Federal Register, Volume 63 Issue 60 (Monday, March 30, 1998)

[Federal Register Volume 63, Number 60 (Monday, March 30, 1998)]
[Notices]
[Pages 15248-15254]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-8135]

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SOCIAL SECURITY ADMINISTRATION

Social Security Ruling, SSR 98-1p; Title XVI: Determining Medical
Equivalence in Childhood Disability Claims When a Child Has Marked
Limitations in Cognition and Speech

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling, SSR 98-1p. This
Ruling results from the ``top-to-bottom'' review of the implementation
of changes to the Supplemental Security Income childhood disability
program necessitated by the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Pub. L. 104-193). It provides a
policy interpretation that children who have a ``marked'' limitation in
cognitive functioning and a ``marked'' limitation in speech have an
impairment or combination of impairments that medically equals Listing
2.09. It also provides guidance for determining when a child has a
``marked'' or an ``extreme'' limitation in each of these areas.

EFFECTIVE DATE: March 30, 1998.

FOR FURTHER INFORMATION CONTACT: Ken Nibali, Social Security
Administration,

[[Page 15249]]

6401 Security Boulevard, Baltimore, MD, 21235, (410) 965-1250.

SUPPLEMENTARY INFORMATION: Although we are not required to do so
pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this
Social Security Ruling in accordance with 20 CFR 402.35(b)(1).
Social Security rulings make available to the public precedential
decisions relating to the Federal old-age, survivors, disability,
supplemental security income, and black lung benefits programs. Social
Security Rulings may be based on case decisions made at all
administrative levels of adjudication, Federal court decisions,
Commissioner's decisions, opinions of the Office of the General
counsel, and policy interpretations of the law and regulations.
Although Social Security Rulings do not have the same force and
effect as the statute or regulations, they are binding on all
components of the Social Security Administration, in accordance with 20
CFR 402.35(b)(1), and are to be relied upon as precedents in
adjudicating cases.
If this Social Security Ruling is later superseded, modified, or
rescinded, we will publish a notice in the Federal Register to that
effect.

(Catalog of Federal Domestic Assistance, Program 96.006 Supplemental
Security Income)

Dated: March 19, 1998.
Kenneth S. Apfel,
Commissioner of Social Security.

Policy Interpretation Ruling--Title XVI: Determining Medical
Equivalence in Childhood Disability Claims When a Child Has Marked
Limitations in Cognition and Speech

Purpose: To provide a policy interpretation that children who have
a ``marked'' limitation in cognitive functioning and a ``marked''
limitation in speech have an impairment or combination of impairments
that medically equals Listing 2.09. Also, to provide guidance for
determining when a child has a ``marked'' or an ``extreme'' limitation
in each of these areas.
Citations (Authority): Section 1614(a) of the Social Security Act,
as amended; Regulations No. 16, subpart I, sections 416.902, 416.923,
416.924, 416.925, 416.926; Regulations No. 4, subpart P, appendix 1--
Listing of Impairments.
Background: On December 17, 1997, the Commissioner of Social
Security issued the Review of SSA's Implementation of New SSI Childhood
Disability Legislation (Pub. No. 64-070), a report of a ``top-to-
bottom'' review of the implementation of changes to the Supplemental
Security Income (SSI) childhood disability program necessitated by the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(Pub. L. 104-193).
As a result of the review, the Commissioner directed additional
instruction on the evaluation of a combination of cognitive and speech
disorders that separates speech disorders from cognitive disorders.
Among other things, the Commissioner directed the issuance of a Ruling
on the evaluation of speech disorders in combination with cognitive
limitations. ¹
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\1\ This Ruling addresses evaluation of speech disorders in
combination with cognitive limitations. It does not address
evaluation of receptive or expressive language disorders, which can
also result in disability. In addition, this Ruling does not address
evaluation of the area of Cognition/Communication under the broad
areas of functioning of the functional equivalence provision, as
discussed in 20 CFR 416.926a(c)(4).
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Introduction: The regulations at 20 CFR 416.906 explain that, for
children claiming SSI benefits under the Social Security Act (the Act),
an impairment or combination of impairments must cause ``marked and
severe functional limitations'' in order to be found disabling. The
regulations at 20 CFR 416.902 provide that ``marked and severe
functional limitations,'' when used as a phrase, is a level of severity
that meets, medically equals, or functionally equals the severity of a
listing in the Listing of Impairments, appendix 1 of subpart P of 20
CFR part 404 (the listings).
The regulations at 20 CFR 416.925(b)(2) explain that, in general, a
child's impairment or combination of impairments is ``of listing-level
severity'' if it causes marked limitation in two broad areas of
functioning or extreme limitation in one such area.
The regulations at 20 CFR 416.926 explain that we will decide that
a child's impairment or combination of impairments is medically
equivalent to a listed impairment if the medical findings are at least
equal in severity and duration to the listed findings. We will compare
the signs, symptoms, and laboratory findings concerning the child's
impairment or combination of impairments, as shown in the medical
evidence we have about the claim, with the corresponding medical
criteria shown for any listed impairment.
In particular, the regulations at 20 CFR 416.926(a)(2) provide
that, if a child has an impairment that is not described in the
listings, or a combination of impairments, no one of which meets or is
medically equivalent to a listing, we will compare the child's medical
findings with those for closely analogous listed impairments. If the
medical findings related to the child's impairment or combination of
impairments are at least of equal medical significance to those of a
listed impairment, we will find that the child's combination of
impairments is medically equivalent to the analogous listing.

