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Addison v. Commissioner of Social Security Administration

United States District Court, N.D. Ohio, Eastern Division

March 22, 2018





         Chantel Addison (“Addison”) filed a Complaint against the Commissioner of Social Security (“Commissioner”) on behalf of her daughter, K.S. (“Plaintiff”), seeking judicial review of the Commissioner's decision to deny supplemental security income (“SSI”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g). The parties consented to the undersigned's exercise of jurisdiction in accordance with 28 U.S.C. § 636(c) and Civil Rule 73. (Doc. 14). For the reasons stated below, the undersigned affirms the decision of the Commissioner.

         Procedural background

         Addison filed an application for SSI on behalf of Plaintiff in September 2013, alleging a disability onset date of August 1, 2010. (Tr. 178-82, 186, 190). Her claim was denied initially and upon reconsideration. (Tr. 126-28, 132-35). Addison then requested a hearing before an administrative law judge (“ALJ”). (Tr. 136). On July 23, 2015, Addison and Plaintiff (represented by an attorney) appeared and testified in at a hearing before the ALJ. (Tr. 33-107). On December 28, 2014, the ALJ found Plaintiff not disabled in a written decision. (Tr. 13-29). The Appeals Council denied Addison's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-6); 20 C.F.R. §§ 416.1455, 416.1481. Addison filed the instant action on behalf of Plaintiff on December 15, 2016. (Doc. 1).

         Factual Background[1]

         Personal Background and Education Information

         Plaintiff was born in November 2011 (Tr. 178), making her eleven years old as of her disability application, and thirteen years old on the date of her hearing (Tr. 36).

         In the 2013-2014 school year (sixth grade), Plaintiff was suspended from her school (Believe to Achieve Academy) on five occasions. (Tr. 220, 222, 226, 231, 234). These suspensions were for tackling another student (Tr. 220); engaging in disruptive behavior and willfully failing to comply with adult direction (Tr. 222); fighting (Tr. 226); refusing to follow directions (Tr. 231); and constant disruption in class (Tr. 234). Plaintiff also had other disciplinary issues during this time period, mostly involving disruptive behavior (verbal and physical). (Tr. 219, 221, 223, 225, 227-30, 235). Plaintiff received grades ranging from A to C in the first quarter, and A to D in the second quarter. (Tr. 238). In the second quarter, she “seldom” demonstrated responsibility and reliability, interacted with others cooperatively, or demonstrated appropriate behavior. (Tr. 238). This was a decrease from the first quarter, in which she was assessed as doing these things “sometimes” or “usually”. Id. The teacher noted she was “a very smart girl with a lot of potential”, but “her behavior is quite concerning”. Id. She continued: “She should be a straight A student but her attitude and behavior in the class and in the hallways is constantly landing her in trouble. As a result, her grades are dropping due to missing assignments”. (Tr. 238-39).

         Plaintiff's sixth grade teacher completed an undated Vanderbilt Assessment Scale. (Tr. 213-14). She indicated Plaintiff “often” had difficulty with attention to detail, sustaining attention to tasks, and listening when spoken to directly. (Tr. 213).[2] She also indicated Plaintiff either did not have, or only “occasionally” had other listed symptoms. See Id. For example, she indicated Plaintiff “never”: lost her temper; bullied or threatened others; initiated physical fights; or was physically cruel to others. Id. And, Plaintiff “occasionally”: did not follow through on instructions, had difficulty organizing tasks and activities; left her seat when remaining seated was expected; and actively defied or refused to comply with an adult's requests. Id. She indicated Plaintiff's academic performance was “somewhat of a problem.” (Tr. 214). However, Plaintiff also had “average” classroom behavioral performance (including relationship with peers, following directions, disrupting class, completing assignments, and organizational skills). Id.

         Another sixth grade teacher also completed an undated Vanderbilt Assessment Scale. (Tr. 215-16). In it, she indicated Plaintiff “occasionally” had difficulty with attention to detail, sustaining attention, listening, following instructions, organizing tasks and activities, and fidgeting. (Tr. 215). She was also “occasionally” anxious, self-conscious, afraid to try new things, and felt inferior, guilty, lonely, or sad. (Tr. 215-16). She indicated Plaintiff never had other listed symptoms. Id. She indicated Plaintiff's academic performance was “average” in reading, and “somewhat of a problem” in math and writing. (Tr. 216). Like the other teacher, she indicated Plaintiff had average classroom behavioral performance. Id.

