Attention must be given to the effect of medication on the child's signs, symptoms,
and ability to function. While drugs used to modify psychological functions and mental
states may control certain primary manifestations of a mental disorder, e.g., hallucinations,
impaired attention, restlessness, or hyperactivity, such treatment may not affect
all functional limitations imposed by the mental disorder. In cases where overt symptomatology
is attenuated by the use of such drugs, particular attention must be focused on the
functional limitations that may persist. These functional limitations must be considered
in assessing impairment severity.
Psychotropic medicines used in the treatment of some mental illnesses may cause drowsiness,
blunted affect, or other side effects involving other body systems. Such side effects
must be considered in evaluating overall impairment severity.
112.01 Category of Impairments, Mental
112.02 Organic Mental Disorders: Abnormalities in perception, cognition, affect, or behavior associated with dysfunction
of the brain. The history and physical examination or laboratory tests, including
psychological or neuropsychological tests, demonstrate or support the presence of
an organic factor judged to be etiologically related to the abnormal mental state
and associated deficit or loss of specific cognitive abilities, or affective changes,
or loss of previously acquired functional abilities.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented persistence of at least one of the following:
1. Developmental arrest, delay or regression; or
2. Disorientation to time and place; or
3. Memory impairment, either short-term (inability to learn new information), intermediate,
or long-term (inability to remember information that was known sometime in the past);
or
4. Perceptual or thinking disturbance (e.g., hallucinations, delusions, illusions,
or paranoid thinking); or
5. Disturbance in personality (e.g., apathy, hostility); or
6. Disturbance in mood (e.g., mania, depression); or
7. Emotional lability (e.g., sudden crying); or
8. Impairment of impulse control (e.g., disinhibited social behavior, explosive temper
outbursts); or
9. Impairment of cognitive function, as measured by clinically timely standardized
psychological testing; or
10. Disturbance of concentration, attention, or judgment;
AND
B. Select the appropriate age group to evaluate the severity of the impairment:
1. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the following:
a. Gross or fine motor development at a level generally acquired by children no more
than one-half the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings (see 112.00C); or
b. Cognitive/communicative function at a level generally acquired by children no more
than one-half the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings of equivalent cognitive/communicative abnormality, such
as the inability to use simple verbal or nonverbal behavior to communicate basic needs
or concepts; or
c. Social function at a level generally acquired by children no more than one-half
the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings of an equivalent abnormality of social functioning, exemplified
by serious inability to achieve age-appropriate autonomy as manifested by excessive
clinging or extreme separation anxiety; or
d. Attainment of development or function generally acquired by children no more than
two-thirds of the child's chronological age in two or more areas covered by a., b.,
or c., as measured by an appropriate standardized test or other appropriate medical
findings.
2. For children (age 3 to attainment of age 18), resulting in at least two of the
following:
a. Marked impairment in age-appropriate cognitive/communicative function, documented
by medical findings (including consideration of historical and other information from
parents or other individuals who have knowledge of the child, when such information
is needed and available) and including, if necessary, the results of appropriate standardized
psychological tests, or for children under age 6, by appropriate tests of language
and communication; or
b. Marked impairment in age-appropriate social functioning, documented by history
and medical findings (including consideration of information from parents or other
individuals who have knowledge of the child, when such information is needed and available)
and including, if necessary, the results of appropriate standardized tests; or
c. Marked impairment in age-appropriate personal functioning, documented by history
and medical findings (including consideration of information from parents or other
individuals who have knowledge of the child, when such information is needed and available)
and including, if necessary, appropriate standardized tests; or
d. Marked difficulties in maintaining concentration, persistence, or pace.
112.03 Schizophrenic, Delusional (Paranoid), Schizoaffective, and Other Psychotic
Disorders: Onset of psychotic features, characterized by a marked disturbance of thinking,
feeling, and behavior, with deterioration from a previous level of functioning or
failure to achieve the expected level of social functioning.
A. The required level of severity for these disorders is met when the requirements
in both A and B are satisfied.