Policy Interpretation

I. Need To Establish a Medically Determinable Impairment

Section 1614(a)(3)(C)(i) of the Act and 20 CFR 416.906 provide that
a child's disability must result from a medically determinable physical
or mental impairment. Section 1614(a)(3)(D) of the Act and 20 CFR
416.908 further provide that the physical or mental impairment must
result from anatomical, physiological, or psychological abnormalities
which can be shown by medically acceptable clinical and laboratory
diagnostic techniques. A physical or mental impairment must be
established by medical evidence consisting of signs, symptoms, and
laboratory findings.
The discussions in this Ruling address the evaluation of the
severity of impairments affecting speech and cognition. They presume
that the existence of such medically determinable impairments has
already been established.

II. Terms and Definitions

A. Cognition involves the ability to learn, understand, and solve
problems through intuition, perception, auditory and visual sequencing,
verbal and nonverbal reasoning, and the application of acquired
knowledge. It also involves the ability to retain and recall
information, images, events, and procedures during the process of
thinking. There are many impairments that can cause limitations in
cognition, such as genetic disorders or brain injury.
B. Speech is the production of sounds (phonemes) in a smooth and
rhythmic fashion for the purposes of oral communication. It includes
articulation, voice (pitch, volume, quality), and fluency (the flow, or
rate and rhythm, of speech). Understandable speech results from precise
neuromuscular functioning of the speech mechanism (e.g., lips, tongue,
hard palate, vocal folds, respiratory mechanism), and intact structure
and functioning of the speech centers in the brain.
There are many impairments that can cause limitations in speech,
such as brain lesions or cortical injury resulting

[[Page 15250]]

in apraxia; other neurological abnormalities, such as cerebral palsy
producing dysarthria; or structural abnormalities, such as cleft palate
producing hypernasality. Speech differs from language (receptive and
expressive). Speech is the production of sounds for purposes of oral
communication; language provides the message of the communication, and
involves the use of semantics (e.g., vocabulary), syntax (e.g.,
grammar), and pragmatics (i.e., use of language in its social context)
in the understanding and expression of messages.