         The record also contains two letters from Plaintiff to her teachers, dated September 2013. (Tr. 232-33). In them, she acknowledged difficulties, as well as efforts her teachers made for her; she thanked her teachers. Id.

         Addison completed a disability report for the Social Security Administration sometime after November 2013. (Tr. 197-201). In it, she indicated Plaintiff would “not comb her hair” and “does not match her clothes when she dresses.” (Tr. 199). Addison reported she had to “argue with [and] tussle with [Plaintiff] to clean her up [and] do her hair.” Id.

         In February 2014, Addison was asked to withdraw Plaintiff from her school (Believe to Achieve). (Tr. 41, 209). Plaintiff transferred to Alfred A. Benesch School in the middle of sixth grade. (Tr. 41).

         At the conclusion of the 2014-2015 school year (seventh grade), the principal of Alfred A. Benesch School wrote a “to whom it may concern” letter. (Tr. 254). In it, she noted Plaintiff: 1) “continue[d] to have problems with other students”; 2) “continue[d] to be disrespectful to teachers and other adults”; and 3) had “79 attendance marks for the 2014-15 school year” including unexcused absences, tardies, and out of school suspensions. Id.[3]

         Plaintiff attended the “shelter care program” at Carrington Youth Academy from February 12, 2015 through March 11, 2015. (Tr. 253, 256). Case manager / court liaison Pamela Grady noted Plaintiff “struggled with her interactions with her peers” and had “been involved into [sic] several verbal altercations that almost ended into [sic] physical altercations”. (Tr. 253). She received several “in house restrictions” for not following directions, but “processed with staff and was able to rejoin the unit with no further issues.” Id. She also “did manage to turn her behaviors around while in shelter care” and began to “interact[] with her peers in a positive manner, follow staff directives, and all shelter care programming.” Id.

         Plaintiff returned to Carrington Youth Academy from April 6, 2015 through April 15, 2015. (Tr. 252, 255). She “participated in programming with little redirections from staff”, but was “continuously redirected for being off task” and “struggle[d] to follow staff's directives”. (Tr. 252). She was disrespectful toward staff, and her “interactions with peers were often negative”, including a verbal altercation with a peer on her first day. Id. Ms. Grady noted that “[o]verall[, ] [Plaintiff] struggled with adjusting to shelter care placement.” Id.

         In December 2015, the Cuyahoga County Court of Common Pleas, Juvenile Court Division declared Plaintiff a delinquent child for knowingly causing or attempting to cause physical harm to her mother. (Tr. 261-62). The court noted Plaintiff was previously adjudicated as a delinquent on May 1, 2015 for domestic violence. (Tr. 261).

         Medical Records

         In May 2013, Plaintiff (age eleven) was assessed at Applewood Centers. (Tr. 264-72). She was referred “for conduct behavior” and it was reported that she “gets into several fights with her peers and is physically and verbally aggressive toward adults.” (Tr. 264). Addison reported Plaintiff had recently been suspended for 10 days after an altercation that “resulted in several children [and] the bus driver getting hurt.” Id. She also reported Plaintiff shoplifted, stayed out past her curfew, and set a fire in the bathroom out of anger. Id. On examination, the evaluator noted Plaintiff's appearance, thought content, speech, intellectual behavior, and behavior were unremarkable. (Tr. 268-69). She had decreased impulse control and frustration tolerance. (Tr. 268). Her mood was angry/hostile, and she expressed infrequent suicidal ideation. (Tr. 269). Plaintiff was diagnosed with a conduct disorder (Tr. 270), and assessed a Global Assessment of Functioning (“GAF”) score of 50[4]. (Tr. 270). The evaluator recommended medication, a psychiatric evaluation, and a neurological evaluation. (Tr. 271).

         An individual service plan for Plaintiff was established that day. (Tr. 273-75). The rationale for treatment was that Plaintiff “display[ed] aggressive, disrespectful, and disruptive behavior at school and at home” including “verbal and physical conflict”, and had “outbursts when angry.” (Tr. 273). The treatment goals were: “[e]xpress anger in a controlled, respectful manner on a consistent basis per parent and child report” and “[d]emonstrate marked improvement in impulse control per parent and child report”. (Tr. 274-75).

