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Childhood Disability Evaluations - The Six Domains

The regulations evaluate six domains, and each domain is further broken down based on 5 distinct age categories:

· (a) Newborn and young infant (birth to attainment of age 1)

· (b) Older infants and toddlers (age 1 to attainment of age 3)

· (c) Preschool children (age 4 to attainment of age 6)

· (d) School age children (age 6 to attainment of age 12)

· (e) Adolescents (age 12 to attainment of age 18)

Each age category contains descriptive information about expected normal activities for a child of that age within the domain. At the end of each domain description. SSA provides at least five examples that describe “some" limitations SSA may consider in the domain being discussed. The examples are not considered the only possible limitations a child may have, nor are they aperseexample of a “marked" or “extreme" limitation. Each domain reiterates the requirement that SSA consider “all of the relevant information in [the child’s] case record" when deciding whether the medically determinable impairment(s) result in a “marked" or “extreme" limitations in the domain being discussed, and also notes that applicability of the example(s) will depend on the child’s age and developmental stage.

F-(1) Acquiring and using information

Here, SSA considers how well the child acquires or learns informationANDhow well the child uses the information learned. Learning may occur through play, where the child may acquire concepts, learn names, learn language skills and then begin using those skills, progressing from speaking to reading to writing and then to more complex subjects like math or learning and understanding new information. Thinking involves abilities to perceive, reason and make logical choices, and then use that learned information by language skills - written or verbal. The child must be able to use language, understand others and express himself, such as by asking directions or information, follow directions, or be able to explain something.

Examples of limited function by the child in this domain include:

inability to rhyme words or the sounds in words

difficulty recalling important things learned in school yesterday

difficulty solving mathematics questions or computing arithmetic answer

talking only in short, simple sentences and having difficulty explaining what is meant

F-(2) Attending and completing tasks

In this domain SSA evaluates how well the child is able to focus and maintain

attention,ANDhow well the child begins, carries through and finishes activities. The child must be able to modulate attention skills like alertness and initiating and maintaining concentration, filter out distraction, and remain focused on the activity or task at hand. This means focusing long enough to initiateandcomplete a project, task or activity or, if interrupted, that the child is able to return to the task and complete that task without being reminded frequently to do so. Adequate attention - the ability to think and reflect before starting or deciding to stop an activity, and predict possible outcomes before acting - is needed to maintain both the physical and mental effort and concentration a task requires. Focusing allows tasks to be attempted at an appropriate pace and helps determine the time needed to finish a task within appropriate time frames.

This includes consideration of the pace at which the child performs activitiesandthe ease with which the child changes activities. Examples of limitations in this domain may include a child that is :

easily startled, distractedorover-reactive to sounds, movements or touch

slow to focus on, or failure to complete, activities of interest (e.g. games)

repeatedly becoming sidetracked from activitiesorfrequently interrupts others

requires extra supervision to be kept engaged in an activity

F-(3) Interacting and relating with others

Interacting means initiatingandresponding to exchanges with other people for practical or social purposes. Interaction includes facial expressions, gestures, action,orwords; and may occur once (as in asking directions of a stranger)ormany times (as when the child describes school day activities to parents). Interaction may be with people one at a time (listening to one student in a school hallway)orin groups (as when playing with others). Relating to others means forming intimate relationships with family membersandwith friends who are the child’s age,andsustaining the relationships over time. Relating to others includes sibling, parents, best friends,orgroups such as children in daycare, school friends, teammates in sportsorpeople in the neighborhood.

Interacting and relating require the child to: respond appropriately to a variety of emotionalandbehavioral uses; be able to speak intelligibly and fluently so that others can understand; participate in verbal turn-taking and nonverbal exchanges; consider others’ feelings and points of view; follow social rules for interaction and conversation;andrespond to others appropriately and meaningfully. Activities at homeorschoolorin the child’s community may involve: learning, playingandworking cooperatively with other children, one at a time or in groups; joining voluntarily in activities with other children in the schoolorcommunity;andresponding to persons in authority (e.g., parents, teachers, bus drivers, coaches or employers). Examples of limitation in this domain include:

failure to reach out to be picked up and held by the caregiver

having no close friends,orthe child’s friends are all older or younger

difficulty playing gamesorsports with rules

difficulty speaking intelligibly or with adequate fluency.

F-(4) Moving about and manipulating objects

This domain involves consideration of how the child moves his or her body from one place to anotherandhow the child moves and manipulates things - gross and fine motor skills. Moving the body can include rolling the body; the ability to rise or pull oneself from a sitting to a standing position; raising the head, arms and legs, and twisting the hands and feet; bending, kneeling, stoopingorcrouching; moving forward or backward or when crawling, walkingorrunning; and negotiating different terrains (e.g. curbs, steps and hills). Moving and manipulating things involves: engaging upper and lower body to push, pull, lift or carry objects; controlling shoulders, arms, and hands to hold or transfer objects; coordinating eyes and hands to manipulate small objects or parts of objects. Their actions require varying degrees of strength, coordination, dexterity, pace and physical ability to persist at the task. They also require a sense by the child of where the body is and how it moves, integration of sensory input and motor output, and the capacity to plan, remember and complete controlled motor movements. Limited function in this domain may include:

muscle weakness, joint stiffnessorsensory loss that interferes with the child’s motor activities (e.g. unintentionally drop things)

difficulty with sequencing handorfinger movements

difficulty with fine motor movements (gripping or grasping objects)

poor eye-hand coordination when using a pencil or scissors

F-(5) Caring for yourself

Social Security here considers how well the child maintains a healthy emotional and physical state, including how well the child gets physical and emotional wants and needs met in appropriate ways; how the child copes with stress and changes in his or her environment;andwhether the child takes care of his or her own health, living area and possessions. This may include ability to respond to changes in emotions and the daily demands of the environment in order for the child to help himself or herself and cooperate with others in caring for personal needs, health and safety; characterized by a sense of independence and competence. Effective caring for oneself means the child becomes increasingly independent in making and following his or her own decisions, relying on one’s own abilities and skills, and displaying consistent judgment about the consequences of caring for oneself. It also means independence and competence to meet physical needs such as feeding, dressing, toiletry and bathing, as appropriate for age. It also means a basic understanding of the body and normal body functioning, ability to employ effective coping strategies, and ability to regulate feelings, thoughts, urges and intentions. Caring for yourself also means the child is able to recognize when he or she is ill, follow recommended treatment, take medication as prescribed, follow safety rules, respond to particular circumstances in safe and appropriate ways, make decisions that do not endanger oneself and knowing when to ask for help from others. Examples of limitations in this domain:

· continuing to place non-nutritive or inedible objects in the mouth

· not dressing or bathing appropriately for age because of impairment(s) that affects their domain

F-(6) Health and physical well being

SSA here considers cumulative physical effects of physicalor mental impairmentsand their associated treatments or therapies on the child’s functioning that were not considered in domain 4, above (moving about and manipulating objects). When the physical impairments, mental impairments or combined physical and mental impairments cause “extreme" limitation in function in this domain, the child generally has an impairment that “meets" or “medically equals" a listing. Considered here might be symptoms due to a physical disorder such as generalized weakness, dizziness, shortness of breath, reduce stamina, psychomotor retardation, allergic reactions, recurrent infections, poor growth, incontinenceor local or generalized pain. Also considered are the physical effects of medications taken by the child (e.g. asthma, depression) or treatments the child receives (e.g. chemotherapy, multiple surgeries) that limit performance of activities. Also considered is how the child functions during periods of worseningand how often and for how long these periods occur.

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