[Federal Register Volume 74, Number 30 (Tuesday, February 17, 2009)]
[Notices]
[Pages 7521-7524]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-3384]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2008-0062; Social Security Ruling, SSR 09-7p.]


Title XVI: Determining Childhood Disability--The Functional 
Equivalence Domain of ``Caring for Yourself''

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are giving notice of SSR 09-7p. This SSR consolidates 
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of ``Caring 
for yourself.'' It also explains our policy about that domain.

DATES: Effective Date: March 19, 2009.

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

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

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

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

Policy Interpretation Ruling

Title XVI: Determining Childhood Disability--The Functional Equivalence 
Domain of ``Caring for Yourself''

    Purpose: This SSR consolidates information from our regulations, 
training materials, and question-and-answer documents about the 
functional equivalence domain of ``Caring for yourself.'' It also 
explains our policy about that domain.
    Citations: Sections 1614(a)(3), 1614(a)(4), and 1614(c) of the 
Social Security Act, as amended; Regulations No. 4, subpart P, appendix 
1; and Regulations No. 16, subpart I, sections 416.902, 416.906, 
416.909, 416.923, 416.924, 416.924a, 416.924b, 416.925, 416.926, 
416.926a, 416.930, and 416.994a.
    Introduction: A child \1\ who applies for Supplemental Security 
Income (SSI) \2\ is ``disabled'' if the child is not engaged in 
substantial gainful activity and has a medically determinable physical 
or mental impairment or

[[Page 7522]]

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\

    \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 ``Caring for yourself,'' we consider a child's 
ability to maintain a healthy emotional and physical state. This 
includes:
     How well children get their emotional and physical wants 
and needs met in appropriate ways,
     How children cope with stress and changes in the 
environment, and
     How well children take care of their own health, 
possessions, and living area.
    Although newborns and young infants are almost entirely dependent 
on caregivers for getting their emotional and physical wants and needs 
met, the ability to care for oneself is first manifested at birth. For 
example, a young infant who feels upset (an emotional need) or hungry 
(a physical need) may cry to alert a caregiver. As children mature, 
they are expected to deal with emotional and physical wants and needs 
with increasing competence and independence.
    However, the domain of ``Caring for yourself'' does not address 
children's physical abilities to perform self-care tasks like bathing, 
getting dressed, or cleaning up their room. We address these physical 
abilities in the domain of ``Moving about and manipulating objects'' 
and, if appropriate, ``Health and physical well-being.'' \10\ Nor does 
it concern the ability to relate to other people, which we address in 
the domain of ``Interacting and relating with others.'' Rather, in 
``Caring for yourself,'' we focus on how well a child relates to self 
by maintaining a healthy emotional and physical state in ways that are 
age-appropriate and in comparison to other same-age children who do not 
have impairments.
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    \10\ A child may have limitations in the ability to do these 
self-care tasks because of impairment-related effects in other 
domains as well. For example, we evaluate the limitations of a child 
who has difficulty getting dressed because of an impairment that 
affects cognition in the domain of ``Acquiring and using 
information.'' See SSR 09-1p.
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    A child may have limitations in the domain of ``Caring for 
yourself'' because of a mental or a physical impairment(s), medication, 
or other treatment. For example, if an adolescent who is prescribed a 
medication that causes weight gain frequently fails or refuses to take 
it because of embarrassment about his weight, thereby endangering his 
health, we would evaluate this limitation in the domain of ``Caring for 
yourself.'' \11\
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    \11\ We do not consider a child fully responsible for failing to 
follow prescribed treatment. Also, the policy of failure to follow 
prescribed treatment does not apply unless we first find that the 
child is disabled. Under this policy, we must also find that 
treatment was prescribed by the child's ``treating source'' (as 
defined in 20 CFR 416.902) and that it is clearly expected that, 
with the treatment, the child would no longer be disabled. Even 
then, we must consider whether there is a ``good reason'' for the 
failure to follow the prescribed treatment. For example, if the 
child's caregiver believes the side effects of treatment are 
unacceptable, or an adolescent refuses to take medication because of 
a mental disorder, we would find that there is a good reason for not 
following the prescribed treatment. However, if there is not a good 
reason and all the other requirements are met, a denial based on 
failure to follow prescribed treatment would be appropriate. See 20 
CFR 416.930 and SSR 82-59, Titles II and XVI: Failure To Follow 
Prescribed Treatment.
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    As with limitations in any domain, we do not consider a limitation 
in the domain of ``Caring for yourself'' unless it results from a 
medically determinable impairment(s). However, while it is common for 
all 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.