III. Limitations in Cognition and Speech

A. Mental Retardation and Speech Impairment. In the childhood
disability program, children who have a valid diagnosis of mental
retardation (``significantly subaverage general intellectual
functioning with deficits in adaptive functioning'') have, by
definition, at least a ``marked'' cognitive limitation. However, a
child may have a marked limitation in cognitive functioning without
being diagnosed with mental retardation. (See B.)
Listing 112.05 is used to evaluate mental retardation, which is
demonstrated by significantly subaverage general intellectual
functioning with deficits in adaptive functioning. A child's impairment
meets Listing 112.05D or 112.05F when the child has a diagnosis of mild
mental retardation and a physical or other mental impairment imposing
``additional and significant limitation of function'' [i.e., more than
minimal limitation of function]. In these listings, the significantly
subaverage general intellectual functioning needed to establish that
component of the diagnosis of mild mental retardation is shown by a
valid verbal, performance, or full scale IQ of 60 through 70 (under
Listing 112.05D) or ``marked'' limitation in the area of cognition/
communication (under Listing 112.05F, by reference to Listing 112.02B1b
or 112.02B2a). Of course, mild mental retardation may be sufficiently
severe in itself to meet the criteria of Listing 112.05 A or E. More
impairing cases of mental retardation (i.e., moderate, severe, or
profound) will meet the criteria of Listing 112.05 B or C.
A speech impairment may satisfy the criterion for a physical or
other mental impairment imposing ``additional and significant
limitation of function'' under Listings 112.05D and 112.05F when it
causes more than minimal limitation of function. To satisfy this
criterion, a child's problems in speech must be separate from his/her
mild mental retardation.
A child with mild mental retardation may have speech
problems resulting from an impairment of known etiology that is clearly
separate from the mental retardation; e.g., a congenital disorder (as
with a congenital brain injury, or a cleft palate resulting in
hypernasality) or an acquired disorder (as in a child who already has
mental retardation and who suffers a traumatic head injury resulting in
a neurological or physical problem affecting the ability to produce
speech sounds).
A child with mental retardation may also have speech
problems resulting from an impairment of unknown etiology that
nevertheless is clearly separate from the mental retardation; e.g.,
poorly intelligible speech of unknown etiology.
It is possible for a child with mental retardation to have
limitations in speech that do not constitute an impairment separate
from the mental retardation. In a child with mental retardation, speech
development is often commensurate with the level of cognitive
functioning. Therefore, in the absence of an impairment of speech that
is separate from the child's mental retardation, a speech pattern that
has been and continues to be consistent with the child's general
intellectual functioning is not regarded as separate from the mental
retardation and will not be found to satisfy the criterion in Listings
112.05D and 112.05F for a physical or other mental impairment imposing
additional and significant limitation of function.
On the other hand, if a child's speech development is not even
commensurate with his/her general intellectual functioning (i.e., is
significantly below that which would be expected given the level of
cognitive functioning), then the limitations in speech would be
regarded as an impairment separate from the mental retardation that
would satisfy the criterion in Listings 112.05D and 112.05F for a
physical or other mental impairment imposing additional and significant
limitation of function.
B. ``Marked'' Limitations in Cognition and Speech. A child whose
impairment does not meet the capsule definition of mental retardation
in Listing 112.05 may nevertheless have a marked limitation in
cognitive functioning. When such a child also has an impairment that
causes a ``marked'' limitation in speech (see Table 1 and Section VI),
the combination of limitations in cognition and speech will be found
medically equivalent to Listing 2.09 in part A of the
listings.²
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\2\ In general, part A of the listings contains medical criteria
that apply to persons age 18 and over; part B contains medical
criteria that apply to persons under age 18. However, the medical
criteria in part A may also be applied in evaluating impairments in
persons under age 18 if the disease processes have a similar effect
on adults and younger persons, as in Listing 2.09. See 20 CFR
416.925(b).
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This policy interpretation regarding the evaluation of a
combination of cognition and speech impairments is an exception to the
guidance in listings section 2.00B3. That section explains that
impairments of speech due to neurologic disorders should be evaluated
under 11.00-11.19, the neurological listings generally used to evaluate
impairments in individuals age 18 or older. For the purposes of this
Ruling only, however, neither the neurological listings in 11.00-11.19,
nor those in 111.00 for individuals who have not attained age 18 will
be used; only Listing 2.09 will be employed.
C. ``Extreme'' Limitations in Cognition and Speech. An
impairment(s) that causes an ``extreme'' limitation in cognition or in
speech is always of listing-level severity and, thus, will always meet
or equal the severity of a listing.
1. Cognition. The vast majority of children with ``extreme''
limitations in cognition will have mental retardation and will have an
impairment that meets one of the listings in 112.05. Very infrequently,
however, a child with an IQ in the ``extreme'' range will not have the
deficits in adaptive functioning needed to establish the diagnosis of
mental retardation. In these rare instances, the validity of the IQ and
the assessment of adaptive functioning should be verified. If both
appear accurate and a diagnosis of mental retardation is not
supportable, the child's impairment will nevertheless medically equal
the criteria of a childhood mental disorders listing; e.g., Listing
112.02.
2. Speech. Listing 2.09 recognizes disability on the basis of an
``[o]rganic loss of speech due to any cause with inability to produce
by any means speech which can be heard, understood, and sustained.''
This listing applies to children as well as adults, and describes the
most extreme limitation of speech. However, children with less serious
limitations of speech than are described in Listing 2.09 may still have
an ``extreme'' limitation, as noted in Table 1, and, therefore, may
also have impairments that meet or equal the requirements of a listing.

