[Federal Register Volume 74, Number 30 (Tuesday, February 17, 2009)]
[Notices]
[Pages 7518-7521]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-3383]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2008-0062]


Social Security Ruling, SSR 09-6p.; Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Moving 
About and Manipulating Objects''

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are giving notice of SSR 09-6p. This SSR consolidates 
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of ``Moving 
about and manipulating objects.'' It also explains our policy about 
that domain.

DATES: Effective Date: March 19, 2009.

FOR FURTHER INFORMATION CONTACT: Janet Truhe, Office of Disability 
Programs, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, (410) 965-1020.

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are doing so under 20 CFR 
402.35(b)(1).
    SSRs make available to the public precedential decisions relating 
to the Federal old-age, survivors, disability, supplemental security 
income, special veterans benefits, and black lung benefits programs. 
SSRs may be based on determinations or decisions made at all levels of 
administrative adjudication, Federal court decisions, Commissioner's 
decisions, opinions of the Office of the General Counsel, or other 
interpretations of the law and regulations.
    Although SSRs do not have the same force and effect as statutes or

[[Page 7519]]

regulations, they are binding on all components of the Social Security 
Administration. 20 CFR 402.35(b)(1).
    This SSR will be in effect until we publish a notice in the Federal 
Register that rescinds it, or publish a new SSR that replaces or 
modifies it.

(Catalog of Federal Domestic Assistance, Program No. 96.006 
Supplemental Security Income.)

    Dated: February 9, 2009.
Michael J. Astrue,
Commissioner of Social Security.

Policy Interpretation Ruling

Title XVI: Determining Childhood Disability--The Functional Equivalence 
Domain of ``Moving About and Manipulating Objects''

    Purpose: This SSR consolidates information from our regulations, 
training materials, and question-and-answer documents about the 
functional equivalence domain of ``Moving about and manipulating 
objects.'' It also explains our policy about that domain.
    Citations: Sections 1614(a)(3), 1614(a)(4), and 1614(c) of the 
Social Security Act, as amended; Regulations No. 4, subpart P, appendix 
1; and Regulations No. 16, subpart I, sections 416.902, 416.906, 
416.909, 416.923, 416.924, 416.924a, 416.924b, 416.925, 416.926, 
416.926a, and 416.994a.
    Introduction: A child \1\ who applies for Supplemental Security 
Income (SSI) \2\ is ``disabled'' if the child is not engaged in 
substantial gainful activity and has a medically determinable physical 
or mental impairment or combination of impairments \3\ that results in 
``marked and severe functional limitations.'' \4\ 20 CFR 416.906. This 
means that the impairment(s) must meet or medically equal a listing in 
the Listing of Impairments (the listings),\5\ or functionally equal the 
listings (also referred to as ``functional equivalence''). 20 CFR 
416.924 and 416.926a.
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    \1\ The definition of disability in section 1614(a)(3)(C) of the 
Social Security Act (the Act) applies to any ``individual'' who has 
not attained age 18. In this SSR, we use the word ``child'' to refer 
to any such person, regardless of whether the person is considered a 
``child'' for purposes of the SSI program under section 1614(c) of 
the Act.
    \2\ For simplicity, we refer in this SSR only to initial claims 
for benefits. However, the policy interpretations in this SSR also 
apply to continuing disability reviews of children under section 
1614(a)(4) of the Act and 20 CFR 416.994a.
    \3\ We use the term ``impairment(s)'' in this SSR to refer to an 
``impairment or a combination of impairments.''
    \4\ The impairment(s) must also satisfy the duration requirement 
in section 1614(a)(3)(A) of the Act; that is, it must be expected to 
result in death, or must have lasted or be expected to last for a 
continuous period of not less than 12 months.
    \5\ For each major body system, the listings describe 
impairments we consider severe enough to cause ``marked and severe 
functional limitations.'' 20 CFR 416.925(a); 20 CFR part 404, 
subpart P, appendix 1.
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    As we explain in greater detail in SSR 09-1p, we always evaluate 
the ``whole child'' when we make a finding regarding functional 
equivalence, unless we can otherwise make a fully favorable 
determination or decision.\6\ We focus first on the child's activities, 
and evaluate how appropriately, effectively, and independently the 
child functions compared to children of the same age who do not have 
impairments. 20 CFR 416.926a(b) and (c). We consider what activities 
the child cannot do, has difficulty doing, needs help doing, or is 
restricted from doing because of the impairment(s). 20 CFR 416.926a(a). 
Activities are everything a child does at home, at school, and in the 
community, 24 hours a day, 7 days a week.\7\
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    \6\ See SSR 09-1p, Title XVI: Determining Childhood Disability 
Under the Functional Equivalence Rule--The ``Whole Child'' Approach.
    \7\ However, some children have chronic physical or mental 
impairments that are characterized by episodes of exacerbation 
(worsening) and remission (improvement); therefore, their level of 
functioning may vary considerably over time. To properly evaluate 
the severity of a child's limitations in functioning, as described 
in the following paragraphs, we must consider any variations in the 
child's level of functioning to determine the impact of the chronic 
illness on the child's ability to function longitudinally; that is, 
over time. For more information about how we evaluate the severity 
of a child's limitations, see SSR 09-1p. For a comprehensive 
discussion of how we document a child's functioning, including 
evidentiary sources, see SSR 09-2p, Title XVI: Determining Childhood 
Disability--Documenting a Child's Impairment-Related Limitations.
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    We next evaluate the effects of a child's impairment(s) by rating 
the degree to which the impairment(s) limits functioning in six 
``domains.'' Domains are broad areas of functioning intended to capture 
all of what a child can or cannot do. We use the following six domains:
    (1) Acquiring and using information,
    (2) Attending and completing tasks,
    (3) Interacting and relating with others,
    (4) Moving about and manipulating objects,
    (5) Caring for yourself, and
    (6) Health and physical well-being.