         In August 2013, Plaintiff underwent a psychiatric diagnostic interview with Shree Sarathy, M.D. (Tr. 281-84). Addison reported Plaintiff “does not listen at all and always does whatever she wants to do”. (Tr. 281). Plaintiff had repeated suspensions, and reports of disruptive behavior. Id. Addison reported Plaintiff had set fires, and bit her mother when her mother disciplined her by spanking. Id. Plaintiff believed that spanking was abuse, and her mother had been imprisoned after being accused of abuse, but was released after an investigation. Id. Plaintiff was in sixth grade at the time of the evaluation, had never failed a grade, and had received passing grades of A, B, and C the prior year. (Tr. 282). On examination, Dr. Sarathy noted impaired grooming and hygiene, as well as decreased impulse control, decreased frustration tolerance, impaired judgment, and impaired interpersonal boundaries. Id. Plaintiff had reduced eye contact, was disinhibited and impulsive, and had impaired concentration. (Tr. 282-83) (“pt was impulsive during appointment, spoke out of turn frequently, was restless”). Her speech was argumentative, and Dr. Sarathy noted possible safety concerns of increased risk-taking behavior, intentional fire starting, and other careless or unsafe behavior. (Tr. 283). Her thought content, intellectual functioning, and perceptions were unremarkable, and she did not evidence suicidal or homicidal ideations. Id. Dr. Sarathy assessed conduct disorder, and ADHD, hyperactive type. (Tr. 294). She assigned a GAF score of 45.[5] Dr. Sarathy started Plaintiff on Guanfacine, noting it would help with “her aggressive behavior and her ADHD hyperactive type”. Id. She also instructed Plaintiff to continue weekly therapy, and noted she would later reevaluate whether a stimulant was needed. Id.

         In September 2013, Plaintiff followed-up with Dr. Sarathy. (Tr. 278-80). Plaintiff had been taking her medication “for the most part”, but her mother felt it was not working. (Tr. 278); see also Tr. 279 (“her mother has noted little change in her behavior and hyperactivity”). Plaintiff had been suspended three times since the start of the school year, and continued to physically fight with her mother. Id. On examination, Dr. Sarathy checked a box indicating “[n]o significant change from last visit.” (Tr. 278). She noted Plaintiff “continue[d] to be very hyperactive and pressured in her speech” and “[h]er violent behavior with other children is also an ongoing problem for her.” (Tr. 279). Dr. Sarathy discontinued Guanfacine, and started Plaintiff on Focalin and Intuniv. (Tr. 280).

         Plaintiff returned to Dr. Sarathy in November 2013. (Tr. 365-67). Dr. Sarathy noted “[t]hough her mother stated last visit that the patient was much improved, she states this visit that her behavior is unchanged.” (Tr. 365). Addison reported Plaintiff was not taking her mediations at times, and was more difficult without them. Id. Dr. Sarathy also noted: “Vanderbilt forms returned by her school show minimal ADHD symptoms only.” Id. On examination, Dr. Sarathy checked the “[n]o significant change from last visit” box regarding her mental status examination. Id. Plaintiff's appearance was noted to be unremarkable, and although her behavior was disinhibited and hyperactive, Dr. Sarathy noted it was “much improved.” Id. Dr. Sarathy instructed Plaintiff to continue taking Focalin XR and Intuniv, and to add Focalin in the afternoon. (Tr. 367)

         Plaintiff also returned to Applewood Centers for a pharmacological management appointment in November 2013. (Tr. 319-20).[6] The provider stopped the Focalin due to non-coverage by insurance, and started Plaintiff on Concerta. (Tr. 320). The provider also checked a box indicating improvement, noting: “pt's behavior and attitude have improved at school according to teachers but behavior at home is unchanged.” Id.

         In December 2013, Plaintiff returned to Dr. Sarathy. (Tr. 316-17).[7] Dr. Sarathy noted Plaintiff's medications “appear[ed] to be working well” for her. (Tr. 316). She was less hyperactive, but still had “a ‘mouth' on her per mother”, though she was working on this in therapy. Id. Dr. Sarathy again checked a box indicating “[n]o significant change from last visit”, but did note impaired grooming and hygiene. Id. She again noted Plaintiff was “still hyperactive and disinhibited but much improved.” Id. Dr. Sarathy again noted improvement at school, but that her mother continued to report “severe symptoms while she is at home.” (Tr. 317). In conclusion, Dr. Sarathy noted Plaintiff was “currently stable and doing well on the combination of Concerta in the morning, immediate acting Focalin in the afternoon, and Intuniv at bedtime.” Id.