IV. Documenting Limitations in Cognition and Speech

A. Documentation of Severity. 1. Evidence of the severity of
cognitive

[[Page 15251]]

limitation should generally include the results of psychological
testing, with subtest scores, and the psychologist's interpretation of
the results, including his/her conclusion regarding the validity of the
testing. The psychological test scores must also be sufficiently
current for accurate assessment.³
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\3\ The interpretation of the psychological testing is primarily
the responsibility of the psychologist or other professional who
administered the test. When an appropriate medical professional has
provided test results that meet the standards in SSA regulations
(e.g., that are consistent with the other evidence in the case
record, or that note and resolve discrepancies between the test
results and the child's customary behavior and daily activities),
the adjudicator will ordinarily accept the results, unless
contradictory evidence in the case record establishes that the
results are incorrect.
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Evidence of the severity of cognitive limitation should also
include information about learning achievement (e.g., test scores,
school performance records) and descriptions (from medical and lay
sources) of the child's ability to do age-appropriate, cognitively
related tasks and activities at home and school.
2. Evidence of the severity of speech limitation should generally
include the results of a comprehensive examination of the child's
speech (articulation, voice, fluency), and descriptions of the child's
speech in daily circumstances (e.g., the sounds a child produces, the
percentage of intelligibility of the child's speech). These
descriptions come from persons who have opportunities to listen to the
child; i.e., both lay and professional sources (see Section VI.C.). The
evidence must be sufficient and recent enough to permit a judgment
about the child's current level of functioning. In some instances, it
may be necessary to obtain a consultative examination in order to
assure recency of the evidence.⁴
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\4\ The same principles apply here as for psychological testing.
When an appropriate medical professional has provided test results
that would meet SSA standards (e.g., that are consistent with the
other evidence in the case record, or that note and resolve
discrepancies between the test results and the child's customary
behavior and daily activities), the adjudicator will ordinarily
accept the results, unless contradictory evidence in the case record
establishes that the results are incorrect.
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B. Sources of Evidence. Evidence of a child's cognitive functioning
and speech may be available from various sources. For example, if a
child is receiving special education services, the school should be
able to provide records of testing, clinical observations, and
classroom performance. Examples of some sources include the following.
1. Multidisciplinary teams. Children being assessed for possible
developmental problems are evaluated by a multidisciplinary team that
may include a psychologist, physician, speech-language pathologist,
audiologist, special educator, teacher, and other related specialists
as needed; information concerning the child's cognitive abilities and
speech should be available from the team's comprehensive report(s). The
remediation plans for infants and toddlers (birth to age 3) are
reviewed every 6 months. School-aged children in the public school
system should be reassessed at least every 3 years.
2. Comprehensive evaluations. A child with documented problems in
cognition and speech who is already receiving special education
services must have had a comprehensive evaluation prior to receiving
such services. That evaluation should include results of formal testing
and clinical observations.
3. Individualized plans. Children who are cognitively limited,
speech-impaired, or limited in both areas, may receive special
education services in Early Intervention Programs (infants and
toddlers, from birth to age 3 years), or in school-based educational
programs in preschool, kindergarten, elementary, and secondary school.
Annual goals and objectives for such programs, as well as test results,
are documented yearly in individualized plans of intervention: for
infants and toddlers, in the Individualized Family Service Plan (IFSP);
for children age 3 and older, in the Individualized Education Program
(IEP).
4. Speech-language progress notes. For any child receiving speech-
language special education services, the speech-language pathologist
should have prepared periodic progress notes that document the child's
current strengths and weaknesses.
5. Other sources. Other potential sources of evidence of severity
include reports from parents, daycare providers, social workers, case
managers, teachers, treatment sources, or consultative examinations.

