.00C5, we explain how longitudinal evidence can help us 
learn how a person functions over time, and how we evaluate impairments 
when there is no longitudinal evidence. We moved the discussion about 
how we evaluate exacerbations and remissions of mental disorders from 
proposed 12.00G6a to final 12.00F4 because final 12.00F provides 
information about how we evaluate a person's mental disorder,

[[Page 66157]]

and the discussion of exacerbations and remissions of mental disorders 
is most appropriate in that section. In response to public comments, we 
added case managers, community support staff, and outreach workers as 
examples of non-medical sources of longitudinal evidence.
    Final 12.00C5c is a new section that provides additional guidance 
about how we will evaluate a person's mental disorder when there is no 
longitudinal evidence. In partial response to public comments 
recommending that we recognize the unique circumstances of people who 
are experiencing homelessness, we included chronic homelessness as an 
example of a situation that may make it difficult to obtain 
longitudinal medical evidence.
    In final 12.00C6, we added more information about how we use 
evidence of a person's functioning in unfamiliar or supportive 
situations, and we removed the paragraphs that discussed the effects of 
work-related stress.

Final 12.00D (Proposed 12.00F): How do we consider psychosocial 
supports, structured settings, living arrangements, and treatment?

    Final 12.00D describes how we consider the effects of psychosocial 
supports, structured settings, living arrangements, and treatment on a 
person's functioning. In these final rules, we moved this discussion 
from proposed 12.00F to final 12.00D to present the information earlier 
in the introductory text.
    In final 12.00D1, we explain how psychosocial supports and highly 
structured settings may help a person function. We added ``living 
arrangements'' and ``assistance from your family or others'' to this 
discussion for clarity. In response to public comments, we clarified 
that the list of examples of psychosocial supports and highly 
structured settings includes only ``some'' examples of supports that a 
person ``may'' receive. We added this language to indicate that the 
list of supports does not include all of the possible supports that we 
consider. We simplified the list of examples of supports and settings 
by combining the examples that illustrate similar situations. In 
response to public comments, we added comprehensive ``24/7'' mental 
health services, also known as ``wrap-around'' services, to the list of 
examples. Also in response to public comments, we added an example of 
receiving assistance from mental health workers who help the person 
meet physical needs and who may assist in dealings with government or 
social services.
    We added a new section, final 12.00D2, to explain how we consider 
different levels of support and structure in psychosocial 
rehabilitation programs. Based on our adjudicative experience, we 
realized that we needed to provide further guidance about how to 
evaluate the extent of a person's participation and what that tells us 
about the effects of the person's mental disorder and current 
functioning.
    We added another new section, final 12.00D3, in response to public 
comments expressing concern about how we consider a person's strengths 
and deficits in his or her daily functioning. Final 12.00D3 explains 
that we acknowledge that a person may demonstrate both strengths and 
deficits, and we will consider the complete picture of a person's daily 
functioning when we evaluate whether that person is able to use his or 
her areas of mental functioning in a work setting.

Final 12.00E (Proposed 12.00C): What are the paragraph B criteria?

    Final 12.00E defines and describes the four paragraph B criteria, 
which represent the areas of mental functioning a person uses in a work 
setting. Final 12.00E has four numbered paragraphs. There is one 
paragraph for each paragraph B criterion. For example, final 12.00E1 
contains the definition and description for paragraph B criterion B1, 
understand, remember, or apply information.
    In these final rules, we moved the discussion of the paragraph B 
criteria from proposed 12.00C to final 12.00E. We removed the 
introductory paragraph in proposed 12.00E because the information was 
only descriptive or included elsewhere in the introductory text.
    We expanded the definitions of each paragraph B criterion, and we 
added more examples of how a person uses his or her areas of mental 
functioning in the workplace. We made these changes in response to 
public comments we received suggesting that we should be more specific 
about each of the areas of mental functioning in the context of a work 
setting. We discuss these public comments and our responses to them 
earlier in this preamble. In final 12.00E4 where we define and describe 
the paragraph B4 criterion, after we revised the definition and 
examples in response to the public comments, we changed the title of 
this criterion to include the word ``adapt'' to reflect the abilities 
and behaviors that we consider more accurately and completely. We also 
added a statement at the end of each paragraph clarifying that the 
examples illustrate the nature of the areas of mental functioning, and 
we do not require documentation of all of the examples.
    We changed the title of paragraph B1 from ``understand, remember, 
and apply information'' to ``understand, remember, or apply 
information.'' We changed the title of paragraph B3 from ``concentrate, 
persist, and maintain pace'' to ``concentrate, persist, or maintain 
pace.'' We made this change to link the parts in the title with the 
word ``or'' rather than ``and'' in response to several public comments 
that we received. The commenters were concerned that people could 
misinterpret the titles as proposed in the NPRM as a change from our 
prior policy that would set a higher standard for a person's mental 
disorder to satisfy those criteria. We adopted the comment, and we 
explain our reasons earlier in this preamble.

Final 12.00F (Proposed 12.00D): How do we use the paragraph B criteria 
to evaluate your mental disorder?

    Final 12.00F explains how we use the paragraph B criteria and a 
rating scale to evaluate a person's mental disorder. In these final 
rules, we moved this guidance from proposed 12.00D to final 12.00F. We 
also made several significant changes to this section because of public 
comments we received. We explain these changes below.
    In final 12.00F1, we introduce the concept of using a rating scale. 
A public commenter requested that we explain how adjudicators assess 
limitations in cases where psychosocial supports and highly structured 
settings are present. In partial response to this comment, we added an 
explanation that we will consider the nature of the difficulty the 
person would have, whether the person could function without extra 
help, and whether the person would require special conditions with 
regard to activities or other people.
    In final 12.00F2, we explain that we use a five-point rating scale 
consisting of none, mild, moderate, marked, and extreme to assess the 
degrees of limitation an adult has using his or her areas of mental 
functioning. Several public commenters objected to our proposal in the 
NPRM to use only the terms ``marked'' and ``extreme'' to assess an 
adult's limitations. The commenters advised us that continuing our use 
of the 5-point rating scale from our prior rules would help ``anchor'' 
the standards of ``marked'' and ``extreme.'' We adopted the suggestion 
to keep our five-point rating scale in these final rules. We discuss 
these public comments and our responses earlier in this preamble.

[[Page 66158]]

    Also in final 12.00F2, we provide definitions for each of the five 
points of the scale. The definitions are consistent with how our 
adjudicators have understood and used the rating scale since we first 
introduced it in 1985. As we explain earlier in this preamble, we 
provide these definitions to respond, in part, to the significant 
public comments we received that objected to the descriptions of 
``marked'' and ``extreme'' that we proposed in the NPRM. In the NPRM, 
we proposed to describe ``marked'' and ``extreme'' as equivalent to 
scores that are a certain number of standard deviations below the mean 
on individually administered standardized tests. However, in light of 
the objections raised in the majority of the public comments, we did 
not adopt those definitions in these final rules.
    Also in response to those public comments, we did not make final 
most of the rules we proposed in 12.00D4 about how we would consider 
test results when we assessed a person's functional limitations. In 
these final rules, we moved and changed the guidance about professional 
interpretation of test results to final 12.00H2d because final 12.00H 
provides additional information about the criteria in listing 12.05, 
and listing 12.05B is the only listing that requires standardized test 
results.
    In final 12.00F3, we discuss how we rate the severity of 
limitations resulting from a mental disorder. In final 12.00F3a, we 
explain that when rating a person's impairment-related limitations, we 
use all relevant evidence in the case record. We received public 
comments raising concern that adjudicators might misconstrue a 
clinician's use of the term ``mild'' or ``moderate'' in diagnosing the 
stage of a person's mental disorder as a description of the person's 
level of functioning with respect to the paragraph B criteria. In 
response to this concern, we added language to final 12.00F3a 
explaining that although the medical evidence may include descriptors 
regarding the diagnostic stage or level of a disorder, such as ``mild'' 
or ``moderate,'' these terms will not always be the same as the degree 
of limitation in a paragraph B area of mental functioning.
    Final 12.00F3b and F3c are new sections that explain how we 
consider evidence about and assess a person's ability to use his or her 
areas of mental functioning in daily functioning and in work settings. 
Final 12.00F3d and F3e incorporate the proposed sections 12.00D1c and 
D1d, which provide additional guidance concerning overall effect of 
limitations and effects of support, supervision, and structure on 
functioning.
    We added a new section, final 12.00F3f, in response to public 
comments asking that we clearly explain how we will rate the limitation 
of the individual parts of paragraphs B1, B3 and B4. As requested, we 
explain that the greatest degree of limitation in any part of a 
paragraph B1, B3 or B4 area of mental functioning will be the degree of 
limitation for that whole area of functioning.
    Final 12.00F4 incorporates proposed section 12.00G6 and describes 
how we evaluate mental disorders involving exacerbations and 
remissions. In response to a public comment, we added an explanation 
that we will consider whether a person can use the affected area of 
mental functioning on a regular and continuing basis (8 hours a day, 5 
days a week, or an equivalent work schedule).

Final 12.00G (Proposed 12.00E): What are the paragraph C criteria, and 
how do we use them to evaluate your mental disorder?

    Final 12.00G defines and describes the paragraph C criteria, which 
are an alternative to the paragraph B criteria under listings 12.02, 
12.03, 12.04, 12.06, and 12.15. In these final rules, we moved the 
discussion of the paragraph C criteria from proposed 12.00E to final 
12.00G. We retained the two-year documentation requirement from our 
prior rules in these final rules to ensure that the disorders evaluated 
using these criteria are ``serious and persistent.''
    In final 12.00G2b, we provide more information about the 
requirement that continuing treatment, psychosocial supports, or 
structured settings diminish the symptoms and signs of a person's 
mental disorder. We clarify that a claimant must rely, on an ongoing 
basis, upon medical treatment, mental health therapy, psychosocial 
supports, or a highly structured setting, to diminish the symptoms and 
signs of his or her mental disorder. As we discuss earlier in this 
preamble, a public commenter raised concern that many people with 
mental disorders lack awareness about their mental disorders and 
therefore refuse treatment. To respond to this comment, we added 
language in final 12.00G2b to explain how we will consider a claimant's 
inconsistent treatment or lack of compliance when we determine whether 
the claimant relies upon ``ongoing'' medical treatment as this section 
requires.

Final 12.00H: How do we document and evaluate intellectual disorder 
under 12.05?

    Final 12.00H is a new section that brings together the rules 
pertaining to listing 12.05, intellectual disorder. This section 
devoted to listing 12.05 is necessary because of the differences 
between this listing and all other mental disorders listings, and the 
several clarifications provided in these final rules about adjudicating 
claims under listing 12.05. Final 12.00H includes information and 
guidance about establishing significantly subaverage general 
intellectual functioning, establishing significant deficits in adaptive 
functioning, and establishing that the disorder began before age 22. We 
include subsections that discuss the evidence we consider, standardized 
tests of intelligence, adaptive functioning, and our consideration of 
common everyday activities and work activity.
    Final 12.00H2a describes how we establish significantly subaverage 
general intellectual functioning, which is one of the criteria for 
listing 12.05. This section explains that we identify significantly 
subaverage general intellectual functioning by an IQ score(s). Final 
12.00H2b and H2c are new sections that describe our psychometric 
standards. We added these sections in response to a public comment 
noting that our prior rules had information on these important topics, 
but the proposed rules did not.
    We moved and changed the guidance about how we will consider IQ 
test scores from proposed 12.00B4d and 12.00D4 to final 12.00H2d. We 
revised the policies in response to several public comments raising 
concern that the proposed rules about interpreting test results gave 
too much discretion to adjudicators who may not have the expertise of 
the test administrators. In response to these comments, final 12.00H2d 
indicates that only qualified specialists, Federal and State agency 
medical and psychological consultants, and other contracted medical and 
psychological experts may conclude that an obtained IQ score is not an 
accurate reflection of a claimant's general intellectual functioning. 
We explain our reasons for making this change in detail earlier in this 
preamble.

Final 12.00I (Proposed 12.00H): How do we evaluate substance use 
disorders?

    This section explains how we evaluate mental disorders that do not 
meet one of the mental disorders listings. In these final rules, we 
moved this information from proposed 12.00H

[[Page 66159]]

to final 12.00I to accommodate adding new a section, final 12.00H 
earlier in the introductory text. Although we received several public 
comments requesting changes regarding this section of the rules, we 
were unable to make those changes for reasons we explain earlier in 
this preamble. We did not make any substantive changes to this section.

Final 12.00J (Proposed 12.00I): How do we evaluate mental disorders 
that do not meet one of the mental disorders listings?

    This section explains how we evaluate mental disorders that do not 
meet one of the mental disorders listings. This section also explains 
what rules we use when we decide whether a person receiving benefits 
continues to be disabled. In these final rules, we moved this 
information from proposed 12.00I to final 12.00J to accommodate adding 
final 12.00H earlier in the introductory text. We did not make any 
substantive changes to this section.

12.01 Category of Impairments, Mental Disorders

    The final rules revise all of the mental disorders listings. We 
made many of the revisions in response to public comments on the NPRM. 
To avoid repeating the same information multiple times, the list below 
summarizes the changes that apply to many or all of the listings:
     The final rules update the titles of listings 12.02, 
12.03, 12.04, 12.06, 12.07, 12.08, 12.11, and 12.15 to reflect the 
terms the APA uses to describe the categories of mental disorders in 
the DSM-5.
     All final listings (except for 12.05 and 112.05) include 
``paragraph A criteria'' that are similar to our prior rules. We kept 
the paragraph A criteria in the listings in response to a public 
comment on the NPRM that identified the benefits of having the 
criteria. The paragraph A criteria in the final listings reflect the 
diagnostic criteria of disorders in the DSM-5. Although a claimant must 
have a medically determinable mental impairment, the claimant does not 
have to have a diagnosis for his or her mental impairment to satisfy 
the listing criteria. The medical evidence must demonstrate the 
required paragraph A criteria are present for us to find that the 
impairment meets the listing.
     We changed the title of the paragraph B1 criteria to 
``understand, remember, or apply information,'' and the title of the 
paragraph B3 criteria to ``concentrate, persist, or maintain pace.'' 
The titles are linked by ``or'' rather than ``and'' in response to 
public comments on the NPRM, and to clarify our rules about how we rate 
a person's degree of functional limitation.
     We changed the title of paragraph B4 to ``adapt or manage 
oneself'' in partial response to public comments on the NPRM.
     The final rules revise the paragraph C criteria in 
listings 12.02, 12.03, 12.04, 12.06, and 12.15. The paragraph C 
criteria state that a person must have a medically documented history 
of the existence of his or her disorder over a period of at least 2 
years. This requirement is consistent with our prior rules.
     Final listings 12.07, 12.08, 12.10, 12.11 and 12.13 do not 
include paragraph C criteria. We made this change because our medical 
and psychological experts, and our program experience, indicate that 
the unique medical situation we identify with the paragraph C criteria 
typically does not apply to the disorders we evaluate under these 
listings.
    In addition to these changes, we also made changes to individual 
listings. We describe those changes in the following sections.

12.05 Intellectual Disorder

    Final listing 12.05 includes important revisions that we made in 
response to public comments. The name of the listing is now 
intellectual disorder, and we organized the criteria in the listing to 
reflect the three elements of the medical definition of intellectual 
disability. We explain these changes and our reasons for making them 
earlier in this preamble.

12.15 Trauma- and Stressor-Related Disorders

    Final listing 12.15 is a new listing we will use to evaluate 
trauma- and stressor-related disorders such as posttraumatic stress 
disorder. Prior versions of the DSM, such as the DSM-IV-TR, included 
trauma- and stressor-related disorders as a type of anxiety disorder. 
Under our prior rules, we evaluated trauma- and stressor-related 
disorders under prior listing 12.06, anxiety-related disorders. 
However, the DSM-5 created a separate diagnostic category for trauma- 
and stressor-related disorders. As a result, we created new listing 
12.15 to evaluate these types of impairments.
    The paragraph A criteria in final listing 12.15 reflect diagnostic 
criteria of posttraumatic stress disorder, which is a type of trauma- 
and stressor-related disorder included in the DSM-5. Final listing 
12.15 includes paragraph C criteria because prior listing 12.06 
included the criteria, and because our medical and psychological 
experts advised us that the unique medical situation that we identify 
with the paragraph C criteria often applies to trauma- and stressor-
related disorders.
    The following is a detailed description of the changes in pertinent 
sections of Part B, the Childhood Mental Disorders Listings.

112.00 Mental Disorders

    We made a number of changes throughout 112.00 to make the final 
childhood mental disorders listings consistent with the final adult 
listings. In some cases, the revisions are not substantive. In others, 
our reasons for the changes are the same as our reasons for changing 
the adult rules, and we explain them earlier in this preamble. We also 
made minor changes in 112.00, either to clarify or enhance our 
discussion of the rules for children. In the following sections, we 
explain the substantive changes to 112.00 that were not applicable to 
our explanation of the changes to the adult rules.

Final 112.00F (Proposed 112.00D): How do we use the paragraph B 
criteria to evaluate mental disorders in children?

    Final 112.00F explains how we use the paragraph B criteria to 
evaluate a child's mental disorder. In final 112.00F2, we explain that 
a child's mental disorder must result in extreme limitation of one, or 
marked limitation of two, paragraph B criteria. We provide citations to 
Sec. Sec.  416.925(b)(2)(ii) and 416.926a(e) for the definitions of the 
terms ``marked'' and ``extreme'' for child claimants. Although we 
suggested definitions for marked and extreme in proposed 112.00D2 and 
D3, we did not make those definitions final. The definitions we 
proposed for children were similar to the definitions that we proposed 
for adults. We did not make final the proposed definitions in the adult 
listings for the reasons we explained earlier in the preamble. 
Furthermore, our childhood policy regulations already include 
definitions for the terms marked and extreme. For these reasons, we 
removed definitions of marked and extreme from 112.00F2, and we include 
a citation to the definitions of those terms in our regulations.