20 CFR 416.926a(b)(1).\8\
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    \8\ For the first five domains, we describe typical development 
and functioning using five age categories: Newborns and young 
infants (birth to attainment of age 1); older infants and toddlers 
(age 1 to attainment of age 3); preschool children (age 3 to 
attainment of age 6); school-age children (age 6 to attainment of 
age 12); and adolescents (age 12 to attainment of age 18). We do not 
use age categories in the sixth domain because that domain does not 
address typical development and functioning, as we explain in SSR 
09-8p, Title XVI: Determining Childhood Disability--The Functional 
Equivalence Domain of ``Health and Physical Well-Being.''
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    To functionally equal the listings, an impairment(s) must be of 
listing-level severity; that is, it must result in ``marked'' 
limitations in two domains of functioning or an ``extreme'' limitation 
in one domain.\9\ 20 CFR 416.926a(a).
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    \9\ See 20 CFR 416.926a(e) for definitions of the terms 
``marked'' and ``extreme.''
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Policy Interpretation

General

    In the domain of ``Moving about and manipulating objects,'' we 
consider the physical ability to move one's body from one place to 
another, and to move and manipulate things. These activities may 
require gross or fine motor skills, or a combination of both.
    Moving one's body includes several kinds of actions, such as:
     Rolling,
     Rising or pulling up from a sitting position,
     Raising the head, arms, and legs,
     Twisting the hands and feet,
     Shifting weight while sitting or standing,
     Transferring from one surface to another,
     Lowering down to the floor, as when bending, kneeling, 
stooping, or crouching, and
     Moving forward and backward as when crawling, walking, 
running, and negotiating different terrains (for example, curbs, steps, 
and hills).
    Moving and manipulating objects includes several kinds of actions, 
such as:
     Engaging the upper and lower body to push, pull, lift, or 
carry objects from one place to another,
     Controlling the shoulders, arms, and hands to hold or 
transfer objects, and
     Coordinating the eyes and hands to manipulate small 
objects or parts of objects.
    All of these physical actions require children to exhibit varying 
degrees of strength, coordination, dexterity, and pace to accomplish a 
given task or activity (for example, getting dressed). They also 
require children to have a sense of where their bodies are in relation 
to the environment and an understanding of how their bodies move in 
space (for example, jumping rope). In addition, gross and fine motor 
skills require the integration of sensory input with motor output (for 
example, seeing a ball and catching it). Those skills also require the 
capacity for motor planning and motor memory, that is, the ability to 
plan, remember, and execute controlled movement (for example, riding a 
bicycle).

[[Page 7520]]

    Both physical and mental impairments can affect a child's ability 
to move about and manipulate objects. For example:
     A child with a benign brain tumor may have difficulty with 
balance.
     A child with rheumatoid arthritis may have difficulty 
writing.
     A child with a developmental coordination disorder may be 
clumsy or have slow eye-hand coordination.

