[Federal Register Volume 74, Number 31 (Wednesday, February 18, 2009)]
[Notices]
[Pages 7630-7633]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-3380]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2008-0062, Social Security Ruling, SSR 09-4p.]


Title XVI: Determining Childhood Disability--The Functional 
Equivalence Domain of ``Attending and Completing Tasks''

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are giving notice of SSR 09-4p. This SSR consolidates 
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of ``Attending 
and completing tasks.'' It also explains our policy about that domain.

DATES: Effective Date: March 20, 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

[[Page 7631]]

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 ``Attending and 
Completing Tasks''

    Purpose: This SSR consolidates information from our regulations, 
training materials, and question-and-answer documents about the 
functional equivalence domain of ``Attending and completing tasks.'' 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\ 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:
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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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    (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 ``Attending and completing tasks,'' we consider a 
child's ability to focus and maintain attention, and to begin, carry 
through, and finish activities or tasks. We consider the child's 
ability to initiate and maintain attention, including the child's 
alertness and ability to focus on an activity or task despite 
distractions, and to perform tasks at an appropriate pace. We also 
consider the child's ability to change focus after completing a task 
and to avoid impulsive thinking and acting. Finally, we evaluate a 
child's ability to organize, plan ahead, prioritize competing tasks, 
and manage time.\10\
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    \10\ In 20 CFR 416.924a(b)(5), we provide that how independently 
a child can ``initiate, sustain, and complete'' activities is a 
``factor'' we consider when evaluating a child's functioning. The 
difference between this ``factor'' and the domain of ``Attending and 
completing tasks'' is that the factor addresses the issue of 
independence in functioning at every step in the sequential 
evaluation process and in all domains--the extent to which a child 
can begin, carry out, and finish age-appropriate activities at an 
appropriate rate and without needing extra help. The child may 
receive help in a number of ways: Personal service from another 
person; special equipment, devices, or medications; adaptations 
(such as special appliances); and structured or supportive settings, 
including the amount of help the child needs to remain in a regular 
setting. The domain of ``Attending and completing tasks'' assesses a 
child's specific ability to focus and maintain attention.
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    The ability to attend and to complete tasks develops throughout 
childhood, evolving from an infant's earliest response to stimuli, such 
as light, sound, and movement, to an adolescent's completion of 
academic requirements. Over time, this evolution can be seen in the 
steady development of a child's ability to attend and to complete 
increasingly complex tasks. For example:
     Newborns or young infants gaze at human faces or moving 
objects, and listen in the direction of a human voice.
     Toddlers engage in activities that interest them, such as 
listening to a story.