Final 112.00I: What additional considerations do we use to evaluate 
developmental disorders of infants and toddlers?

    Final 112.00I explains how we use listing 112.14 to evaluate 
developmental disorders of infants and toddlers from birth to age 
three. In these final rules, we made changes to this section and

[[Page 66160]]

reorganized how we present the information to avoid repeating guidance 
found elsewhere in the introductory text.
    In final 112.00I2, we discuss how we calculate a child's age and 
how we assess a child's level of development. We expanded our 
discussion from proposed 112.00I2c to include guidance about when we 
will use a child's corrected chronological age, and how we use 
developmental assessments. We moved the description of the listing 
category from proposed 112.00I2a and I2b to 112.00B, where we describe 
all other listing categories.
    In final 112.00I3, we added additional information about the types 
of evidence that we typically receive for infants and toddlers from 
birth to age three. We removed proposed sections 112.00I4 and I5 that 
provided information about how we use the paragraph B criteria to 
evaluate a developmental disorder and how we consider supports when we 
evaluate a child's functioning. These sections duplicated the revised 
guidance we provide in final 112.00F and G, and we do not need to 
repeat them. We renumbered the guidelines about deferring 
determinations from proposed 112.00I6 to final 112.00I5.
    The following is a detailed description of the changes in 
Sec. Sec.  404.1520a and 416.920a.

Sections 404.1520a and 416.920a: Evaluation of Mental Impairments

    Sections 404.1520a and 416.920a describe a special technique, known 
as the psychiatric review technique, which we use when we evaluate the 
severity of mental impairments for adults, and for persons under age 18 
when we use Part A of the listings. Although we proposed in the NPRM to 
remove these two sections, the final rules keep these sections because 
of public comments we received, and for the reasons we explained 
earlier in the preamble. Therefore, we are not making final the changes 
proposed in the NPRM to sections 404.941, 404.1503, 404.1615, 416.903, 
416.934, 416.1015, and 416.1441. We are making conforming changes to 
sections 404.1520a and 416.920a to be consistent with the final rules. 
In paragraphs (c) and (d) of each section, we removed the references to 
the four paragraph B criteria from our prior rules and replaced them 
with the four updated paragraph B criteria from these final rules. We 
also removed the references to the unique rating scale that only 
applied to paragraph B4 under our prior rules, ``episodes of 
decompensation,'' because it is no longer necessary under the final 
rules.

What is our authority to make rules and set procedures for determining 
whether a person is disabled under our statutory definition?

    Under the Act, we have authority to make rules and regulations and 
to establish necessary and appropriate procedures to carry out such 
provisions.\18\
---------------------------------------------------------------------------

    \18\ See sections 205(a), 702(a)(5), and 1631(d)(1) (42 U.S.C. 
405(a), 902(a)(5), 1383(d)(1)).
---------------------------------------------------------------------------

How long will these final rules be in effect?

    These final rules will remain in effect for 5 years after the date 
they become effective, unless we extend them, or revise and issue them 
again. We will continue to monitor these rules to ensure that they 
continue to meet program purposes, and may revise them before the end 
of the 5-year period if warranted.

Regulatory Procedures

Executive Order 12866, as Supplemented by Executive Order 13563

    We consulted with the Office of Management and Budget (OMB) and 
determined that these final rules meet the criteria for a significant 
regulatory action under Executive Order 12866, as supplemented by 
Executive Order 13563. Therefore, OMB reviewed these final rules.

Regulatory Flexibility Act

    We certify that these final rules will not have a significant 
economic impact on a substantial number of small entities because they 
affect individuals only. Therefore, the Regulatory Flexibility Act, as 
amended, does not require us to prepare a regulatory flexibility 
analysis.

Paperwork Reduction Act

    These rules do not create any new or affect any existing 
collections and, therefore, do not require Office of Management and 
Budget approval under the Paperwork Reduction Act.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
Security--Disability Insurance; 96.002, Social Security--Retirement 
Insurance; 96.004, Social Security--Survivors Insurance; and 96.006, 
Supplemental Security Income)

List of Subjects

20 CFR Part 404

    Administrative practice and procedure; Blind; Disability benefits; 
Old-age, Survivors, and Disability Insurance; Reporting and 
recordkeeping requirements; Social Security.

20 CFR Part 416

    Administrative practice and procedure, Aged, Blind, Disability cash 
payments, Public assistance programs, Supplemental Security Income 
(SSI), Reporting and recordkeeping requirements.

Carolyn W. Colvin,
Acting Commissioner of Social Security.
    For the reasons set out in the preamble, we are amending subpart P 
of part 404 and subpart I of part 416 of chapter III of title 20 of the 
Code of Federal Regulations as set forth below:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
(1950- )

Subpart P--Determining Disability and Blindness

0
1. The authority citation for subpart P of part 404 continues to read 
as follows:

    Authority:  Secs. 202, 205(a)-(b) and (d)-(h), 216(i), 221(a), 
(i), and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security 
Act (42 U.S.C. 402, 405(a)-(b) and (d)-(h), 416(i), 421(a), (i), and 
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42 
U.S.C. 902 note).


0
2. Amend Sec.  404.1520a by revising paragraphs (c)(3) and (4) and 
(d)(1) to read as follows:


Sec.  404.1520a  Evaluation of mental impairments.

* * * * *
    (c) * * *
    (3) We have identified four broad functional areas in which we will 
rate the degree of your functional limitation: Understand, remember, or 
apply information; interact with others; concentrate, persist, or 
maintain pace; and adapt or manage oneself. See 12.00E of the Listing 
of Impairments in appendix 1 to this subpart.
    (4) When we rate your degree of limitation in these areas 
(understand, remember, or apply information; interact with others; 
concentrate, persist, or maintain pace; and adapt or manage oneself), 
we will use the following five-point scale: None, mild, moderate, 
marked, and extreme. The last point on the scale represents a degree of 
limitation that is incompatible with the ability to do any gainful 
activity.
    (d) * * *
    (1) If we rate the degrees of your limitation as ``none'' or 
``mild,'' we will generally conclude that your impairment(s) is not 
severe, unless the evidence otherwise indicates that there is more than 
a minimal limitation in

[[Page 66161]]

your ability to do basic work activities (see Sec.  404.1521).
* * * * *

0
3. Amend appendix 1 to subpart P of part 404 as follows:
0
a. Revise item 13 of the introductory text before part A.
0
b. Revise section 12.00 of part A.
0
c. In Part B:
0
i. Revise section 112.00.
0
ii. Revise the first sentence of section 114.00D6e(ii).
0
iii. Remove section 114.00I and redesignate section 114.00J as section 
114.00I.
0
iv. Revise 114.02 and 114.03.
0
v. Remove the semicolon and the word ``or'' after section 114.04C2 and 
add a period in their place.
0
vi. Remove section 114.04D.
0
vii. Remove the word ``or'' after section 114.05D.
0
viii. Remove section 114.05E.
0
ix. Revise 114.06.
0
x. Remove the word ``or'' after section 114.07B.
0
xi. Remove section 114.07C.
0
xii. Remove the word ``or'' after section 114.08K6.
0
xiii. Remove section 114.08L.
0
xiv. Remove the word ``or'' after section 114.09C2.
0
xv. Remove section 114.09D.
0
xvi. Revise 114.10.
    The revisions read as follows:

Appendix 1 to Subpart P of Part 404--Listing of Impairments

* * * * *
    13. Mental Disorders (12.00 and 112.00): January 17, 2022.
* * * * *

Part A

* * * * *

12.00 Mental Disorders

    A. How are the listings for mental disorders arranged, and what 
do they require?
    1. The listings for mental disorders are arranged in 11 
categories: Neurocognitive disorders (12.02); schizophrenia spectrum 
and other psychotic disorders (12.03); depressive, bipolar and 
related disorders (12.04); intellectual disorder (12.05); anxiety 
and obsessive-compulsive disorders (12.06); somatic symptom and 
related disorders (12.07); personality and impulse-control disorders 
(12.08); autism spectrum disorder (12.10); neurodevelopmental 
disorders (12.11); eating disorders (12.13); and trauma- and 
stressor-related disorders (12.15).
    2. Listings 12.07, 12.08, 12.10, 12.11, and 12.13 have two 
paragraphs, designated A and B; your mental disorder must satisfy 
the requirements of both paragraphs A and B. Listings 12.02, 12.03, 
12.04, 12.06, and 12.15 have three paragraphs, designated A, B, and 
C; your mental disorder must satisfy the requirements of both 
paragraphs A and B, or the requirements of both paragraphs A and C. 
Listing 12.05 has two paragraphs that are unique to that listing 
(see 12.00A3); your mental disorder must satisfy the requirements of 
either paragraph A or paragraph B.
    a. Paragraph A of each listing (except 12.05) includes the 
medical criteria that must be present in your medical evidence.
    b. Paragraph B of each listing (except 12.05) provides the 
functional criteria we assess, in conjunction with a rating scale 
(see 12.00E and 12.00F), to evaluate how your mental disorder limits 
your functioning. These criteria represent the areas of mental 
functioning a person uses in a work setting. They are: Understand, 
remember, or apply information; interact with others; concentrate, 
persist, or maintain pace; and adapt or manage oneself. We will 
determine the degree to which your medically determinable mental 
impairment affects the four areas of mental functioning and your 
ability to function independently, appropriately, effectively, and 
on a sustained basis (see Sec. Sec.  404.1520a(c)(2) and 
416.920a(c)(2) of this chapter). To satisfy the paragraph B 
criteria, your mental disorder must result in ``extreme'' limitation 
of one, or ``marked'' limitation of two, of the four areas of mental 
functioning. (When we refer to ``paragraph B criteria'' or ``area[s] 
of mental functioning'' in the introductory text of this body 
system, we mean the criteria in paragraph B of every listing except 
12.05.)
    c. Paragraph C of listings 12.02, 12.03, 12.04, 12.06, and 12.15 
provides the criteria we use to evaluate ``serious and persistent 
mental disorders.'' To satisfy the paragraph C criteria, your mental 
disorder must be ``serious and persistent''; that is, there must be 
a medically documented history of the existence of the disorder over 
a period of at least 2 years, and evidence that satisfies the 
criteria in both C1 and C2 (see 12.00G). (When we refer to 
``paragraph C'' or ``the paragraph C criteria'' in the introductory 
text of this body system, we mean the criteria in paragraph C of 
listings 12.02, 12.03, 12.04, 12.06, and 12.15.)
    3. Listing 12.05 has two paragraphs, designated A and B, that 
apply to only intellectual disorder. Each paragraph requires that 
you have significantly subaverage general intellectual functioning; 
significant deficits in current adaptive functioning; and evidence 
that demonstrates or supports (is consistent with) the conclusion 
that your disorder began prior to age 22.
    B. Which mental disorders do we evaluate under each listing 
category?
    1. Neurocognitive disorders (12.02).
    a. These disorders are characterized by a clinically significant 
decline in cognitive functioning. Symptoms and signs may include, 
but are not limited to, disturbances in memory, executive 
functioning (that is, higher-level cognitive processes; for example, 
regulating attention, planning, inhibiting responses, decision-
making), visual-spatial functioning, language and speech, 
perception, insight, judgment, and insensitivity to social 
standards.
    b. Examples of disorders that we evaluate in this category 
include major neurocognitive disorder; dementia of the Alzheimer 
type; vascular dementia; dementia due to a medical condition such as 
a metabolic disease (for example, late-onset Tay-Sachs disease), 
human immunodeficiency virus infection, vascular malformation, 
progressive brain tumor, neurological disease (for example, multiple 
sclerosis, Parkinsonian syndrome, Huntington disease), or traumatic 
brain injury; or substance-induced cognitive disorder associated 
with drugs of abuse, medications, or toxins. (We evaluate 
neurological disorders under that body system (see 11.00). We 
evaluate cognitive impairments that result from neurological 
disorders under 12.02 if they do not satisfy the requirements in 
11.00 (see 11.00G).)
    c. This category does not include the mental disorders that we 
evaluate under intellectual disorder (12.05), autism spectrum 
disorder (12.10), and neurodevelopmental disorders (12.11).
    2. Schizophrenia spectrum and other psychotic disorders (12.03).
    a. These disorders are characterized by delusions, 
hallucinations, disorganized speech, or grossly disorganized or 
catatonic behavior, causing a clinically significant decline in 
functioning. Symptoms and signs may include, but are not limited to, 
inability to initiate and persist in goal-directed activities, 
social withdrawal, flat or inappropriate affect, poverty of thought 
and speech, loss of interest or pleasure, disturbances of mood, odd 
beliefs and mannerisms, and paranoia.
    b. Examples of disorders that we evaluate in this category 
include schizophrenia, schizoaffective disorder, delusional 
disorder, and psychotic disorder due to another medical condition.
    3. Depressive, bipolar and related disorders (12.04).
    a. These disorders are characterized by an irritable, depressed, 
elevated, or expansive mood, or by a loss of interest or pleasure in 
all or almost all activities, causing a clinically significant 
decline in functioning. Symptoms and signs may include, but are not 
limited to, feelings of hopelessness or guilt, suicidal ideation, a 
clinically significant change in body weight or appetite, sleep 
disturbances, an increase or decrease in energy, psychomotor 
abnormalities, disturbed concentration, pressured speech, 
grandiosity, reduced impulse control, sadness, euphoria, and social 
withdrawal.
    b. Examples of disorders that we evaluate in this category 
include bipolar disorders (I or II), cyclothymic disorder, major 
depressive disorder, persistent depressive disorder (dysthymia), and 
bipolar or depressive disorder due to another medical condition.
    4. Intellectual disorder (12.05).
    a. This disorder is characterized by significantly subaverage 
general intellectual functioning, significant deficits in current 
adaptive functioning, and manifestation of the disorder before age 
22. Signs may include, but are not limited to, poor conceptual, 
social, or practical skills evident in your adaptive functioning.
    b. The disorder that we evaluate in this category may be 
described in the evidence as intellectual disability, intellectual 
developmental disorder, or historically used terms such as ``mental 
retardation.''
    c. This category does not include the mental disorders that we 
evaluate under