1. Medically documented persistence, for at least 6 months, either continuous or intermittent,
of one or more of the following:
2. Delusions or hallucinations; or
3. Catatonic, bizarre, or other grossly disorganized behavior; or
4. Incoherence, loosening of associations, illogical thinking, or poverty of content
of speech; or
5. Flat, blunt, or inappropriate affect; or
6. Emotional withdrawal, apathy, or isolation;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.04 Mood Disorders: Characterized by a disturbance of mood (referring to a prolonged emotion that colors
the whole psychic life, generally involving either depression or elation), accompanied
by a full or partial manic or depressive syndrome.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one of
the following:
1. Major depressive syndrome, characterized by at least five of the following, which
must include either depressed or irritable mood or markedly diminished interest or
pleasure:
a. Depressed or irritable mood; or
b. Markedly diminished interest or pleasure in almost all activities; or
c. Appetite or weight increase or decrease, or failure to make expected weight gains;
or
d. Sleep disturbance; or
e. Psychomotor agitation or retardation; or
f. Fatigue or loss of energy; or
g. Feelings of worthlessness or guilt; or
h. Difficulty thinking or concentrating; or
i. Suicidal thoughts or acts; or
j. Hallucinations, delusions, or paranoid thinking;
OR
2. Manic syndrome, characterized by elevated, expansive, or irritable mood, and at
least three of the following:
a. Increased activity or psychomotor agitation; or
b. Increased talkativeness or pressure of speech; or
c. Flight of ideas or subjectively experienced racing thoughts; or
d. Inflated self-esteem or grandiosity; or
e. Decreased need for sleep; or
f. Easy distractibility; or
g. Involvement in activities that have a high potential of painful consequences which
are not recognized; or
h. Hallucinations, delusions, or paranoid thinking;
OR
3. Bipolar or cyclothymic syndrome with a history of episodic periods manifested by
the full symptomatic picture of both manic and depressive syndromes (and currently
or most recently characterized by the full or partial symptomatic picture of either
or both syndromes);
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.05 Intellectual Disability: Characterized by significantly subaverage general intellectual functioning with
deficits in adaptive functioning.
The required level of severity for this disorder is met when the requirements in A,
B, C, D, E, or F are satisfied.
A. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02;
OR
B. Mental incapacity evidenced by dependence upon others for personal needs (grossly
in excess of age-appropriate dependence) and inability to follow directions such that
the use of standardized measures of intellectual functioning is precluded;
OR
C. A valid verbal, performance, or full scale IQ of 59 or less;
OR
D. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or
other mental impairment imposing an additional and significant limitation of function;
OR
E. A valid verbal, performance, or full scale IQ of 60 through 70 and:
1. For older infants and toddlers (age 1 to attainment of age 3), resulting in attainment
of development or function generally acquired by children no more than two-thirds
of the child's chronological age in either paragraphs B1a or B1c of 112.02; or
2. For children (age 3 to attainment of age 18), resulting in at least one of paragraphs
B2b or B2c or B2d of 112.02;
OR
F. Select the appropriate age group:
1. For older infants and toddlers (age 1 to attainment of age 3), resulting in attainment
of development or function generally acquired by children no more than two-thirds
of the child's chronological age in paragraph B1b of 112.02, and a physical or other
mental impairment imposing an additional and significant limitation of function;
OR
2. For children (age 3 to attainment of age 18), resulting in the satisfaction of
112.02B2a, and a physical or other mental impairment imposing an additional and significant
limitation of function.
112.06 Anxiety Disorders: In these disorders, anxiety is either the predominant disturbance or is experienced
if the individual attempts to master symptoms, e.g., confronting the dreaded object
or situation in a phobic disorder, attempting to go to school in a separation anxiety
disorder, resisting the obsessions or compulsions in an obsessive compulsive disorder,
or confronting strangers or peers in avoidant disorders.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented findings of at least one of the following:
1. Excessive anxiety manifested when the child is separated, or separation is threatened,
from a parent or parent surrogate; or
2. Excessive and persistent avoidance of strangers; or
3. Persistent unrealistic or excessive anxiety and worry (apprehensive expectation),
accompanied by motor tension, autonomic hyperactivity, or vigilance and scanning;
or
4. A persistent irrational fear of a specific object, activity, or situation which
results in a compelling desire to avoid the dreaded object, activity, or situation;
or
5. Recurrent severe panic attacks, manifested by a sudden unpredictable onset of intense
apprehension, fear, or terror, often with a sense of impending doom, occurring on
the average of at least once a week; or
6. Recurrent obsessions or compulsions which are a source of marked distress; or
7. Recurrent and intrusive recollections of a traumatic experience, including dreams,
which are a source of marked distress;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), B resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.07 Somatoform, Eating, and Tic Disorders: Manifested by physical symptoms for which there are no demonstrable organic findings
or known physiologic mechanisms; or eating or tic disorders with physical manifestations.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented findings of one of the following:
