Effective Date: March 19, 2009
Publication Date: February 17, 2009
Federal Register Vol. 74, No. 30, page 7518
POLICY INTERPRETATION RULING
SSR 09-6p: Title XVI: Determining Childhood Disability – The Functional Equivalence Domain of “Moving About and Manipulating Objects”
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.
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.
A child who applies for Supplemental Security Income (SSI) 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 that results in "marked and severe functional limitations." 20 CFR 416.906. This means that the impairment(s) must meet or medically equal a listing in the Listing of Impairments (the listings), or functionally equal the listings (also referred to as “functional equivalence”). 20 CFR 416.924 and 416.926a.
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. 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.
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.
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. 20 CFR 416.926a(a).
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:
- 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).
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.
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”).
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.
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.
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.
- 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.
This SSR is effective on March 19, 2009
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 — “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”; SSR 98-1p, Title XVI: Determining Medical Equivalence in 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.
 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.
 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.
 We use the term “impairment(s)” in this SSR to refer to an “impairment or a combination of impairments.”
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.
 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.
 See SSR 09-1p, Title XVI: Determining Childhood Disability Under the Functional Equivalence Rule – The “Whole Child” Approach.
 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.
 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.”
 See 20 CFR 416.926a(e) for definitions of the terms “marked” and “extreme.”
 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.”
 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.
 For more information about how we rate limitations, including their interactive and cumulative effects, see SSR 09-1p.
 See 20 CFR 416.924b.