Some somatoform disorders can also have effects in this domain.
    Some medications can affect a child's ability to move about and 
manipulate objects. For example, some antidepressant medications may 
cause hand tremors that interfere with fine motor skills. If these 
effects persist over time, we consider them in this domain.
    As with limitations in any domain, we do not consider a limitation 
in the domain of ``Moving about and manipulating objects'' unless it 
results from a medically determinable impairment(s). However, while it 
is common for some children (especially younger children) to experience 
some difficulty in this area from time to time, a child who has 
significant but unexplained problems in this domain may have an 
impairment(s) that was not alleged or has not yet been diagnosed. In 
such cases, adjudicators should pursue any indications that an 
impairment(s) may be present.

The Difference Between the Domains of ``Moving About and Manipulating 
Objects'' and ``Health and Physical Well-Being''

    In the domain of ``Moving about and manipulating objects,'' we 
consider how well children are able to move their own bodies and handle 
things. We evaluate limitations of fine and gross motor movements 
caused by musculoskeletal and neurological impairments, by other 
impairments (including mental disorders) that may result in motor 
limitations, and by medications or other treatments that cause such 
limitations.
    In the domain of ``Health and physical well-being,'' we consider 
the cumulative physical effects of physical and mental impairments and 
their associated treatments or therapies not addressed in the domain of 
``Moving about and manipulating objects.'' We evaluate the problems of 
children who are physically ill or who manifest physical effects of 
mental impairments (except for effects on motor functioning). Physical 
effects, such as pain, weakness, dizziness, nausea, reduced stamina, or 
recurrent infections, may result from the impairment(s) itself, from 
medications or other treatment, or from chronic illness. These effects 
can determine whether a child feels well enough and has sufficient 
energy to engage in age-appropriate activities, either alone or with 
other children.\10\
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    \10\ For more information about the domain of ``Health and 
physical well-being,'' see SSR 09-8p, Title XVI: Determining 
Childhood Disability: The Functional Equivalence Domain of ``Health 
and Physical Well-Being.''
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    In fact, an impairment(s) or its treatment may have effects in both 
domains when it affects fine or gross motor functioning and the child's 
general physical state. For example, some medications used to treat 
impairments that affect motor functioning may have physical effects 
(such as nausea, headaches, allergic reactions, or insomnia) that sap a 
child's energy or make the child feel ill. We evaluate these 
generalized, cumulative effects on the child's overall physical 
functioning in the domain of ``Health and physical well-being.'' We 
evaluate any limitations in fine or gross motor functioning in the 
domain of ``Moving about and manipulating objects.''

Effects in Other Domains

    Impairments that affect motor functioning and their associated 
treatments can have effects in other domains as well. For example, 
generalized or localized pain that results from an impairment(s) may 
interfere with a child's ability to concentrate, an effect that we 
evaluate in the domain of ``Attending and completing tasks'' and often 
in the domain of ``Acquiring and using information.'' Pain may also 
cause a child to be less active socially, an effect that we evaluate in 
the domain of ``Interacting and relating with others.'' Some 
medications for physical impairments may cause restlessness, agitation, 
or anxiety that may affect a child's social functioning (which we 
evaluate in the domain of ``Interacting and relating with others'') or 
emotional well-being (which we evaluate in the domain of ``Caring for 
yourself'').\11\
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    \11\ Further, a child may also have social difficulties because 
of a device used for treatment or assistance in functioning, such as 
a prosthesis for a missing limb or other adaptive equipment, that 
results in social stigma.
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    Therefore, as in any case, we evaluate the effects of a child's 
impairment(s), including the effects of medication or other treatment 
and therapies, in all relevant domains. Rating the limitations caused 
by a child's impairment(s) in each and every domain that is affected is 
not ``double-weighting'' of either the impairment(s) or its effects. 
Rather, it recognizes the particular effects of the child's 
impairment(s) in all domains involved in the child's limited 
activities.\12\
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    \12\ For more information about how we rate limitations, 
including their interactive and cumulative effects, see SSR 09-1p.
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Examples of Typical Functioning in the Domain of ``Moving About and 
Manipulating Objects''

