Childhood Impairment Guides
Determinations of growth impairment should be based on the comparison of current height with at least three previous determinations, including length at birth, if available. Heights (or lengths) should be plotted on the Standard Growth Chart prepared by the Harvard School of Public Health; this should be included in the folder. Height should be measured without shoes. Body weight corresponding to the ages represented by the heights should be furnished, if available. The adult heights of the child's natural parents and the height and age of siblings should also be furnished, if available, to provide a basis upon which to identify those children whose short stature represents a family characteristic rather than a result of disease.
Bone age determinations should include a full descriptive report, and must cite the standardization method used. Where roentgenograms have not previously been outlined to determine bone age in a child otherwise displaying apparent growth retardation, they must be obtained currently as a basis for adjudication under the following criteria. Where bone roentgenograms are obtained by the Administration, views of the left hand and wrist should be ordered. Additional roentgenograms of the knee and ankle should be obtained when cessation of growth is being evaluated. The results of such roentgenograms should always be made available to the treating physician. The requirement of bone age retardation is not applicable to individuals with growth impairment resulting from malabsorption; growth impairment in these individuals should be considered under the criteria in Section C 100.02B and C. The criteria in this section are applicable only until closure of the major epiphyses.
Category of Impairments, Growth
Growth impairment, as evidenced by bone age greater than one standard deviation (1 SD) below the mean for chronolgoical age, and one of the following:
Continuing or sustained fall of greater than 25 percentiles in height; or
Continuing or sustained fall of greater than 15 percentiles in height and an additional medically determined impairment; or
Fall to, or persistence of, height below the third percentile and an additional medically determined impairment.
Special Sense Organs
Deafness. The criteria for hearing loss in children take into account that a smaller loss occurring at an early age, which is not correctable by definitive short-term therapy, may result in a severe speech defect. The criteria in Section 102.08 describe conditions most applicable in the younger age group, and should be used in children through 12 years of age. Above the age of 12 years, the criteria in Section 2.08 should be applied.
Improvement by a hearing aid, as predicted by the testing procedure, must be demonstrated to be feasible in that child, since younger children may be unable to use a hearing aid effectively.
The type of testing performed should be described. A copy of the graphic representation of audiometric testing should be included in the report. If a standard audiometer is used, as will usually be the case, the report should indicate whether the apparatus was calibrated according to American National Standard Institute Specifications for Audiometers, S 3.6. - 1969 (ANSI-1969) or American Standard, Z 24.5 - 1951 (ASA-1951). The decibel levels cited in Section C 102.08 are based on use of the ANSI-1969 calibration. Testing should be done at the three frequencies of 500, 1000 and 2000 Hertz (Hz). Auditory perception of better than the level required in Section 102.08 at only a single tonal frequencey between 500 and 2000 Hz will be considered as meeting the requirements of the criteria.
For children whose claims are adjudicated below age 5 years, absence of bilateral auditory perception at greater than 40 decibels; or
For children whose claims are adjudicated from 5 years of age and above:
Absence of bilateral auditory perception at greater than 80 decibels, not correctable by a hearing aid; or
Absence of bilateral auditory perception at greater than 40 decibels, not correctable by a hearing aid and speech deficit involving clarity and content, attributable to the hearing loss.
Hemic and Lymphatic System
Leukemia: The criteria in Section C 107.11 take into account the implications and consequences to the child attendant upon this diagnosis, as well as the recent great strides in treatment, with an increasing number of prolonged, sustained remissions.
Sickle Cell Anemia: With hematocrit of 25 percent or less; and
Growth retardation as in Section C 100.00; or
Documented recurrent, severe, painful (thrombotic) crises; or
Recurrent major lower respiratory infections requiring hospitalization; or
A major complication (such as hyperhemolytic or aplastic crisis, renal or cardiac failure, severe meningitis, or osteomyelitis) within six months preceding adjudication.