Emotional Wants and Needs

    Children must learn to recognize and respond appropriately to their 
feelings in ways that meet their emotional wants and needs; for 
example, seeking comfort when sad, expressing enthusiasm and joy when 
glad, and showing anger safely when upset. To be successful as they 
mature, children must also be able to cope with negative feelings and 
express positive feelings appropriately. In

[[Page 7523]]

addition, after experiencing any emotion, children must be able to 
return to a state of emotional equilibrium. The ability to experience, 
use, and express emotion is often referred to as self-regulation. 
Children should demonstrate an increased capacity to self-regulate as 
they develop.
    Ordinary circumstances may cause emotions, such as fear, sadness, 
or frustration. Examples of age-appropriate, self-consoling activities 
to regulate such emotions include:
     For a newborn or young infant, sucking on a pacifier or 
thumb when upset.
     For a toddler, carrying a stuffed animal for a sense of 
security.
     For a preschool child, playing with a favorite toy when 
feeling lonely.
     For a school-age child, playing a computer game when 
bored.
     For an adolescent, listening to music when feeling stress.
    However, children whose mental or physical impairments affect the 
ability to regulate their emotional well-being may respond in 
inappropriate ways. For example:
     A child with an anxiety disorder may use denial or escape 
rather than problem-solving skills to deal with a stressful situation.
     A child with attention-deficit/hyperactivity disorder who 
has difficulty completing assignments may express frustration by 
destroying school materials.
     A teenager with a depressive disorder may have adequate 
hygiene, but seek emotional comfort by engaging in self-injurious 
behaviors (for example, binge eating, substance abuse, or suicidal 
gestures).
     A child with a traumatic brain injury who has poor impulse 
control may have problems managing anger.
     A child with a musculoskeletal disorder who feels awkward 
and frustrated during recess time may refuse to leave the classroom.

Physical Wants and Needs

    In addition to regulating emotional well-being, a child must be 
able to satisfy physical wants and needs every day. This requires 
children to have a basic understanding of their own bodies, including 
their bodies' normal functioning, and adequate emotional health for 
carrying out the tasks involved in self-care. The domain of ``Caring 
for yourself'' involves the emotional ability to engage in self-care 
activities, such as feeding, dressing, toileting, and maintaining 
hygiene and physical health.
    Taking care of physical needs, however, also includes other aspects 
of self-care; for example:
     Recognizing when one feels ill,
     Seeking medical attention,
     Following safety rules,
     Asking for help when needed,
     Responding to circumstances in safe and appropriate ways, 
and
     Making decisions that do not endanger oneself.

The Difference Between the Domains of ``Caring for Yourself'' and 
``Interacting and Relating With Others''

    The domains of ``Caring for yourself'' and ``Interacting and 
relating with others'' are related, but different from each other. The 
domain of ``Caring for yourself'' involves a child's feelings and 
behavior in relation to self (as when controlling stress in an age-
appropriate manner). The domain of ``Interacting and relating with 
others'' involves a child's feelings and behavior in relation to other 
people (as when the child is playing with other children, helping a 
grandparent, or listening carefully to a teacher).
    A decision about which domain is appropriate for the evaluation of 
a specific limitation depends on the impact of the particular behavior. 
For example:
     If a girl with hyperactivity impulsively runs into the 
street, endangering herself, we evaluate this problem in self-care in 
the domain of ``Caring for yourself.'' On the other hand, if she 
interrupts conversations inappropriately, we evaluate this problem in 
social functioning in the domain of ``Interacting and relating with 
others.''
     If a language disorder limits a boy's ability to use 
``self-talk'' to calm himself in a stressful situation, we evaluate 
this problem in self-regulation in the domain of ``Caring for 
yourself.'' But if he avoids other children during playtime because of 
the language disorder, we evaluate this problem in social functioning 
in the domain of ``Interacting and relating with others.''
    Some impairments may cause limitations in both domains. For 
example, a boy with Oppositional Defiant Disorder who refuses to obey a 
parent's instruction not to run on a slippery surface endangers himself 
and disrespects the parent's authority. In this case, the child's 
mental disorder is causing limitations in the domains of ``Caring for 
yourself'' and ``Interacting and relating with others.'' Similarly, a 
teenage girl with depression who develops poor eating habits as a form 
of comfort, may also avoid friends and want to be left alone. We 
evaluate the limitations resulting from her depression in both the 
domains of ``Caring for yourself'' and ``Interacting and relating with 
others.'' 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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Effects in Other Domains

    Children with limitations in the domain of ``Caring for yourself'' 
may also have limitations in other domains. For example, children with 
impairments that affect self-regulation may have difficulties in 
school, resulting in a limitation in the domain of ``Acquiring and 
using information'' in addition to the domain of ``Caring for 
yourself.'' Limitations in caring for self are also frequently found in 
connection with impairments whose most obvious effects are in other 
domains. For example, some children with learning disorders, which have 
effects in the domain of ``Acquiring and using information,'' also have 
difficulties with self-regulation.
    Therefore, as in any case, we evaluate the effects of the child's 
impairment(s), including the effects of medication or other treatment 
and therapies, in all relevant domains.

