JOHN M. BODENHAUSEN, Magistrate Judge.
Katie Kientzy ("Plaintiff"), on behalf of J.P., a minor, appeals the decision of the Commissioner of Social Security ("Defendant") denying disability benefits under Title XVI of the Social Security Act. Because Defendant's decision is supported by substantial evidence, as discussed below, it is affirmed.
On April 18, 2012, Plaintiff filed an application for disability benefits on behalf of J.P., a child under the age of eighteen. (Tr.
J.P. was an 11 year old boy at the time of the administrative hearing in this matter. (Tr. 35) J.P. suffers from an autism-spectrum disorder and ADHD. At the hearing, both Plaintiff and J.P. testified regarding the nature of J.P.'s disabilities and symptomatology. (Tr. 33-54) Among other symptoms, J.P. allegedly fights continuously with his sister, expresses negative thoughts about himself, and has trouble interacting with other children. (Tr. 42, 44, 47) J.P.'s mother testified that J.P. sometimes engages in "self-injurious behavior." (Tr. 41) J.P. attended an alternative school from August of 2010 until August of 2013, because he "had severe behavioral problems" that the local traditional school "could not accommodate." (Tr. 41) By August of 2013, however, J.P. transitioned to a regular, mainstream school, where he has been succeeding educationally, including placement on the honor roll. (Tr. 190, 396-99)
After hearing Plaintiff's and J.P.'s testimony, and reviewing the objective medical records and other evidence in this case, the ALJ ultimately found J.P. not disabled. (Tr. 27) In arriving at this decision, the ALJ followed the three-step inquiry that applies in child disability cases, as set out in the Commissioner's regulations.
At step one, the ALJ found that J.P. was a school-age child on the date of the application, and that he was not engaged in substantial gainful activity. (Tr. 13) At step two, the ALJ found that J.P. had the following severe impairments: (1) Asperger's syndrome versus oppositional defiant disorder; (2) attention deficit hyperactivity disorder (ADHD); and (3) obesity. (Id.) At step three, the ALJ determined that none of J.P.'s severe impairments: (i) met; (ii) medically equaled; or (iii) functionally equaled a Listing in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 13-14) In conducting his step three inquiry, the ALJ focused on Listing 112.10 (other pervasive developmental disorders) and Listing 112.11 (ADHD). (Id.) The ALJ held that none of J.P.'s severe impairments "met" or "medically equaled" either of those Listings.
In analyzing whether J.P.'s severe impairments "functionally" equaled a Listing, the ALJ evaluated J.P.'s functioning within the six required domains.
In conducting his analysis, the ALJ made several credibility findings and determinations in which he weighed the evidence. For example, the ALJ found that Plaintiff and J.P. were "not entirely credible" concerning the limiting effects of J.P.'s symptoms. (Tr. 16) Regarding the medical opinion evidence, the ALJ partially credited the opinion evidence of J.P.'s treating psychiatrist, Dr. Lisa Delaney, M.D., agreeing with her that J.P. had marked limitations in interacting and relating with others; but disagreeing with Dr. Delaney's opinion that J.P. has marked limitations in (1) attending and competing tasks and (2) caring for himself. (Tr. 18)
Additionally, the ALJ gave "some weight" to Dr. Joan Singer, Ph.D., a state agency non-examining doctor who reviewed the medical files in J.P's case. (Tr. 18-19) Dr. Singer found that J.P. had marked limitations in interacting and relating to others, but no additional limitations in any other domain. (Tr. 546-52) The ALJ agreed with Dr. Singer's assessment regarding the domain of interacting and relating to others, but disagreed that J.P. had no other limitations—the ALJ thought it more accurate to find that J.P. had "less than marked" limitations in the remaining domains. (Tr. 18)
Finally, the ALJ gave "great weight" to the opinion of J.P.'s teacher at the alternative school, Dave Haessig. (Tr. 19) Mr. Haessig thought that J.P. had moderate limitations in the domain of acquiring and using information; mostly moderate limitations in attending and completing tasks; no limitations in moving about and manipulating objects; mostly moderate or no limitations in caring for self, along with mostly no limitations in areas of health and physical well-being. (Tr. 153-159) Taking all of this evidence into account, the ALJ found that Plaintiff had not met her burden in proving that J.P's impairments functionally equaled a Listing. (Tr. 27) Therefore, the ALJ concluded that J.P. was not disabled under the law. (Id.)
