[Federal Register Volume 74, Number 30 (Tuesday, February 17, 2009)]
[Notices]
[Pages 7524-7527]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-3385]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2008-0062]


Social Security Ruling, SSR 09-8p. Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Health and 
Physical Well-Being''

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are giving notice of SSR 09-8p. This SSR consolidates 
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of ``Health 
and physical well-being.'' 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 programs. SSRs may be 
based on determinations or decisions made at all levels of 
administrative adjudication,

[[Page 7525]]

Federal court decisions, Commissioner's decisions, opinions of the 
Office of the General Counsel, or policy 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 ``Health and Physical Well-Being''

    Purpose: This SSR consolidates information from our regulations, 
training materials, and question-and-answer documents about the 
functional equivalence domain of ``Health and physical well-being.'' 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, as we explain in 
this SSR, that domain does not address typical development and 
functioning.
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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 ``Health and physical well-being,'' we consider 
the cumulative physical effects of physical and mental impairments and 
their associated treatments on a child's health and functioning. Unlike 
the other five domains of functional equivalence (which address a 
child's abilities), this domain does not address typical development 
and functioning.\10\ Rather, the ``Health and physical well-being'' 
domain addresses how such things as recurrent illness, the side effects 
of medication, and the need for ongoing treatment affect a child's 
body; that is, the child's health and sense of physical well-being.\11\
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    \10\ For more information about the other five domains of 
functional equivalence, see the cross-references at the end of this 
SSR.
    \11\ In 20 CFR 416.924a(b)(8) and (b)(9), we provide that ``the 
impact of chronic illness'' and ``effects of treatment'' are 
``factors'' we consider when evaluating a child's functioning. The 
difference between these ``factors'' and the domain of ``Health and 
physical well-being'' is that the factors address any kind of effect 
(physical or mental) that a child's impairment(s) has on 
functioning, and we consider those effects at every step in the 
sequential evaluation process. However, we consider the domain only 
when determining whether a child's impairment(s) ``functionally 
equals the listings,'' and the domain addresses only the physical 
effects of a child's physical or mental impairment(s) (including 
associated treatment) on a child's overall health.
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    Some physical effects that we consider in this domain can result 
directly from a physical or mental impairment(s). For example:
     Feeling weak, dizzy, agitated, short of breath, fatigued, 
low in energy, short on stamina, or ``slowed down'' (as with 
psychomotor retardation),\12\ or having local or generalized pain; and
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    \12\ Most pediatricians and developmental specialists use the 
term ``psychomotor retardation'' to describe children with some 
combination of cognitive, communicative, and motor limitations. 
However, psychiatrists and psychologists use the term in a more 
restricted sense, to mean the motor effects of psychiatric 
disorders, such as the slow or limited movement that may be seen in 
a seriously depressed individual. In our regulation describing this 
domain (20 CFR 416.926a(l)) and in our mental disorders listings, 
the term has the same meaning as it does for psychiatrists and 
psychologists. Because different specialists use the term 
differently, it is important to read carefully any evidence that 
uses this term in order to determine how it is being used.

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[[Page 7526]]

     Allergic reactions, recurrent infections, poor growth, 
bladder or bowel incontinence, changes in weight or eating habits, 
stomach discomfort, nausea, seizures or convulsive activity, headaches, 
or insomnia.
    These and other physical effects can also be the consequence of 
treatment a child receives. For example:
     Medications for physical or mental disorders can cause 
generalized symptoms, such as fatigue, dizziness, or drowsiness, or 
more specific problems, such as nausea or weight loss. Certain 
medications used to treat mental disorders can have indirect physical 
effects. For example, some medications used to treat attention-deficit/
hyperactivity disorder may cause a change in eating habits which may, 
in turn, limit growth.
     Therapy (for example, chemotherapy, multiple surgeries or 
procedures, chelation, pulmonary cleansing, or nebulizer treatments) 
can have physical effects, including generalized symptoms, such as 
weakness, or more specific problems, such as nausea. In addition, 
periods of therapy can be frequent or time-consuming, require recovery 
time, or reduce a child's endurance.
    There are other considerations in this domain. For example:
     A child who otherwise appears to be functioning 
appropriately may be doing so because of intensive medical or other 
care needed to maintain health and physical well-being. We evaluate 
such medical fragility in this domain.
     Some disorders (for example, cystic fibrosis and asthma) 
are episodic, with periods of worsening (exacerbation) and improvement 
(remission). When symptoms and signs fluctuate, we consider the 
frequency and duration of exacerbations, as well as the extent to which 
they affect a child's ability to function physically.\13\
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    \13\ We generally do not consider brief episodes of illness (for 
example, ear infections) in this domain because they would not meet 
the duration requirement. However, there are certain impairments, 
such as immune deficiency diseases, that increase a child's 
susceptibility to infection or other disorders. In the domain of 
``Health and physical well-being,'' we consider such episodes of 
illness when they are associated with the child's underlying 
impairment.
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    In all cases, it is important to remember that the cumulative 
physical effects of a child's physical or mental impairment(s) can vary 
in kind and intensity, and can affect each child differently.
    As with limitations in any domain, we do not consider a limitation 
in the domain of ``Health and physical well-being'' unless it results 
from a medically determinable impairment(s). However, it is unlikely 
that a child who has a significant problem in this domain does not have 
an impairment(s) that causes the problem. Therefore, if a child has a 
significant problem in this domain, and there is no evidence of a 
medically determinable impairment(s) that could be the cause of the 
limitations, adjudicators should ensure that they have made all 
necessary attempts to obtain evidence of an impairment(s) and explain 
any finding that there is no medically determinable impairment(s) to 
account for the limitations in the determination or decision.