Examples of Typical Functioning in the Domain of ``Caring for 
Yourself''

    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 impairment-related limitations in the domain of ``Caring 
for yourself,'' 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 maintaining a healthy emotional and 
physical state.
1. Newborns and Young Infants (Birth to Attainment of Age 1)
     Responds to body's signals (for example, hunger, 
discomfort, pain) by alerting caregiver to needs (for example, crying).
     Consoles self until help comes (for example, sucking on a 
hand).

[[Page 7524]]

     Begins to expand capacity for self-regulation to include 
rhythmic behaviors (for example, rocking).
     Tries to do things for self, perhaps when still too young 
(for example, insisting on putting food in mouth, refusing caregiver's 
help).
2. Older Infants and Toddlers (Age 1 to Attainment of Age 3)
     Is increasingly able to console self (for example, 
carrying a favorite blanket).
     Cooperates with caregiver in dressing, bathing, and 
brushing teeth, but also shows what he can do (for example, pointing to 
the bathroom, pulling off coat).
     Insists on trying to feed self with spoon.
     Experiments with independence by a degree of contrariness 
(for example, ``No! No!'') and declaring own identity (for example, by 
hoarding toys).
3. Preschool Children (Age 3 to Attainment of Age 6)
     Tries to do things that he is not fully able to do (for 
example, climbing on chair to reach something up high).
     Agrees easily and early in this age range to do what 
caregiver wants, but gradually wants to do many things her own way or 
not at all.
     Develops more confidence in abilities (for example, wants 
to use toilet, feed self independently).
     Begins to understand how to control behaviors that are 
potentially dangerous (for example, crossing street without an adult).
4. School-Age Children (Age 6 to Attainment of Age 12)
     Recognizes circumstances that lead to feeling good and bad 
about himself.
     Begins to develop understanding of what is right and 
wrong, and what is acceptable and unacceptable behavior.
     Demonstrates consistent control over behavior and avoids 
behaviors that are unsafe.
     Begins to imitate more of the behavior of adults she 
knows.
     Performs most daily activities independently (for example, 
dressing, bathing), but may need to be reminded.
5. Adolescents (Age 12 to Attainment of Age 18)
     Discovers appropriate ways to express good and bad 
feelings (for example, keeps a diary, exercises).
     Feels more independent from others and becomes 
increasingly independent in all daily activities.
     Sometimes feels confused about how she feels about 
herself.
     Notices significant changes in his body's development, 
which can result in some anxiety or worry about self and body (may 
sometimes cause anger and frustration).
     Begins to think about future plans (for example, work).
     Maintains personal hygiene adequately (for example, 
bathing, brushing teeth, wearing clean clothing appropriate for weather 
and context).
     Takes medications as prescribed.

Examples of Limitations in the Domain of ``Caring for Yourself''

    To further assist adjudicators in evaluating impairment-related 
limitations in the domain of ``Caring for yourself,'' 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, school-age children would be expected to bathe themselves, 
but toddlers would not; young children may place non-nutritive or 
inedible objects in their mouth, but older children typically would 
not.\13\
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    \13\ See 20 CFR 416.924b.
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     Consoles self with activities that show developmental 
regression (for example, an older child who sucks his thumb).
     Has restrictive or stereotyped mannerisms (for example, 
head banging, body rocking).
     Does not spontaneously pursue enjoyable activities or 
interests (for example, listening to music, reading a book).
     Engages in self-injurious behavior (for example, refusal 
to take medication, self-mutilation, suicidal gestures) or ignores 
safety rules.
     Does not feed, dress, bathe, or toilet self appropriately 
for age.
     Has disturbance in eating or sleeping patterns.
     Places non-nutritive or inedible objects in mouth (for 
example, dirt, chalk).

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 XVI: 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 09-6p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Moving and Manipulating Objects''; SSR 09-8p, Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Health and 
Physical Well-Being''; SSR 82-59, Titles II and XVI: Failure To Follow 
Prescribed Treatment; and Program Operations Manual System (POMS) DI 
25225.030, DI 25225.035, DI 25225.040, DI 25225.045, DI 25225.050, DI 
25225.055, DI 23010.001-23010.010, and DI 23010.020.

[FR Doc. E9-3384 Filed 2-13-09; 8:45 am]
BILLING CODE 4191-02-P