The presence of a mental disorder in a child must be documented on the basis of reports
from acceptable sources of medical evidence. See §§ 404.1513 and 416.913. Descriptions
of functional limitations may be available from these sources, either in the form
of standardized test results or in other medical findings supplied by the sources,
or both. (Medical findings consist of symptoms, signs, and laboratory findings.)
Whenever possible, a medical source"s findings should reflect the medical source"s
consideration of information from parents or other concerned individuals who are aware
of the child"s activities of daily living, social functioning, and ability to adapt
to different settings and expectations, as well as the medical source"s findings and
observations on examination, consistent with standard clinical practice. As necessary,
information from nonmedical sources, such as parents, should also be used to supplement
the record of the child"s functioning to establish the consistency of the medical
evidence and longitudinality of impairment severity.
For some newborn and younger infants, it may be very difficult to document the presence
or severity of a mental disorder. Therefore, with the exception of some genetic diseases
and catastrophic congenital anomalies, it may be necessary to defer making a disability
decision until the child attains 3 months of age in order to obtain adequate observation
of behavior or affect. See, also, 110.00 of this part. This period could be extended
in cases of premature infants depending on the degree of prematurity and the adequacy
of documentation of their developmental and emotional status.
For infants and toddlers, programs of early intervention involving occupational, physical,
and speech therapists, nurses, social workers, and special educators, are a rich source
of data. They can provide the developmental milestone evaluations and records on the
fine and gross motor functioning of these children. This information is valuable and
can complement the medical examination by a physician or psychologist. A report of
an interdisciplinary team that contains the evaluation and signature of an acceptable
medical source is considered acceptable medical evidence rather than supplemental
data.
In children with mental disorders, particularly those requiring special placement,
school records are a rich source of data, and the required reevaluations at specified
time periods can provide the longitudinal data needed to trace impairment progression
over time.
In some cases where the treating sources lack expertise in dealing with mental disorders
of children, it may be necessary to obtain evidence from a psychiatrist, psychologist,
or pediatrician with experience and skill in the diagnosis and treatment of mental
disorders as they appear in children. In these cases, however, every reasonable effort
must be made to obtain the records of the treating sources, since these records will
help establish a longitudinal picture that cannot be established through a single
purchased examination.
A reference to standardized psychological testing indicates the use of a psychological
test that has appropriate characteristics of validity, reliability, and norms, administered
individually by a psychologist, psychiatrist, pediatrician, or other physician specialist
qualified by training and experience to perform such an evaluation. Psychological
tests are best considered as sets of tasks or questions designed to elicit particular
behaviors when presented in a standardized manner.
The salient characteristics of a good test are: (1) Validity, i.e., the test measures
what it is supposed to measure, as determined by appropriate methods; 2) reliability,
i.e., the consistency of results obtained over time with the same test and the same
individual; 3) appropriate normative data, i.e., individual test scores must be comparable
to test data from other individuals or groups of a similar nature, representative
of that population. In considering the validity of a test result, any discrepancies
between formal test results and the child"s customary behavior and daily activities
should be duly noted and resolved.
Tests meeting the above requirements are acceptable for the determination of the conditions
contained in these listings. The psychologist, psychiatrist, pediatrician, or other
physician specialist administering the test must have a sound technical and professional
understanding of the test and be able to evaluate the research documentation related
to the intended application of the test.
Identical IQ scores obtained from different tests do not always reflect a similar
degree of intellectual functioning. The IQ scores in listing 112.05 reflect values
from tests of general intelligence that have a mean of 100 and a standard deviation
of 15, e.g., the Wechsler series and the Revised Stanford-Binet scales. Thus IQs below
60 reflect a level of intellectual functioning below 99.5 percent of the general population,
and IQs of 70 and below are characteristic of approximately the lowest 2 percent of
the general population. IQs obtained from standardized tests that deviate from a mean
of 100 and standard deviation of 15 require conversion to the corresponding percentile
rank in the general population so that the actual degree of impairment reflected by
the IQ scores can be determined. In cases where more than one IQ is customarily derived
from the test administered, e.g., where verbal, performance, and full scale IQs are
provided, as on the Wechsler series, the lowest of these is used in conjunction with
listing 112.05.
