SSR 11-2p: Titles II and XVI: Documenting and Evaluating Disability in Young Adults

I. Sources of evidence about a young adult's ability to work

Once we have evidence from an acceptable medical source^[17] that establishes the existence of at least one medically determinable impairment (MDI), we consider all relevant evidence in the case record to determine whether a young adult is disabled. This evidence may come from acceptable medical sources and from a wide variety of "other sources."^[18] Although we always need evidence from an acceptable medical source, we will determine what other evidence we need based on the facts of the case.

1. Medical sources

   1. In addition to providing evidence establishing an MDI, acceptable medical sources can provide information about how an impairment(s) affects a young adult's ability to do work-related activities. For example, a physician might discuss the impact of asthma on a young adult's participation in physical activities, or a speech-language pathologist might discuss how a language disorder contributes to limited attention and problems on a job.

   2. We may receive evidence from other medical sources who are not "acceptable medical sources," such as nurse-practitioners, physicians' assistants, naturopaths, chiropractors, audiologists, occupational therapists (OTs), physical therapists (PTs), and psychiatric social workers (PSWs). We cannot use evidence from these sources to establish that a young adult has an MDI. However, we can use evidence from these sources to determine the severity of the impairment(s) and how it affects the young adult's ability to do work-related activities. This evidence can be very helpful, especially if a source sees the young adult regularly. For example:

      • A PSW might comment on the young adult's ability to deal with changes in a routine work setting.

      • An OT or PT might evaluate the impact of a neurological disorder on the young adult's activities and comment on muscle tone and strength and how it affects his or her ability to stand and walk.

      • An OT might comment on the young adult's ability to use fine motor skills to use a computer.

2. Non-Medical Sources.

   Evidence from other sources who are not medical sources, but who know and have contact with the young adult, can also help us evaluate the severity and impact of a young adult's impairment(s). These sources include family members, educational personnel (for example, teachers and counselors), public and private social welfare agency personnel, and others (for example, friends, neighbors, and clergy). Therefore, we consider evidence in the case record from non-medical sources when we determine the severity of the young adult's impairment(s) and how the young adult is able to function.

3. School programs

   Evidence from school programs, including secondary and post-secondary schools, can also help us evaluate the severity and impact of a young adult's impairment(s).

   1. Many young adults who received special education (including transition services) or related services^[19] before they attained age 18 continue to receive these services until they are age 22. Other young adults may participate in postsecondary programs, including college or vocational training.^[20]

   2. Young adults who receive special education services after age 17 will have an Individualized Education Program (IEP),^[21] including an IEP transition plan. The IEP transition plan describes a student's levels of functioning based on reasonable estimates by both the student and the special education team. It also identifies the kinds of vocational and living skills the young adult needs to develop in order to function independently as an adult.

   3. The IEP transition goals may range from the development of skills appropriate to supervised and supported work and living settings to those needed in independent work and living situations. For example, an IEP transition goal for an 18-year-old might be, "The student will independently use public transportation," while specific objectives would identify the skills to be developed (for example, reading a bus schedule) and the particular instruction methods to be used to develop the skills (for example, one-to-one tutoring with practice reading a bus schedule).

   4. The goals in an IEP may be set at a level that the young adult can readily achieve to foster a sense of accomplishment and may be lower than what would be expected of a young adult without impairments. In this regard:

      • A young adult who achieves a goal may or may not have limitations. The young adult may be developing or acquiring skills at a slower rate than young adults without impairments and may have achieved the goal simply because it was set low.

      • A young adult who does not achieve a goal likely has an impairment-related limitation(s). A young adult's failure to achieve a goal, however, does not, by itself, establish that the impairment(s) is disabling.

II. Considerations Related to Evaluating a Young Adult's Impairment-Related Limitations

We evaluate a young adult's impairment-related limitations when we:

• Determine whether his or her MDI(s) is "severe"? that is, significantly limits his or her physical or mental ability to do basic work activities;

• Determine whether his or her MDI(s) meets or medically equals a listed impairment; and

• Assess his or her RFC.

The examples in the sections below do not necessarily establish that a young adult is disabled, only that the person may have limitations that affect what work he or she may be able to do.