V. Rating Limitations in Cognition and Speech

When the outcome of a disability determination depends on
conclusions regarding a child's cognitive and speech limitations,
experts in the fields of cognitive assessment and speech-language
should participate in the evaluation of the claim whenever possible.
A. Cognition. Marked cognitive limitation is usually identified
under any of the following circumstances: ⁵
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\5\ The basic definitions of ``marked'' and ``extreme''
limitation are provided in 20 CFR 416.926a(c)(3). This Ruling
provides further interpretation of the definitions of ``marked.''
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1. When standardized intelligence tests provide a valid score that
is 2 Standard Deviations (SDs) or more below the norm for the test (but
less than 3 SDs), with appropriate consideration of the Standard Error
of Measurement.
2. In the absence of valid standardized scores, when a child from
birth to attainment of age 3 has an impairment or combination of
impairments that results in cognitive functioning at a level that is
more than one-half but not more than two-thirds of the child's
chronological age.
3. When a child from age 3 to attainment of age 18 has an
impairment or combination of impairments that causes ``more than
moderate'' but ``less than extreme'' limitation in cognitive
functioning; i.e., when the limitation interferes seriously with the
child's cognitive functioning.
A finding that a limitation in a child's cognitive abilities is
``marked'' or ``extreme,'' or that it is less than ``marked,'' must be
based on all of the relevant evidence in the case record.
B. Speech. Marked limitation in speech will be evaluated under the
guidelines in Table 1. Section VI explains how to use the table.

VI. Table 1: Guidelines for Evaluating the Severity of Speech
Impairments

A. General. 1. The guidelines for evaluating severity in Table 1
use age groupings that do not correspond to the age ranges in 20 CFR
416.926a and the childhood mental disorders listings but, rather, are
related to the developmental progression of speech; e.g., the aspects
of speech development that tend to occur between birth and age 2. The
guidelines refer to errors that are not typical or expected for the
particular age grouping; e.g., 2 to 3\1/2\ years. This principle of
evaluation is based on the fact that speech development, like fine and
gross motor development, is incremental and follows milestones as
predictable as rolling over, crawling, and standing. The upper age
category in Table 1 is age 5 and older because, by age 5, almost all
sounds are mastered; however, the few age-appropriate sound errors
still occurring after age 5 involve sounds (e.g., ``r,'' ``th'') that
may not be completely refined until age 8. Thus, by age 8, a child
should have a repertoire of sounds that is complete and accurate; by
definition, any misarticulations beginning at age 8 are inappropriate.
A child's speech patterns and misarticulations, and when these
occur, can be indicative of whether a child's speech is developing, or
has developed, appropriately.

