United States District Court, N.D. Alabama, Middle Division
CHRISTINA WILLIAMS, o.b.o. K.G., Claimant
CAROLYN W. COLVIN, as acting Commissioner of the Social Security Administration, Defendant.
KARON OWEN BOWDRE, Chief District Judge.
On July 2, 2010, the claimant's mother, Christina Williams, applied for supplemental security income on behalf of the claimant, a child under the age of eighteen, under Title XVI of the Social Security Act, alleging disability commencing on July 2, 2008. The claimant alleged severe depression with psychosis, severe auditory and visual hallucinations, borderline intellectual functioning, and developmental reading disorder. (R. 109-112). The Commissioner denied these claims initially on November 5, 2010. (R. 52).
The claimant timely filed a request for a hearing before an Administrative Law Judge on January 7, 2011. (R. 16). The ALJ held the hearing on May 17, 2012. (R. 35). In an opinion dated June 26, 2012, the ALJ found that the claimant was ineligible for supplemental security income benefits. (R. 20-32). The Appeals Council subsequently denied the claimant's request for review on May 6, 2013, and the ALJ's decision became the final decision of the Commissioner of the Social Security Administration (R. 1-6). As the claimant has exhausted her administrative remedies, this court has jurisdiction pursuant to 42 U.S.C. § 1383(c)(3).
For the following reasons, the court reverses and remands the decision of the Commissioner because of the ALJ's failed to apply the proper legal standard regarding the weight he must give treating physicians.
II. ISSUES PRESENTED
Whether the ALJ committed a reversible error by failing to state with particularity the weight he afforded to the medical opinions of the claimant's treating physician Dr. Khan.
III. STANDARD OF REVIEW
The standard of review of the Commissioner's decision is limited. This court must affirm the Commissioner's decision if he applied the correct legal standards and if substantial evidence supports the factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
"No... presumption of validity attaches to the [Commissioner's] legal conclusions, including determination of the proper standards to be applied in evaluating claims." Walker, 826 F.2d at 999. This court does not review the Commissioner's factual determinations de novo. The court will affirm those factual determinations that are supported by substantial evidence. "Substantial evidence" is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971).
The court must remember that opinions, such as whether a claimant is disabled, the nature and extent of a claimant's residual functional capacity, and the application of vocational factors, "are not medical opinions, ... but are, instead, opinions on issues reserved to the Commissioner because they are administrative findings that are dispositive of a case; i.e, that would direct the determination or decision of disability." 20 C.F.R. §§ 404.1527(e), 416.927(d). Whether the claimant meets the listing and is qualified for Social Security disability benefits is a question reserved for the ALJ, and the court "may not decide facts anew, reweigh the evidence, or substitute [its] judgment for that of the Commissioner." Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ about the significance of certain facts, the court has no power to reverse that finding as long as substantial evidence in the record supports the ALJ's finding.
The court must "scrutinize the record in its entirety to determine the reasonableness of the [Commissioner]'s factual findings." Walker, 826 F.2d at 999. A reviewing court must not look only to those parts of the record that support the decision of the ALJ, but also must view the record in its entirety and take account of evidence that detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).
IV. LEGAL STANDARD
The Social Security Administration has established a three-step sequential evaluation process to determine if an individual under the age of 18 is disabled. 20 C.F.R. § 416.924(a). At step one, the ALJ must determine if the child is engaged in substantial gainful activity. If the child is not engaged in substantial gainful activity, the ALJ then determines whether the child suffers from a severe impairment or combination of impairments that cause more than minimal functional limitations. Id. at § 416.924(a) and (c). If the child suffers from a severe impairment or combination of impairments that has lasted or is expected to continue for a continuous period of at least 12 months, then the ALJ must determine whether the child's impairments meet, medically equal, or functionally equal an impairment listed under Appendix I to Subpart P of Part 404. Id. at § 416.924(a).
The ALJ must state with particularity the weight given different medical opinions and the reasons therefor, and the failure to do so is reversible error. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987); see also MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). The ALJ must give the testimony of a treating physician substantial or considerable weight unless "good cause" is shown to the contrary. Crawford v. Commissioner, 363 F.3d 1155, 1159 (11th Cir. 2004). The Commissioner may reject any medical opinion if the evidence supports a contrary finding. Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir. 1985). Where the ALJ articulated specific reasons for failing to give the opinion of a treating physician controlling weight and those reasons are supported by substantial evidence, the ALJ commits no reversible error. Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005).