1. Evidence Regarding Functioning From Educational Programs

   As we discussed in section I.C above, we may have evidence about a young adult's functioning from school programs, including IEPs. This evidence may indicate how well a young adult can use his or her physical or mental abilities to perform work activities. The following examples of school-reported difficulties might indicate difficulty with work activities:

   • Difficulty in understanding, remembering, and carrying out simple instructions and work procedures during a school-sponsored work experience;

   • Difficulty communicating spontaneously and appropriately in the classroom;

   • Difficulty with maintaining attention for extended periods in a classroom;

   • Difficulty relating to authority figures and responding appropriately to correction or criticism during school or a work-study experience;

   • Difficulty using motor skills to move from one classroom to another.

2. Community Experiences, Including Job Placements

   1. A young adult may receive services in a community setting(s) through a school or a community agency, such as a mental health center or vocational rehabilitation agency. These services may include:

      • Community-based instruction (CBI), or instruction in a natural, age-appropriate setting (for example, trips to the grocery store to develop math, sequencing, travel, and social skills).

      • On-the-job training (OJT), or placement in various work sites in the community for vocational training and experience, frequently in an "enclave" (small group) of students with a job coach (for example, placement in an enclave in a motel to learn housekeeping tasks such as bed-making and vacuuming).

      • Work experience, or supervised part-time or full-time employment to assist a young adult in acquiring job skills and good work attitudes and habits.

   2. A young adult may participate in several—or even many—OJT or work experience placements that are unpaid, paid at SGA levels, or paid at less than SGA levels. Some young adults have multiple placements as part of a transition plan that expose them to a variety of work settings. Other young adults have multiple placements because of unsatisfactory performance.

   Regardless of whether the work was SGA, information about how well a young adult performed in these placements can help us assess how the young adult functions. For example, a young adult who was unable to sustain OJT placements may have limitations in the ability to understand and remember instructions or to persist at work-related tasks. In contrast, a young adult who performed OJT placements successfully may have a good ability to respond appropriately to supervision. In addition, information about the degree to which a young adult needs special supports in order to work (such as in supported or transitional employment programs) may also help us assess the young adult's functioning.

3. Psychosocial Supports and Highly Structured or Supportive Settings

   As for all adults, psychosocial supports and highly structured or supportive settings may reduce the demands on a young adult and help him or her function. However, the young adult's ability to function in settings that are less demanding, more structured, or more supportive than those in which people typically work does not necessarily show how the young adult will be able to function in a work setting. We will consider the kind and extent of support or assistance and the characteristics of any structured setting in which the young adult spends his or her time when we evaluate the effects of his or her impairment(s) on functioning.

4. Extra Help and Accommodations

   Working requires a person to be able to do the tasks of a job independently, appropriately, effectively, and on a sustained basis. In this regard, the analysis for adult disability determination purposes is similar to our "extra help" rules for children.^[22] If an adult with an impairment(s) needs or would need greater supervision or assistance, or some other type of accommodation, because of the impairment(s) than an employee who does not have an impairment, the adult has a work-related limitation.

   We consider how independently a young adult is able to function, including whether the young adult needs help from other people or special equipment, devices, or medications to perform day-to-day activities. If a young adult can function only if he or she receives more help than would generally be provided to people without medical impairments, we consider how well the young adult would function without the extra help. The more extra help or support of any kind that a young adult receives because of his or her impairment(s), the less independent he or she is in functioning, and the more severe we will find the limitation to be.

   1. Accommodations

      1. Accommodations are practices and procedures that allow a person to complete the same activity or task as other people. Accommodations can include a change in setting, timing, or scheduling, or an assistive or adaptive device.

      2. Some young adults with impairments need accommodations in their educational program in order to participate in the general curriculum or in a transitional program.^[23] The fact that a young adult receives or has received accommodations as a part of his or her IEP or Section 504 plan,^[24] may be an indication that he or she has a work-related limitation. For example, evidence showing that a student requires an audiotape recording of oral directions for replay at school because he cannot remember more than a one-step instruction might indicate that the student will have the same inability to remember more than a one-step instruction without special assistance in a work setting.

