Effective Date: March 19, 2009
Publication Date: February 17, 2009
Federal Register Vol. 74, No. 30, page 7521

POLICY INTERPRETATION RULING

SSR 09- 7p: Title XVI: Determining Childhood Disability – The Functional Equivalence Domain of “Caring for Yourself”

Purpose:

This SSR consolidates information from our regulations, training materials, and question-and-answer documents about the functional equivalence domain of “Caring for yourself.” It also explains our policy about that domain.

Citations:

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.

Introduction:

A child ^[1] who applies for Supplemental Security Income (SSI) ^[2] 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 ^[3] that results in "marked and severe functional limitations." ^[4] 20 CFR 416.906. This means that the impairment(s) must meet or medically equal a listing in the Listing of Impairments (the listings) ^[5] 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. ^[6]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. ^[7]

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.

20 CFR 416.926a(b)(1). ^[8]

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. ^[9] 20 CFR 416.926a(a).

Policy Interpretation

General

In the domain of “Caring for yourself,” we consider a child’s ability to maintain a healthy emotional and physical state. This includes:

How well children get their emotional and physical wants and needs met in appropriate ways,
How children cope with stress and changes in the environment, and
How well children take care of their own health, possessions, and living area.

Although newborns and young infants are almost entirely dependent on caregivers for getting their emotional and physical wants and needs met, the ability to care for oneself is first manifested at birth. For example, a young infant who feels upset (an emotional need) or hungry (a physical need) may cry to alert a caregiver. As children mature, they are expected to deal with emotional and physical wants and needs with increasing competence and independence.

However, the domain of “Caring for yourself” does not address children’s physical abilities to perform self-care tasks like bathing, getting dressed, or cleaning up their room. We address these physical abilities in the domain of “Moving about and manipulating objects” and, if appropriate, “Health and physical well-being.” ^[10] Nor does it concern the ability to relate to other people, which we address in the domain of “Interacting and relating with others.” Rather, in “Caring for yourself,” we focus on how well a child relates to self by maintaining a healthy emotional and physical state in ways that are age-appropriate and in comparison to other same-age children who do not have impairments.

A child may have limitations in the domain of “Caring for yourself” because of a mental or a physical impairment(s), medication, or other treatment. For example, if an adolescent who is prescribed a medication that causes weight gain frequently fails or refuses to take it because of embarrassment about his weight, thereby endangering his health, we would evaluate this limitation in the domain of “Caring for yourself.” ^[11]

As with limitations in any domain, we do not consider a limitation in the domain of “Caring for yourself” unless it results from a medically determinable impairment(s). However, while it is common for all 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.

Emotional wants and needs

Children must learn to recognize and respond appropriately to their feelings in ways that meet their emotional wants and needs; for example, seeking comfort when sad, expressing enthusiasm and joy when glad, and showing anger safely when upset. To be successful as they mature, children must also be able to cope with negative feelings and express positive feelings appropriately. In addition, after experiencing any emotion, children must be able to return to a state of emotional equilibrium. The ability to experience, use, and express emotion is often referred to as self-regulation. Children should demonstrate an increased capacity to self-regulate as they develop.

Ordinary circumstances may cause emotions, such as fear, sadness, or frustration. Examples of age-appropriate, self-consoling activities to regulate such emotions include:

For a newborn or young infant, sucking on a pacifier or thumb when upset.
For a toddler, carrying a stuffed animal for a sense of security.
For a preschool child, playing with a favorite toy when feeling lonely.
For a school-age child, playing a computer game when bored.
For an adolescent, listening to music when feeling stress.

However, children whose mental or physical impairments affect the ability to regulate their emotional well-being may respond in inappropriate ways. For example:

A child with an anxiety disorder may use denial or escape rather than problem-solving skills to deal with a stressful situation.

A child with attention-deficit/hyperactivity disorder who has difficulty completing assignments may express frustration by destroying school materials.

A teenager with a depressive disorder may have adequate hygiene, but seek emotional comfort by engaging in self-injurious behaviors (for example, binge eating, substance abuse, or suicidal gestures).

A child with a traumatic brain injury who has poor impulse control may have problems managing anger.

A child with a musculoskeletal disorder who feels awkward and frustrated during recess time may refuse to leave the classroom.