The claimant was twelve years old at the time of the administrative hearing and was in the fifth grade. (R. 37). The claimant alleges disability beginning on July 2, 2008, because of severe depression with psychosis, severe auditory and visual hallucinations, borderline intellectual functioning, and developmental reading disorder. (R. 100).
In an undated Function Report, the claimant's mother reported that the claimant had the ability to see, hear, and talk. She further reported that the claimant's disability did not limit his physical abilities. His mother did note that the claimant does or can deliver telephone messages, talk with family and friends; read capital and small letters; read simple words; print some letters; print his name; spell most 3-4 letter words; understand money, know the days of the week and the months of the year; have friends his own age; make new friends; get along with her or other adults; get along with school teachers; use a zipper, button clothes, and choose clothes by himself; tie his shoelaces; take a bath or shower without assistance; brush his teeth; comb or brush his hair; eat by using a knife, fork, and spoon; help out around the house; obey commands most of the time; obey safety rules; get to school on time; keep busy on his own; finish things he starts; work on arts and crafts projects; complete homework; and complete chores most of the time. (R. 121-30).
The claimant's mother also stated that the claimant did not or could not do the following: repeat stories he had heard; tell jokes or riddles accurately; explain why he did something; use sentences with "because, " "what if, " or "should have been;" read and understand simple sentences; read and understand stories in a book or magazine; write in script; write a simple story with 6-7 sentences; add and subtract numbers over 10; tell time; play team sports; wash his hair by himself; pick up and put away toys; or accept criticism or correction. She specifically noted that when he is corrected, the claimant cries and refuses to talk for a while. (R. 121-30).
On September 25, 2007, Ms. A. Milam, a licensed professional counselor at JBS Mental Health/Mental Retardation Authority, completed the claimant's intake assessment. She reported that Ashville Elementary held the claimant back in the first grade because of an inability to learn the material. Ms. Milam reported that the claimant heard voices, saw his dead grandmother, and saw and heard voices of a little boy who was not there. She also reported that the claimant sometimes struggled to feel joyful, and that the voices disturbed his sleep and caused concentration problems. Ms. Milam discussed that the claimant tended to follow the directions that the voices gave him. She concluded by providing goals for the claimant of attending evaluations and following recommendations, as well as increasing social skills and coping skills. (R. 232, 240-51).
Between October 23, 2007 and May 28, 2008, Ms. Milam visited the claimant 14 times. On each visit, she noted that the claimant complained of visual and auditory hallucinations of his grandmother and a young boy. On November 26, 2007, she completed a diagnosis and update on the claimant's progress, noting that the claimant continued to cooperate with Ms. Milam, to appear depressed, and to report hallucinations, as discussed below. (R. 225-92).
On November 7, 2007, the claimant visited Dr. Shakil Khan, a psychiatrist in the Children's Services Program at JBS Mental Health/Mental Retardation Authority. Dr. Khan reported that the claimant complained of auditory and visual hallucinations, including seeing his deceased grandmother and a young boy. Dr. Khan noted that the Conner's Report from September 25, 2007 showed that the claimant exhibited extreme impulsivity, inattentiveness, fidgeting, and frustration, as well as frequent crying. Dr. Khan stated that the claimant had problems in school that required him to repeat kindergarten. After a mental status exam, Dr. Khan reported that the claimant looked sad, depressed, and withdrawn, and that his thought processes and content positively demonstrated auditory and visual hallucinations. Dr. Khan prescribed Risperdal 0.25mg in the morning, Risperdal 0.50mg at bedtime, and one half tablet of Zoloft 25mg twice a day. (R. 228-29).
On December 13, 2007, Dr. Khan reported that, since the patient started therapy, his psychosis appeared better. The claimant did not complain of command hallucinations, but still reported seeing a boy and his deceased grandmother. Dr. Khan noted that he had no side effects from the medication. Dr. Khan changed the timing of his Risperdal doses to 0.5mg at 5:00 PM and 0.5mg at 8:00 PM, and increased his ...