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

    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 disorders (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, 
medication or other treatment, or 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.
    In the domain of ``Moving about and manipulating objects,'' we 
consider how well children can 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.\14\
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    \14\ For more information about the domain of ``Moving about and 
manipulating objects,'' see SSR 09-6p, Title XVI: Determining 
Childhood Disability: The Functional Equivalence Domain of ``Moving 
About and Manipulating Objects.''
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    In fact, an impairment(s) may have effects in both domains when it 
affects the child's general physical state and fine or gross motor 
functioning. 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 health and physical well-being can have 
effects in other domains as well. For example, a child who must 
frequently miss school because of illness (including the need to go for 
treatment) may have social limitations that we also evaluate in the 
domain of ``Interacting and relating with others,'' behavioral 
manifestations that we evaluate in the domain of ``Caring for 
yourself,'' or both. In some cases, chronic absence from school may 
result in limitations we also evaluate in the domain of ``Acquiring and 
using information.''
    Additionally, 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 affect mental 
functioning, interfering with a child's ability to pay attention, 
remember, or follow directions. We consider these effects in the domain 
of ``Acquiring and using information,'' ``Attending and completing 
tasks,'' or both depending upon the type of limitation that results. 
Other 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'').\15\
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    \15\ Further, a child may also have social difficulties because 
of a device used for treatment or assistance in functioning, such as 
the need to use a breathing device 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

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recognizes the particular effects of the child's impairment(s) in all 
domains involved in the child's limited activities.\16\
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    \16\ For more information about how we rate limitations, 
including their interactive and cumulative effects, see SSR 09-1p.
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Examples of Limitations in the Domain of ``Health and Physical Well-
Being''

    To assist adjudicators in evaluating a child's impairment-related 
limitations in the domain of ``Health and physical well-being,'' we 
provide the following examples of limitations that are drawn from our 
regulations, training, and case reviews. They are not the only 
limitations in this domain, nor do they necessarily describe a 
``marked'' or an ``extreme'' limitation.\17\
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    \17\ There are some rules for determining whether there is a 
``marked'' or an ``extreme'' limitation in the ``Health and physical 
well-being'' domain that are unique to this domain. See 20 CFR 
416.926a(e)(2)(iv) and 416.926a(e)(3)(iv).
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    In addition, as in the examples of limitations for the other five 
domains, we consider a child's age \18\ in determining whether there is 
a limitation in functioning in the domain of ``Health and physical 
well-being.'' 20 CFR 416.926a(1)(4). While it is less likely that age 
will be a factor in determining whether there is a limitation in this 
domain, it is still possible, and we must consider the expected level 
of functioning for a given child's age in determining the severity of a 
limitation.
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    \18\ See 20 CFR 416.924b.
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     Has generalized symptoms caused by an impairment(s) (for 
example, tiredness due to depression).
     Has somatic complaints related to an impairment(s) (for 
example, epilepsy).
     Has chronic medication side effects (for example, 
dizziness).
     Needs frequent treatment or therapy (for example, 
multiplesurgeries or chemotherapy).
     Experiences periodic exacerbations (for example, pain 
crises in sickle cell anemia).
     Needs intensive medical care as a result of being 
medically fragile.

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 09-6p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Moving About and Manipulating Objects''; SSR 09-7p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Caring for Yourself''; 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. E9-3385 Filed 2-13-09; 8:45 am]
BILLING CODE 4191-02-P