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neurocognitive disorders (12.02), autism spectrum disorder (12.10), 
or neurodevelopmental disorders (12.11).
    5. Anxiety and obsessive-compulsive disorders (12.06).
    a. These disorders are characterized by excessive anxiety, 
worry, apprehension, and fear, or by avoidance of feelings, 
thoughts, activities, objects, places, or people. Symptoms and signs 
may include, but are not limited to, restlessness, difficulty 
concentrating, hyper-vigilance, muscle tension, sleep disturbance, 
fatigue, panic attacks, obsessions and compulsions, constant 
thoughts and fears about safety, and frequent physical complaints.
    b. Examples of disorders that we evaluate in this category 
include social anxiety disorder, panic disorder, generalized anxiety 
disorder, agoraphobia, and obsessive-compulsive disorder.
    c. This category does not include the mental disorders that we 
evaluate under trauma- and stressor-related disorders (12.15).
    6. Somatic symptom and related disorders (12.07).
    a. These disorders are characterized by physical symptoms or 
deficits that are not intentionally produced or feigned, and that, 
following clinical investigation, cannot be fully explained by a 
general medical condition, another mental disorder, the direct 
effects of a substance, or a culturally sanctioned behavior or 
experience. These disorders may also be characterized by a 
preoccupation with having or acquiring a serious medical condition 
that has not been identified or diagnosed. Symptoms and signs may 
include, but are not limited to, pain and other abnormalities of 
sensation, gastrointestinal symptoms, fatigue, a high level of 
anxiety about personal health status, abnormal motor movement, 
pseudoseizures, and pseudoneurological symptoms, such as blindness 
or deafness.
    b. Examples of disorders that we evaluate in this category 
include somatic symptom disorder, illness anxiety disorder, and 
conversion disorder.
    7. Personality and impulse-control disorders (12.08).
    a. These disorders are characterized by enduring, inflexible, 
maladaptive, and pervasive patterns of behavior. Onset typically 
occurs in adolescence or young adulthood. Symptoms and signs may 
include, but are not limited to, patterns of distrust, 
suspiciousness, and odd beliefs; social detachment, discomfort, or 
avoidance; hypersensitivity to negative evaluation; an excessive 
need to be taken care of; difficulty making independent decisions; a 
preoccupation with orderliness, perfectionism, and control; and 
inappropriate, intense, impulsive anger and behavioral expression 
grossly out of proportion to any external provocation or 
psychosocial stressors.
    b. Examples of disorders that we evaluate in this category 
include paranoid, schizoid, schizotypal, borderline, avoidant, 
dependent, obsessive-compulsive personality disorders, and 
intermittent explosive disorder.
    8. Autism spectrum disorder (12.10).
    a. These disorders are characterized by qualitative deficits in 
the development of reciprocal social interaction, verbal and 
nonverbal communication skills, and symbolic or imaginative 
activity; restricted repetitive and stereotyped patterns of 
behavior, interests, and activities; and stagnation of development 
or loss of acquired skills early in life. Symptoms and signs may 
include, but are not limited to, abnormalities and unevenness in the 
development of cognitive skills; unusual responses to sensory 
stimuli; and behavioral difficulties, including hyperactivity, short 
attention span, impulsivity, aggressiveness, or self-injurious 
actions.
    b. Examples of disorders that we evaluate in this category 
include autism spectrum disorder with or without accompanying 
intellectual impairment, and autism spectrum disorder with or 
without accompanying language impairment.
    c. This category does not include the mental disorders that we 
evaluate under neurocognitive disorders (12.02), intellectual 
disorder (12.05), and neurodevelopmental disorders (12.11).
    9. Neurodevelopmental disorders (12.11).
    a. These disorders are characterized by onset during the 
developmental period, that is, during childhood or adolescence, 
although sometimes they are not diagnosed until adulthood. Symptoms 
and signs may include, but are not limited to, underlying 
abnormalities in cognitive processing (for example, deficits in 
learning and applying verbal or nonverbal information, visual 
perception, memory, or a combination of these); deficits in 
attention or impulse control; low frustration tolerance; excessive 
or poorly planned motor activity; difficulty with organizing (time, 
space, materials, or tasks); repeated accidental injury; and 
deficits in social skills. Symptoms and signs specific to tic 
disorders include sudden, rapid, recurrent, non-rhythmic, motor 
movement or vocalization.
    b. Examples of disorders that we evaluate in this category 
include specific learning disorder, borderline intellectual 
functioning, and tic disorders (such as Tourette syndrome).
    c. This category does not include the mental disorders that we 
evaluate under neurocognitive disorders (12.02), autism spectrum 
disorder (12.10), or personality and impulse-control disorders 
(12.08).
    10. Eating disorders (12.13).
    a. These disorders are characterized by disturbances in eating 
behavior and preoccupation with, and excessive self-evaluation of, 
body weight and shape. Symptoms and signs may include, but are not 
limited to, restriction of energy consumption when compared with 
individual requirements; recurrent episodes of binge eating or 
behavior intended to prevent weight gain, such as self-induced 
vomiting, excessive exercise, or misuse of laxatives; mood 
disturbances, social withdrawal, or irritability; amenorrhea; dental 
problems; abnormal laboratory findings; and cardiac abnormalities.
    b. Examples of disorders that we evaluate in this category 
include anorexia nervosa, bulimia nervosa, binge-eating disorder, 
and avoidant/restrictive food disorder.
    11. Trauma- and stressor-related disorders (12.15).
    a. These disorders are characterized by experiencing or 
witnessing a traumatic or stressful event, or learning of a 
traumatic event occurring to a close family member or close friend, 
and the psychological aftermath of clinically significant effects on 
functioning. Symptoms and signs may include, but are not limited to, 
distressing memories, dreams, and flashbacks related to the trauma 
or stressor; avoidant behavior; diminished interest or participation 
in significant activities; persistent negative emotional states (for 
example, fear, anger) or persistent inability to experience positive 
emotions (for example, satisfaction, affection); anxiety; 
irritability; aggression; exaggerated startle response; difficulty 
concentrating; and sleep disturbance.
    b. Examples of disorders that we evaluate in this category 
include posttraumatic stress disorder and other specified trauma- 
and stressor-related disorders (such as adjustment-like disorders 
with prolonged duration without prolonged duration of stressor).
    c. This category does not include the mental disorders that we 
evaluate under anxiety and obsessive-compulsive disorders (12.06), 
and cognitive impairments that result from neurological disorders, 
such as a traumatic brain injury, which we evaluate under 
neurocognitive disorders (12.02).
    C. What evidence do we need to evaluate your mental disorder?
    1. General. We need evidence from an acceptable medical source 
to establish that you have a medically determinable mental disorder. 
We also need evidence to assess the severity of your mental disorder 
and its effects on your ability to function in a work setting. We 
will determine the extent and kinds of evidence we need from medical 
and non-medical sources based on the individual facts about your 
disorder. For additional evidence requirements for intellectual 
disorder (12.05), see 12.00H. For our basic rules on evidence, see 
Sec. Sec.  404.1512, 404.1513, 404.1520b, 416.912, 416.913, and 
416.920b of this chapter. For our rules on evaluating opinion 
evidence, see Sec. Sec.  404.1527 and 416.927 of this chapter. For 
our rules on evidence about your symptoms, see Sec. Sec.  404.1529 
and 416.929 of this chapter.
    2. Evidence from medical sources. We will consider all relevant 
medical evidence about your disorder from your physician, 
psychologist, and other medical sources, which include health care 
providers such as physician assistants, psychiatric nurse 
practitioners, licensed clinical social workers, and clinical mental 
health counselors. Evidence from your medical sources may include:
    a. Your reported symptoms.
    b. Your medical, psychiatric, and psychological history.
    c. The results of physical or mental status examinations, 
structured clinical interviews, psychiatric or psychological rating 
scales, measures of adaptive functioning, or other clinical 
findings.
    d. Psychological testing, imaging results, or other laboratory 
findings.
    e. Your diagnosis.
    f. The type, dosage, and beneficial effects of medications you 
take.

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    g. The type, frequency, duration, and beneficial effects of 
therapy you receive.
    h. Side effects of medication or other treatment that limit your 
ability to function.
    i. Your clinical course, including changes in your medication, 
therapy, or other treatment, and the time required for therapeutic 
effectiveness.
    j. Observations and descriptions of how you function during 
examinations or therapy.
    k. Information about sensory, motor, or speech abnormalities, or 
about your cultural background (for example, language or customs) 
that may affect an evaluation of your mental disorder.
    l. The expected duration of your symptoms and signs and their 
effects on your functioning, both currently and in the future.
    3. Evidence from you and people who know you. We will consider 
all relevant evidence about your mental disorder and your daily 
functioning that we receive from you and from people who know you. 
We will ask about your symptoms, your daily functioning, and your 
medical treatment. We will ask for information from third parties 
who can tell us about your mental disorder, but you must give us 
permission to do so. This evidence may include information from your 
family, caregivers, friends, neighbors, clergy, case managers, 
social workers, shelter staff, or other community support and 
outreach workers. We will consider whether your statements and the 
statements from third parties are consistent with the medical and 
other evidence we have.
    4. Evidence from school, vocational training, work, and work-
related programs.
    a. School. You may have recently attended or may still be 
attending school, and you may have received or may still be 
receiving special education services. If so, we will try to obtain 
information from your school sources when we need it to assess how 
your mental disorder affects your ability to function. Examples of 
this information include your Individualized Education Programs 
(IEPs), your Section 504 plans, comprehensive evaluation reports, 
school-related therapy progress notes, information from your 
teachers about how you function in a classroom setting, and 
information about any special services or accommodations you receive 
at school.
    b. Vocational training, work, and work-related programs. You may 
have recently participated in or may still be participating in 
vocational training, work-related programs, or work activity. If so, 
we will try to obtain information from your training program or your 
employer when we need it to assess how your mental disorder affects 
your ability to function. Examples of this information include 
training or work evaluations, modifications to your work duties or 
work schedule, and any special supports or accommodations you have 
required or now require in order to work. If you have worked or are 
working through a community mental health program, sheltered or 
supported work program, rehabilitation program, or transitional 
employment program, we will consider the type and degree of support 
you have received or are receiving in order to work (see 12.00D).
    5. Need for longitudinal evidence.
    a. General. Longitudinal medical evidence can help us learn how 
you function over time, and help us evaluate any variations in the 
level of your functioning. We will request longitudinal evidence of 
your mental disorder when your medical providers have records 
concerning you and your mental disorder over a period of months or 
perhaps years (see Sec. Sec.  404.1512(d) and 416.912(d) of this 
chapter).
    b. Non-medical sources of longitudinal evidence. Certain 
situations, such as chronic homelessness, may make it difficult for 
you to provide longitudinal medical evidence. If you have a severe 
mental disorder, you will probably have evidence of its effects on 
your functioning over time, even if you have not had an ongoing 
relationship with the medical community or are not currently 
receiving treatment. For example, family members, friends, 
neighbors, former employers, social workers, case managers, 
community support staff, outreach workers, or government agencies 
may be familiar with your mental health history. We will ask for 
information from third parties who can tell us about your mental 
disorder, but you must give us permission to do so.
    c. Absence of longitudinal evidence. In the absence of 
longitudinal evidence, we will use current objective medical 
evidence and all other relevant evidence available to us in your 
case record to evaluate your mental disorder. If we purchase a 
consultative examination to document your disorder, the record will 
include the results of that examination (see Sec. Sec.  404.1514 and 
416.914 of this chapter). We will take into consideration your 
medical history, symptoms, clinical and laboratory findings, and 
medical source opinions. If you do not have longitudinal evidence, 
the current evidence alone may not be sufficient or appropriate to 
show that you have a disorder that meets the criteria of one of the 
mental disorders listings. In that case, we will follow the rules in 
12.00J.
    6. Evidence of functioning in unfamiliar situations or 
supportive situations.
    a. Unfamiliar situations. We recognize that evidence about your 
functioning in unfamiliar situations does not necessarily show how 
you would function on a sustained basis in a work setting. In one-
time, time-limited, or other unfamiliar situations, you may function 
differently than you do in familiar situations. In unfamiliar 
situations, you may appear more, or less, limited than you do on a 
daily basis and over time.
    b. Supportive situations. Your ability to complete tasks in 
settings that are highly structured, or that are less demanding or 
more supportive than typical work settings does not necessarily 
demonstrate your ability to complete tasks in the context of regular 
employment during a normal workday or work week.
    c. Our assessment. We must assess your ability to complete tasks 
by evaluating all the evidence, such as reports about your 
functioning from you and third parties who are familiar with you, 
with an emphasis on how independently, appropriately, and 
effectively you are able to complete tasks on a sustained basis.
    D. How do we consider psychosocial supports, structured 
settings, living arrangements, and treatment?
    1. General. Psychosocial supports, structured settings, and 
living arrangements, including assistance from your family or 
others, may help you by reducing the demands made on you. In 
addition, treatment you receive may reduce your symptoms and signs 
and possibly improve your functioning, or may have side effects that 
limit your functioning. Therefore, when we evaluate the effects of 
your mental disorder and rate the limitation of your areas of mental 
functioning, we will consider the kind and extent of supports you 
receive, the characteristics of any structured setting in which you 
spend your time, and the effects of any treatment. This evidence may 
come from reports about your functioning from you or third parties 
who are familiar with you, and other third-party statements or 
information. Following are some examples of the supports you may 
receive:
    a. You receive help from family members or other people who 
monitor your daily activities and help you to function. For example, 
family members administer your medications, remind you to eat, shop 
for you and pay your bills, or change their work hours so you are 
never home alone.
    b. You participate in a special education or vocational training 
program, or a psychosocial rehabilitation day treatment or community 
support program, where you receive training in daily living and 
entry-level work skills.
    c. You participate in a sheltered, supported, or transitional 
work program, or in a competitive employment setting with the help 
of a job coach or supervisor.
    d. You receive comprehensive ``24/7 wrap-around'' mental health 
services while living in a group home or transitional housing, while 
participating in a semi-independent living program, or while living 
in individual housing (for example, your own home or apartment).
    e. You live in a hospital or other institution with 24-hour 
care.
    f. You receive assistance from a crisis response team, social 
workers, or community mental health workers who help you meet your 
physical needs, and who may also represent you in dealings with 
government or community social services.
    g. You live alone and do not receive any psychosocial 
support(s); however, you have created a highly structured 
environment by eliminating all but minimally necessary contact with 
the world outside your living space.
    2. How we consider different levels of support and structure in 
psychosocial rehabilitation programs.
    a. Psychosocial rehabilitation programs are based on your 
specific needs. Therefore, we cannot make any assumptions about your 
mental disorder based solely on the fact that you are associated 
with such a program. We must know the details of the program(s) in 
which you are involved and the pattern(s) of your involvement over 
time.
    b. The kinds and levels of supports and structures in 
psychosocial rehabilitation programs typically occur on a scale of 
``most restrictive'' to ``least restrictive.'' Participation in a 
psychosocial rehabilitation program at the most restrictive level 
would

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suggest greater limitation of your areas of mental functioning than 
would participation at a less restrictive level. The length of time 
you spend at different levels in a program also provides information 
about your functioning. For example, you could begin participation 
at the most restrictive crisis intervention level but gradually 
improve to the point of readiness for a lesser level of support and 
structure and possibly some form of employment.
    3. How we consider the help or support you receive.
    a. We will consider the complete picture of your daily 
functioning, including the kinds, extent, and frequency of help and 
support you receive, when we evaluate your mental disorder and 
determine whether you are able to use the four areas of mental 
functioning in a work setting. The fact that you have done, or 
currently do, some routine activities without help or support does 
not necessarily mean that you do not have a mental disorder or that 
you are not disabled. For example, you may be able to take care of 
your personal needs, cook, shop, pay your bills, live by yourself, 
and drive a car. You may demonstrate both strengths and deficits in 
your daily functioning.
    b. You may receive various kinds of help and support from others 
that enable you to do many things that, because of your mental 
disorder, you might not be able to do independently. Your daily 
functioning may depend on the special contexts in which you 
function. For example, you may spend your time among only familiar 
people or surroundings, in a simple and steady routine or an 
unchanging environment, or in a highly structured setting. However, 
this does not necessarily show how you would function in a work 
setting on a sustained basis, throughout a normal workday and 
workweek. (See 12.00H for further discussion of these issues 
regarding significant deficits in adaptive functioning for the 
purpose of 12.05.)
    4. How we consider treatment. We will consider the effect of any 
treatment on your functioning when we evaluate your mental disorder. 
Treatment may include medication(s), psychotherapy, or other forms 
of intervention, which you receive in a doctor's office, during a 
hospitalization, or in a day program at a hospital or outpatient 
treatment program. With treatment, you may not only have your 
symptoms and signs reduced, but may also be able to function in a 
work setting. However, treatment may not resolve all of the 
limitations that result from your mental disorder, and the 
medications you take or other treatment you receive for your 
disorder may cause side effects that limit your mental or physical 
functioning. For example, you may experience drowsiness, blunted 
affect, memory loss, or abnormal involuntary movements.
    E. What are the paragraph B criteria?
    1. Understand, remember, or apply information (paragraph B1). 
This area of mental functioning refers to the abilities to learn, 
recall, and use information to perform work activities. Examples 
include: Understanding and learning terms, instructions, procedures; 
following one- or two-step oral instructions to carry out a task; 
describing work activity to someone else; asking and answering 
questions and providing explanations; recognizing a mistake and 
correcting it; identifying and solving problems; sequencing multi-
step activities; and using reason and judgment to make work-related 
decisions. These examples illustrate the nature of this area of 
mental functioning. We do not require documentation of all of the 
examples.
    2. Interact with others (paragraph B2). This area of mental 
functioning refers to the abilities to relate to and work with 
supervisors, co-workers, and the public. Examples include: 
cooperating with others; asking for help when needed; handling 
conflicts with others; stating own point of view; initiating or 
sustaining conversation; understanding and responding to social cues 
(physical, verbal, emotional); responding to requests, suggestions, 
criticism, correction, and challenges; and keeping social 
interactions free of excessive irritability, sensitivity, 
argumentativeness, or suspiciousness. These examples illustrate the 
nature of this area of mental functioning. We do not require 
documentation of all of the examples.
    3. Concentrate, persist, or maintain pace (paragraph B3). This 
area of mental functioning refers to the abilities to focus 
attention on work activities and stay on task at a sustained rate. 
Examples include: Initiating and performing a task that you 
understand and know how to do; working at an appropriate and 
consistent pace; completing tasks in a timely manner; ignoring or 
avoiding distractions while working; changing activities or work 
settings without being disruptive; working close to or with others 
without interrupting or distracting them; sustaining an ordinary 
routine and regular attendance at work; and working a full day 
without needing more than the allotted number or length of rest 
periods during the day. These examples illustrate the nature of this 
area of mental functioning. We do not require documentation of all 
of the examples.
    4. Adapt or manage oneself (paragraph B4). This area of mental 
functioning refers to the abilities to regulate emotions, control 
behavior, and maintain well-being in a work setting. Examples 
include: Responding to demands; adapting to changes; managing your 
psychologically based symptoms; distinguishing between acceptable 
and unacceptable work performance; setting realistic goals; making 
plans for yourself independently of others; maintaining personal 
hygiene and attire appropriate to a work setting; and being aware of 
normal hazards and taking appropriate precautions. These examples 
illustrate the nature of this area of mental functioning. We do not 
require documentation of all of the examples.
    F. How do we use the paragraph B criteria to evaluate your 
mental disorder?
    1. General. We use the paragraph B criteria, in conjunction with 
a rating scale (see 12.00F2), to rate the degree of your 
limitations. We consider only the limitations that result from your 
mental disorder(s). We will determine whether you are able to use 
each of the paragraph B areas of mental functioning in a work 
setting. We will consider, for example, the kind, degree, and 
frequency of difficulty you would have; whether you could function 
without extra help, structure, or supervision; and whether you would 
require special conditions with regard to activities or other people 
(see 12.00D).
    2. The five-point rating scale. We evaluate the effects of your 
mental disorder on each of the four areas of mental functioning 
based on a five-point rating scale consisting of none, mild, 
moderate, marked, and extreme limitation. To satisfy the paragraph B 
criteria, your mental disorder must result in extreme limitation of 
one, or marked limitation of two, paragraph B areas of mental 
functioning. Under these listings, the five rating points are 
defined as follows:
    a. No limitation (or none). You are able to function in this 
area independently, appropriately, effectively, and on a sustained 
basis.
    b. Mild limitation. Your functioning in this area independently, 
appropriately, effectively, and on a sustained basis is slightly 
limited.
    c. Moderate limitation. Your functioning in this area 
independently, appropriately, effectively, and on a sustained basis 
is fair.
    d. Marked limitation. Your functioning in this area 
independently, appropriately, effectively, and on a sustained basis 
is seriously limited.
    e. Extreme limitation. You are not able to function in this area 
independently, appropriately, effectively, and on a sustained basis.
    3. Rating the limitations of your areas of mental functioning.
    a. General. We use all of the relevant medical and non-medical 
evidence in your case record to evaluate your mental disorder: The 
symptoms and signs of your disorder, the reported limitations in 
your activities, and any help and support you receive that is 
necessary for you to function. The medical evidence may include 
descriptors regarding the diagnostic stage or level of your 
disorder, such as ``mild'' or ``moderate.'' Clinicians may use these 
terms to characterize your medical condition. However, these terms 
will not always be the same as the degree of your limitation in a 
paragraph B area of mental functioning.
    b. Areas of mental functioning in daily activities. You use the 
same four areas of mental functioning in daily activities at home 
and in the community that you would use to function at work. With 
respect to a particular task or activity, you may have trouble using 
one or more of the areas. For example, you may have difficulty 
understanding and remembering what to do; or concentrating and 
staying on task long enough to do it; or engaging in the task or 
activity with other people; or trying to do the task without 
becoming frustrated and losing self-control. Information about your 
daily functioning can help us understand whether your mental 
disorder limits one or more of these areas; and, if so, whether it 
also affects your ability to function in a work setting.
    c. Areas of mental functioning in work settings. If you have 
difficulty using an area of mental functioning from day-to-day at 
home or in your community, you may also