On appeal to this Court, the parties dispute: (1) whether the ALJ properly considered the effects of a structured setting on J.P.'s level of functioning; and (2) whether the ALJ properly considered the opinion evidence in the record. After the initial briefing in this case, the Court ordered oral argument on the first question disputed by the parties, in an effort to ensure that the Court applied the correct legal standards and properly addressed the relevant facts. The Court also gave the parties the option of submitting additional briefing. Defendants submitted additional briefing, and both parties appeared for oral argument on July 7, 2016. After hearing from the parties, the Court took the matter under submission.
Children from low income families may receive Title XVI benefits if certain income and asset requirements are met, and if the child qualifies as "disabled."
At step one, the Commissioner determines whether the child is engaged in "substantial gainful activity." If so, the claim is denied; if not, the Commissioner moves on to step two.
To "meet" or "medically equal" a Listing, a child's severe impairment must meet the severity criteria for an individual Listing impairment.
In considering functional equivalence, the Commissioner looks at how the child's impairment(s) affect "broad areas of functioning," known as "domains."
The Eighth Circuit has repeatedly emphasized that a district court's review of an ALJ's disability determination is intended to be narrow and that courts should "defer heavily to the findings and conclusions of the Social Security Administration."
Despite this deferential stance, a district court's review must be "more than an examination of the record for the existence of substantial evidence in support of the Commissioner's decision."
Finally, a reviewing court should not disturb the ALJ's decision unless it falls outside the available "zone of choice" defined by the evidence of record.
As noted above, the parties dispute whether the ALJ properly considered the effects of a structured setting on J.P.'s level of functioning, and whether the ALJ properly considered the opinion evidence in the record. The Court concludes that the ALJ properly considered both of those issues, and that the decision of the ALJ in this matter is supported by substantial evidence.
Plaintiff's first argument is that the ALJ failed to consider the effects of a structured environment on J.P.'s ability to function. (ECF No. 16 at 3) As Plaintiff points out, the ALJ must consider the effect of a structured environment on a claimant's symptomatology:
20 C.F.R. § 416.924a(b)(5)(iv)(E) (emphasis added).
Similarly, the preamble to the child's Listing of impairments for mental impairments includes the following language:
20 C.F.R. pt. 404, subpart P, app. 1 § 112.00E.
It is clear, therefore, that the ALJ was required to consider how J.P. could function outside of a highly-structured setting. Plaintiff argues that the ALJ omitted this analysis. Plaintiff notes that J.P. required a structured treatment at the alternative school, including an Individualized Education Plan ("IEP"), and a "therapeutic environment." (ECF No. 16 at 4-5) Plaintiff also contends that J.P. continued to need a structured environment when he was at his mainstream school, including "accommodations" at his new school, and the presence of a "para-professional."
Defendant responds by arguing that the ALJ was required to consider the structured environment, but he did not have to explicitly cite the controlling regulation. Additionally, Defendant argues that the "relevant question is whether or not the evidence shows that J.P. can function outside of" a structured environment. (ECF No. 17 at 5) Defendant points to the ALJ's analysis of J.P.'s success at his mainstream school, and the improvement that J.P. made in order to be ready for a mainstream school as evidence that J.P.'s functioning is increasing, even as his environment became less structured. Therefore, Defendant contends that the ALJ substantially complied with his obligation to consider J.P.'s structured environment, even though he did not cite the controlling regulations.
As an initial matter, the Court agrees that the ALJ was required to understand the nature of J.P.'s structured environment, and analyze how that environment affected J.P.'s functioning. But while the law dictates that the ALJ consider the impact of J.P.'s structured environment, the law is not as strict as Plaintiff's arguments suggest. For example, the ALJ is not required to cite the regulations or to follow a particular format in carrying out this duty.
