From Justoneanalyst on the Connect Board comes this helpful post:
“An internal memo now being circulated offers a kind of clarification about the extent of deficits in adaptive functioning required for 12.05C. I offer three observations about what the memo says:
- As a conceptual framework, it’s about the best we’re going to be able to do short of revising the listing.
- It’s not new. It’s a restatement of policy first circulated in 3/98 and later published in the FR in 2/02.
- Even with this not-new clarification, most cases involving 12.05C as it applies to adults well past age 22 are still going to be marked by much uncertainty about adaptive functioning, at least from the perspective of the lay adjudicator.
First, here’s one paragraph from the new statement circulated today:
The diagnostic description of MR also requires “deficits in adaptive functioning.” However, we do not specify the degree of deficits of adaptive functioning required to satisfy this component of the diagnostic description. Therefore, as we explain in 20 CFR §§ 404.1525(c) and 416.925(c), “[i]f the medical findings needed to support the diagnosis are not given in the introduction or elsewhere in the listing, the diagnosis must still be established on the basis of medically acceptable clinical and laboratory diagnostic techniques.” In this case, we look to the diagnostic manuals of the American Association on Mental Retardation, the American Psychiatric Association, and the American Psychological Association. They all generally define deficits of behavior consistent with MR as performance that is at least 2 standard deviations below the mean on standardized measures of adaptive behavior. (The DSM-IV-TR requires “significant limitations” in at least 2 of 10 sill areas.)
But let’s compare the above with the 3/98 publication Childhood Disability Evaluation Issues (SSA Pub. No. 64-076). After expressly noting that 112.05C doesn’t specify the degree of deficits in adaptive functioning, this publication cites 20 CFR 416.925c), just as does the above. Then it goes on as follows:
[W]e look to the standards established by the professional community in defining the degree of deficits in adaptive functioning, as well as the methods for documenting those deficits. The three most prominent professional organizations which promulgate methods and criteria for establishing the diagnosis of MR are the American Association on Mental Retardation, the American Psychological Association, and the American Psychiatric Association. The AAMR manual, the APA manual and the DSM-IV provide qualitative and quantitative definitions of adaptive functioning.
There’s more. In 4/02 SSA published technical revisions to the listings. The agency declined to adopt a suggestion that it use the DSM-IV definition for mental retardation (67 FR 20022). It gave a quick and dirty review of how its own definition compared with that of the AAMR, the APA, and the DSM-IV, both in terms of IQ scores and deficits in adaptive functioning. The agency then ended its response to this particular suggestion with this paragraph:
The definition of MR used by SSA in the listings is not restricted to diagnostic uses alone, nor does it seek to endorse the methodology of one professional organization over another. While capturing the essence of the definitions used by the professional organizations, it also is used to determine eligibility for disability benefits. SSA’s definition establishes the necessary elements, while allowing use of any of the measurement methods recognized and endorsed by the professional organizations.
The important part of this in the last phrase, “use of any of the measurement methods recognized and endorsed by the professional organizations.” This is, it seems to me, equivalent to where we started, about , how SSA will “look to the diagnostic manuals of the American Association on Mental Retardation, the American Psychiatric Association, and the American Psychological Association.” That is, the required degree of deficits in adaptive functioning is the degree that is “medically acceptable” by these organizations (and perhaps others as well) to establish the diagnostic presence of mental retardation.
But what precisely does this mean in practical terms? Especially, what does it mean for this common situation:
- The record does not include the results, for an adult, of any “standardized measures of adaptive behavior,” and
- There’s no prospect of securing any such evidence.
Well, in this circumstance the AAMR endorse the use of clinical judgement (AAMR manual, 10th edition, pp. 93 ff.). I expect the other professional organizations do the same. But this just pushes the mystery one step further back–what’s “clinical judgement”?
So far as I can understand, clinical judgment is what the clinician exercises during what the National Research Committee refers to as the results of an “unstructured interview.” The committee goes on to say this, in Mental Retardation, Determining Eligibility for Social Security Benefits, at p. 156:
In an unstructured interview, the clinician applies personal, experience-based clinical norms to the adaptive behavior assessment. The advantage of the method is that if frees the clinician from using a set of criteria that may be seen as restrictive. The disadvantage is that each clinician imposes his or her own subjective criteria, a process that threatens both the reliability and the validity of the assessment.
So in the end, where are we? No so very far from where we started.”