      3. Some accommodations may indicate an impairment(s) that meets or medically equals a listing. For example, the need for an augmentative or alternative communication or AAC device (for example, an electronic picture board or an electrolarynx) might indicate a speech impairment that meets listing 2.09 or an impairment that meets one of the neurological listings in section 11.00 of the listings.

      4. When we determine whether a person can perform his or her past relevant work, we do not consider potential accommodations unless his or her employer actually made the accommodation. This means that we cannot find that a young adult can do past relevant work with accommodations unless the young adult actually performed that work with those same accommodations and is still able to do so now.

      5. When we determine whether a person can do other work that exists in significant numbers in the national economy, we do not consider whether he or she could do so with accommodations, even if an employer would be required to provide reasonable accommodations under the Americans with Disabilities Act of 1990.^[25]

   2. Effects of treatment, including medications

      Treatment, including medications, can have a positive effect on a person's ability to function in a work setting. For example, a young adult who takes an antidepressant medication may be able to interact appropriately with supervisors and co-workers. Treatment, however, may not resolve all of the functional limitations that result from an impairment(s). Medications or other treatment may cause side effects that affect the mental or physical ability to work. For example, an anti-epileptic medication may cause drowsiness that affects the ability to concentrate; daily chest percussion therapy for cystic fibrosis may cause fatigue because of the physical effort involved in the therapy. The frequency of a young adult's treatment may preclude him or her from maintaining a full-time work schedule; that is, 8 hours a day, 5 days a week on a sustained basis.

5. Work-Related Stress

   1. Working involves many factors and demands that can be stressful. For example, some people may experience stress related to the demands of getting to work regularly, having work performance supervised, or remaining in the workplace for a full day, 5 days a week on a sustained basis. Moreover, one person's reaction to stress associated with the demands of work may be different from another's, even among people with the same impairments.

   2. Sources familiar with the young adult may provide insight about the effect of stress on his or her physical or mental functioning and what, if any, psychosocial supports or structure he or she would need when experiencing work-related stress.^[26] We consider impairment-related limitations created by a person's response to the demands of work when we assess RFC.

III. Insured status for young adults

1. When a young adult has worked, we consider whether he or she is insured for purposes of establishing a period of disability or becoming entitled to disability insurance benefits. While the Social Security Act provides the standard for determining insured status for young adults aged 21 up to age 24, there is no similar statutory standard for young adults under the age of 21. We use the same rule for both groups—a young adult meets the disability insured status requirements if he or she has 6 quarters of coverage in the 12-quarter period ending with the quarter in which the disability began.^[27]

2. When our records do not establish disability insured status but the claimant alleges sufficient work and earnings for that purpose, we will look to see if there are any covered earnings that are not yet shown in our records. Covered earnings from an unsuccessful work attempt may also provide work credits that can establish disability insured status.

IV. Determining disability

1. Determining Whether a Young Adult's Work Activity is SGA^[28]

   When we determine a young adult's earnings for SGA purposes, we count only those earnings that are attributable to his or her own productivity. We assume that a young adult's reported earnings are attributable to his or her own productivity unless there is evidence indicating that those earnings are greater than would be attributable to his or her productivity.

   1. Work activity

      Many young adults with disabilities have worked. The work experience may have been (or may be, if the person is still working) subsidized, in a sheltered setting, or performed under special conditions. As for any adult, we exclude subsidized earnings.^[29] In addition:

      • Some young adults whose impairments arose during military service continue on active duty and receive full pay while they are in treatment for their impairments. They may also receive payments while working in a designated therapy program or on limited duty. Active duty status or receipt of pay (for example, sick pay) by a member of the military does not indicate by itself that the service person has demonstrated the ability to do SGA. We will consider the actual work activity, not the amount of pay the service person receives or the duty status of the service person, when we determine whether the work is SGA.^[30]

      • Young adults may have impairment-related work expenses; that is, expenses for an item or service that directly enables a person to work and that the person necessarily incurs because of an impairment(s). We deduct impairment-related work expenses from a person's wages or self-employment income before we determine whether the wages or self-employment income constitute SGA.^[31]