Physical wants and needs

In addition to regulating emotional well-being, a child must be able to satisfy physical wants and needs every day. This requires children to have a basic understanding of their own bodies, including their bodies’ normal functioning, and adequate emotional health for carrying out the tasks involved in self-care. The domain of “Caring for yourself” involves the emotional ability to engage in self-care activities, such as feeding, dressing, toileting, and maintaining hygiene and physical health.

Taking care of physical needs, however, also includes other aspects of self-care; for example:

Recognizing when one feels ill,
Seeking medical attention,
Following safety rules,
Asking for help when needed,
Responding to circumstances in safe and appropriate ways, and
Making decisions that do not endanger oneself.

The difference between the domains of “Caring for yourself” and “Interacting and relating with others”

The domains of “Caring for yourself” and “Interacting and relating with others” are related, but different from each other. The domain of “Caring for yourself” involves a child’s feelings and behavior in relation to self (as when controlling stress in an age-appropriate manner). The domain of “Interacting and relating with others” involves a child’s feelings and behavior in relation to other people (as when the child is playing with other children, helping a grandparent, or listening carefully to a teacher).

A decision about which domain is appropriate for the evaluation of a specific limitation depends on the impact of the particular behavior. For example:

If a girl with hyperactivity impulsively runs into the street, endangering herself, we evaluate this problem in self-care in the domain of “Caring for yourself.” On the other hand, if she interrupts conversations inappropriately, we evaluate this problem in social functioning in the domain of “Interacting and relating with others.”

If a language disorder limits a boy’s ability to use “self-talk” to calm himself in a stressful situation, we evaluate this problem in self-regulation in the domain of “Caring for yourself.” But if he avoids other children during playtime because of the language disorder, we evaluate this problem in social functioning in the domain of “Interacting and relating with others.”

Some impairments may cause limitations in both domains. For example, a boy with Oppositional Defiant Disorder who refuses to obey a parent’s instruction not to run on a slippery surface endangers himself and disrespects the parent’s authority. In this case, the child’s mental disorder is causing limitations in the domains of “Caring for yourself” and “Interacting and relating with others.”Similarly, a teenage girl with depression who develops poor eating habits as a form of comfort, may also avoid friends and want to be left alone. We evaluate the limitations resulting from her depression in both the domains of “Caring for yourself” and “Interacting and relating with others.” 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. ^[12]

Effects in other domains

Children with limitations in the domain of “Caring for yourself” may also have limitations in other domains. For example, children with impairments that affect self-regulation may have difficulties in school, resulting in a limitation in the domain of “Acquiring and using information” in addition to the domain of “Caring for yourself.” Limitations in caring for self are also frequently found in connection with impairments whose most obvious effects are in other domains. For example, some children with learning disorders, which have effects in the domain of “Acquiring and using information,” also have difficulties with self-regulation.

Therefore, as in any case, we evaluate the effects of the child’s impairment(s), including the effects of medication or other treatment and therapies, in all relevant domains.

Examples of typical functioning in the domain of “Caring for yourself”

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 impairment-related limitations in the domain of “Caring for yourself,” 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 maintaining a healthy emotional and physical state.

1. Newborns and young infants (birth to attainment of age 1)

Responds to body’s signals (for example, hunger, discomfort, pain) by alerting caregiver to needs (for example, crying).
Consoles self until help comes (for example, sucking on a hand).
Begins to expand capacity for self-regulation to include rhythmic behaviors (for example, rocking).
Tries to do things for self, perhaps when still too young (for example, insisting on putting food in mouth, refusing caregiver’s help).

2. Older infants and toddlers (age 1 to attainment of age 3)

Is increasingly able to console self (for example, carrying a favorite blanket).
Cooperates with caregiver in dressing, bathing, and brushing teeth, but also shows what he can do (for example, pointing to the bathroom, pulling off coat).
Insists on trying to feed self with spoon.
Experiments with independence by a degree of contrariness (for example, “No! No!”) and declaring own identity (for example, by hoarding toys).

3. Preschool children (age 3 to attainment of age 6)

Tries to do things that he is not fully able to do (for example, climbing on chair to reach something up high).
Agrees easily and early in this age range to do what caregiver wants, but gradually wants to do many things her own way or not at all.
Develops more confidence in abilities (for example, wants to use toilet, feed self independently).
Begins to understand how to control behaviors that are potentially dangerous (for example, crossing street without an adult).