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have difficulty using that area to function in a work setting. On 
the other hand, if you are able to use an area of mental functioning 
at home or in your community, we will not necessarily assume that 
you would also be able to use that area to function in a work 
setting where the demands and stressors differ from those at home. 
We will consider all evidence about your mental disorder and daily 
functioning before we reach a conclusion about your ability to work.
    d. Overall effect of limitations. Limitation of an area of 
mental functioning reflects the overall degree to which your mental 
disorder interferes with that area. The degree of limitation is how 
we document our assessment of your limitation when using the area of 
mental functioning independently, appropriately, effectively, and on 
a sustained basis. It does not necessarily reflect a specific type 
or number of activities, including activities of daily living, that 
you have difficulty doing. In addition, no single piece of 
information (including test results) can establish the degree of 
limitation of an area of mental functioning.
    e. Effects of support, supervision, structure on functioning. 
The degree of limitation of an area of mental functioning also 
reflects the kind and extent of supports or supervision you receive 
and the characteristics of any structured setting where you spend 
your time, which enable you to function. The more extensive the 
support you need from others or the more structured the setting you 
need in order to function, the more limited we will find you to be 
(see 12.00D).
    f. Specific instructions for paragraphs B1, B3, and B4. For 
paragraphs B1, B3, and B4, the greatest degree of limitation of any 
part of the area of mental functioning directs the rating of 
limitation of that whole area of mental functioning.
    (i) To do a work-related task, you must be able to understand 
and remember and apply information required by the task. Similarly, 
you must be able to concentrate and persist and maintain pace in 
order to complete the task, and adapt and manage yourself in the 
workplace. Limitation in any one of these parts (understand or 
remember or apply; concentrate or persist or maintain pace; adapt or 
manage oneself) may prevent you from completing a work-related task.
    (ii) We will document the rating of limitation of the whole area 
of mental functioning, not each individual part. We will not add 
ratings of the parts together. For example, with respect to 
paragraph B3, if you have marked limitation in maintaining pace, and 
mild or moderate limitations in concentrating and persisting, we 
will find that you have marked limitation in the whole paragraph B3 
area of mental functioning.
    (iii) Marked limitation in more than one part of the same 
paragraph B area of mental functioning does not satisfy the 
requirement to have marked limitation in two paragraph B areas of 
mental functioning.
    4. How we evaluate mental disorders involving exacerbations and 
remissions.
    a. When we evaluate the effects of your mental disorder, we will 
consider how often you have exacerbations and remissions, how long 
they last, what causes your mental disorder to worsen or improve, 
and any other relevant information. We will assess any limitation of 
the affected paragraph B area(s) of mental functioning using the 
rating scale for the paragraph B criteria. We will consider whether 
you can use the area of mental functioning on a regular and 
continuing basis (8 hours a day, 5 days a week, or an equivalent 
work schedule). We will not find that you are able to work solely 
because you have a period(s) of improvement (remission), or that you 
are disabled solely because you have a period of worsening 
(exacerbation), of your mental disorder.
    b. If you have a mental disorder involving exacerbations and 
remissions, you may be able to use the four areas of mental 
functioning to work for a few weeks or months. Recurrence or 
worsening of symptoms and signs, however, can interfere enough to 
render you unable to sustain the work.
    G. What are the paragraph C criteria, and how do we use them to 
evaluate your mental disorder?
    1. General. The paragraph C criteria are an alternative to the 
paragraph B criteria under listings 12.02, 12.03, 12.04, 12.06, and 
12.15. We use the paragraph C criteria to evaluate mental disorders 
that are ``serious and persistent.'' In the paragraph C criteria, we 
recognize that mental health interventions may control the more 
obvious symptoms and signs of your mental disorder.
    2. Paragraph C criteria.
    a. We find a mental disorder to be ``serious and persistent'' 
when there is a medically documented history of the existence of the 
mental disorder in the listing category over a period of at least 2 
years, and evidence shows that your disorder satisfies both C1 and 
C2.
    b. The criterion in C1 is satisfied when the evidence shows that 
you rely, on an ongoing basis, upon medical treatment, mental health 
therapy, psychosocial support(s), or a highly structured setting(s), 
to diminish the symptoms and signs of your mental disorder (see 
12.00D). We consider that you receive ongoing medical treatment when 
the medical evidence establishes that you obtain medical treatment 
with a frequency consistent with accepted medical practice for the 
type of treatment or evaluation required for your medical condition. 
We will consider periods of inconsistent treatment or lack of 
compliance with treatment that may result from your mental disorder. 
If the evidence indicates that the inconsistent treatment or lack of 
compliance is a feature of your mental disorder, and it has led to 
an exacerbation of your symptoms and signs, we will not use it as 
evidence to support a finding that you have not received ongoing 
medical treatment as required by this paragraph.
    c. The criterion in C2 is satisfied when the evidence shows 
that, despite your diminished symptoms and signs, you have achieved 
only marginal adjustment. ``Marginal adjustment'' means that your 
adaptation to the requirements of daily life is fragile; that is, 
you have minimal capacity to adapt to changes in your environment or 
to demands that are not already part of your daily life. We will 
consider that you have achieved only marginal adjustment when the 
evidence shows that changes or increased demands have led to 
exacerbation of your symptoms and signs and to deterioration in your 
functioning; for example, you have become unable to function outside 
of your home or a more restrictive setting, without substantial 
psychosocial supports (see 12.00D). Such deterioration may have 
necessitated a significant change in medication or other treatment. 
Similarly, because of the nature of your mental disorder, evidence 
may document episodes of deterioration that have required you to be 
hospitalized or absent from work, making it difficult for you to 
sustain work activity over time.
    H. How do we document and evaluate intellectual disorder under 
12.05?
    1. General. Listing 12.05 is based on the three elements that 
characterize intellectual disorder: Significantly subaverage general 
intellectual functioning; significant deficits in current adaptive 
functioning; and the disorder manifested before age 22.
    2. Establishing significantly subaverage general intellectual 
functioning.
    a. Definition. Intellectual functioning refers to the general 
mental capacity to learn, reason, plan, solve problems, and perform 
other cognitive functions. Under 12.05A, we identify significantly 
subaverage general intellectual functioning by the cognitive 
inability to function at a level required to participate in 
standardized intelligence testing. Our findings under 12.05A are 
based on evidence from an acceptable medical source. Under 12.05B, 
we identify significantly subaverage general intellectual 
functioning by an IQ score(s) on an individually administered 
standardized test of general intelligence that meets program 
requirements and has a mean of 100 and a standard deviation of 15. A 
qualified specialist (see 12.00H2c) must administer the standardized 
intelligence testing.
    b. Psychometric standards. We will find standardized 
intelligence test results usable for the purposes of 12.05B1 when 
the measure employed meets contemporary psychometric standards for 
validity, reliability, normative data, and scope of measurement; and 
a qualified specialist has individually administered the test 
according to all pre-requisite testing conditions.
    c. Qualified specialist. A ``qualified specialist'' is currently 
licensed or certified at the independent level of practice in the 
State where the test was performed, and has the training and 
experience to administer, score, and interpret intelligence tests. 
If a psychological assistant or paraprofessional administered the 
test, a supervisory qualified specialist must interpret the test 
findings and co-sign the examination report.
    d. Responsibility for conclusions based on testing. We generally 
presume that your obtained IQ score(s) is an accurate reflection of 
your general intellectual functioning, unless evidence in the record 
suggests otherwise. Examples of this evidence include: a statement 
from the test administrator indicating that your obtained score is 
not an accurate reflection of your general intellectual functioning, 
prior or internally inconsistent IQ scores, or information about 
your daily functioning. Only qualified specialists, Federal and 
State

[[Page 66166]]

agency medical and psychological consultants, and other contracted 
medical and psychological experts may conclude that your obtained IQ 
score(s) is not an accurate reflection of your general intellectual 
functioning. This conclusion must be well supported by appropriate 
clinical and laboratory diagnostic techniques and must be based on 
relevant evidence in the case record, such as:
    (i) The data obtained in testing;
    (ii) Your developmental history, including when your signs and 
symptoms began;
    (iii) Information about how you function on a daily basis in a 
variety of settings; and
    (iv) Clinical observations made during the testing period, such 
as your ability to sustain attention, concentration, and effort; to 
relate appropriately to the examiner; and to perform tasks 
independently without prompts or reminders.
    3. Establishing significant deficits in adaptive functioning.
    a. Definition. Adaptive functioning refers to how you learn and 
use conceptual, social, and practical skills in dealing with common 
life demands. It is your typical functioning at home and in the 
community, alone or among others. Under 12.05A, we identify 
significant deficits in adaptive functioning based on your 
dependence on others to care for your personal needs, such as eating 
and bathing. We will base our conclusions about your adaptive 
functioning on evidence from a variety of sources (see 12.00H3b) and 
not on your statements alone. Under 12.05B2, we identify significant 
deficits in adaptive functioning based on whether there is extreme 
limitation of one, or marked limitation of two, of the paragraph B 
criteria (see 12.00E; 12.00F).
    b. Evidence. Evidence about your adaptive functioning may come 
from:
    (i) Medical sources, including their clinical observations;
    (ii) Standardized tests of adaptive functioning (see 12.00H3c);
    (iii) Third party information, such as a report of your 
functioning from a family member or friend;
    (iv) School records, if you were in school recently;
    (v) Reports from employers or supervisors; and
    (vi) Your own statements about how you handle all of your daily 
activities.
    c. Standardized tests of adaptive functioning. We do not require 
the results of an individually administered standardized test of 
adaptive functioning. If your case record includes these test 
results, we will consider the results along with all other relevant 
evidence; however, we will use the guidelines in 12.00E and F to 
evaluate and determine the degree of your deficits in adaptive 
functioning, as required under 12.05B2.
    d. How we consider common everyday activities.
    (i) The fact that you engage in common everyday activities, such 
as caring for your personal needs, preparing simple meals, or 
driving a car, will not always mean that you do not have deficits in 
adaptive functioning as required by 12.05B2. You may demonstrate 
both strengths and deficits in your adaptive functioning. However, a 
lack of deficits in one area does not negate the presence of 
deficits in another area. When we assess your adaptive functioning, 
we will consider all of your activities and your performance of 
them.
    (ii) Our conclusions about your adaptive functioning rest on 
whether you do your daily activities independently, appropriately, 
effectively, and on a sustained basis. If you receive help in 
performing your activities, we need to know the kind, extent, and 
frequency of help you receive in order to perform them. We will not 
assume that your ability to do some common everyday activities, or 
to do some things without help or support, demonstrates that your 
mental disorder does not meet the requirements of 12.05B2. (See 
12.00D regarding the factors we consider when we evaluate your 
functioning, including how we consider any help or support you 
receive.)
    e. How we consider work activity. The fact that you have engaged 
in work activity, or that you work intermittently or steadily in a 
job commensurate with your abilities, will not always mean that you 
do not have deficits in adaptive functioning as required by 12.05B2. 
When you have engaged in work activity, we need complete information 
about the work, and about your functioning in the work activity and 
work setting, before we reach any conclusions about your adaptive 
functioning. We will consider all factors involved in your work 
history before concluding whether your impairment satisfies the 
criteria for intellectual disorder under 12.05B. We will consider 
your prior and current work history, if any, and various other 
factors influencing how you function. For example, we consider 
whether the work was in a supported setting, whether you required 
more supervision than other employees, how your job duties compared 
to others in the same job, how much time it took you to learn the 
job duties, and the reason the work ended, if applicable.
    4. Establishing that the disorder began before age 22. We 
require evidence that demonstrates or supports (is consistent with) 
the conclusion that your mental disorder began prior to age 22. We 
do not require evidence that your impairment met all of the 
requirements of 12.05A or 12.05B prior to age 22. Also, we do not 
require you to have met our statutory definition of disability prior 
to age 22. When we do not have evidence that was recorded before you 
attained age 22, we need evidence about your current intellectual 
and adaptive functioning and the history of your disorder that 
supports the conclusion that the disorder began before you attained 
age 22. Examples of evidence that can demonstrate or support this 
conclusion include:
    a. Tests of intelligence or adaptive functioning;
    b. School records indicating a history of special education 
services based on your intellectual functioning;
    c. An Individualized Education Program (IEP), including your 
transition plan;
    d. Reports of your academic performance and functioning at 
school;
    e. Medical treatment records;
    f. Interviews or reports from employers;
    g. Statements from a supervisor in a group home or a sheltered 
workshop; and
    h. Statements from people who have known you and can tell us 
about your functioning in the past and currently.
    I. How do we evaluate substance use disorders? If we find that 
you are disabled and there is medical evidence in your case record 
establishing that you have a substance use disorder, we will 
determine whether your substance use disorder is a contributing 
factor material to the determination of disability (see Sec. Sec.  
404.1535 and 416.935 of this chapter).
    J. How do we evaluate mental disorders that do not meet one of 
the mental disorders listings?
    1. These listings include only examples of mental disorders that 
we consider serious enough to prevent you from doing any gainful 
activity. If your severe mental disorder does not meet the criteria 
of any of these listings, we will consider whether you have an 
impairment(s) that meets the criteria of a listing in another body 
system. You may have another impairment(s) that is secondary to your 
mental disorder. For example, if you have an eating disorder and 
develop a cardiovascular impairment because of it, we will evaluate 
your cardiovascular impairment under the listings for the 
cardiovascular body system.
    2. If you have a severe medically determinable impairment(s) 
that does not meet a listing, we will determine whether your 
impairment(s) medically equals a listing (see Sec. Sec.  404.1526 
and 416.926 of this chapter).
    3. If your impairment(s) does not meet or medically equal a 
listing, we will assess your residual functional capacity for 
engaging in substantial gainful activity (see Sec. Sec.  404.1545 
and 416.945 of this chapter). When we assess your residual 
functional capacity, we consider all of your impairment-related 
mental and physical limitations. For example, the side effects of 
some medications may reduce your general alertness, concentration, 
or physical stamina, affecting your residual functional capacity for 
non-exertional or exertional work activities. Once we have 
determined your residual functional capacity, we proceed to the 
fourth, and if necessary, the fifth steps of the sequential 
evaluation process in Sec. Sec.  404.1520 and 416.920 of this 
chapter. We use the rules in Sec. Sec.  404.1594 and 416.994 of this 
chapter, as appropriate, when we decide whether you continue to be 
disabled.

12.01 Category of Impairments, Mental Disorders

    12.02 Neurocognitive disorders (see 12.00B1), satisfied by A and 
B, or A and C:
    A. Medical documentation of a significant cognitive decline from 
a prior level of functioning in one or more of the cognitive areas:
    1. Complex attention;
    2. Executive function;
    3. Learning and memory;
    4. Language;
    5. Perceptual-motor; or
    6. Social cognition.

[[Page 66167]]

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 12.00G2c).
    12.03 Schizophrenia spectrum and other psychotic disorders (see 
12.00B2), satisfied by A and B, or A and C:
    A. Medical documentation of one or more of the following:
    1. Delusions or hallucinations;
    2. Disorganized thinking (speech); or
    3. Grossly disorganized behavior or catatonia.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 12.00G2c).
    12.04 Depressive, bipolar and related disorders (see 12.00B3), 
satisfied by A and B, or A and C:
    A. Medical documentation of the requirements of paragraph 1 or 
2:
    1. Depressive disorder, characterized by five or more of the 
following:
    a. Depressed mood;
    b. Diminished interest in almost all activities;
    c. Appetite disturbance with change in weight;
    d. Sleep disturbance;
    e. Observable psychomotor agitation or retardation;
    f. Decreased energy;
    g. Feelings of guilt or worthlessness;
    h. Difficulty concentrating or thinking; or
    i. Thoughts of death or suicide.
    2. Bipolar disorder, characterized by three or more of the 
following:
    a. Pressured speech;
    b. Flight of ideas;
    c. Inflated self-esteem;
    d. Decreased need for sleep;
    e. Distractibility;
    f. Involvement in activities that have a high probability of 
painful consequences that are not recognized; or
    g. Increase in goal-directed activity or psychomotor agitation.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 12.00G2c).
    12.05 Intellectual disorder (see 12.00B4), satisfied by A or B:
    A. Satisfied by 1, 2, and 3 (see 12.00H):
    1. Significantly subaverage general intellectual functioning 
evident in your cognitive inability to function at a level required 
to participate in standardized testing of intellectual functioning; 
and
    2. Significant deficits in adaptive functioning currently 
manifested by your dependence upon others for personal needs (for 
example, toileting, eating, dressing, or bathing); and
    3. The evidence about your current intellectual and adaptive 
functioning and about the history of your disorder demonstrates or 
supports the conclusion that the disorder began prior to your 
attainment of age 22.