   2. Volunteer service

      Young adults with disabilities may participate in government-sponsored programs for volunteer activity, such as AmeriCorps VISTA. We do not count as earnings payments a person receives from some of these programs.^[32]

   3. Unsuccessful work attempts

      Some people have brief periods of work with earnings at the SGA level. We will consider the possibility that a brief period of work was an unsuccessful work attempt when we are determining whether the work was SGA. If a period of work is an unsuccessful work attempt, we will not consider that work to be SGA when we determine if the young adult is under a disability.^[33] However, as we noted in section III.A, covered wages or self-employment income from an unsuccessful work attempt may provide work credits that establish disability insured status under title II.

2. Determining Whether the Young Adult Has an MDI(s)

   Young adults often have the same kinds of impairments as children; for example, attention deficit/hyperactivity disorder, language disorders, or learning disorders. Sometimes, the impairment may be evident before age 18; at other times, the impairment may not be identified until later. We will consider all MDIs the young adult has, including MDIs that are usually found in children.

3. Determining Whether a Young Adult Can Do Past Relevant Work

   Many young adults have performed work that was SGA for at least brief periods. This work will usually meet the 15-year recency test for past relevant work. If the work also lasted long enough for the young adult to learn to do it, it will be past relevant work.^[34] We do not consider work done during a period of entitlement to disability benefits under title II or title XVI to be past relevant work;^[35] however, we may consider the young adult's job performance when we assess his or her RFC.

4. Determining Whether a Young Adult Can Adjust to Other Work

   1. As for any adult, we consider a young adult's RFC, age, education, and work experience to determine if he or she can make an adjustment to other work. A young adult does not need to have an impairment(s) that meets or medically equals a listing to qualify for disability benefits. We may find that a young adult is disabled because of an inability to adjust to other work.

   2. When a young adult has only exertional (strength) limitations and has an RFC and vocational factors that match the criteria of a rule in the Medical-Vocational Guidelines in appendix 2 of subpart P of the Regulations No. 4 (grid rules), the grid rules always direct a decision of "not disabled" for young adults.

   3. In many young adult cases, however, the grid rules will not direct a conclusion of "disabled" or "not disabled." For example, many young adults who qualify for disability benefits have impairments (such as mental and neurological disorders) that cause non-exertional limitations. These limitations may erode the occupational base at some, or even all, levels of exertion.^[36] Other young adults have solely exertional limitations but are unable to do a full range of work in one of the exertional categories in appendix 2. Some young adults have limitations that prevent them from performing even the full range of sedentary work. In these cases, we consider the type and extent of the young adult's limitations and the extent of the erosion of the occupational base and other relevant factors. The following guidelines apply:

      1. If the young adult has solely exertional limitations but is able to do somewhat more than the full range of sedentary work, the young adult will not be disabled based on a framework of a grid rule. In this case, the exertional capacity will always fall between two rules (that is, a sedentary and a light rule) that direct a conclusion of "not disabled."^[37]

      2. If a young adult has solely nonexertional limitations or both exertional and nonexertional limitations, we follow the guidance in the regulations and the relevant SSRs to determine any erosion of the occupational base.^[38] If the occupational base is significantly eroded, we will find the young adult disabled despite his or her young age.^[39]

      3. If a young adult has a substantial loss of one or more of the basic mental demands of competitive, remunerative, unskilled work, the occupational base will be significantly eroded, despite vocational factors that we would ordinarily consider favorable (for example, young age, college education, and skilled work experience).^[40] The basic mental demands of competitive, remunerative, unskilled work include the abilities to:

         • Understand, remember, and carry out instructions;

         • Make simple work-related judgments typically required for unskilled work;

         • Respond appropriately to supervision, coworkers, and work situations; and

         • Deal with changes in a routine work setting.

      4. Adjudicators must remember that young adults are more likely to have recent educational experience that provides for direct entry into skilled work; some will also have vocational experiences (see section C. above) that provide them with skills they can use in skilled or semiskilled work.

   4. A young adult needs only basic communication abilities to do unskilled work.^[41] Basic communication abilities include the ability to hear and understand simple oral messages, including instructions, and to communicate simple messages orally. If the person has these basic communication abilities, there will not be a significant impact on the unskilled occupational base.

