Effective Date: March 19, 2009
Publication Date: February 17, 2009
Federal Register Vol. 74, No. 30, page 7524
POLICY INTERPRETATION RULING
SSR 09- 8p: Title XVI: Determining Childhood Disability – The Functional Equivalence Domain of “Health and Physical Well-Being”
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.
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 “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. 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.
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), or having local or generalized pain; and
- 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.
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.
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.”
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”).
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.
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.
In addition, as in the examples of limitations for the other five domains, we consider a child’s age 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.
- 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, multiple surgeries or chemotherapy).
- Experiences periodic exacerbations (for example, pain crises in sickle cell anemia).
- Needs intensive medical care as a result of being medically fragile.
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 09-6p, 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.
 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, as we explain in this SSR , that domain does not address typical development and functioning.
 For more information about the other five domains of functional equivalence, see the cross-references at the end of this SSR.
 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.
 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.
 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.
 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.”
 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.
 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).