OR

    B. Satisfied by 1, 2, and 3 (see 12.00H):
    1. Significantly subaverage general intellectual functioning 
evidenced by a or b:
    a. A full scale (or comparable) IQ score of 70 or below on an 
individually administered standardized test of general intelligence; 
or
    b. A full scale (or comparable) IQ score of 71-75 accompanied by 
a verbal or performance IQ score (or comparable part score) of 70 or 
below on an individually administered standardized test of general 
intelligence; and
    2. Significant deficits in adaptive functioning currently 
manifested by extreme limitation of one, or marked limitation of 
two, of the following areas of mental functioning:
    a. Understand, remember, or apply information (see 12.00E1); or
    b. Interact with others (see 12.00E2); or
    c. Concentrate, persist, or maintain pace (see 12.00E3); or
    d. Adapt or manage oneself (see 12.00E4); and
    3. The evidence about your current intellectual and adaptive 
functioning and about the history of your disorder demonstrates or 
supports the conclusion that the disorder began prior to your 
attainment of age 22.
    12.06 Anxiety and obsessive-compulsive disorders (see 12.00B5), 
satisfied by A and B, or A and C:
    A. Medical documentation of the requirements of paragraph 1, 2, 
or 3:
    1. Anxiety disorder, characterized by three or more of the 
following;
    a. Restlessness;
    b. Easily fatigued;
    c. Difficulty concentrating;
    d. Irritability;
    e. Muscle tension; or
    f. Sleep disturbance.
    2. Panic disorder or agoraphobia, characterized by one or both:
    a. Panic attacks followed by a persistent concern or worry about 
additional panic attacks or their consequences; or
    b. Disproportionate fear or anxiety about at least two different 
situations (for example, using public transportation, being in a 
crowd, being in a line, being outside of your home, being in open 
spaces).
    3. Obsessive-compulsive disorder, characterized by one or both:
    a. Involuntary, time-consuming preoccupation with intrusive, 
unwanted thoughts; or
    b. Repetitive behaviors aimed at reducing anxiety.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 12.00G2c).
    12.07 Somatic symptom and related disorders (see 12.00B6), 
satisfied by A and B:
    A. Medical documentation of one or more of the following:

[[Page 66168]]

    1. Symptoms of altered voluntary motor or sensory function that 
are not better explained by another medical or mental disorder;
    2. One or more somatic symptoms that are distressing, with 
excessive thoughts, feelings, or behaviors related to the symptoms; 
or
    3. Preoccupation with having or acquiring a serious illness 
without significant symptoms present.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).
    12.08 Personality and impulse-control disorders (see 12.00B7), 
satisfied by A and B:
    A. Medical documentation of a pervasive pattern of one or more 
of the following:
    1. Distrust and suspiciousness of others;
    2. Detachment from social relationships;
    3. Disregard for and violation of the rights of others;
    4. Instability of interpersonal relationships;
    5. Excessive emotionality and attention seeking;
    6. Feelings of inadequacy;
    7. Excessive need to be taken care of;
    8. Preoccupation with perfectionism and orderliness; or
    9. Recurrent, impulsive, aggressive behavioral outbursts.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).
    12.09 [Reserved]
    12.10 Autism spectrum disorder (see 12.00B8), satisfied by A and 
B:
    A. Medical documentation of both of the following:
    1. Qualitative deficits in verbal communication, nonverbal 
communication, and social interaction; and
    2. Significantly restricted, repetitive patterns of behavior, 
interests, or activities.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).
    12.11 Neurodevelopmental disorders (see 12.00B9), satisfied by A 
and B:
    A. Medical documentation of the requirements of paragraph 1, 2, 
or 3:
    1. One or both of the following:
    a. Frequent distractibility, difficulty sustaining attention, 
and difficulty organizing tasks; or
    b. Hyperactive and impulsive behavior (for example, difficulty 
remaining seated, talking excessively, difficulty waiting, appearing 
restless, or behaving as if being ``driven by a motor'').
    2. Significant difficulties learning and using academic skills; 
or
    3. Recurrent motor movement or vocalization.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).
    12.12 [Reserved]
    12.13 Eating disorders (see 12.00B10), satisfied by A and B:
    A. Medical documentation of a persistent alteration in eating or 
eating-related behavior that results in a change in consumption or 
absorption of food and that significantly impairs physical or 
psychological health.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).
    12.15 Trauma- and stressor-related disorders (see 12.00B11), 
satisfied by A and B, or A and C:
    A. Medical documentation of all of the following:
    1. Exposure to actual or threatened death, serious injury, or 
violence;
    2. Subsequent involuntary re-experiencing of the traumatic event 
(for example, intrusive memories, dreams, or flashbacks);
    3. Avoidance of external reminders of the event;
    4. Disturbance in mood and behavior; and
    5. Increases in arousal and reactivity (for example, exaggerated 
startle response, sleep disturbance).

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 12.00F):
    1. Understand, remember, or apply information (see 12.00E1).
    2. Interact with others (see 12.00E2).
    3. Concentrate, persist, or maintain pace (see 12.00E3).
    4. Adapt or manage oneself (see 12.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 12.00G2c).
* * * * *

Part B

* * * * *

112.00 Mental Disorders

    A. How are the listings for mental disorders for children 
arranged, and what do they require?
    1. The listings for mental disorders for children are arranged 
in 12 categories: neurocognitive disorders (112.02); schizophrenia 
spectrum and other psychotic disorders (112.03); depressive, bipolar 
and related disorders (112.04); intellectual disorder (112.05); 
anxiety and obsessive-compulsive disorders (112.06); somatic symptom 
and related disorders (112.07); personality and impulse-control 
disorders (112.08); autism spectrum disorder (112.10); 
neurodevelopmental disorders (112.11); eating disorders (112.13); 
developmental disorders in infants and toddlers (112.14); and 
trauma- and stressor-related disorders (112.15). All of these 
listings, with the exception of 112.14, apply to children from age 
three to attainment of age 18. Listing 112.14 is for children from 
birth to attainment of age 3.
    2. Listings 112.07, 112.08, 112.10, 112.11, 112.13, and 112.14 
have two paragraphs, designated A and B; your mental disorder must 
satisfy the requirements of both paragraphs A and B. Listings 
112.02, 112.03, 112.04, 112.06, and 112.15 have three paragraphs, 
designated A, B, and C; your mental disorder must satisfy the 
requirements of both paragraphs A and B, or the requirements of both 
paragraphs A and C. Listing 112.05 has two paragraphs that are 
unique to that listing (see 112.00A3); your mental disorder must 
satisfy the requirements of either paragraph A or paragraph B.
    a. Paragraph A of each listing (except 112.05) includes the 
medical criteria that must be present in your medical evidence.
    b. Paragraph B of each listing (except 112.05) provides the 
functional criteria we assess to evaluate how your mental disorder 
limits your functioning. For children ages 3 to 18, these criteria 
represent the areas of mental functioning a child uses to perform 
age-appropriate activities. They are: understand, remember, or apply 
information; interact with others; concentrate, persist, or maintain 
pace; and adapt or manage oneself. (See 112.00I for a discussion of 
the criteria for children from birth to attainment of age 3 under 
112.14.) We will determine the degree to which your medically 
determinable mental impairment affects the four areas of mental 
functioning and your ability to function age-appropriately in a 
manner comparable to that of other children your age who do not have 
impairments. (Hereinafter, the words ``age-appropriately'' 
incorporate the qualifying statement, ``in a manner comparable to 
that of other children your age who do not have impairments.'') To 
satisfy the paragraph B criteria, your mental disorder must result 
in ``extreme'' limitation

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of one, or ``marked'' limitation of two, of the four areas of mental 
functioning. (When we refer to ``paragraph B criteria'' or ``area[s] 
of mental functioning'' in the introductory text of this body 
system, we mean the criteria in paragraph B of every listing except 
112.05 and 112.14.)
    c. Paragraph C of listings 112.02, 112.03, 112.04, 112.06, and 
112.15 provides the criteria we use to evaluate ``serious and 
persistent mental disorders.'' To satisfy the paragraph C criteria, 
your mental disorder must be ``serious and persistent''; that is, 
there must be a medically documented history of the existence of the 
disorder over a period of at least 2 years, and evidence that 
satisfies the criteria in both C1 and C2 (see 112.00G). (When we 
refer to ``paragraph C'' or ``the paragraph C criteria'' in the 
introductory text of this body system, we mean the criteria in 
paragraph C of listings 112.02, 112.03, 112.04, 112.06, and 112.15.)
    3. Listing 112.05 has two paragraphs, designated A and B, that 
apply to only intellectual disorder. Each paragraph requires that 
you have significantly subaverage general intellectual functioning 
and significant deficits in current adaptive functioning.
    B. Which mental disorders do we evaluate under each listing 
category for children?
    1. Neurocognitive disorders (112.02).
    a. These disorders are characterized in children by a clinically 
significant deviation in normal cognitive development or by a 
decline in cognitive functioning. Symptoms and signs may include, 
but are not limited to, disturbances in memory, executive 
functioning (that is, higher-level cognitive processes; for example, 
regulating attention, planning, inhibiting responses, decision-
making), visual-spatial functioning, language and speech, 
perception, insight, and judgment.
    b. Examples of disorders that we evaluate in this category 
include major neurocognitive disorder; mental impairments resulting 
from medical conditions such as a metabolic disease (for example, 
juvenile Tay-Sachs disease), human immunodeficiency virus infection, 
vascular malformation, progressive brain tumor, or traumatic brain 
injury; or substance-induced cognitive disorder associated with 
drugs of abuse, medications, or toxins. (We evaluate neurological 
disorders under that body system (see 111.00). We evaluate cognitive 
impairments that result from neurological disorders under 112.02 if 
they do not satisfy the requirements in 111.00. We evaluate 
catastrophic genetic disorders under listings in 110.00, 111.00, or 
112.00, as appropriate. We evaluate genetic disorders that are not 
catastrophic under the affected body system(s).)
    c. This category does not include the mental disorders that we 
evaluate under intellectual disorder (112.05), autism spectrum 
disorder (112.10), and neurodevelopmental disorders (112.11).
    2. Schizophrenia spectrum and other psychotic disorders 
(112.03).
    a. These disorders are characterized by delusions, 
hallucinations, disorganized speech, or grossly disorganized or 
catatonic behavior, causing a clinically significant decline in 
functioning. Symptoms and signs may include, but are not limited to, 
inability to initiate and persist in goal-directed activities, 
social withdrawal, flat or inappropriate affect, poverty of thought 
and speech, loss of interest or pleasure, disturbances of mood, odd 
beliefs and mannerisms, and paranoia.
    b. Examples of disorders that we evaluate in this category 
include schizophrenia, schizoaffective disorder, delusional 
disorder, and psychotic disorder due to another medical condition.
    3. Depressive, bipolar and related disorders (112.04).
    a. These disorders are characterized by an irritable, depressed, 
elevated, or expansive mood, or by a loss of interest or pleasure in 
all or almost all activities, causing a clinically significant 
decline in functioning. Symptoms and signs may include, but are not 
limited to, feelings of hopelessness or guilt, suicidal ideation, a 
clinically significant change in body weight or appetite, sleep 
disturbances, an increase or decrease in energy, psychomotor 
abnormalities, disturbed concentration, pressured speech, 
grandiosity, reduced impulse control, sadness, euphoria, and social 
withdrawal. Depending on a child's age and developmental stage, 
certain features, such as somatic complaints, irritability, anger, 
aggression, and social withdrawal may be more commonly present than 
other features.
    b. Examples of disorders that we evaluate in this category 
include bipolar disorders (I or II), cyclothymic disorder, 
disruptive mood dysregulation disorder, major depressive disorder, 
persistent depressive disorder (dysthymia), and bipolar or 
depressive disorder due to another medical condition.
    4. Intellectual disorder (112.05).
    a. This disorder is characterized by significantly subaverage 
general intellectual functioning and significant deficits in current 
adaptive functioning. Signs may include, but are not limited to, 
poor conceptual, social, or practical skills evident in your 
adaptive functioning.
    b. The disorder that we evaluate in this category may be 
described in the evidence as intellectual disability, intellectual 
developmental disorder, or historically used terms such as ``mental 
retardation.''
    c. This category does not include the mental disorders that we 
evaluate under neurocognitive disorders (112.02), autism spectrum 
disorder (112.10), or neurodevelopmental disorders (112.11).
    5. Anxiety and obsessive-compulsive disorders (112.06).
    a. These disorders are characterized by excessive anxiety, 
worry, apprehension, and fear, or by avoidance of feelings, 
thoughts, activities, objects, places, or people. Symptoms and signs 
may include, but are not limited to, restlessness, difficulty 
concentrating, hyper-vigilance, muscle tension, sleep disturbance, 
fatigue, panic attacks, obsessions and compulsions, constant 
thoughts and fears about safety, and frequent physical complaints. 
Depending on a child's age and developmental stage, other features 
may also include refusal to go to school, academic failure, frequent 
stomachaches and other physical complaints, extreme worries about 
sleeping away from home, being overly clinging, and exhibiting 
tantrums at times of separation from caregivers.
    b. Examples of disorders that we evaluate in this category 
include separation anxiety disorder, social anxiety disorder, panic 
disorder, generalized anxiety disorder, agoraphobia, and obsessive-
compulsive disorder.
    c. This category does not include the mental disorders that we 
evaluate under trauma- and stressor-related disorders (112.15).
    6. Somatic symptom and related disorders (112.07).
    a. These disorders are characterized by physical symptoms or 
deficits that are not intentionally produced or feigned, and that, 
following clinical investigation, cannot be fully explained by a 
general medical condition, another mental disorder, the direct 
effects of a substance, or a culturally sanctioned behavior or 
experience. Symptoms and signs may include, but are not limited to, 
pain and other abnormalities of sensation, gastrointestinal 
symptoms, fatigue, abnormal motor movement, pseudoseizures, and 
pseudoneurological symptoms, such as blindness or deafness.
    b. Examples of disorders that we evaluate in this category 
include somatic symptom disorder and conversion disorder.
    7. Personality and impulse-control disorders (112.08).
    a. These disorders are characterized by enduring, inflexible, 
maladaptive, and pervasive patterns of behavior. Onset may occur in 
childhood but more typically occurs in adolescence or young 
adulthood. Symptoms and signs may include, but are not limited to, 
patterns of distrust, suspiciousness, and odd beliefs; social 
detachment, discomfort, or avoidance; hypersensitivity to negative 
evaluation; an excessive need to be taken care of; difficulty making 
independent decisions; a preoccupation with orderliness, 
perfectionism, and control; and inappropriate, intense, impulsive 
anger and behavioral expression grossly out of proportion to any 
external provocation or psychosocial stressors.
    b. Examples of disorders that we evaluate in this category 
include paranoid, schizoid, schizotypal, borderline, avoidant, 
dependent, obsessive-compulsive personality disorders, and 
intermittent explosive disorder.
    8. Autism spectrum disorder (112.10).
    a. These disorders are characterized by qualitative deficits in 
the development of reciprocal social interaction, verbal and 
nonverbal communication skills, and symbolic or imaginative play; 
restricted repetitive and stereotyped patterns of behavior, 
interests, and activities; and stagnation of development or loss of 
acquired skills. Symptoms and signs may include, but are not limited 
to, abnormalities and unevenness in the development of cognitive 
skills; unusual responses to sensory stimuli; and behavioral 
difficulties, including hyperactivity, short attention span, 
impulsivity, aggressiveness, or self-injurious actions.
    b. Examples of disorders that we evaluate in this category 
include autism spectrum