      1. Nevertheless, when a person has a physical or mental impairment(s) that affects communication, it is important to consider the nature of the impairment and whether the person has other associated limitations. Many disorders that cause limitations in basic communication may cause other limitations as well. For example, a physical disorder like cerebral palsy that can affect a person's facial muscles and limit the ability to communicate simple messages orally may also affect the arm muscles and limit the ability to lift and carry. Language disorders, as well as mental and neurological impairments commonly found in young adults who allege disability, may also cause limitations in abilities such as the ability to concentrate, persist, or maintain pace in job tasks, and the ability to adapt to changes in a work setting.

      2. Language disorders are not the only kinds of impairments that can affect communication. Some physical impairments may also affect communication, particularly speech. For example, congenital or acquired facial deformities may affect speech because a person cannot use his or her facial muscles for articulation; cerebral palsy may affect speech because of muscle spasms that make it difficult to speak clearly.

   5. Under the grid rules, we find younger individuals not disabled even if we determine that their vocational factor of education is "illiterate."

      1. However, a young adult's educational level can be an indication of an underlying impairment(s) that affects our assessment of RFC.^[42] For example, if a young adult, despite having attended high school, is illiterate or has a limited reading ability, he or she may have an MDI, such as a learning disability or language disorder. Any such underlying MDI may affect a young adult's RFC. As we noted in Section III.F.4.b, these types of disorders can cause limitations in many areas.

      2. When illiteracy or limited reading ability is related to an MDI, we consider how the underlying MDI affects the person's ability to meet the requirements of work when we assess RFC. For example, a person who has borderline intellectual functioning (BIF) may be limited in her ability to understand and remember instructions, which results in an inability to read and write. The BIF also affects her ability to maintain attention on tasks that she has difficulty remembering. When we assess her RFC, we assess limitations in maintaining attention as well as in understanding and remembering instructions. When we determine whether she can do other work, we consider the vocational factor of illiteracy.^[43]

5. Additional considerations for age-18 redeterminations

   1. Young adult previously found disabled as a child under a listing.^[44]

      1. Although our rules use different words to describe the concept, "listing-level severity" is generally the same for both parts A and B of the listings. Most of the part B listings have an equivalent listing in part A, and many contain identical criteria. Listings that include functioning among their criteria are generally based on a standard of "extreme" limitation in a specific function (such as walking) or in a broad area (domain) of functioning (such as concentration, persistence, or pace), or on "marked" limitations in two areas of functioning.

      2. While the areas of functioning may differ between analogous listings in parts A and B, we intend for these criteria to be equally severe. Therefore, a child's impairment(s) that met or medically equaled a part B listing will often meet or medically equal a part A listing at age 18 unless the impairment(s) has medically improved. Note though that we do not use the medical improvement review standard for CDRs in age-18 redeterminations.^[45]

   2. Young adult previously found disabled as a child based on functional equivalence.

      1. To functionally equal the listings under title XVI, a child's impairment(s) must result in "marked" limitations in two of the childhood domains or an "extreme" limitation in one.^[46] Although we do not use these domains for adults, they describe aspects of functioning that are relevant to our evaluation of a young adult's work-related limitations. We use similar domains when we evaluate a child's mental impairments and some physical impairments, such as immune disorders. We may find that the young adult has the same severity rating for a domain under a part A listing as he or she had as a child under a similar functional equivalence domain. For example, absent medical improvement or new evidence demonstrating that the prior finding was in error, a young adult who had an extreme limitation in the ability to interact and relate with others as a child will probably have extreme limitation in social functioning as an adult. Similarly, unless the impairment(s) has improved or there is new evidence indicating that the prior finding was in error, a finding of marked limitation in the ability to attend and complete tasks as a child is likely to translate to a marked limitation in the ability to concentrate, persist, or maintain pace in work-related task completion as an adult.