IQ test results must also be sufficiently current for accurate assessment under 112.05.
Generally, the results of IQ tests tend to stabilize by the age of 16. Therefore,
IQ test results obtained at age 16 or older should be viewed as a valid indication
of the child"s current status, provided they are compatible with the child"s current
behavior. IQ test results obtained between ages 7 and 16 should be considered current
for 4 years when the tested IQ is less than 40, and for 2 years when the IQ is 40
or above. IQ test results obtained before age 7 are current for 2 years if the tested
IQ is less than 40 and 1 year if at 40 or above.
Standardized intelligence test results are essential to the adjudication of all cases
of mental retardation that are not covered under the provisions of listings 112.05A,
112.05B, and 112.05F. Listings 112.05A, 112.05B, and 112.05F may be the bases for
adjudicating cases where the results of standardized intelligence tests are unavailable,
e.g., where the child"s young age or condition precludes formal standardized testing.
In conjunction with clinical examinations, sources may report the results of screening
tests, i.e., tests used for gross determination of level of functioning. These tests
do not have high validity and reliability and generally are not considered appropriate
primary evidence for disability determinations. These screening instruments may be
useful in uncovering potentially serious impairments, but generally must be supplemented
by the use of formal, standardized psychological testing for the purposes of a disability
determination, unless the determination is to be made on the basis of findings other
than psychological test data; however, there will be some cases in which the results
of screening tests show such obvious abnormalities that further testing will clearly
be unnecessary.
Where reference is made to developmental milestones, this is defined as the attainment
of particular mental or motor skills at an age-appropriate level, i.e., the skills
achieved by an infant or toddler sequentially and within a given time period in the
motor and manipulative areas, in general understanding and social behavior, in self-feeding,
dressing, and toilet training, and in language. This is sometimes expressed as a developmental
quotient (DQ), the relation between developmental age and chronological age as determined
by specific standardized measurements and observations. Such tests include, but are
not limited to, the Cattell Infant Intelligence Scale, the Bayley Scales of Infant
Development, and the Revised Stanford-Binet. Formal tests of the attainment of developmental
milestones are generally used in the clinical setting for determination of the developmental
status of infants and toddlers.
Formal psychological tests of cognitive functioning are generally in use for preschool
children, for primary school children, and for adolescents except for those instances
noted below.
Exceptions to formal standardized psychological testing may be considered when a psychologist,
psychiatrist, pediatrician, or other physician specialist who is qualified by training
and experience to perform such an evaluation is not readily available. In such instances,
appropriate medical, historical, social, and other information must be reviewed in
arriving at a determination.
Exceptions may also be considered in the case of ethnic/cultural minorities where
the native language or culture is not principally English-speaking. In such instances,
psychological tests that are culture-free, such as the Leiter International Performance
Scale or the Scale of Multi-Culture Pluralistic Assessment (SOMPA) may be substituted
for the standardized tests described above. Any required tests must be administered
in the child's principal language. When this is not possible, appropriate medical,
historical, social, and other information must be reviewed in arriving at a determination.
Furthermore, in evaluating mental impairments in children from a different culture,
the best indicator of severity is often the level of adaptive functioning and how
the child performs activities of daily living and social functioning.
Neuropsychological testing refers to the administration of standardized tests that are reliable and valid with
respect to assessing impairment in brain functioning. It is intended that the psychologist
or psychiatrist using these tests will be able to evaluate the following functions:
Attention/concentration, problem-solving, language, memory, motor, visual-motor and
visual-perceptual, laterality, and general intelligence (if not previously obtained).