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disorder with or without accompanying intellectual impairment, and 
autism spectrum disorder with or without accompanying language 
impairment.
    c. This category does not include the mental disorders that we 
evaluate under neurocognitive disorders (112.02), intellectual 
disorder (112.05), and neurodevelopmental disorders (112.11).
    9. Neurodevelopmental disorders (112.11).
    a. These disorders are characterized by onset during the 
developmental period, that is, during childhood or adolescence, 
although sometimes they are not diagnosed until adulthood. Symptoms 
and signs may include, but are not limited to, underlying 
abnormalities in cognitive processing (for example, deficits in 
learning and applying verbal or nonverbal information, visual 
perception, memory, or a combination of these); deficits in 
attention or impulse control; low frustration tolerance; excessive 
or poorly planned motor activity; difficulty with organizing (time, 
space, materials, or tasks); repeated accidental injury; and 
deficits in social skills. Symptoms and signs specific to tic 
disorders include sudden, rapid, recurrent, non-rhythmic, motor 
movement or vocalization.
    b. Examples of disorders that we evaluate in this category 
include specific learning disorder, borderline intellectual 
functioning, and tic disorders (such as Tourette syndrome).
    c. This category does not include the mental disorders that we 
evaluate under neurocognitive disorders (112.02), autism spectrum 
disorder (112.10), or personality and impulse-control disorders 
(112.08).
    10. Eating disorders (112.13).
    a. These disorders are characterized in young children by 
persistent eating of nonnutritive substances or repeated episodes of 
regurgitation and re-chewing of food, or by persistent failure to 
consume adequate nutrition by mouth. In adolescence, these disorders 
are characterized by disturbances in eating behavior and 
preoccupation with, and excessive self-evaluation of, body weight 
and shape. Symptoms and signs may include, but are not limited to, 
failure to make expected weight gains; restriction of energy 
consumption when compared with individual requirements; recurrent 
episodes of binge eating or behavior intended to prevent weight 
gain, such as self-induced vomiting, excessive exercise, or misuse 
of laxatives; mood disturbances, social withdrawal, or irritability; 
amenorrhea; dental problems; abnormal laboratory findings; and 
cardiac abnormalities.
    b. Examples of disorders that we evaluate in this category 
include anorexia nervosa, bulimia nervosa, binge-eating disorder, 
and avoidant/restrictive food disorder.
    11. Developmental disorders in infants and toddlers (112.14).
    a. Developmental disorders are characterized by a delay or 
deficit in the development of age-appropriate skills, or a loss of 
previously acquired skills, involving motor planning and control, 
learning, relating and communicating, and self-regulating.
    b. Examples of disorders that we evaluate in this category 
include developmental coordination disorder, separation anxiety 
disorder, autism spectrum disorder, and regulation disorders of 
sensory processing (difficulties in regulating emotions, behaviors, 
and motor abilities in response to sensory stimulation). Some 
infants and toddlers may have only a general diagnosis of 
``developmental delay.''
    c. This category does not include eating disorders related to 
low birth weight and failure to thrive, which we evaluate under that 
body system (100.00).
    12. Trauma- and stressor-related disorders (112.15).
    a. These disorders are characterized by experiencing or 
witnessing a traumatic or stressful event, or learning of a 
traumatic event occurring to a close family member or close friend, 
and the psychological aftermath of clinically significant effects on 
functioning. Symptoms and signs may include, but are not limited to, 
distressing memories, dreams, and flashbacks related to the trauma 
or stressor; avoidant or withdrawn behavior; constriction of play 
and significant activities; increased frequency of negative 
emotional states (for example, fear, sadness) or reduced expression 
of positive emotions (for example, satisfaction, affection); 
anxiety; irritability; aggression; exaggerated startle response; 
difficulty concentrating; sleep disturbance; and a loss of 
previously acquired developmental skills.
    b. Examples of disorders that we evaluate in this category 
include posttraumatic stress disorder, reactive attachment disorder, 
and other specified trauma- and stressor-related disorders (such as 
adjustment-like disorders with prolonged duration without prolonged 
duration of stressor).
    c. This category does not include the mental disorders that we 
evaluate under anxiety and obsessive-compulsive disorders (112.06), 
and cognitive impairments that result from neurological disorders, 
such as a traumatic brain injury, which we evaluate under 
neurocognitive disorders (112.02).
    C. What evidence do we need to evaluate your mental disorder?
    1. General. We need evidence from an acceptable medical source 
to establish that you have a medically determinable mental disorder. 
We also need evidence to assess the severity of your mental disorder 
and its effects on your ability to function age-appropriately. We 
will determine the extent and kinds of evidence we need from medical 
and non-medical sources based on the individual facts about your 
disorder. For additional evidence requirements for intellectual 
disorder (112.05), see 112.00H. For our basic rules on evidence, see 
Sec. Sec.  416.912, 416.913, and 416.920b of this chapter. For our 
rules on evaluating opinion evidence, see Sec.  416.927 of this 
chapter. For our rules on evidence about your symptoms, see Sec.  
416.929 of this chapter.
    2. Evidence from medical sources. We will consider all relevant 
medical evidence about your disorder from your physician, 
psychologist, and other medical sources, which include health care 
providers such as physician assistants, psychiatric nurse 
practitioners, licensed clinical social workers, and clinical mental 
health counselors. Evidence from your medical sources may include:
    a. Your reported symptoms.
    b. Your developmental, medical, psychiatric, and psychological 
history.
    c. The results of physical or mental status examinations, 
structured clinical interviews, psychiatric or psychological rating 
scales, measures of adaptive functioning, or other clinical 
findings.
    d. Developmental assessments, psychological testing, imaging 
results, or other laboratory findings.
    e. Your diagnosis.
    f. The type, dosage, and beneficial effects of medications you 
take.
    g. The type, frequency, duration, and beneficial effects of 
therapy you receive.
    h. Side effects of medication or other treatment that limit your 
ability to function.
    i. Your clinical course, including changes in your medication, 
therapy, or other treatment, and the time required for therapeutic 
effectiveness.
    j. Observations and descriptions of how you function during 
examinations or therapy.
    k. Information about sensory, motor, or speech abnormalities, or 
about your cultural background (for example, language or customs) 
that may affect an evaluation of your mental disorder.
    l. The expected duration of your symptoms and signs and their 
effects on your ability to function age-appropriately, both 
currently and in the future.
    3. Evidence from you and people who know you. We will consider 
all relevant evidence about your mental disorder and your daily 
functioning that we receive from you and from people who know you. 
If you are too young or unable to describe your symptoms and your 
functioning, we will ask for a description from the person who is 
most familiar with you. We will ask about your symptoms, your daily 
functioning, and your medical treatment. We will ask for information 
from third parties who can tell us about your mental disorder, but 
we must have permission to do so. This evidence may include 
information from your family, caregivers, teachers, other educators, 
neighbors, clergy, case managers, social workers, shelter staff, or 
other community support and outreach workers. We will consider 
whether your statements and the statements from third parties are 
consistent with the medical and other evidence we have.
    4. Evidence from early intervention programs, school, vocational 
training, work, and work-related programs.
    a. Early intervention programs. You may receive services in an 
Early Intervention Program (EIP) to help you with your developmental 
needs. If so, we will consider information from your Individualized 
Family Service Plan (IFSP) and the early intervention specialists 
who help you.
    b. School. You may receive special education or related services 
at your preschool or school. If so, we will try to obtain 
information from your school sources when we need it to assess how 
your mental disorder affects your ability to function. Examples of 
this information include your Individualized Education Programs 
(IEPs), your Section 504 plans, comprehensive evaluation reports, 
school-related therapy

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progress notes, information from your teachers about how you 
function in a classroom setting, and information from special 
educators, nurses, school psychologists, and occupational, physical, 
and speech/language therapists about any special education services 
or accommodations you receive at school.
    c. Vocational training, work, and work-related programs. You may 
have recently participated in or may still be participating in 
vocational training, work-related programs, or work activity. If so, 
we will try to obtain information from your training program or your 
employer when we need it to assess how your mental disorder affects 
your ability to function. Examples of this information include 
training or work evaluations, modifications to your work duties or 
work schedule, and any special supports or accommodations you have 
required or now require in order to work. If you have worked or are 
working through a community mental health program, sheltered or 
supported work program, rehabilitation program, or transitional 
employment program, we will consider the type and degree of support 
you have received or are receiving in order to work (see 112.00D).
    5. Need for longitudinal evidence.
    a. General. Longitudinal medical evidence can help us learn how 
you function over time, and help us evaluate any variations in the 
level of your functioning. We will request longitudinal evidence of 
your mental disorder when your medical providers have records 
concerning you and your mental disorder over a period of months or 
perhaps years (see Sec.  416.912(d) of this chapter).
    b. Non-medical sources of longitudinal evidence. Certain 
situations, such as chronic homelessness, may make it difficult for 
you to provide longitudinal medical evidence. If you have a severe 
mental disorder, you will probably have evidence of its effects on 
your functioning over time, even if you have not had an ongoing 
relationship with the medical community or are not currently 
receiving treatment. For example, family members, caregivers, 
teachers, neighbors, former employers, social workers, case 
managers, community support staff, outreach workers, or government 
agencies may be familiar with your mental health history. We will 
ask for information from third parties who can tell us about your 
mental disorder, but you must give us permission to do so.
    c. Absence of longitudinal evidence. In the absence of 
longitudinal evidence, we will use current objective medical 
evidence and all other relevant evidence available to us in your 
case record to evaluate your mental disorder. If we purchase a 
consultative examination to document your disorder, the record will 
include the results of that examination (see Sec.  416.914 of this 
chapter). We will take into consideration your medical history, 
symptoms, clinical and laboratory findings, and medical source 
opinions. If you do not have longitudinal evidence, the current 
evidence alone may not be sufficient or appropriate to show that you 
have a disorder that meets the criteria of one of the mental 
disorders listings. In that case, we will follow the rules in 
112.00K.
    6. Evidence of functioning in unfamiliar situations or 
supportive situations.
    a. Unfamiliar situations. We recognize that evidence about your 
functioning in unfamiliar situations does not necessarily show how 
you would function on a sustained basis in a school or other age-
appropriate setting. In one-time, time-limited, or other unfamiliar 
situations, you may function differently than you do in familiar 
situations. In unfamiliar situations, you may appear more, or less, 
limited than you do on a daily basis and over time.
    b. Supportive situations. Your ability to function in settings 
that are highly structured, or that are less demanding or more 
supportive than settings in which children your age without 
impairments typically function, does not necessarily demonstrate 
your ability to function age-appropriately.
    c. Our assessment. We must assess your ability to function age-
appropriately by evaluating all the evidence, such as reports about 
your functioning from third parties who are familiar with you, with 
an emphasis on how well you can initiate, sustain, and complete age-
appropriate activities despite your impairment(s), compared to other 
children your age who do not have impairments.
    D. How do we consider psychosocial supports, structured 
settings, living arrangements, and treatment when we evaluate the 
functioning of children?
    1. General. Psychosocial supports, structured settings, and 
living arrangements, including assistance from your family or 
others, may help you by reducing the demands made on you. In 
addition, treatment you receive may reduce your symptoms and signs 
and possibly improve your functioning, or may have side effects that 
limit your functioning. Therefore, when we evaluate the effects of 
your mental disorder and rate the limitation of your areas of mental 
functioning, we will consider the kind and extent of supports you 
receive, the characteristics of any structured setting in which you 
spend your time (compared to children your age without impairments), 
and the effects of any treatment. This evidence may come from 
reports about your functioning from third parties who are familiar 
with you, and other third-party statements or information. Following 
are some examples of the supports you may receive:
    a. You receive help from family members or other people in ways 
that children your age without impairments typically do not need in 
order to function age-appropriately. For example, an aide may 
accompany you on the school bus to help you control your actions or 
to monitor you to ensure you do not injure yourself or others.
    b. You receive one-on-one assistance in your classes every day; 
or you have a full-time personal aide who helps you to function in 
your classroom; or you are a student in a self-contained classroom; 
or you attend a separate or alternative school where you receive 
special education services.
    c. You participate in a special education or vocational training 
program, or a psychosocial rehabilitation day treatment or community 
support program, where you receive training in daily living and 
entry-level work skills.
    d. You participate in a sheltered, supported, or transitional 
work program, or in a competitive employment setting with the help 
of a job coach or supervisor.
    e. You receive comprehensive ``24/7 wrap-around'' mental health 
services while living in a group home or transitional housing, while 
participating in a semi-independent living program, or while living 
at home.
    f. You live in a residential school, hospital, or other 
institution with 24-hour care.
    g. You receive assistance from a crisis response team, social 
workers, or community mental health workers who help you meet your 
physical needs, and who may also represent you in dealings with 
government or community social services.
    2. How we consider different levels of support and structure in 
psychosocial rehabilitation programs.
    a. Psychosocial rehabilitation programs are based on your 
specific needs. Therefore, we cannot make any assumptions about your 
mental disorder based solely on the fact that you are associated 
with such a program. We must know the details of the program(s) in 
which you are involved and the pattern(s) of your involvement over 
time.
    b. The kinds and levels of supports and structures in 
psychosocial rehabilitation programs typically occur on a scale of 
``most restrictive'' to ``least restrictive.'' Participation in a 
psychosocial rehabilitation program at the most restrictive level 
would suggest greater limitation of your areas of mental functioning 
than would participation at a less restrictive level. The length of 
time you spend at different levels in a program also provides 
information about your functioning. For example, you could begin 
participation at the most restrictive crisis intervention level but 
gradually improve to the point of readiness for a lesser level of 
support and structure and, if you are an older adolescent, possibly 
some form of employment.
    3. How we consider the help or support you receive.
    a. We will consider the complete picture of your daily 
functioning, including the kinds, extent, and frequency of help and 
support you receive, when we evaluate your mental disorder and 
determine whether you are able to use the four areas of mental 
functioning age-appropriately. The fact that you have done, or 
currently do, some routine activities without help or support does 
not necessarily mean that you do not have a mental disorder or that 
you are not disabled. For example, you may be able to take age-
appropriate care of your personal needs, or you may be old enough 
and able to cook, shop, and take public transportation. You may 
demonstrate both strengths and deficits in your daily functioning.
    b. You may receive various kinds of help and support from others 
that enable you to do many things that, because of your mental 
disorder, you might not be able to do independently. Your daily 
functioning may depend on the special contexts in which you 
function. For example, you may spend your time among only familiar 
people or surroundings, in a simple and steady routine or an 
unchanging environment, or in a highly structured classroom or 
alternative school.

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However, this does not necessarily show whether you would function 
age-appropriately without those supports or contexts. (See 112.00H 
for further discussion of these issues regarding significant 
deficits in adaptive functioning for the purpose of 112.05.)
    4. How we consider treatment. We will consider the effect of any 
treatment on your functioning when we evaluate your mental disorder. 
Treatment may include medication(s), psychotherapy, or other forms 
of intervention, which you receive in a doctor's office, during a 
hospitalization, or in a day program at a hospital or outpatient 
treatment program. With treatment, you may not only have your 
symptoms and signs reduced, but may also be able to function age-
appropriately. However, treatment may not resolve all of the 
limitations that result from your mental disorder, and the 
medications you take or other treatment you receive for your 
disorder may cause side effects that limit your mental or physical 
functioning. For example, you may experience drowsiness, blunted 
affect, memory loss, or abnormal involuntary movements.
    E. What are the paragraph B criteria for children age 3 to the 
attainment of age 18?
    1. Understand, remember, or apply information (paragraph B1). 
This area of mental functioning refers to the abilities to learn, 
recall, and use information to perform age-appropriate activities. 
Examples include: Understanding and learning terms, instructions, 
procedures; following one- or two-step oral instructions to carry 
out a task; describing an activity to someone else; asking and 
answering questions and providing explanations; recognizing a 
mistake and correcting it; identifying and solving problems; 
sequencing multi-step activities; and using reason and judgment to 
make decisions. These examples illustrate the nature of the area of 
mental functioning. We do not require documentation of all of the 
examples. How you manifest this area of mental functioning and your 
limitations in using it depends, in part, on your age.
    2. Interact with others (paragraph B2). This area of mental 
functioning refers to the abilities to relate to others age-
appropriately at home, at school, and in the community. Examples 
include: Engaging in interactive play; cooperating with others; 
asking for help when needed; initiating and maintaining friendships; 
handling conflicts with others; stating own point of view; 
initiating or sustaining conversation; understanding and responding 
to social cues (physical, verbal, emotional); responding to 
requests, suggestions, criticism, correction, and challenges; and 
keeping social interactions free of excessive irritability, 
sensitivity, argumentativeness, or suspiciousness. These examples 
illustrate the nature of this area of mental functioning. We do not 
require documentation of all of the examples. How you manifest this 
area of mental functioning and your limitations in using it depends, 
in part, on your age.
    3. Concentrate, persist, or maintain pace (paragraph B3). This 
area of mental functioning refers to the abilities to focus 
attention on activities and stay on task age-appropriately. Examples 
include: Initiating and performing an activity that you understand 
and know how to do; engaging in an activity at home or in school at 
an appropriate and consistent pace; completing tasks in a timely 
manner; ignoring or avoiding distractions while engaged in an 
activity or task; changing activities without being disruptive; 
engaging in an activity or task close to or with others without 
interrupting or distracting them; sustaining an ordinary routine and 
regular attendance at school; and engaging in activities at home, 
school, or in the community without needing an unusual amount of 
rest. These examples illustrate the nature of this area of mental 
functioning. We do not require documentation of all of the examples. 
How you manifest this area of mental functioning and your 
limitations in using it depends, in part, on your age.
    4. Adapt or manage oneself (paragraph B4). This area of mental 
functioning refers to the abilities to regulate emotions, control 
behavior, and maintain well-being in age-appropriate activities and 
settings. Examples include: Responding to demands; adapting to 
changes; managing your psychologically based symptoms; 
distinguishing between acceptable and unacceptable performance in 
community- or school-related activities; setting goals; making plans 
independently of others; maintaining personal hygiene; and 
protecting yourself from harm and exploitation by others. These 
examples illustrate the nature of this area of mental functioning. 
We do not require documentation of all of the examples. How you 
manifest this area of mental functioning and your limitations in 
using it depends, in part, on your age.
    F. How do we use the paragraph B criteria to evaluate mental 
disorders in children?
    1. General. We use the paragraph B criteria to rate the degree 
of your limitations. We consider only the limitations that result 
from your mental disorder(s). We will determine whether you are able 
to use each of the paragraph B areas of mental functioning in age-
appropriate activities in a manner comparable to that of other 
children your age who do not have impairments. We will consider, for 
example, the range of your activities and whether they are age-
appropriate; how well you can initiate, sustain, and complete your 
activities; the kinds and frequency of help or supervision you 
receive; and the kinds of structured or supportive settings you need 
in order to function age-appropriately (see 112.00D).
    2. Degrees of limitation. We evaluate the effects of your mental 
disorder on each of the four areas of mental functioning. To satisfy 
the paragraph B criteria, your mental disorder must result in 
extreme limitation of one, or marked limitation of two, paragraph B 
areas of mental functioning. See Sec. Sec.  416.925(b)(2)(ii) and 
416.926a(e) of this chapter for the definitions of the terms marked 
and extreme as they apply to children.
    3. Rating the limitations of your areas of mental functioning.
    a. General. We use all of the relevant medical and non-medical 
evidence in your case record to evaluate your mental disorder: The 
symptoms and signs of your disorder, the reported limitations in 
your activities, and any help and support you receive that is 
necessary for you to function. The medical evidence may include 
descriptors regarding the diagnostic stage or level of your 
disorder, such as ``mild'' or ``moderate.'' Clinicians may use these 
terms to characterize your medical condition. However, these terms 
will not always be the same as the degree of your limitation in a 
paragraph B area of mental functioning.
    b. Areas of mental functioning in daily activities. You use the 
same four areas of mental functioning in daily activities at home, 
at school, and in the community. With respect to a particular task 
or activity, you may have trouble using one or more of the areas. 
For example, you may have difficulty understanding and remembering 
what to do; or concentrating and staying on task long enough to do 
it; or engaging in the task or activity with other people; or trying 
to do the task without becoming frustrated and losing self-control. 
Information about your daily functioning in your activities at home, 
at school, or in your community can help us understand whether your 
mental disorder limits one or more of these areas; and, if so, 
whether it also affects your ability to function age-appropriately.
    c. Overall effect of limitations. Limitation of an area of 
mental functioning reflects the overall degree to which your mental 
disorder interferes with that area. The degree of limitation does 
not necessarily reflect a specific type or number of activities, 
including activities of daily living, that you have difficulty 
doing. In addition, no single piece of information (including test 
results) can establish whether you have extreme or marked limitation 
of an area of mental functioning.
    d. Effects of support, supervision, structure on functioning. 
The degree of limitation of an area of mental functioning also 
reflects the kind and extent of supports or supervision you receive 
(beyond what other children your age without impairments typically 
receive) and the characteristics of any structured setting where you 
spend your time, which enable you to function. The more extensive 
the support you need from others (beyond what is age-appropriate) or 
the more structured the setting you need in order to function, the 
more limited we will find you to be (see 112.00D).
    e. Specific instructions for paragraphs B1, B3, and B4. For 
paragraphs B1, B3, and B4, the greatest degree of limitation of any 
part of the area of mental functioning directs the rating of 
limitation of that whole area of mental functioning.
    (i) To do an age-appropriate activity, you must be able to 
understand and remember and apply information required by the 
activity. Similarly, you must be able to concentrate and persist and 
maintain pace in order to complete the activity, and adapt and 
manage yourself age-appropriately. Limitation in any one of these 
parts (understand or remember or apply; concentrate or persist or 
maintain pace; adapt or manage oneself) may prevent you from 
completing age-appropriate activities.
    (ii) We will document the rating of limitation of the whole area 
of mental