1. An unrealistic fear and perception of fatness despite being underweight, and persistent
refusal to maintain a body weight which is greater than 85 percent of the average
weight for height and age, as shown in the most recent edition of the Nelson Textbook
of Pediatrics, Richard E. Behrman and Victor C. Vaughan, III, editors, Philadelphia:
W. B. Saunders Company; or
2. Persistent and recurrent involuntary, repetitive, rapid, purposeless motor movements
affecting multiple muscle groups with multiple vocal tics; or
3. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance, psychogenic seizures);
or
f. Sensation (diminished or heightened); or
g. Digestion or elimination; or
4. Preoccupation with a belief that one has a serious disease or injury;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.08 Personality Disorders: Manifested by pervasive, inflexible, and maladaptive personality traits, which are
typical of the child's long-term functioning and not limited to discrete episodes
of illness.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior, associated with one of the
following:
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech, and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressiveness; or
6. Intense and unstable interpersonal relationships and impulsive and exploitative
behavior; or
7. Pathological perfectionism and inflexibility;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.09 Psychoactive Substance Dependence Disorders: Manifested by a cluster of cognitive, behavioral, and physiologic symptoms that
indicate impaired control of psychoactive substance use with continued use of the
substance despite adverse consequences.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented findings of at least four of the following:
1. Substance taken in larger amounts or over a longer period than intended and a great
deal of time is spent in recovering from its effects; or
2. Two or more unsuccessful efforts to cut down or control use; or
3. Frequent intoxication or withdrawal symptoms interfering with major role obligations;
or
4. Continued use despite persistent or recurring social, psychological, or physical
problems; or
5. Tolerance, as characterized by the requirement for markedly increased amounts of
substance in order to achieve intoxication; or
6. Substance taken to relieve or avoid withdrawal symptoms;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.10 Autistic Disorder and Other Pervasive Developmental Disorders: Characterized by qualitative deficits in the development of reciprocal social interaction,
in the development of verbal and nonverbal communication skills, and in imaginative
activity. Often, there is a markedly restricted repertoire of activities and interests,
which frequently are stereotyped and repetitive.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented findings of the following:
1. For autistic disorder, all of the following:
a. Qualitative deficits in the development of reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity;
and
c. Markedly restricted repertoire of activities and interests;
OR
2. For other pervasive developmental disorders, both of the following:
a. Qualitative deficits in the development of reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.11 Attention Deficit Hyperactivity Disorder: Manifested by developmentally inappropriate degrees of inattention, impulsiveness,
and hyperactivity.
The required level of severity for these disorders is met when the requirements in
both A and B are satisfied.
A. Medically documented findings of all three of the following:
1. Marked inattention; and
2. Marked impulsiveness; and
3. Marked hyperactivity;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at
least one of the appropriate age-group criteria in paragraph B1 of 112.02; or, for
children (age 3 to attainment of age 18), resulting in at least two of the appropriate
age-group criteria in paragraph B2 of 112.02.
112.12 Developmental and Emotional Disorders of Newborn and Younger Infants (Birth
to attainment of age 1): Developmental or emotional disorders of infancy are evidenced by a deficit or lag
in the areas of motor, cognitive/communicative, or social functioning. These disorders
may be related either to organic or to functional factors or to a combination of these
factors.
The required level of severity for these disorders is met when the requirements of
A, B, C, D, or E are satisfied.
A. Cognitive/communicative functioning generally acquired by children no more than
one-half the child's chronological age, as documented by appropriate medical findings
(e.g., in infants 0-6 months, markedly diminished variation in the production or imitation
of sounds and severe feeding abnormality, such as problems with sucking, swallowing,
or chewing) including, if necessary, a standardized test;
OR
B. Motor development generally acquired by children no more than one-half the child's
chronological age, documented by appropriate medical findings, including if necessary,
a standardized test;
OR
C. Apathy, over-excitability, or fearfulness, demonstrated by an absent or grossly
excessive response to one of the following:
1. Visual stimulation; or
2. Auditory stimulation; or
3. Tactile stimulation;
OR
D. Failure to sustain social interaction on an ongoing, reciprocal basis as evidenced
by:
1. Inability by 6 months to participate in vocal, visual, and motoric exchanges (including
facial expressions); or
2. Failure by 9 months to communicate basic emotional responses, such as cuddling
or exhibiting protest or anger; or
3. Failure to attend to the caregiver's voice or face or to explore an inanimate object
for a period of time appropriate to the infant's age;
OR
E. Attainment of development or function generally acquired by children no more than
two-thirds of the child's chronological age in two or more areas (i.e., cognitive/communicative,
motor, and social), documented by appropriate medical findings, including if necessary,
standardized testing.