4. School-age children (age 6 to attainment of age 12)

Recognizes circumstances that lead to feeling good and bad about himself.
Begins to develop understanding of what is right and wrong, and what is acceptable and unacceptable behavior.
Demonstrates consistent control over behavior and avoids behaviors that are

unsafe.

Begins to imitate more of the behavior of adults she knows.
Performs most daily activities independently (for example, dressing, bathing), but may need to be reminded.

5. Adolescents (age 12 to attainment of age 18)

Discovers appropriate ways to express good and bad feelings (for example, keeps a diary, exercises).
Feels more independent from others and becomes increasingly independent in all daily activities.
Sometimes feels confused about how he feels about herself.
Notices significant changes in his body’s development, which can result in some anxiety or worry about self and body (may sometimes cause anger and frustration).
Begins to think about future plans (for example, work).
Maintains personal hygiene adequately (for example, bathing, brushing teeth, wearing clean clothing appropriate for weather and context).
Takes medications as prescribed.

Examples of limitations in the domain of “Caring for yourself”

To further assist adjudicators in evaluating impairment-related limitations in the domain of “Caring for yourself,” 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, school-age children would be expected to bathe themselves, but toddlers would not; young children may place non-nutritive or inedible objects in their mouth, but older children typically would not. ^[13]

Consoles self with activities that show developmental regression (for example, an older child who sucks his thumb).
Has restrictive or stereotyped mannerisms (for example, head banging, body rocking).
Does not spontaneously pursue enjoyable activities or interests (for example, listening to music, reading a book).
Engages in self-injurious behavior (for example, refusal to take medication, self-mutilation, suicidal gestures) or ignores safety rules.
Does not feed, dress, bathe, or toilet self appropriately for age.
Has disturbance in eating or sleeping patterns.
Places non-nutritive or inedible objects in mouth (for example, dirt, chalk).

Effective date:

This SSR is effective on March 19, 2009

Cross-References:

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 09-8p, Title XVI: Determining Childhood Disability — The Functional Equivalence Domain of “Health and Physical Well-Being”; SSR 82-59, Titles II and XVI: Failure To Follow Prescribed Treatment; and Program Operations Manual System (POMS) DI 25225.030, DI 25225.035, DI 25225.040, DI 25225.045, DI 25225.050, DI 25225.055, DI 23010.001-23010.010, and DI 23010.020.

^[1] 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.

^[2] 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.

^[3] We use the term “impairment(s)” in this SSR to refer to an “impairment or a combination of impairments.”

^[4] 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.

^[5] 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.

^[6] See SSR 09-1p, Title XVI: Determining Childhood Disability Under the Functional Equivalence Rule – The “Whole Child” Approach.

^[7] 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.

^[8] 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.”

^[9] See 20 CFR 416.926a(e) for definitions of the terms “marked” and “extreme.”

^[10] A child may have limitations in the ability to do these self-care tasks because of impairment-related effects in other domains as well. For example, we evaluate the limitations of a child who has difficulty getting dressed because of an impairment that affects cognition in the domain of “Acquiring and using information.” See SSR 09-1p.

^[11] We do not consider a child fully responsible for failing to follow prescribed treatment. Also, the policy of failure to follow prescribed treatment does not apply unless we first find that the child is disabled. Under this policy, we must also find that treatment was prescribed by the child’s “treating source” (as defined in 20 CFR 416.902) and that it is clearly expected that, with the treatment, the child would no longer be disabled. Even then, we must consider whether there is a “good reason” for the failure to follow the prescribed treatment. For example, if the child’s caregiver believes the side effects of treatment are unacceptable, or an adolescent refuses to take medication because of a mental disorder, we would find that there is a good reason for not following the prescribed treatment. However, if there is not a good reason and all the other requirements are met, a denial based on failure to follow prescribed treatment would be appropriate. See 20 CFR 416.930 and SSR 82-59, Titles II and XVI: Failure To Follow Prescribed Treatment.

^[12] For more information about how we rate limitations, including their interactive and cumulative effects, see SSR 09-1p.

^[13] See 20 CFR 416.924b.

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