[[Page 66173]]

functioning, not each individual part. We will not add ratings of 
the parts together. For example, with respect to paragraph B3, if 
you have marked limitation in concentrating, but your limitations in 
persisting and maintaining pace do not rise to a marked level, we 
will find that you have marked limitation in the whole paragraph B3 
area of mental functioning.
    (iii) Marked limitation in more than one part of the same 
paragraph B area of mental functioning does not satisfy the 
requirement to have marked limitation in two paragraph B areas of 
mental functioning.
    4. How we evaluate mental disorders involving exacerbations and 
remissions.
    a. When we evaluate the effects of your mental disorder, we will 
consider how often you have exacerbations and remissions, how long 
they last, what causes your mental disorder to worsen or improve, 
and any other relevant information. We will assess whether your 
mental impairment(s) causes marked or extreme limitation of the 
affected paragraph B area(s) of mental functioning (see 112.00F2). 
We will consider whether you can use the area of mental functioning 
age-appropriately on a sustained basis. We will not find that you 
function age-appropriately solely because you have a period(s) of 
improvement (remission), or that you are disabled solely because you 
have a period of worsening (exacerbation), of your mental disorder.
    b. If you have a mental disorder involving exacerbations and 
remissions, you may be able to use the four areas of mental 
functioning at home, at school, or in the community for a few weeks 
or months. Recurrence or worsening of symptoms and signs, however, 
can interfere enough to render you unable to function age-
appropriately.
    G. What are the paragraph C criteria, and how do we use them to 
evaluate mental disorders in children age 3 to the attainment of age 
18?
    1. General. The paragraph C criteria are an alternative to the 
paragraph B criteria under listings 112.02, 112.03, 112.04, 112.06, 
and 112.15. We use the paragraph C criteria to evaluate mental 
disorders that are ``serious and persistent.'' In the paragraph C 
criteria, we recognize that mental health interventions may control 
the more obvious symptoms and signs of your mental disorder.
    2. Paragraph C criteria.
    a. We find a mental disorder to be ``serious and persistent'' 
when there is a medically documented history of the existence of the 
mental disorder in the listing category over a period of at least 2 
years, and evidence shows that your disorder satisfies both C1 and 
C2.
    b. The criterion in C1 is satisfied when the evidence shows that 
you rely, on an ongoing basis, upon medical treatment, mental health 
therapy, psychosocial support(s), or a highly structured setting(s), 
to diminish the symptoms and signs of your mental disorder (see 
112.00D). We consider that you receive ongoing medical treatment 
when the medical evidence establishes that you obtain medical 
treatment with a frequency consistent with accepted medical practice 
for the type of treatment or evaluation required for your medical 
condition. We will consider periods of inconsistent treatment or 
lack of compliance with treatment that may result from your mental 
disorder. If the evidence indicates that the inconsistent treatment 
or lack of compliance is a feature of your mental disorder, and it 
has led to an exacerbation of your symptoms and signs, we will not 
use it as evidence to support a finding that you have not received 
ongoing medical treatment as required by this paragraph.
    c. The criterion in C2 is satisfied when the evidence shows 
that, despite your diminished symptoms and signs, you have achieved 
only marginal adjustment. ``Marginal adjustment'' means that your 
adaptation to the requirements of daily life is fragile; that is, 
you have minimal capacity to adapt to changes in your environment or 
to demands that are not already part of your daily life. We will 
consider that you have achieved only marginal adjustment when the 
evidence shows that changes or increased demands have led to 
exacerbation of your symptoms and signs and to deterioration in your 
functioning; for example, you have become unable to function outside 
of your home or a more restrictive setting, without substantial 
psychosocial supports (see 112.00D). Such deterioration may have 
necessitated a significant change in medication or other treatment. 
Similarly, because of the nature of your mental disorder, evidence 
may document episodes of deterioration that have required you to be 
hospitalized or absent from school, making it difficult for you to 
sustain age-appropriate activity over time.
    H. How do we document and evaluate intellectual disorder under 
112.05?
    1. General. Listing 112.05 is based on the two elements that 
characterize intellectual disorder for children up to age 18: 
Significantly subaverage general intellectual functioning and 
significant deficits in current adaptive functioning.
    2. Establishing significantly subaverage general intellectual 
functioning.
    a. Definition. Intellectual functioning refers to the general 
mental capacity to learn, reason, plan, solve problems, and perform 
other cognitive functions. Under 112.05A, we identify significantly 
subaverage general intellectual functioning by the cognitive 
inability to function at a level required to participate in 
standardized intelligence testing. Our findings under 112.05A are 
based on evidence from an acceptable medical source. Under 112.05B, 
we identify significantly subaverage general intellectual 
functioning by an IQ score(s) on an individually administered 
standardized test of general intelligence that meets program 
requirements and has a mean of 100 and a standard deviation of 15. A 
qualified specialist (see 112.00H2c) must administer the 
standardized intelligence testing.
    b. Psychometric standards. We will find standardized 
intelligence test results usable for the purposes of 112.05B1 when 
the measure employed meets contemporary psychometric standards for 
validity, reliability, normative data, and scope of measurement; and 
a qualified specialist has individually administered the test 
according to all pre-requisite testing conditions.
    c. Qualified specialist. A ``qualified specialist'' is currently 
licensed or certified at the independent level of practice in the 
State where the test was performed, and has the training and 
experience to administer, score, and interpret intelligence tests. 
If a psychological assistant or paraprofessional administered the 
test, a supervisory qualified specialist must interpret the test 
findings and co-sign the examination report.
    d. Responsibility for conclusions based on testing. We generally 
presume that your obtained IQ score(s) is an accurate reflection of 
your general intellectual functioning, unless evidence in the record 
suggests otherwise. Examples of this evidence include: A statement 
from the test administrator indicating that your obtained score is 
not an accurate reflection of your general intellectual functioning, 
prior or internally inconsistent IQ scores, or information about 
your daily functioning. Only qualified specialists, Federal and 
State agency medical and psychological consultants, and other 
contracted medical and psychological experts may conclude that your 
obtained IQ score(s) is not an accurate reflection of your general 
intellectual functioning. This conclusion must be well supported by 
appropriate clinical and laboratory diagnostic techniques and must 
be based on relevant evidence in the case record, such as:
    (i) The data obtained in testing;
    (ii) Your developmental history, including when your signs and 
symptoms began;
    (iii) Information about how you function on a daily basis in a 
variety of settings; and
    (iv) Clinical observations made during the testing period, such 
as your ability to sustain attention, concentration, and effort; to 
relate appropriately to the examiner; and to perform tasks 
independently without prompts or reminders.
    3. Establishing significant deficits in adaptive functioning.
    a. Definition. Adaptive functioning refers to how you learn and 
use conceptual, social, and practical skills in dealing with common 
life demands. It is your typical functioning at home, at school, and 
in the community, alone or among others. Under 112.05A, we identify 
significant deficits in adaptive functioning based on your 
dependence on others to care for your personal needs, such as eating 
and bathing (grossly in excess of age-appropriate dependence). We 
will base our conclusions about your adaptive functioning on 
evidence from a variety of sources (see 112.00H3b) and not on your 
statements alone. Under 112.05B2, we identify significant deficits 
in adaptive functioning based on whether there is extreme limitation 
of one, or marked limitation of two, of the paragraph B criteria 
(see 112.00E; 112.00F).
    b. Evidence. Evidence about your adaptive functioning may come 
from:
    (i) Medical sources, including their clinical observations;
    (ii) Standardized tests of adaptive functioning (see 112.00H3c);
    (iii) Third party information, such as a report of your 
functioning from a family member or your caregiver;
    (iv) School records;

[[Page 66174]]

    (v) A teacher questionnaire;
    (vi) Reports from employers or supervisors; and
    (vii) Your own statements about how you handle all of your daily 
activities.
    c. Standardized tests of adaptive functioning. We do not require 
the results of an individually administered standardized test of 
adaptive functioning. If your case record includes these test 
results, we will consider the results along with all other relevant 
evidence; however, we will use the guidelines in 112.00E and F to 
evaluate and determine the degree of your deficits in adaptive 
functioning, as required under 112.05B2.
    d. Standardized developmental assessments. We do not require the 
results of standardized developmental assessments, which compare 
your level of development to the level typically expected for your 
chronological age. If your case record includes test results, we 
will consider the results along with all other relevant evidence. 
However, we will use the guidelines in 112.00E and F to evaluate and 
determine the degree of your deficits in adaptive functioning, as 
required under 112.05B2.
    e. How we consider common everyday activities.
    (i) The fact that you engage in common everyday activities, such 
as caring for your personal needs, preparing simple meals, or 
driving a car, will not always mean that you do not have deficits in 
adaptive functioning as required by 112.05B2. You may demonstrate 
both strengths and deficits in your adaptive functioning. However, a 
lack of deficits in one area does not negate the presence of 
deficits in another area. When we assess your adaptive functioning, 
we will consider all of your activities and your performance of 
them.
    (ii) Our conclusions about your adaptive functioning rest on the 
quality of your daily activities and whether you do them age-
appropriately. If you receive help in performing your activities, we 
need to know the kind, extent, and frequency of help you receive in 
order to perform them. We will not assume that your ability to do 
some common everyday activities, or to do some things without help 
or support, demonstrates that your mental disorder does not meet the 
requirements of 112.05B2. (See 112.00D regarding the factors we 
consider when we evaluate your functioning, including how we 
consider any help or support you receive.)
    f. How we consider work activity. The fact that you have engaged 
in work activity, or that you work intermittently or steadily in a 
job commensurate with your abilities, will not always mean that you 
do not have deficits in adaptive functioning as required by 
112.05B2. When you have engaged in work activity, we need complete 
information about the work, and about your functioning in the work 
activity and work setting, before we reach any conclusions about 
your adaptive functioning. We will consider all factors involved in 
your work history before concluding whether your impairment 
satisfies the criteria for intellectual disorder under 112.05B. We 
will consider your prior and current work history, if any, and 
various other factors influencing how you function. For example, we 
consider whether the work was in a supported setting, whether you 
required more supervision than other employees, how your job duties 
compared to others in the same job, how much time it took you to 
learn the job duties, and the reason the work ended, if applicable.
    I. What additional considerations do we use to evaluate 
developmental disorders of infants and toddlers?
    1. General. We evaluate developmental disorders from birth to 
attainment of age 3 under 112.14. We evaluate your ability to 
acquire and maintain the motor, cognitive, social/communicative, and 
emotional skills that you need to function age-appropriately. When 
we rate your impairment-related limitations for this listing (see 
Sec. Sec.  416.925(b)(2)(ii) and 416.926a(e) of this chapter), we 
consider only limitations you have because of your developmental 
disorder. If you have a chronic illness or physical 
abnormality(ies), we will evaluate it under the affected body 
system, for example, the cardiovascular or musculoskeletal system.
    2. Age and typical development in early childhood.
    a. Prematurity and age. If you were born prematurely, we will 
use your corrected chronological age (CCA) for comparison. CCA is 
your chronological age adjusted by a period of gestational 
prematurity. CCA = (chronological age)-(number of weeks premature). 
If you have not attained age 1, we will correct your chronological 
age, using the same formula. If you are over age 1, we will decide 
whether to correct your chronological age, based on our judgment and 
all the facts of your case (see Sec.  416.924b(b) of this chapter).
    b. Developmental assessment. We will use the results from a 
standardized developmental assessment to compare your level of 
development with that typically expected for your chronological age. 
When there are no results from a comprehensive standardized 
developmental assessment in the case record, we need narrative 
developmental reports from your medical sources in sufficient detail 
to assess the limitations resulting from your developmental 
disorder.
    c. Variation. When we evaluate your developmental disorder, we 
will consider the wide variation in the range of normal or typical 
development in early childhood. At the end of a recognized milestone 
period, new skills typically begin to emerge. If your new skills 
begin to emerge later than is typically expected, the timing of 
their emergence may or may not indicate that you have a 
developmental delay or deficit that can be expected to last for 1 
year.
    3. Evidence.
    a. Standardized developmental assessments. We use standardized 
test reports from acceptable medical sources or from early 
intervention specialists, physical or occupational therapists, and 
other qualified professionals. Only the qualified professional who 
administers the test, Federal and State agency medical and 
psychological consultants, and other contracted medical and 
psychological experts may conclude that the assessment results are 
not an accurate reflection of your development. This conclusion must 
be well supported by appropriate clinical and laboratory diagnostic 
techniques and must be based on relevant evidence in the case 
record. If the assessment results are not an accurate reflection of 
your development, we may purchase a new developmental assessment. If 
the developmental assessment is inconsistent with other information 
in your case record, we will follow the guidelines in Sec.  416.920b 
of this chapter.
    b. Narrative developmental reports. A narrative developmental 
report is based on clinical observations, progress notes, and well-
baby check-ups, and includes your developmental history, examination 
findings (with abnormal findings noted on repeated examinations), 
and an overall assessment of your development (that is, more than 
one or two isolated skills) by the medical source. Although medical 
sources may refer to screening test results as supporting evidence 
in the narrative developmental report, screening test results alone 
cannot establish a diagnosis or the severity of developmental 
disorder.
    4. What are the paragraph B criteria for 112.14?
    a. General. The paragraph B criteria for 112.14 are slightly 
different from the paragraph B criteria for the other listings. They 
are the developmental abilities that infants and toddlers use to 
acquire and maintain the skills needed to function age-
appropriately. An infant or toddler is expected to use his or her 
developmental abilities to achieve a recognized pattern of 
milestones, over a typical range of time, in order to acquire and 
maintain the skills needed to function age-appropriately. We will 
find that your developmental disorder satisfies the requirements of 
112.14 if it results in extreme limitation of one, or marked 
limitation of two, of the 112.14 paragraph B criteria. (See 
Sec. Sec.  416.925(b)(2)(ii) and 416.926a(e) of this chapter for the 
definitions of the terms marked and extreme as they apply to 
children.)
    b. Definitions of the 112.14 paragraph B developmental 
abilities.
    (i) Ability to plan and control motor movement. This criterion 
refers to the developmental ability to plan, remember, and execute 
controlled motor movements by integrating and coordinating 
perceptual and sensory input with motor output. Using this ability 
develops gross and fine motor skills, and makes it possible for you 
to engage in age-appropriate symmetrical or alternating motor 
activities. You use this ability when, for example, you grasp and 
hold objects with one or both hands, pull yourself up to stand, walk 
without holding on, and go up and down stairs with alternating feet. 
These examples illustrate the nature of the developmental ability. 
We do not require documentation of all of the examples. How you 
manifest this developmental ability and your limitations in using it 
depends, in part, on your age.
    (ii) Ability to learn and remember. This criterion refers to the 
developmental ability to learn by exploring the environment, 
engaging in trial-and-error experimentation, putting things in 
groups, understanding that

