United States District Court, N.D. Alabama, Southern Division
KARON OWEN BOWDRE, Chief District Judge.
On June 30, 2010, the claimant's mother, Ornette Murphy, applied for childhood supplemental security income under Title XVI of the Social Security Act on behalf of the claimant, who alleges disability commencing on January 1, 2001, because of hearing voices and suicidal thoughts. (R. 21, 135). The Commissioner denied the claim both initially and on reconsideration. (R. 71-73). The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on April 26, 2012. (R. 47).
In a decision dated May 23, 2012, the ALJ found that the claimant was not disabled as defined by the Social Security Act and, thus, was ineligible for supplemental security income. (R. 35). On May 3, 2013, the Appeals Council denied the claimant's request for review; consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. (R. 1). The claimant has exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons stated below, this court reverses and remands the decision of the ALJ because she failed to apply the proper legal standard in assessing the teacher's evaluations of the claimant's functional limitations and substantial evidence does not support her findings.
II. ISSUE PRESENTED
Whether the ALJ applied the proper legal standard in assessing the weight he gave to the claimant's teachers, who are considered acceptable sources that the ALJ can consider in determining the severity of her limitations, and whether substantial evidence supports the weight she afforded the opinions of Ms. Glover and Mr. Clark, the claimant's teachers.
III. STANDARD OF REVIEW
The standard of review of the Commissioner's decision is limited. This court must affirm the Commissioner's decision if the Commissioner 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, 401 U.S. 389, 402 (1971).
The court must keep in mind 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 Plaintiff 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 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 the 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) & (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 listened under Appendix I to Subpart P of Part 404. Id. at § 416.924(a).
Functional equivalence is dependent on the child's impairments or combination of impairments resulting in marked limitations in two broad categories of functioning or extreme limitation in one broad category of functioning. 20 C.F.R. § 416.926a(a). A "marked" limitation is one that is "more than moderate" but "less than extreme." Id. At 416.926a(e)(2)(I). The Regulations list six broad areas of functioning: (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. Id. at § 416.926a(b)(1)(i-vi).
For attending and completing tasks, the ALJ should consider the child's "ability to filter out distractions and to remain focused on an activity or task at a consistent level of performance." Id. at § 416.926a(h)(1)(i)-(ii). As part of determining the child's ability to attend and complete tasks, the ALJ should consider whether the child is "unduly distracted by [her] peers or unduly distracting to them in a school or work setting." Id. The ALJ should determine the frequency at which the child interrupts others. Id. at § 416.926a(h)(3)(iii).
For the domain of "caring for yourself, " the ALJ should consider a child's ability to show "consistent judgment about the consequences of caring for [herself], " and a child's ability to employ "effective coping strategies... to identify and regulate [her] feelings, thoughts, urges, and intentions." Id. § 416.926a(k)(1)(i)-(iv). In determining whether the child has a marked limitation in this domain, the ALJ should consider whether she follows safety rules; whether she responds to her "circumstances in safe and appropriate ways"; and whether she makes "decisions that do not endanger [herself]...." Id. The ALJ should determine if her impairment results in the claimant "engag[ing] in self-injurious behavior (e.g., suicidal thoughts or actions...), or ignor[ing] safety rules." Id . § 416.926a(k)(3)(iv).
The Social Security Regulations provide that an ALJ may consider evidence from sources other than acceptable medical sources "to show the severity of [an impairment and]... how [the claimant] typically function[s]." 20 C.F.R. § 416.913(d). The Regulations list "Educational personnel" as an acceptable source for the ALJ to consider in determining the severity of a claimant's impairments. Id. The ALJ must fully explain the weight she affords to these "other sources." SSR 06-03p. The ALJ's reasons for the weight she gives must "ensure that the discussion of the evidence in the... decision allows a... subsequent reviewer to follow the [ALJ's] reasoning, when such opinions may have an effect on the outcome of the case." Id.
The ALJ must explain the reasons for the weight she gives each item of evidence so the reviewing court can determine whether her "ultimate decision on the merits of the claim is rational and supported by substantial evidence." Coward v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981). "Unless the [ALJ] has analyzed all evidence and has sufficiently explained the weight [she] has given to obviously probative exhibits, to say that [her] decision is supported by substantial evidence approaches an abdication of the court's "duty to scrutinize the record as a whole to determine whether the conclusions reached are rational."'" Id. (citations omitted).
Although the ALJ does not have to discuss every document in the record separately, "an ALJ may not select only the evidence that favors her ultimate conclusion." Garfield v. Schweiker, 732 F.2d 605, 609 (7th Cir. 1984).
The claimant was thirteen years old at the time of the administrative hearing and was in the seventh grade. (R. 54). The claimant alleges disability beginning January 1, 2001, because of hearing voices and suicidal thoughts. (R. 135).
The claimant's primary physician at Marks Village Health Center referred the claimant to Children's Behavioral Health for a psychological evaluation on June 29, 2010. Dr. Vinita Yalamanchili, a psychiatrist at Children's Behavioral, evaluated the claimant. Dr. Yalamanchili indicated that the claimant reportedly missed appointments with the claimant's psychiatrist because of financial difficulties. The claimant told Dr. Yalamanchili that the claimant heard a male's voice, believed to be the devil, in her head for about a year telling the claimant to kill herself, but only recently told her mother. The claimant's mother told Dr. Yalamanchili that the claimant pulled her own hair out, and reported that the claimant was previously sexually abused, which the claimant denied. After hearing the claimant's psychiatric problems, Dr. Yalamanchili admitted the claimant to Children's Hospital of Alabama for further psychiatric evaluation. (R. 230-34).