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     Preschool children engage in uninterrupted periods of 
play, such as putting a puzzle together.
     School-age children focus long enough to do classwork and 
homework.
     Adolescents may perform part-time work requiring sustained 
attention to assigned duties that must be completed on time.
    As in any domain, when we evaluate a child's limitations in the 
domain of ``Attending and completing tasks,'' we consider how 
appropriately, effectively, and independently the child functions 
compared to children of the same age who do not have impairments. For 
example, a teacher may report that a child ``pays attention well with 
frequent prompting.'' The need for frequent prompting demonstrates that 
the child is not paying attention as appropriately, effectively, or 
independently as children of the same age who do not have impairments. 
Despite the fact that the child is paying attention with prompting, 
this child is not functioning well in this domain.
    The domain of ``Attending and completing tasks'' covers only the 
mental aspects of task completion; such as the mental pace that a child 
can maintain to complete a task.\11\ Therefore, limitations in the 
domain of ``Attending and completing tasks'' are most often seen in 
children with mental disorders. For example, in school:
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    \11\ We evaluate a child's physical ability to complete tasks in 
the domain of ``Moving about and manipulating objects,'' or when 
appropriate, ``Health and physical well-being.'' For example, a 
child who has difficulty getting dressed at an age-appropriate pace 
because of rheumatoid arthritis has a limitation that we evaluate in 
the domain of ``Moving about and manipulating objects'' or ``Health 
and physical well-being'' depending on the specific physical reason 
for the limitation; for example, joint deformity (Moving about and 
manipulating objects) or constitutional symptoms and signs (Health 
and physical well-being). A physical impairment may have effects 
that we evaluate in both the domains of ``Moving about and 
manipulating objects'' and ``Health and physical well-being''; such 
as when a child has both a musculoskeletal deformity and 
constitutional symptoms and signs because of systemic sclerosis. In 
addition to the SSRs for the other domains cited at the end of this 
SSR, see generally SSR 09-1p.
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     Children with attention-deficit/hyperactivity disorder 
(AD/HD) whose primary difficulty is inattention may be easily 
distracted or have difficulty focusing on what is important and staying 
on task. They may fail to pay close attention to details and make 
careless mistakes in schoolwork, avoid projects that require sustained 
attention, or lose things needed for school or other activities beyond 
what is expected of children their age who do not have impairments.
     Children with AD/HD whose primary difficulty is 
hyperactivity and impulsivity may fidget with objects instead of paying 
attention, talk instead of listening to instructions, or get up from 
their desks and wander around the classroom beyond what is expected of 
children their age who do not have impairments.\12\
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    \12\ We provide a number of examples involving AD/HD and autism 
spectrum disorders in this SSR because these impairments frequently 
occur in childhood SSI cases. However, many other kinds of mental 
disorders can cause limitations in the ability to attend and to 
complete tasks. For example, mood disorders, such as depression, 
often cause difficulties in concentration.
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    Although we more often see limitations in this domain in connection 
with mental disorders, a physical impairment(s) can also affect a 
child's mental ability to attend and to complete tasks. For example, 
pain caused by a musculoskeletal disorder can distract a child and 
interfere with the child's ability to concentrate and to complete 
assignments on time. Medications that affect concentration or interfere 
with other mental processes, such as some medications for seizure 
disorders, may also affect a child's ability to attend and to complete 
tasks.
    Some children with impairments can attend to some tasks, but not to 
all tasks in all settings. Such children may exhibit ``hyperfocus,'' an 
intense focus on things that interest them, such as video games, but be 
limited in their ability to focus on other tasks. These kinds of 
limitations in the domain of ``Attending and completing tasks'' are 
common in children with AD/HD and autistic spectrum disorders (ASD). 
For example, some children with ASD may be distracted by, or become 
fixated on, everyday sounds (such as the hum of an air conditioner) 
that children without impairments can easily ignore. Children with 
autism may become fixated on parts of an object (such as the wheels on 
a toy truck) rather than on the more obvious and primary use of the 
object. Children with Asperger's disorder (one type of ASD), may 
hyperfocus on a single area of interest and have difficulty discussing 
or paying attention to any other subject. These children may appear to 
function well, or even better than other children, in the area of 
hyperfocus, but may be very limited in some other tasks and settings.
    As with limitations in any domain, we do not consider a limitation 
in the domain of ``Attending and completing tasks'' unless it results 
from a medically determinable impairment(s). However, while it is 
common for all children to experience some difficulty attending and 
completing tasks 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.

 Effects in Other Domains

    In the domain of ``Attending and completing tasks,'' we consider 
the mental aspects of a child's ability to focus, maintain attention, 
and complete age-appropriate tasks throughout the day. In addition, 
because the ability to attend and to complete tasks is involved in 
nearly everything a child does, an impairment(s) that affects this 
ability may cause limitations in other domains.
    For example, school-age children with AD/HD may have limitations in 
multiple domains. The effects of inattention and hyperactivity can 
impede the learning process and affect competence in many areas of 
life. These effects can result in limitations in the domain of 
``Acquiring and using information''; for example, by undermining 
academic performance. They may also have effects in the domain of 
``Interacting and relating with others''; for example, children with 
AD/HD may interrupt others in conversation or have difficulty taking 
turns during play activities. They may also cause limitations in the 
domain of ``Caring for yourself''; for example, when a child risks 
personal safety by not stopping and thinking before doing something.
    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.\13\
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    \13\ 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 ``Attending and 
Completing Tasks''

