SSR-98-1p EFFECTIVE/PUBLICATION DATE:
POLICY INTERPRETATION RULING
TITLE XVI: DETERMINING MEDICAL EQUIVALENCE IN CHILDHOOD DISABILITY CLAIMS
WHEN A CHILD HAS MARKED LIMITATIONS IN COGNITION AND SPEECH
PURPOSE: To provide a policy interpretation that children who have a "marked" limitation in
cognitive functioning and a "marked" limitation in speech have an impairment or combination
of impairments that medically equals Listing 2.09. Also, to provide guidance for determining
when a child has a "marked" or an "extreme" limitation in each of these areas.
CITATIONS (AUTHORITY): Section 1614(a) of the Social Security Act, as amended; Regulations No. 16, subpart
I, sections 416.902, 416.923, 416.924, 416.925, 416.926; Regulations No. 4, subpart
P, appendix 1 - Listing of Impairments.
On December 17, 1997, the Commissioner of Social Security issued the Review of SSA's Implementation of New SSI Childhood Disability Legislation (Pub. No. 64-070), a report of a "top-to-bottom" review of the implementation of
changes to the Supplemental Security Income (SSI) childhood disability program necessitated
by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public
As a result of the review, the Commissioner directed additional instruction on the
evaluation of a combination of cognitive and speech disorders that separates speech
disorders from cognitive disorders. Among other things, the Commissioner directed
the issuance of a Ruling on the evaluation of speech disorders in combination with
1 This Ruling addresses evaluation of speech disorders in combination with cognitive
limitations. It does not address evaluation of receptive or expressive language disorders,
which can also result in disability. In addition, this Ruling does not address evaluation
of the area of Cognition/Communication under the broad areas of functioning of the
functional equivalence provision, as discussed in 20 CFR 416.926a(c)(4).
The regulations at 20 CFR 416.906 explain that, for children claiming SSI benefits
under the Social Security Act (the Act), an impairment or combination of impairments
must cause "marked and severe functional limitations" in order to be found disabling.
The regulations at 20 CFR 416.902 provide that "marked and severe functional limitations,"
when used as a phrase, is a level of severity that meets, medically equals, or functionally
equals the severity of a listing in the Listing of Impairments, appendix 1 of subpart
P of 20 CFR part 404 (the listings).
The regulations at 20 CFR 416.925(b)(2) explain that, in general, a child's impairment
or combination of impairments is "of listing-level severity" if it causes marked limitation
in two broad areas of functioning or extreme limitation in one such area.
The regulations at 20 CFR 416.926 explain that we will decide that a child's impairment
or combination of impairments is medically equivalent to a listed impairment if the
medical findings are at least equal in severity and duration to the listed findings.
We will compare the signs, symptoms, and laboratory findings concerning the child's
impairment or combination of impairments, as shown in the medical evidence we have
about the claim, with the corresponding medical criteria shown for any listed impairment.
In particular, the regulations at 20 CFR 416.926(a)(2) provide that, if a child has
an impairment that is not described in the listings, or a combination of impairments,
no one of which meets or is medically equivalent to a listing, we will compare the
child's medical findings with those for closely analogous listed impairments. If the
medical findings related to the child's impairment or combination of impairments are
at least of equal medical significance to those of a listed impairment, we will find
that the child's combination of impairments is medically equivalent to the analogous
I. Need To Establish a Medically Determinable Impairment
Section 1614(a)(3)(C)(i) of the Act and 20 CFR 416.906 provide that a child's disability
must result from a medically determinable physical or mental impairment. Section 1614(a)(3)(D)
of the Act and 20 CFR 416.908 further provide that the physical or mental impairment
must result from anatomical, physiological, or psychological abnormalities which can
be shown by medically acceptable clinical and laboratory diagnostic techniques. A
physical or mental impairment must be established by medical evidence consisting of
signs, symptoms, and laboratory findings.
The discussions in this Ruling address the evaluation of the severity of impairments
affecting speech and cognition. They presume that the existence of such medically
determinable impairments has already been established.
II. Terms and Definitions
A.Cognition involves the ability to learn, understand, and solve problems through intuition,
perception, auditory and visual sequencing, verbal and nonverbal reasoning, and the
application of acquired knowledge. It also involves the ability to retain and recall
information, images, events, and procedures during the process of thinking. There
are many impairments that can cause limitations in cognition, such as genetic disorders
or brain injury.
B.Speech is the production of sounds (phonemes) in a smooth and rhythmic fashion for
the purposes of oral communication. It includes articulation, voice (pitch, volume,
quality), and fluency (the flow, or rate and rhythm, of speech). Understandable speech
results from precise neuromuscular functioning of the speech mechanism (e.g., lips,
tongue, hard palate, vocal folds, respiratory mechanism), and intact structure and
functioning of the speech centers in the brain.
There are many impairments that can cause limitations in speech, such as brain lesions
or cortical injury resulting in apraxia; other neurological abnormalities, such as
cerebral palsy producing dysarthria; or structural abnormalities, such as cleft palate
Speech differs from language (receptive and expressive). Speech is the production
of sounds for purposes of oral communication; language provides the message of the
communication, and involves the use of semantics (e.g., vocabulary), syntax (e.g.,
grammar), and pragmatics (i.e., use of language in its social context) in the understanding
and expression of messages.
III. Limitations in Cognition and Speech