Overview of Functional Information

Functional Criteria in the Mental Disorders Listings

In Class 4, you learned about SSA’s Listing of Impairments for mental disorders and select physical disorders, during which we introduced the concepts of 1) assessing functioning using the "paragraph B" criteria for mental disorders, and 2) functionally equaling the listings.

As a reminder:

For mental disorders, DDS assesses limitations in four areas of mental functioning (known in the mental disorders listings as the paragraph B criteria):

1. Understand, remember, or apply information
2. Interact with others
3. Concentrate, persist, or maintain pace
4. Adapt or manage oneself

Functional Equivalence

If a child has a severe impairment or combination of impairments that does not meet or medically equal any listing, SSA will decide whether it results in limitations that functionally equal the listings. By “functionally equal the listings,” SSA means that the impairment(s) must be of listing-level severity; i.e., it must result in “marked” limitations in two domains of functioning or an “extreme” limitation in one domain. To assess functional equivalence, SSA considers how the child functions in his or her activities in terms of 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
6. Health and physical well-being

There is overlap between the four areas of mental functioning and the six domains for functional equivalence. Some of the information you gather about one activity may inform the ratings of more than one area of mental functioning or domain.

Making a Link between the Illness and Functional Limitations

Case managers must make a link between a child’s illness and their ability to function on a daily basis. Like the adult analysis, the key inquiry centers on functioning. Unlike adults, however, the childhood functional analysis is concerned with the child’s abilities as compared to children of the same age who do not have illnesses.

• This information is rarely included in medical records, so you must describe how the child’s illness(es) interfere with their ability to function on a day-to-day basis using detailed descriptions, quotes, and anecdotes.
• Your description should be linked to the listings or the functional equivalence domains, as appropriate.

What are “Marked” and “Extreme” Limitations?

The Meaning of “Marked”

A "marked" limitation is found when the impairment interferes seriously with the child’s ability to independently initiate, sustain, or complete age-appropriate activities.

Quantitative definitions:

• Child of any age (birth to attainment of age 18): Valid score two standard deviations or more below the mean, but less than three standard deviations, on a comprehensive standardized test designed to measure ability or functioning in that domain, and day-to-day functioning in domain-related activities is consistent with that score.
• Child under age 3: Functioning at a level more than one-half but not more than two-thirds of chronological age when there are no standard scores from standardized tests in case record.

The Meaning of “Extreme”

An “extreme” limitation is found when the impairment interferes very seriously with the child’s ability to independently initiate, sustain, or complete age-appropriate activities.

Quantitative definitions:

• Child of any age (birth to attainment of age 18): Valid score three standard deviations or more below the mean on a comprehensive standardized test designed to measure ability or functioning in that domain, and day-to-day functioning in domain-related activities is consistent with that score.
• Child under age 3: Functioning at a level one-half of chronological age or less when there are no standard scores from standardized tests in case record.

Evaluating Functional Equivalence for Children using Six Domains

When evaluating a child's ability to function in each domain, SSA asks for and considers information that helps answer the following questions about whether the child's impairment(s) affects his or her functioning and "whether [the child’s] activities are typical of other children [the child’s] age who do not have impairments.”

1. What activities is the child able to perform?
2. What activities is the child not able to perform?
3. Which activities are limited or restricted?
4. Where (at home, school, in the community) does the child have difficulty performing activities?
5. Does the child have difficulty independently initiating, sustaining, or completing activities?
6. What kind of help does the child need to do the activities, how much help is needed, and how often is it needed?

As you can see from the above six questions, the central focus of the evaluation of functioning is on what a child can and cannot do on a day-to-day basis.

Determining Severity in Functional Domains

To determine whether there is a “marked” or an “extreme” limitation in a domain, SSA uses a picture constructed from the child's functioning in each domain. This last step in the “whole child” approach summarizes everything we know about a child's limited activities. The rating of limitation in a domain is then based on the answers to these questions:

1. How many of the child's activities in the domain are limited (for example, one, few, several, many, or all)?
2. How important are the limited activities to the child's age-appropriate functioning (for example, basic, marginally important, or essential)?
3. How frequently do the activities occur and how frequently are they limited (for example, daily, once a week, or only occasionally)?
4. Where do the limitations occur (for example, only at home or in all settings)?
5. What factors are involved in the limited activities (for example, does the child receive support from a person, medication, treatment, device, or structured/supportive setting)?

A child’s daily functioning, including growth and development issues, depends on age. Each of the domains, excluding health and physical well-being contains age-appropriate criteria for the following age groups:

• Newborns and young infants (up to age 1)
• Older infants and toddlers (1 – 3)
• Preschool children (3 – 6)
• School age children (6 – 12)
• Adolescents (12 – 18)