    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 
``Attending and completing tasks,'' we provide the following examples 
of typical functioning drawn from our regulations, training, and case 
reviews. These examples are not all-inclusive, and

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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 attending and 
completing tasks.
1. Newborns and Young Infants (Birth to Attainment of Age 1)
     Shows sensitivity to environment by responding to various 
stimuli (for example, light, touch, temperature, movement).
     Stops activity when voices or other sounds are heard.
     Begins to notice and gaze at various moving objects, 
including people and toys.
     Listens to family conversations and plays with people and 
toys for progressively longer periods of time.
     Wants to change activities frequently, but gradually 
expands interest in continuing an interaction or a game.
2. Older Infants and Toddlers (Age 1 to Attainment of Age 3)
     Attends to things of interest (for example, looking at 
picture books, listening to stories).
     Has adequate attention to complete some tasks 
independently (for example, putting a toy away).
     Demonstrates sustained attention (for example, building 
with blocks, helping to put on clothes).
3. Preschool Children (Age 3 to Attainment of Age 6)
     Pays attention when spoken to directly.
     Sustains attention to play and learning activities.
     Concentrates on activities like putting puzzles together 
or completing art projects.
     Focuses long enough to complete many activities 
independently (for example, getting dressed, eating).
     Takes turns and changes activities when told by a 
caregiver or teacher that it is time to do something else.
     Plays contentedly and independently without constant 
supervision.
4. School-age Children (Age 6 to Attainment of Age 12)
     Focuses attention in a variety of situations in order to 
follow directions, completes school assignments, and remembers and 
organizes school-related materials.
     Concentrates on details and avoids making careless 
mistakes.
     Changes activities or routines without distracting self or 
others.
     Sustains attention well enough to participate in group 
sports, read alone, and complete family chores.
     Completes a transition task without extra reminders or 
supervision (for example, changing clothes after gym or going to 
another classroom at the end of a lesson).
5. Adolescents (Age 12 to Attainment of Age 18)
     Pays attention to increasingly longer presentations and 
discussions.
     Maintains concentration while reading textbooks.
     Plans and completes long-range academic projects 
independently.
     Organizes materials and manages time in order to complete 
school assignments.
     Maintains attention on tasks for extended periods of time, 
and is not unduly distracted by or distracting to peers in a school or 
work setting.

Examples of Limitations in the Domain of ``Attending and Completing 
Tasks''

    To further assist adjudicators in evaluating a child's impairment-
related limitations in the domain of ``Attending and completing 
tasks,'' 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 toddler would not be expected to be able to play a game 
or stay on another task for an hour, but a teenager would.\14\
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    \14\ See 20 CFR 416.924b.
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     Is easily startled, distracted, or overreactive to 
everyday sounds.
     Is slow to focus on or fails to complete activities that 
interest the child.
     Gives up easily on tasks that are within the child's 
capabilities.
     Repeatedly becomes sidetracked from activities or 
frequently interrupts others.
     Needs extra supervision to stay on task.
     Cannot plan, manage time, or organize self in order to 
complete assignments or chores.
    Effective date: This SSR is effective upon publication in the 
Federal Register.
    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 09-5p, 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''; SSR 09-8p, Title XVI: Determining Childhood 
Disability--The Functional Equivalence Domain of ``Health and Physical 
Well-Being''; SSR 98-1p, Determining Medical Equivalence in Title XVI 
Childhood Disability Claims When a Child Has Marked Limitations in 
Cognition and Speech; 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. E9-3380 Filed 2-17-09; 8:45 am]
BILLING CODE 4191-02-P