Dr. Tolulope Aduroja, a psychiatrist at Children's Hospital of Alabama, performed a psychological evaluation on the claimant on July 7, 2010, at the request of Dr. Yalamanchili. Her evaluation revealed that the claimant's gross and fine motor coordination were within normal limits. Dr. Aduroja performed the Wechsler Abbreviated Scale of Intelligence on the claimant, showing that the claimant achieved a full-scale IQ score of 68, classified as extremely low. The results of the psychiatric evaluation revealed that the claimant's current estimated intellectual abilities fall within the mild range of mental retardation. Dr. Aduroja, relying on the claimant's achievement test, indicated that the claimant's academic skills of a first or second grader were significantly lower than the claimant's same-age peers. The claimant's personality assessment revealed significant anxiety on both objective and subjective measures, including nightmares; excessive worry at school; general anxiety; fear of the behavior of others; and fear of illness/body integrity. Additionally, the psychiatric evaluation showed the claimant had a Global Assessment of Functioning score of 55, and that the claimant suffered from significant cognitive disorganization caused by the claimant's poor perception of reality, as evidenced by auditory and visual hallucinations. Dr. Aduroja discharged the claimant on July 7, 2010, diagnosing the claimant with psychotic disorder, not otherwise specified, and prescribed the claimant Risperdal and Cogentin. (R. 234-37).
On July 20, 2010, the claimant's mother, Ornetta Murphy, completed a function report for children ranging from 6 years old to 12 years old. The claimant's mother indicated that the claimant could not repeat stories she had heard, but could communicate with family and friends. While Ms. Murphy noted that the claimant's impairments affected her behavior around other people in playing sports, her mother indicated that the claimant had friends her own age; could make new friends; and could generally get along with adults and teachers. Additionally, Ms. Murphy noted that the claimant's impairments do not affect her abilities to cooperate with others, take care of herself, or pay attention. (R. 120-30).
On July 27, 2010, the claimant visited Children's Health System for a follow-up with Stephen Pannel, DO and Dr. Nasima Amin, the attending psychiatrist. Dr. Pennel performed a Child and Adolescent Intake Evaluation, after the claimant complained of being "scared and worried." Dr. Pennel noted that the claimant's mood was anxious, with no visual or auditory hallucinations since her hospitalization. Additionally, Dr. Pennel found that the claimant did not experience any suicidal plans, and that her judgment and thoughts were intact. Dr. Pennel reported that the claimant was "doing better" and that her "psychosis is resolved." (R. 244). He indicated that the claimant had no acute safety issues and that her condition could be managed on an outpatient basis. Dr. Pennel and Dr. Amin increased her Risperdal from.5 mg to.75 mg per dose to help with her nightmares and sleep problems. He also noted that the claimant's mother reported that DHR had been involved with their family following sexual abuse of the claimant by her maternal uncle. (R. 241-44).
On August 24, 2010, the claimant followed-up with Dr. Pennel and Dr. Amir at Children's Health System. They noted that the claimant was "mildly better" since her discharge from Children's Hospital in July 2010; that she continued to be somewhat anxious; that she was sleeping better; that her headaches had improved; and that she was happy and smiling at the visit. They instructed the claimant to continue taking her Risperdal and Cogentin and to follow up in four weeks. (R. 240).
The claimant sought treatment at the Emergency Room at Children's Hospital for chest pains on September 25, 2010. The notes from the visit indicate that the claimant was taking.5 mg of Risperdal and.5 mg of Benztropine Mesylate. (R. 281-284).
On October 6, 2010, Dr. Arnold Mindingall, a psychologist, at the request of the Disability Determination Service, assessed the claimant's ability to function on a day-to-day basis using a Childhood Disability Evaluation Form. In assessing the claimant's ability to function in the six functional domains, Dr. Mindingall found the claimant to have "less than marked" limitations for acquiring and using information; attending and completing tasks; interacting and relating with others; and caring for herself. In making this finding, Dr. Mindingall acknowledged that the claimant has difficultly reading and understanding stories in books or magazines; cannot write longhand; had As, Bs, and Cs on her fifth grade report card; requires a reminder to finish her homework or chores; does not play a team sport; has trouble repeating messages from third parties; has to be told more than once to do something; pulls her hair out; feels that something bad may happen; is scared of loud noises and insects; and was hearing voices telling her to kill herself before she started taking her psychotropic medications. Furthermore, Dr. Mindingall noted that the claimant had no limitations in moving about and manipulating objects because no party reported the child as having any such problems. Dr. Mindingall failed to put a mark by the degree of limitation in the health and physical well-being domain and left his assessment of that domain blank. (R. 246-249).
Dr. Mindingall indicated that the claimant was doing much better on her psychotropic medications; that her sleeping problem and headaches had improved; that she had no evidence of auditory or visual hallucinations during her August 24, 2010 evaluation; that she was not in special education classes; and that her activities of daily living did not indicate major issues. He concluded that, although the claimant "does have a MDI that could produce some of the alleged symptoms and functional limitations, the alleged severity at this point is not totally consistent with the objective evidence on file and does not meet or equal a listing." (R. 251-252).
Medical records from the Children's Health Systems indicate that the claimant began taking 5 mg of Lexapro daily on January 25, 2011, although the record contains no ...