Here, when viewed in the context of the ALJ's entire decision, and the whole record, the ALJ adequately discharged his duty to consider J.P.'s functioning outside of his structured environment. First, the ALJ explicitly noted that he considered "all of the relevant evidence," including "objective medical evidence and other relevant evidence from medical sources; information from other sources, such as school teachers, family members, or friends; the claimant's statements (including statements from the claimant's parents or other caregivers); and any other relevant evidence in the case record, including how the claimant functions over time and in all settings (i.e. at home, at school, and in the community)." (Tr. 15) (emphasis added). The ALJ explicitly noted that he considered evidence of Plaintiff's functioning outside of the structured setting at both the alternative and mainstream schools.
Furthermore, the ALJ says that he "first evaluated how the child functions in all settings and at all times. . . . And in evaluating the claimant's limitations, the undersigned has considered the type, extent, and frequency of help the claimant needs to function." (
The ALJ considered other evidence of J.P.'s functioning outside of a structured environment. For example, the ALJ considered the testimony of Plaintiff (J.P.'s mother) at the administrative hearing. She testified as to J.P.'s behavior at home, which was mixed. (Tr. 39-53) Plaintiff testified that J.P. fights with his sister and becomes verbally as well as sometimes physically abusive; but she also made statements to doctors that J.P. was "doing well, and [was] getting along better with everyone in the house. She noted that he had a good week at home and in social activities." (Tr. 42, 534) This is highly relevant evidence concerning J.P.'s functioning outside of a structured environment which the ALJ considered and incorporated into his reasoning.
These statements about J.P. doing well socially and around the house (i.e., outside of the structured school environment) are consistent with treatment notes from J.P.'s doctor on March 21, 2012, April 4, 2012, April 18, 2012, April 25, 2012, and May 2, 2012. (
The ALJ also considered some evidence from Dr. Delaney concerning Plaintiff's functioning outside of the structured environment. In treatment sessions with Dr. Delaney, J.P.'s mother indicated that J.P. "had no major problems in school, he was sleeping well, and he was active in riding his bike and skateboard outside." This is additional evidence of J.P.'s functioning outside of the structured setting of school which the ALJ specifically incorporated into his findings. (Tr. 25)
Finally, the ALJ also noted, and incorporated into his rationale, the evidence that J.P.'s "therapist accompanied the claimant to a restaurant to observe him in a social setting, which resulted in him doing very well. [And] the claimant indicated that he had a friend over during the prior week." (Tr. 17) Both of these pieces of evidence from the medical records, are evidence concerning J.P.'s functioning outside of a structured environment incorporated into the ALJ's reasoning.
These examples demonstrate that the ALJ at least considered evidence of J.P.'s functioning outside of the structured environment of his school setting, where he was assisted in his functioning by the paraprofessional. Because he considered such evidence, the ALJ discharged his duty under the regulations.
Plaintiff's second argument is that the Commissioner did not give proper weight to the opinion of J.P.'s treating psychiatrist, Dr. Delaney. (ECF No. 16 at 8) Dr. Delaney found that J.P. had marked limitations in the domains of: (1) attending to and completing tasks; (2) caring for himself; and (3) interacting and relating with others. Additionally, Dr. Delaney found that J.P. had moderate limitations in a few areas of acquiring and using information, and moving about and manipulating objects. (Tr. 572-77) Findings of this severity, if accepted, would have entitled J.P. to benefits under the regulations. The ALJ, however, found that the record "fails to support marked limitations in attending and completing tasks or in caring for [oneself]." (Tr. 18) The ALJ therefore, only partially credited Dr. Delaney's opinion.
Under the law, an ALJ must give "controlling weight" to a treating physician's opinion if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence.
On the other hand, a treating physician's opinion may be discounted where it provides conclusory statements only, or is inconsistent with the record, and may be discounted or disregarded where other medical assessments are supported by better or more thorough medical evidence, or where a treating physician renders inconsistent opinions.
Plaintiff contends that the ALJ violated these principles in two ways. First, Plaintiff argues that the ALJ was substantively wrong to discount Dr. Delaney's opinion because Plaintiff believes Dr. Delaney's opinion was entitled to controlling weight. (ECF No. 16 at 9) Second, Plaintiff argues that even if Dr. Delaney's opinion was not entitled to controlling weight, the ALJ was required to adequately explain the weight that he gave to Dr. Delaney's opinion. (Id.)