[[Page 66175]]

words represent things, and participating in pretend play. Using 
this ability develops the skills that help you understand what 
things mean, how things work, and how you can make things happen. 
You use this ability when, for example, you show interest in objects 
that are new to you, imitate simple actions, name body parts, 
understand simple cause-and-effect relationships, remember simple 
directions, or figure out how to take something apart. These 
examples illustrate the nature of the developmental ability. We do 
not require documentation of all of the examples. How you manifest 
this developmental ability and your limitations in using it depends, 
in part, on your age.
    (iii) Ability to interact with others. This criterion refers to 
the developmental ability to participate in reciprocal social 
interactions and relationships by communicating your feelings and 
intents through vocal and visual signals and exchanges; physical 
gestures and contact; shared attention and affection; verbal turn 
taking; and understanding and sending increasingly complex messages. 
Using this ability develops the social skills that make it possible 
for you to influence others (for example, by gesturing for a toy or 
saying ``no'' to stop an action); invite someone to interact with 
you (for example, by smiling or reaching); and draw someone's 
attention to what interests you (for example, by pointing or taking 
your caregiver's hand and leading that person). You use this ability 
when, for example, you use vocalizations to initiate and sustain a 
``conversation'' with your caregiver; respond to limits set by an 
adult with words, gestures, or facial expressions; play alongside 
another child; or participate in simple group activities with adult 
help. These examples illustrate the nature of the developmental 
ability. We do not require documentation of all of the examples. How 
you manifest this developmental ability and your limitations in 
using it depends, in part, on your age.
    (iv) Ability to regulate physiological functions, attention, 
emotion, and behavior. This criterion refers to the developmental 
ability to stabilize biological rhythms (for example, by developing 
an age-appropriate sleep/wake cycle); control physiological 
functions (for example, by achieving regular patterns of feeding); 
and attend, react, and adapt to environmental stimuli, persons, 
objects, and events (for example, by becoming alert to things 
happening around you and in relation to you, and responding without 
overreacting or underreacting). Using this ability develops the 
skills you need to regulate yourself and makes it possible for you 
to achieve and maintain a calm, alert, and organized physical and 
emotional state. You use this ability when, for example, you 
recognize your body's needs for food or sleep, focus quickly and pay 
attention to things that interest you, cry when you are hurt but 
become quiet when your caregiver holds you, comfort yourself with 
your favorite toy when you are upset, ask for help when something 
frustrates you, or refuse help from your caregiver when trying to do 
something for yourself. These examples illustrate the nature of the 
developmental ability. We do not require documentation of all of the 
examples. How you manifest this developmental ability and your 
limitations in using it depends, in part, on your age.
    5. Deferral of determination.
    a. Full-term infants. In the first few months of life, full-term 
infants typically display some irregularities in observable 
behaviors (for example, sleep cycles, feeding, responding to 
stimuli, attending to faces, self-calming), making it difficult to 
assess the presence, extent, and duration of a developmental 
disorder. When the evidence indicates that you may have a 
significant developmental delay, but there is insufficient evidence 
to make a determination, we will defer making a disability 
determination under 112.14 until you are at least 6 months old. This 
deferral will allow us to obtain a longitudinal medical history so 
that we can more accurately evaluate your developmental patterns and 
functioning over time. In most cases, when you are at least 6 months 
old, any developmental delay you may have can be better assessed, 
and you can undergo standardized developmental testing, if 
indicated.
    b. Premature infants. When the evidence indicates that you may 
have a significant developmental delay, but there is insufficient 
evidence to make a determination, we will defer your case until you 
attain a CCA (see 112.00I2a) of at least 6 months in order to better 
evaluate your developmental delay.
    c. When we will not defer a determination. We will not defer our 
determination if we have sufficient evidence to determine that you 
are disabled under 112.14 or any other listing, or that you have an 
impairment or combination of impairments that functionally equals 
the listings. In addition, we will not defer our determination if 
the evidence demonstrates that you are not disabled.
    J. How do we evaluate substance use disorders? If we find that 
you are disabled and there is medical evidence in your case record 
establishing that you have a substance use disorder, we will 
determine whether your substance use disorder is a contributing 
factor material to the determination of disability (see Sec.  
416.935 of this chapter).
    K. How do we evaluate mental disorders that do not meet one of 
the mental disorders listings?
    1. These listings include only examples of mental disorders that 
we consider serious enough to result in marked and severe functional 
limitations. If your severe mental disorder does not meet the 
criteria of any of these listings, we will consider whether you have 
an impairment(s) that meets the criteria of a listing in another 
body system. You may have another impairment(s) that is secondary to 
your mental disorder. For example, if you have an eating disorder 
and develop a cardiovascular impairment because of it, we will 
evaluate your cardiovascular impairment under the listings for the 
cardiovascular body system.
    2. If you have a severe medically determinable impairment(s) 
that does not meet a listing, we will determine whether your 
impairment(s) medically equals a listing (see Sec.  416.926 of this 
chapter).
    3. If your impairment(s) does not meet or medically equal a 
listing, we will consider whether you have an impairment(s) that 
functionally equals the listings (see Sec.  416.926a of this 
chapter).
    4. Although we present these alternatives in a specific sequence 
above, each represents listing-level severity, and we can evaluate 
your claim in any order. For example, if the factors of your case 
indicate that the combination of your impairments may functionally 
equal the listings, we may start with that analysis. We use the 
rules in Sec.  416.994a of this chapter, as appropriate, when we 
decide whether you continue to be disabled.

112.01 Category of Impairments, Mental Disorders

    112.02 Neurocognitive disorders (see 112.00B1), for children age 
3 to attainment of age 18, satisfied by A and B, or A and C:
    A. Medical documentation of a clinically significant deviation 
in normal cognitive development or by significant cognitive decline 
from a prior level of functioning in one or more of the cognitive 
areas:
    1. Complex attention;
    2. Executive function;
    3. Learning and memory;
    4. Language;
    5. Perceptual-motor; or
    6. Social cognition.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
112.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 112.00G2c).
    112.03 Schizophrenia spectrum and other psychotic disorders (see 
112.00B2), for children age 3 to attainment of age 18, satisfied by 
A and B, or A and C:
    A. Medical documentation of one or more of the following:
    1. Delusions or hallucinations;
    2. Disorganized thinking (speech); or
    3. Grossly disorganized behavior or catatonia.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).

[[Page 66176]]

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
112.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 112.00G2c).
    112.04 Depressive, bipolar and related disorders (see 112.00B3), 
for children age 3 to attainment of age 18, satisfied by A and B, or 
A and C:
    A. Medical documentation of the requirements of paragraph 1, 2, 
or 3:
    1. Depressive disorder, characterized by five or more of the 
following:
    a. Depressed or irritable mood;
    b. Diminished interest in almost all activities;
    c. Appetite disturbance with change in weight (or a failure to 
achieve an expected weight gain);
    d. Sleep disturbance;
    e. Observable psychomotor agitation or retardation;
    f. Decreased energy;
    g. Feelings of guilt or worthlessness;
    h. Difficulty concentrating or thinking; or
    i. Thoughts of death or suicide.
    2. Bipolar disorder, characterized by three or more of the 
following:
    a. Pressured speech;
    b. Flight of ideas;
    c. Inflated self-esteem;
    d. Decreased need for sleep;
    e. Distractibility;
    f. Involvement in activities that have a high probability of 
painful consequences that are not recognized; or
    g. Increase in goal-directed activity or psychomotor agitation.
    3. Disruptive mood dysregulation disorder, beginning prior to 
age 10, and all of the following:
    a. Persistent, significant irritability or anger;
    b. Frequent, developmentally inconsistent temper outbursts; and
    c. Frequent aggressive or destructive behavior.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
112.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 112.00G2c).
    112.05 Intellectual disorder (see 112.00B4), for children age 3 
to attainment of age 18, satisfied by A or B:
    A. Satisfied by 1 and 2 (see 112.00H):
    1. Significantly subaverage general intellectual functioning 
evident in your cognitive inability to function at a level required 
to participate in standardized testing of intellectual functioning; 
and
    2. Significant deficits in adaptive functioning currently 
manifested by your dependence upon others for personal needs (for 
example, toileting, eating, dressing, or bathing) in excess of age-
appropriate dependence.

OR

    B. Satisfied by 1 and 2 (see 112.00H):
    1. Significantly subaverage general intellectual functioning 
evidenced by a or b:
    a. A full scale (or comparable) IQ score of 70 or below on an 
individually administered standardized test of general intelligence; 
or
    b. A full scale (or comparable) IQ score of 71-75 accompanied by 
a verbal or performance IQ score (or comparable part score) of 70 or 
below on an individually administered standardized test of general 
intelligence; and
    2. Significant deficits in adaptive functioning currently 
manifested by extreme limitation of one, or marked limitation of 
two, of the following areas of mental functioning:
    a. Understand, remember, or apply information (see 112.00E1); or
    b. Interact with others (see 112.00E2); or
    c. Concentrate, persist, or maintain pace (see 112.00E3); or
    d. Adapt or manage oneself (see 112.00E4).
    112.06 Anxiety and obsessive-compulsive disorders (see 
112.00B5), for children age 3 to attainment of age 18, satisfied by 
A and B, or A and C:
    A. Medical documentation of the requirements of paragraph 1, 2, 
3, or 4:
    1. Anxiety disorder, characterized by one or more of the 
following:
    a. Restlessness;
    b. Easily fatigued;
    c. Difficulty concentrating;
    d. Irritability;
    e. Muscle tension; or
    f. Sleep disturbance.
    2. Panic disorder or agoraphobia, characterized by one or both:
    a. Panic attacks followed by a persistent concern or worry about 
additional panic attacks or their consequences; or
    b. Disproportionate fear or anxiety about at least two different 
situations (for example, using public transportation, being in a 
crowd, being in a line, being outside of your home, being in open 
spaces).
    3. Obsessive-compulsive disorder, characterized by one or both:
    a. Involuntary, time-consuming preoccupation with intrusive, 
unwanted thoughts; or;
    b. Repetitive behaviors that appear aimed at reducing anxiety.
    4. Excessive fear or anxiety concerning separation from those to 
whom you are attached.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
112.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 112.00G2c).
    112.07 Somatic symptom and related disorders (see 112.00B6), for 
children age 3 to attainment of age 18, satisfied by A and B:
    A. Medical documentation of one or both of the following:
    1. Symptoms of altered voluntary motor or sensory function that 
are not better explained by another medical or mental disorder; or
    2. One or more somatic symptoms that are distressing, with 
excessive thoughts, feelings, or behaviors related to the symptoms.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).
    112.08 Personality and impulse-control disorders (see 112.00B7), 
for children age 3 to attainment of age 18, satisfied by A and B:
    A. Medical documentation of a pervasive pattern of one or more 
of the following:
    1. Distrust and suspiciousness of others;
    2. Detachment from social relationships;
    3. Disregard for and violation of the rights of others;
    4. Instability of interpersonal relationships;
    5. Excessive emotionality and attention seeking;
    6. Feelings of inadequacy;
    7. Excessive need to be taken care of;
    8. Preoccupation with perfectionism and orderliness; or
    9. Recurrent, impulsive, aggressive behavioral outbursts.

[[Page 66177]]

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).
    112.09 [Reserved]
    112.10 Autism spectrum disorder (see 112.00B8), for children age 
3 to attainment of age 18), satisfied by A and B:
    A. Medical documentation of both of the following:
    1. Qualitative deficits in verbal communication, nonverbal 
communication, and social interaction; and
    2. Significantly restricted, repetitive patterns of behavior, 
interests, or activities.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).
    112.11 Neurodevelopmental disorders (see 112.00B9), for children 
age 3 to attainment of age 18, satisfied by A and B:
    A. Medical documentation of the requirements of paragraph 1, 2, 
or 3:
    1. One or both of the following:
    a. Frequent distractibility, difficulty sustaining attention, 
and difficulty organizing tasks; or
    b. Hyperactive and impulsive behavior (for example, difficulty 
remaining seated, talking excessively, difficulty waiting, appearing 
restless, or behaving as if being ``driven by a motor'').
    2. Significant difficulties learning and using academic skills; 
or
    3. Recurrent motor movement or vocalization.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).
    112.12 [Reserved]
    112.13 Eating disorders (see 112.00B10), for children age 3 to 
attainment of age 18, satisfied by A and B:
    A. Medical documentation of a persistent alteration in eating or 
eating-related behavior that results in a change in consumption or 
absorption of food and that significantly impairs physical or 
psychological health.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).
    112.14 Developmental disorders in infants and toddlers (see 
112.00B11, 112.00I), satisfied by A and B:
    A. Medical documentation of one or both of the following:
    1. A delay or deficit in the development of age-appropriate 
skills; or
    2. A loss of previously acquired skills.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following developmental abilities (see 112.00F):
    1. Plan and control motor movement (see 112.00I4b(i)).
    2. Learn and remember (see 112.00I4b(ii)).
    3. Interact with others (see 112.00I4b(iii)).
    4. Regulate physiological functions, attention, emotion, and 
behavior (see 112.00I4b(iv)).
    112.15 Trauma- and stressor-related disorders (see 112.00B11), 
for children age 3 to attainment of age 18, satisfied by A and B, or 
A and C:
    A. Medical documentation of the requirements of paragraph 1 or 
2:
    1. Posttraumatic stress disorder, characterized by all of the 
following:
    a. Exposure to actual or threatened death, serious injury, or 
violence;
    b. Subsequent involuntary re-experiencing of the traumatic event 
(for example, intrusive memories, dreams, or flashbacks);
    c. Avoidance of external reminders of the event;
    d. Disturbance in mood and behavior (for example, developmental 
regression, socially withdrawn behavior); and
    e. Increases in arousal and reactivity (for example, exaggerated 
startle response, sleep disturbance).
    2. Reactive attachment disorder, characterized by two or all of 
the following:
    a. Rarely seeks comfort when distressed;
    b. Rarely responds to comfort when distressed; or
    c. Episodes of unexplained emotional distress.

AND

    B. Extreme limitation of one, or marked limitation of two, of 
the following areas of mental functioning (see 112.00F):
    1. Understand, remember, or apply information (see 112.00E1).
    2. Interact with others (see 112.00E2).
    3. Concentrate, persist, or maintain pace (see 112.00E3).
    4. Adapt or manage oneself (see 112.00E4).

OR

    C. Your mental disorder in this listing category is ``serious 
and persistent;'' that is, you have a medically documented history 
of the existence of the disorder over a period of at least 2 years, 
and there is evidence of both:
    1. Medical treatment, mental health therapy, psychosocial 
support(s), or a highly structured setting(s) that is ongoing and 
that diminishes the symptoms and signs of your mental disorder (see 
112.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to 
adapt to changes in your environment or to demands that are not 
already part of your daily life (see 112.00G2c).
* * * * *

114.00 Immune System Disorders

* * * * *
    D. * * *
    6. * * *
    e. * * *
    (ii) Listing-level severity is shown in 114.09B and 114.09C2 by 
inflammatory arthritis that involves various combinations of 
complications of one or more major peripheral joints or involves 
other joints, such as inflammation or deformity, extra-articular 
features, repeated manifestations, and constitutional symptoms and 
signs. * * *
* * * * *
    114.02 Systemic lupus erythematosus, as described in 114.00D1. 
With involvement of two or more organs/body systems, and with:
    A. One of the organs/body systems involved to at least a 
moderate level of severity;

AND

    B. At least two of the constitutional symptoms and signs (severe 
fatigue, fever, malaise, or involuntary weight loss).
    114.03 Systemic vasculitis, as described in 114.00D2. With 
involvement of two or more organs/body systems, and with:
    A. One of the organs/body systems involved to at least a 
moderate level of severity;

AND

    B. At least two of the constitutional symptoms and signs (severe 
fatigue, fever, malaise, or involuntary weight loss).
* * * * *
    114.06 Undifferentiated and mixed connective tissue disease, as 
described in 114.00D5. With involvement of two or more organs/body 
systems, and with:
    A. One of the organs/body systems involved to at least a 
moderate level of severity;

AND

    B. At least two of the constitutional symptoms and signs (severe 
fatigue, fever, malaise, or involuntary weight loss).
* * * * *
    114.10 Sj[ouml]gren's syndrome, as described in 114.00D7. With 
involvement of two or more organs/body systems, and with:
    A. One of the organs/body systems involved to at least a 
moderate level of severity;

AND

    B. At least two of the constitutional symptoms and signs (severe 
fatigue, fever, malaise, or involuntary weight loss).
* * * * *

[[Page 66178]]

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
DISABLED

Subpart I--Determining Disability and Blindness

0
4. The authority citation for subpart I of part 416 continues to read 
as follows:

    Authority:  Secs. 221(m), 702(a)(5), 1611, 1614, 1619, 1631(a), 
(c), (d)(1), and (p), and 1633 of the Social Security Act (42 U.S.C. 
421(m), 902(a)(5), 1382, 1382c, 1382h, 1383(a), (c), (d)(1), and 
(p), and 1383b); secs. 4(c) and 5, 6(c)-(e), 14(a), and 15, Pub. L. 
98-460, 98 Stat. 1794, 1801, 1802, and 1808 (42 U.S.C. 421 note, 423 
note, and 1382h note).

0
5. Amend Sec.  416.920a by revising paragraphs (c)(3) and (4) and 
(d)(1) to read as follows:


Sec.  416.920a  Evaluation of mental impairments.

* * * * *
    (c) * * *
    (3) We have identified four broad functional areas in which we will 
rate the degree of your functional limitation: Understand, remember, or 
apply information; interact with others; concentrate, persist, or 
maintain pace; and adapt or manage oneself. See 12.00E of the Listing 
of Impairments in appendix 1 to subpart P of part 404 of this chapter.
    (4) When we rate your degree of limitation in these areas 
(understand, remember, or apply information; interact with others; 
concentrate, persist, or maintain pace; and adapt or manage oneself), 
we will use the following five-point scale: None, mild, moderate, 
marked, and extreme. The last point on the scale represents a degree of 
limitation that is incompatible with the ability to do any gainful 
activity.
    (d) * * *
    (1) If we rate the degrees of your limitation as ``none'' or 
``mild,'' we will generally conclude that your impairment(s) is not 
severe, unless the evidence otherwise indicates that there is more than 
a minimal limitation in your ability to do basic work activities (see 
Sec.  416.921).
* * * * *

0
6. Amend Sec.  416.934 by revising the section heading and paragraph 
(h) to read as follows:


Sec.  416.934  Impairments that may warrant a finding of presumptive 
disability or presumptive blindness.

* * * * *
    (h) Allegation of intellectual disability or another 
neurodevelopmental impairment (for example, autism spectrum disorder) 
with complete inability to independently perform basic self-care 
activities (such as toileting, eating, dressing, or bathing) made by 
another person who files on behalf of a claimant who is at least 4 
years old.
* * * * *
[FR Doc. 2016-22908 Filed 9-23-16; 8:45 am]
 BILLING CODE 4191-02-P