         Plaintiff next saw Dr. Sarathy in February 2014. (Tr. 354-56). Addison reported that “for the past couple of weeks”, Plaintiff had not been taking her medications. (Tr. 354). Addison reported watching Plaintiff take the medications before that; however, Plaintiff herself stated she had not taken her medication “in months”. Id. Plaintiff had been suspended from school for five days in January, and upon her return, it was decided that the Assistant Principal would give Plaintiff her morning and afternoon medications. Id. Plaintiff continued to be disrespectful, disruptive, and oppositional at school. Id. Dr. Sarathy again checked the box noting “[n]o significant change from last visit”, and again noted impaired grooming and hygiene. Id. Dr. Sarathy noted Plaintiff “was stable and doing well on the combination of Concerta in the morning, immediate acting Focalin in the afternoon, and Intuniv at bedtime until recently, when she stopped taking all of her medications.” (Tr. 355); see also Tr. 356 (noting deterioration due to failure to take medication). Dr. Sarathy's plan was to return to the same medication regimen, with the school administering medications “to ensure that she takes it.” (Tr. 355). Dr. Sarathy noted she would consider a low-dose antipsychotic if Plaintiff did not improve or deteriorated. Id.

         Addison cancelled an appointment later in February due to car problems. (Tr. 353). Plaintiff then missed four consecutive appointments with Dr. Sarathy between March and May 2014 without explanation. (Tr. 349-52).

         In April 2014, Plaintiff went to the emergency room after being involved in an altercation with another child which resulted in her fracturing her right fifth metacarpal. (Tr. 326-43). She reportedly punched another child in the head. (Tr. 331).

         In May 2014, Plaintiff returned to Dr. Sarathy. (Tr. 346-48). Addison reported Plaintiff had been kicked out of school one or two months prior, and had been out of medication for the past two months. (Tr. 346). Plaintiff reported getting into frequent fights. Id. Dr. Sarathy noted Addison felt Plaintiff “need[ed] something stronger to control her behavior”, and started Plaintiff on a low-dose antipsychotic. (Tr. 347). She also “[e]mphasized . . . that following up is crucial”, noting Plaintiff had missed the last four appointments. Id.

         Medical Opinion Evidence[8]

         In November 2013, state agency psychologist Paul Tangeman, Ph.D., reviewed Plaintiff's records. (Tr. 112). He concluded Plaintiff had a marked limitation in the domain of interacting and relating with others. Id. He explained:

[Medical evidence of record] submitted w/ claim indicates clt has had frequent behavior problems. Statements from school staff members, however, indicate that clt has few behavior issues when on meds. Most recent f/u at tx source in 9/13 indicates clt has been mostly compliant w/ meds, but behavior problems w/ suspensions from school continued and mother felt meds were not working.

Id. Dr. Tangeman also concluded Plaintiff had a less-than-marked limitation in the domain of caring for oneself, explaining: “Impulsivity and behavior problems may put clt at risk for harm, but she otherwise appears capable of age appropriate self care.” Id.

         In February 2014, state agency psychologist Mary Hill, Ph.D., reviewed Plaintiff's records. (Tr. 121-22). Like Dr. Tangeman, she concluded Plaintiff had a marked limitation in the domain of interacting and relating with others, and a less than marked limitation in the domain of caring for oneself. Id. Regarding interacting and relating with others, Dr. Hill explained:

[Medical evidence of record] submitted w/ claim indicates clt has had frequent behavior problems. Statements from school staff members, however, indicate that clt has few behavior issues when on meds. On recon, mother indicated clmt's behavior worsened as of 11/2013; however, 12/13/13 OV notes state that the new combination of meds “appears to be working well for” clmt. She is less hyperactive. Still mouthy w/ mother. School is going well and she has only gotten in trouble 2x recently. Better at managing impulsivity and anger.

Id. With regard to caring for oneself, Dr. Hill noted: “Impulsivity and anger management have improved. Hygiene/grooming age ...

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