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2. Table 1 is divided into three columns: Chronological Age or
Cognitive Level, Marked Limitation, and Extreme Limitation. Once the
appropriate category for chronological age or cognitive level is
identified (see Section B), use the second and third columns to
determine whether a child with a speech impairment has a ``marked'' or
an ``extreme'' limitation in speech. The evaluation of the severity of
the speech impairment should be based on evidence concerning:
The sound production and intelligibility of the child's
speech in relation to the listener and the topic of conversation (see
Section C); and
The child's speech patterns (see Section D).
A finding that a limitation in speech is ``marked'' or ``extreme,''
or that it is less than ``marked,'' must be based on all of the
relevant evidence in the case record.
3. If the limitation in speech is ``marked'' and the child also has
a ``marked'' limitation in cognition, or if the limitation is
``extreme,'' consider the duration of the impairment (see Section E).
4. Note on use of terms.
a. The terms used in the Table 1 are typically found in reports of
comprehensive speech-language evaluations. However, some reports may
not use these terms or may use the terms differently than intended in
the table. If the evidence does not use the descriptors employed in the
table, or it is not clear how the terms are used, it may be necessary
to contact the source to clarify the information.
b. Terms such as ``poor,'' ``severe,'' ``mild,'' or ``marked'' may
be used in the evidence to describe a child's functioning. These terms
have different meaning to different people. Therefore, when such terms
are not illustrated or explained by the evidence, it may be necessary
to contact the source for an explanation of their meaning.
B. Chronological Age and Cognitive Level. 1. Cognitive level is the
level of a child's thinking. In many instances, cognitive and speech
development are highly correlated, so that a child whose cognitive
level is below chronological age will often have speech development
that is appropriate to the cognitive level rather than the
chronological age. Thus, although a child's speech patterns may not be
appropriate from the perspective of his/her chronological age, they may
be appropriate to his/her cognitive level. For example, a 4-year-old
child's cognitive level may be that of a child in the age range 2 to
3\1/2\ because of an impairment affecting cognitive functioning. Speech
at the 2\1/2\-to-3-year level would be considered a function of
(related to) the child's cognitive level.
2. Use a child's chronological age for evaluation of severity:
a. When the child is 8 years of age or older; or
b. When the child is less than 8 years of age and the limitations
in speech are the result of a congenital or acquired impairment of
speech, either structural or neurological (e.g., cleft palate,
dysarthria, apraxia of speech).
3. Use a child's cognitive level for evaluation of severity in all
other cases.
4. Determining the cognitive level.
a. The cognitive level may be determined from information in the
case record; e.g., score from the Bayley Scales of Infant Development,
Wechsler composite scores (verbal, performance, full scale), or
Stanford-Binet score. Most children with ``marked'' limitation in
cognitive functioning will have evidence of testing showing the
cognitive level, or from which the cognitive level can be determined.
Particularly in the case of young children, the cognitive level is
frequently included along with test scores in evaluation reports. See
Section IV.B. for a list of examples of sources of evidence.
b. Developmental testing often addresses a child's progress in
several areas, and developmental levels may be reported for cognition
and at least one other area; e.g., motor or social functioning. For
purposes of Table 1, use the level reported for the child's cognitive
ability.
c. If the cognitive level is not clearly indicated in the case
record or cannot be determined from the evidence, it may be necessary
to recontact a source who has already evaluated and provided evidence
about the child or to purchase a consultative examination. If a
language level based on the total language score is included in the
case record, it may be used as a proxy for the cognitive level for
children up to age 6. Whether additional information will be needed
will depend on the facts of the case.
C. Sound Production and Intelligibility. 1. Evidence of sound
production and intelligibility.
a. Ideally, to assess a child's sound production and the
intelligibility of speech, descriptions are needed from at least two
listeners, one lay and one professional. If there is a conflict in the
evidence concerning the child's sound production or intelligibility, it
may be necessary to obtain a third descriptive statement, preferably
from an additional professional source who is familiar with the child.
b. Listeners will either be familiar with the child (i.e., have
listened to the child daily or frequently) or unfamiliar (i.e., have
listened to the child infrequently). Familiar lay sources are people
who know the child well, such as parents, relatives, and neighbors.
c. A professional source is a person who has training and
experience in evaluating a child's speech. Examples of professional
sources may include, but are not limited to, speech-language
pathologists, special education teachers, pediatric neurologists,
pediatricians, and occupational therapists. A professional source may
also be a familiar listener (e.g., a source who provides regular
treatment) or an unfamiliar listener (e.g., a consulting examiner).
2. Sound production refers to a young child's vocalizations (e.g.,
``cooing'') that gradually become more complex and develop into
recognizable speech sounds. For example, beginning around 4 to 5 months
of age, an infant engages in ``babbling,'' which consists of consonant-
vowel sequences (e.g., ``ba-ba''). Later, around 10 months of age, an
infant begins ``jargoning,'' which is the production of strings of
speech sounds having the intonational patterns of adult speech. The
variety, pitch, and intensity, of a child's sounds at this stage of
development are important factors in the assessment of a child's very
early speech development. Eventually, the young child uses his/her
repertoire of speech sounds to imitate and produce words; this
repertoire should be complete by 8 years of age.
3. Intelligibility (clarity) means the degree to which the child
can be understood by the listener. To rate the intelligibility of a
child's speech, a listener (regardless of whether a professional or a
lay source) must be asked to provide information about how well the
child can be understood, preferably in terms of a percentage (e.g., 50%
of the time) or fraction (e.g., half the time).
a. The expected degree of intelligibility increases with a child's
age, with a typical rate of 50% intelligibility to family members at 2
years of age, and almost full intelligibility to all listeners by
attainment of 4 years of age.
b. Intelligibility is also affected by the extent to which the
listener is familiar with the child's speech and the topic of
conversation.
Ratings of intelligibility should be evaluated with
respect to the familiarity of the listener with the child and the
frequency of contact; however, see paragraph c.