    While there is a wide range of normal development, most children 
follow a typical course as they grow and mature. To assist adjudicators 
in evaluating a child's impairment-related limitations in the domain of 
``Moving about and manipulating objects,'' we provide the following 
examples of typical functioning drawn from our regulations, training, 
and case reviews. These examples are not all-inclusive, and 
adjudicators are not required to develop evidence about each of them. 
They are simply a frame of reference for determining whether children 
are functioning typically for their age with respect to the development 
and use of gross and fine motor skills.
    1. Newborns and young infants (birth to attainment of age 1)
     Explores immediate environment by moving body and using 
limbs.
     Learns to hold head up, sit, crawl, and stand.
     Tries to hold onto a stable object and stand actively for 
brief periods.
     Begins to practice developing eye-hand control by reaching 
for objects or picking up small objects and dropping them into 
containers.
    2. Older infants and toddlers (age 1 to attainment of age 3)
     Explores a wider area of the physical environment with 
steadily increasing body control and independence from others.
     Begins to walk and run without assistance, and climbs with 
increasing skill.
     Tries frequently to manipulate small objects and to use 
hands to do or get something wanted or needed.
     Uses improving motor skills to play with small blocks, 
scribble with crayons, and feed self.
    3. Preschool children (age 3 to attainment of age 6)
     Walks and runs with ease.
     Climbs stairs and playground equipment with little 
supervision.
     Plays more independently (for example, rides a tricycle, 
swings self).
     Completes puzzles easily, strings beads, and builds with 
assortment of blocks.
     Uses crayons, markers, and small game pieces with 
increasing control.
     Cuts with scissors independently.
     Manipulates buttons and other fasteners.

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    4. School-age children (age 6 to attainment of age 12)
     Uses developing gross motor skills to move at an efficient 
pace at home, at school, and in the neighborhood.
     Uses increasing strength and coordination to participate 
in a variety of physical activities (for example, running, jumping, and 
throwing, kicking, catching and hitting balls).
     Applies developing fine motor skills to use many kitchen 
and household tools independently (for example, scissors).
     Writes with a pen or pencil.
    5. Adolescents (age 12 to attainment of age 18)
     Uses motor skills to move easily and freely at home, at 
school, and in the community.
     Participates in a full range of individual and group 
physical fitness activities.
     Shows mature skills in activities requiring eye-hand 
coordination.
     Possesses the fine motor skills to write efficiently or 
type on a keyboard.

Examples of Limitations in the Domain of ``Moving About and 
Manipulating Objects''

    To further assist adjudicators in evaluating a child's impairment-
related limitations in the domain of ``Moving about and manipulating 
objects,'' we also provide the following examples of some of the 
limitations we consider in this domain. These examples are drawn from 
our regulations and training. They are not the only examples of 
limitations in this domain, nor do they necessarily describe a 
``marked'' or an ``extreme'' limitation.
    In addition, the examples below may or may not describe limitations 
depending on the expected level of functioning for a given child's age. 
For example, a teenager would be expected to run without difficulty, 
but a toddler would not.\13\
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    \13\ See 20 CFR 416.924b.
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     Has muscle weakness, joint stiffness, or sensory loss that 
interferes with motor activities (for example, unintentionally drops 
things).
     Has trouble climbing up and down stairs, or has jerky or 
disorganized locomotion, or difficulty with balance.
     Has trouble coordinating gross motor movements (for 
example, bending, kneeling, crawling, running, jumping rope, or riding 
a bicycle).
     Has difficulty with sequencing hand or finger movements 
(for example, using utensils or manipulating buttons).
     Has difficulty with fine motor movements (for example, 
gripping and grasping objects).
     Has poor eye-hand coordination when using a pencil or 
scissors.

DATES: Effective date: This SSR is effective on March 19, 2009.
    Cross-References: SSR 09-1p, Title XVI: Determining Childhood 
Disability Under the Functional Equivalence Rule--The ``Whole Child'' 
Approach; SSR 09-2p, Title: Determining Childhood Disability--
Documenting a Child's Impairment-Related Limitations; SSR 09-3p, Title 
XVI: Determining Childhood Disability--The Functional Equivalence 
Domain of ``Acquiring and Using Information''; SSR 09-4p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Attending and Completing Tasks''; SSR 09-5p, Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of 
``Interacting and Relating with Others''; SSR 09-7p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Caring for Yourself''; SSR 09-8p, Title XVI: Determining Childhood 
Disability--The Functional Equivalence Domain of ``Health and Physical 
Well-Being''; and Program Operations Manual System (POMS) DI 25225.030, 
DI 25225.035, DI 25225.040, DI 25225.045, DI 25225.050, and DI 
25225.055.

[FR Doc. E9-3383 Filed 2-13-09; 8:45 am]
BILLING CODE 4191-02-P