      2. The broad domains of functioning we used to evaluate a child's impairment-related limitations may also provide guidance for findings about a young adult's RFC on redetermination. Accordingly, it is important to remember that the descriptions of the childhood functional equivalence domains in the regulations include work-related functions for adolescents, defined as children age 12-18.^[47]

V. Continued payments for young adults participating in a vocational rehabilitation or similar program^[48] ("Section 301")^[49]

1. When we determine that a young adult is no longer disabled due to medical improvement, we will continue payments if :

   (1) He or she is participating in the Ticket to Work and Self-Sufficiency program or another appropriate program of vocational rehabilitation (VR), employment, or other support services;^[50] and

   (2) Completion of the program or continued participation for a specified period will increase the likelihood that he or she will not return to the disability or blindness benefit rolls.^[51]

   The title XVI provision for Section 301 payments also applies to a person age 18 or older whose disability has ended as a result of a title XVI age-18 redetermination.^[52]

2. Likelihood Determination

   1. When a young adult is a student age 18 through 21 participating in an IEP under the provisions of the IDEA, we will find that completion of or continuation in the IEP will increase the likelihood that he or she will not return to the disability or blindness benefit rolls.^[53] In this circumstance, we will continue benefit payments until the IEP is completed or the person stops participating in the IEP for any reason.

   2. When a young adult is participating in another appropriate program, we will find that completion of or continuation in that program will increase the likelihood that the person will not return to the disability or blindness benefit rolls if the program provides the person with:

      1. Work experience that will increase the likelihood of doing past relevant work; or,

      2. Education or skilled or semi-skilled work experience that will increase the likelihood of adjusting to other work.^[54]

      For example, the young adult is in a VR-sponsored training program to become a certified computer technician. She is acquiring computer skills that will permit direct entry into semiskilled or skilled occupations, thus increasing her overall ability to adjust to other work. We would determine that the training program would increase the likelihood that she will not return to the disability or blindness benefit rolls.

VI. Resolving inconsistencies in the evidence

We evaluate relevant evidence for consistency and resolve any inconsistencies that need to be resolved.

1. After reviewing all of the relevant evidence, we determine whether there is sufficient evidence to make a finding about disability. "All of the relevant evidence" means:

   • The relevant objective medical evidence and other relevant evidence from medical sources;

   • Relevant information from other sources, such as school teachers, family members, or friends;

   • The claimant's statements (including statements from the young adult's roommates or family members); and

   • Any other relevant evidence in the case record, including how the young adult functions over time and across settings.

2. If there is sufficient evidence and there are no inconsistencies in the case record, we will make a determination or decision. If there are inconsistencies in the record, we may be able to make a determination or decision if the majority of the evidence or the most probative evidence outweighs the inconsistent evidence, and additional information would not change the determination or decision.

3. An inconsistency is not "material" if it would not affect the outcome of the case or any of the major findings. If we can make a fully favorable decision despite the inconsistent evidence, that inconsistency would be immaterial. For example, if a young adult has a digestive disorder that causes weight loss, and one piece of evidence shows a Body Mass Index (BMI) of 16.75 and another a BMI of 17.00, the inconsistency is not material because we would find that the young adult's impairment(s) meets listing 5.08 based on either BMI.

4. An inconsistency could also be immaterial in an unfavorable determination or decision when resolution of the inconsistency would not affect the outcome. This could occur, for example, if there is inconsistent evidence about a limitation in a specific work-related activity; for example, whether the person is able to climb ladders. If the person's overall exertional level was consistent with sedentary work, the ability (or inability) to climb a ladder would not reduce the number of sedentary occupations he or she could do.

5. An apparent inconsistency is not always a true inconsistency. For example, the record for a young adult with attention-deficit/hyperactivity disorder may include good, longitudinal evidence of hyperactivity at home, in the classroom, and on work experience placements in the classroom, but show a lack of hyperactivity during a consultative examination (CE). The observations during the CE may represent a "good" day, rather than the overall level of functioning or the effect of an unusual setting.^[55] In this case, there would be only a normal variation in functioning at the time of the CE.

6. In all other cases in which the evidence is insufficient, including when a material inconsistency exists that we cannot resolve based on an evaluation of all of the relevant evidence in the case record, we will try to complete the record by requesting additional or clarifying information.^[56]