[[Page 15253]]

Consideration must also to be given to the familiarity of
the listener with the topic (i.e., content) of the speech. When the
child's speech is difficult to understand and the topic of the
conversation is unknown or not familiar to the listener, the
intelligibility of the message is reduced.
c. Ratings of intelligibility by unfamiliar listeners for whom the
topic of conversation is unknown assume increasingly greater importance
as children age. Young children typically talk about what is
immediately present in their environment, and listeners may be able to
use external clues to understand such children's speech. As children
age, however, the topics of their conversation should become less
embedded in the immediate physical context (e.g., they talk about past
or future events); the unfamiliar listener, therefore, has fewer clues
available for understanding the child's speech. The older a child
becomes, the more intelligible he/she needs to be in school and social
situations and with infrequent listeners or strangers.⁶
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\6\ Although reference is made to the child's topic of
conversation, which necessarily involves language, the issue being
addressed here is the child's speech and its intelligibility in
conversation; the topic of conversation is one of many variables
that can affect the intelligibility of the child's speech for the
listener.
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D. Speech Patterns. 1. Speech patterns refers to sounds, omissions,
distortions, or phonological patterns, and the fluency, or rate and
rhythm, of speech.
2. Phonological patterns refers to the selection, sequence,
combination, and placement of sounds that the rules of sound production
comprise. A child's ``phonological development'' (the acquisition of
sounds and understanding of their use) consists of learning these rules
through instinctual experimentation and practice. For example, a child
may use ``yedow'' for ``yellow,'' or ``ba-oon'' for ``balloon,'' until
normal phonological development makes possible his/her use of the ``l''
sound in a word. A child's phonological patterns are appropriate if
they are typical for his/her cognitive level; they are inappropriate if
they are not typical for his/her cognitive level. Information about
phonological patterns is included in speech-language evaluations.
3. Misarticulations are incorrect productions of speech sounds, and
may include various kinds of ``speech errors''; e.g., distortions (such
as vowel distortions, lateralized ``s''), substitutions (such as
lisping), or omissions of sounds. Such errors may occur in the
beginning, middle, or end of words. As noted previously, certain
misarticulations are appropriate because they are typical of various
stages of phonological development. As a child grows older, certain
misarticulations are not typical of his/her group and are, thus,
inappropriate. The nature of the misarticulation and its placement in
the word can affect the seriousness of the ``speech error'' and its
effect on intelligibility. For example, the omission of consonant
sounds at the beginning of many words can render much of a child's
speech unintelligible.
4. Dysfluent speech is a break in the rhythm and rate of speech.
Children between ages 2\1/2\ and 4 may go through a period in which
they produce ``normal dysfluencies.'' The pattern of a child's
dysfluencies, and whether it is typical or atypical for the child's
cognitive level, can be indicative of whether a child's speech is
developing appropriately.
5. Voice refers to the pitch, quality, and intensity of a child's
voice. Aberrations in voice are not a function of the child's cognitive
level and are usually atypical at any age.
6. Sources of information. Information concerning a child's speech
in relationship to his/her cognitive level must be provided by persons
who are knowledgeable about the specific milestones of development of
speech; e.g., which misarticulations are appropriate or inappropriate
to the child's cognitive level. If a child is receiving treatment to
remediate a speech impairment, the most likely source of this kind of
information will be the speech-language pathologist. However, a
preschool or special education teacher may also be able to provide the
needed information, as might another health care specialist; e.g.,
developmental pediatrician, pediatric neurologist, occupational
therapist, or a person otherwise qualified by training and experience.
E. Duration. Children who exhibit serious speech difficulties will
sometimes ``outgrow'' them. Some speech difficulties will respond to
treatment more readily than others. Therefore, when it is determined
that a child has a ``marked'' limitation in cognition together with a
``marked'' limitation in speech that has not yet lasted at this level
for 12 months, it will be necessary to determine whether the limitation
in speech is expected to persist at the ``marked'' level for a
continuous period of at least 12 months. The presence of any of the
factors in Table 2 makes it less likely that the child will simply
``outgrow'' the speech impairment, and more likely that a longer period
of intervention will be required for remediation of the speech
impairment.
The presence of one of the factors in Table 2 will strongly suggest
that an impairment has met or will meet the duration requirement.
However, the converse is not necessarily true: A child's speech
impairment may nevertheless still require extensive speech treatment
for a long period of time even though none of the factors in Table 2 is
present in the evidence. Whether the impairment has lasted or is
expected to last for a continuous period of not less than 12 months is
a judgment that must be made based on the evidence particular to each
case.