Defendant responds by arguing that the ALJ was correct in discounting Dr. Delaney's findings because Dr. Delaney's opinion was inconsistent with other opinion evidence in the record, inconsistent with her own treatment notes, and not supported by the record as a whole. Also, Defendant argues that the ALJ properly explained this finding. (ECF No. 17 at 7-12)
The Court will address Plaintiff's second issue first. Plaintiff's argument is unavailing because the ALJ explained in some detail the weight that he assigned to Dr. Delaney's opinion. (Tr. 18) The ALJ was not required to recite the precise level of weight given to the opinion by using a specific term with specific citations to § 416.927. The ALJ needed only to clarify whether he discounted the physician's opinion, and why.
Therefore, to the extent that Plaintiff argues that the ALJ did not give a specific weight to Dr. Delaney's opinion, and specifically cite to the regulatory factors at § 416.927, the Court disagrees with this conclusion for the reasons stated above. Additionally, these are allegations of deficient opinion writing. An arguable deficiency in opinion writing is not a basis for reversal where the substance of the ALJ's analysis is conducted in accordance with the law.
Moving on to the substance of the ALJ's treatment of Dr. Delaney's opinion, the Court agrees with Defendant that where the ALJ discounted Dr. Delaney's opinion, he did so in accordance with the law. As an initial matter, the Court notes that the doctor's opinion was in checklist form, without analysis or citation to medical evidence. (Tr. 571-77) The ALJ could properly take into account the conclusory nature of this evidence when assigning weight to it.
First, Dr. Delaney's conclusion that J.P. suffered "marked" limitations in attending and completing tasks is belied by J.P.'s educational record. In this domain, the ALJ was required to evaluate how well J.P. is able to focus and maintain attention; how well he begins, carries through, and finishes activities; and the pace at which he performs activities and the ease with which he changes them.
As noted above, when J.P. transferred to his new school, he was in normal classes 96.9 percent of the time. (Tr. 173) J.P.'s transcripts show that he achieved almost all A's and B's, and was on the honor roll. (Tr. 396) J.P's teachers commented that he had good class participation, "always tries," and "has a pleasant personality." (Tr. 397) This level of academic success—in normal classes—is simply not consistent with "marked" limitations in attending and completing tasks.
Additionally, Dr. Delaney's conclusions regarding this domain were inconsistent with other, credible evidence. For example, both Mr. Haessig (J.P.'s teacher at the special school) and Dr. Singer (the State agency doctor) thought J.P. did not suffer from marked limitations in his ability to attend and complete tasks. (Tr. 153-59, 546-52) Mr. Haessig specifically found that J.P. had mostly moderate limitations in attending and completing tasks. (Tr. 155) Mr. Haessig also thought that J.P. had mostly no difficulties at all in caring for himself, with only a few moderate exceptions and one marked difficulty concerning periods of unprovoked fear. (Tr. 157) In his written comments, Mr. Haessig said only that when J.P. "is stressed he has significant trouble interacting with others." This is consistent with the ALJ's analysis.
Mr. Haessig's analysis is significant, because he was someone who had the opportunity to observe J.P.'s functioning in depth on a daily basis, and therefore, his opinion was entitled to significant weight under the Commissioner's regulations.
Additionally, as noted in the factual discussion above, Dr. Singer, the State's non-examining doctor, found that J.P. had marked limitations in interacting and relating to others, but no other limitations. (Tr. 546-52) Although the ALJ ultimately did not endorse Dr. Singer's conclusions in their entirety,
Stated another way, J.P.'s educational record, combined with the opinions of Dr. Singer and Mr. Haessig, provides substantial evidence to support the ALJ's finding that J.P. suffers from less than marked limitations in this domain because a reasonable mind could support this conclusion.
Substantial evidence also supports the ALJ's decision to discount Dr. Delaney's finding that J.P. suffered from marked limitations in caring for himself. This domain focuses upon how well a child such as J.P. maintains a healthy emotional and physical state, including how well physical and emotional needs and wants are met in appropriate ways, how well a child like J.P. copes with stress and changes in his environment, and whether he takes care of his own health, possessions, and living area.
Dr. Delaney, in discussing the domain of caring for self, had mixed findings. Out of the 20 areas within the "caring for self" domain, Dr. Delaney found J.P. had moderate or no difficulties in 12 of the areas. (Tr. 575) Dr. Delaney found that J.P. had marked difficulties in the 8 remaining areas, including: following proper nutritional expectations; following through on reaching goals; periods of unprovoked fear or anxiety; being unable to enjoy or fully participate in group activities; disturbance in eating or sleeping patterns; has sense of humor or laughs freely; is willing to be consoled when sad; and demonstrates emotions. (Id.) Dr. Delaney additionally commented that J.P. "overeats, [is] prone to anxiety, fears at bedtime, does not like to sleep alone [sic]." (Id.)
The ALJ properly discounted Dr. Delaney's conclusions with regard to this domain. First—as already discussed above— Dr. Delaney's conclusions are in checklist form, without citation to medical evidence. This is a proper basis upon which to discount her opinion.
Also, Dr. Delaney's opinion evidence was inconsistent with other significant opinion evidence in the record, including that of Mr. Haessig. (Tr. 157) Mr. Haessig disagreed with Dr. Delaney's assessment that J.P. suffered from marked limitations in following proper nutritional expectations, following through on reaching goals, being unable to enjoy or fully participate in group activities, or that J.P. had marked limitations in his sense of humor, or demonstrating emotions. (Id.)
This is important because Mr. Haessig was someone who had the opportunity to observe J.P.'s functioning in-depth on a daily basis, and therefore, his opinion was entitled to significant weight under the Commissioner's regulations.
Other medical evidence is also inconsistent with Dr. Delaney's findings. For example, during his transition from the alternative to the mainstream school, J.P. attended counseling sessions with Bruce Miller, a Licensed Clinical Social Worker. (Tr. 636-648) At the initial assessment on September 6, 2013, J.P.'s mental status screening was entirely within normal limits, except for "some obsessive habits" and Asperger's. (Tr. 644) There were no issues with self-care, and no evidence of risk of suicide, violence, or physical abuse. (Tr. 644) At counseling sessions over the next couple of months, J.P.'s mother noted that J.P. was doing well at school, where he is "content and cooperative," and J.P.'s "irritable behaviors are limited to the home." (Tr. 636) This is more evidence that Dr. Delaney's findings regarding self-care are not supported by the record as a whole, and are therefore, properly discounted.
Additionally, Dr. Delaney's opinion is internally inconsistent. She states that J.P. has a "lot of limitations socially," and yet, J.P.'s GAF score at the time Dr. Delaney gave her opinion was 60, which is at the top end of the moderate range of symptoms, and close to the mild range. (Tr. 577)
As a final matter, evidence of J.P.'s daily activities, as discussed in his daily activity report, presents mixed evidence concerning J.P.'s ability to care for himself. As the ALJ notes, J.P. has some difficulties in performing certain tasks himself, such as buttoning clothes, taking a bath alone, brushing his teeth, and washing or combing his fair, but yet he is also able to use a zipper by himself, tie shoelaces, choose his clothes, do what he is told most of the time, and get to school on time. (Tr. 119-20) Where evidence is mixed, or there is conflicting evidence, it is the job of the ALJ to resolve that conflict.
For all of the above reasons, the ALJ analyzed Dr. Delaney's medical opinion evidence in accordance with the law, and the weight given to her opinion is permissible.
For all of the foregoing reasons, Plaintiff's arguments that the ALJ erred are unavailing. The ALJ thoroughly evaluated the evidence in this case, and gave Plaintiff a full and fair hearing. This is a case where the Court's deferential standard of review is important. This is a difficult case. Although reasonable jurists might have weighed the evidence in this case differently, the ALJ's decision is within the "zone of reasonableness," and therefore must be affirmed.
Accordingly,
A separate Judgment shall be entered this day.