Table 1.--Guidelines For Evaluating Severity of Speech Impairments
----------------------------------------------------------------------------------------------------------------
Chronological age or cognitive
level (see section VI.B.) Marked limitation Extreme limitation
----------------------------------------------------------------------------------------------------------------
Birth to attainment of 2 years... a. Sound production other than crying a. A criterion for Marked Limitation
(e.g., cooing, babbling, jargoning) is met, and
occurs infrequently; child is b. Consonant-vowel repertoire is not
unusually quiet; or sufficient to support the
b. Limited or otherwise abnormal development of expressive language.
variation in pitch, intensity, and
sound production
2 to attainment of 3\1/2\ years.. a. Most messages are not readily a. Criteria for Marked Limitation are
intelligible even in context; and met, and
b. Sounds, omissions, distortions, or b. Gesturing and pointing are used
phonological patterns, or fluency most of the time instead of oral
(rate, rhythm of speech) not typical expression, and
for this group; or significant c. Intelligibility does not improve
aberrations in vocal pitch, quality, even with repetition or models, or
or intensity ability to imitate words is limited.

[[Page 15254]]

3\1/2\ to attainment of 5 years.. a. Sounds, omissions, distortions, or a. Criteria a. and b. for Marked
phonological patterns, or fluency Limitation are met, and
(rate, rhythm of speech) not typical b. Conversation continues to be
for this group; or significant intelligible no more than 1/2 of the
aberrations in vocal pitch, quality, time despite repetitions and
or intensity; and c. Stimulability for production of
b. Conversation is intelligible no sounds is limited, or, ability to
more than \1/2\ of the time on first imitate words is limited.
attempt; and
c. Intelligibility improves with
repetitions
5 years and older................ a. Sounds, omissions, distortions, or a. Sounds, omissions, distortions, or
phonological patterns, or fluency phonological patterns, or fluency
(rate, rhythm of speech) not typical (rate, rhythm of speech) not typical
for this group; or significant for this group; or significant
aberrations in vocal pitch, quality, aberrations in vocal pitch, quality,
or intensity; and or intensity; and
b. Conversation is intelligible no b. Conversation is intelligible no
more than \1/2\ to \2/3\ of the time more than \1/2\ of the time despite
on first attempt; and repetitions.
c. Intelligibility improves with
repetitions
----------------------------------------------------------------------------------------------------------------

Table 2.--Factors Suggesting That the Duration Requirement Will Be Met
------------------------------------------------------------------------

-------------------------------------------------------------------------
1. Neurologically based abnormalities, including--
Oral-motor problems at the volitional level (e.g., ability to
imitate oral-motor movements is limited); or
Oral-motor problems at the automatic level (e.g., drools
profusely, exhibits feeding disorder); or
Oral hypersensitivity (e.g., limited tolerance of different
food textures); or
Insufficient breath support for speech.
2. Hearing abnormalities, including--
Conductive hearing loss; or
Sensorineural hearing loss.
3. Structurally based abnormalities, including--
Defect of the oral mechanism (e.g., vocal fold paralysis); or
Oral-facial abnormality (e.g., cleft lip/palate).
4. Speech-related behavioral abnormalities, including--
Communication-related physical behaviors that are negative
(e.g., grimaces or has excessive eye-blinking during stuttering
episodes; gestures, such as slapping a surface, to end stuttering
block); or
Avoidance of speaking because of speech difficulties.
------------------------------------------------------------------------

EFFECTIVE DATE: This Ruling is effective March 30, 1998.

Cross-references: Program Operations Manual System DI 25201.001-
005, DI 25215.005, DI 34001.000, DI 34005.000.

[FR Doc. 98-8135 Filed 3-27-98; 8:45 am]
BILLING CODE 4190-29-U