Consider under severe impairment for one year after complete remission; or
With relapse or recurrence.
Juvenile Diabetes Mellitus
Juvenile diabetes mellitus manifested by significant ketonemia or lowering of plasma bicarbonate or pH requiring hospital care on the average of at least once every two months.
Juvenile diabetes mellitus with growth retardation (such as in Moriak syndrome or with malabsorption or renal disease).
When juvenile diabetes mellitus exists or results in other physical or mental impairments, consider in conjunction with the criteria for the appropriate body system.
Multiple Body System
Catastrophic Congenital Abnormalities or Disease
With a positive diagnosis (such as anencephaly, trisomy D or E, cyclopsia, etc.), generally regarded as being incompatible with extra-uterine life; or
With a positive diagnosis (such as cri du chat, Tay-Sachs, maple syrup urine disease, etc.), wherein attainment of the growth and development level of two years is not expected to occur.
Convulsive Seizures: The documentation of epilepsy in childhood is subject to the same requirements stated in Section 11.00A. Criteria have been provided in Section C 111.02 for infantile myoclonic seizures and for major convulsive seizures in combination with other impairments. Specific criteria for adjudication of cases involving only major convulsive seizures in children are not being furnished at the present time. Seizures in children may differ from those in adults in terms of pattern, duration, and manifestations of the post-ictal phase and response to therapy. The impact on the child's life may be different. The criteria in Section 11.02 or 11.03 are not felt to describe impairments which significantly interfere with growth or development in a child or which constitute an “impairment of comparable severity” as required in Section 1614(a)(3)(A) of Public Law 92-603. Adjudication of childhood claims based on major convulsive seizures, unaccompanied by another significant impairment should take into account the impact on the child of seizure episodes, duration of the post-ictal phase, and other residua, and the extent to which these interfere with major daily activities for age or progression of development.
Cerebral Palsy: Documentation of cerebral palsy should include results of an examination describing the area of neuromuscular involvement, the appearance, any contractures or deformities, and the degree of spasticity, weakness, tremor, ataxia, or athetosis.
The requirement of significant interference with the stated functions in Section C 111.07A should be interpreted as requiring a level of involvement on a neuro-musculoskeletal basis alone which will interfere with the child's major daily activities for age and with progression of development. The criteria in Sections C 111.07C through F are based on the combined effect of two or more impairments, each of which is short of the requirements listed for a single impairment, but is greater than of slight or mild severity.
Major Convulsive Seizures: Occurring in spite of prescribed therapy.
See Section C 111.00A; or
In combination with:
I.Q. below 70; or
Cerebral palsy; or
Emotional disorder; or
Impaired vision, hearing, or speech; or
Infantile myoclonic seizures with characteristic EEG pattern of hypsarrhythmia.
Cerebral Palsy: With persistent spasticity, weakness, tremor, ataxia, or athetosis involving two extremities; and
Significant interference with gross and fine movements or locomotion and station for age; or
Positive diagnosis of cerebral palsy made before one year of age; or
I.Q. below 70; or
Convulsive seizures; or
Impaired vision, hearing, or speech; or
Mental or emotional disorder.
Mental and Emotional Disorders
This section is primarily intended to describe mental and emotional disorders of young children. The medical criteria describing impairments in adults should be used when they clearly appear to be more appropriate.
Mental retardation. (C 112.05) should be determined on the basis of medical reports, I.Q. measurements and developmental milestone criteria. Standardized tests such as the Wechsler Preschool and Primary Scale of Intelligence (WPPSI), the Wechsler Intelligence Scale for Children (WISC), the Binet, and the Bayley Scale should be used whenever possible. Key data such as subtest scores should be included in the report.
Developmental milestone criteria (such as appear in standard pediatric texts and the February 1973 Pediatric Clinics of North America ) should be included. When the age and condition of the child preclude the standardized tests described above, developmental criteria, based upon a physician's evaluation, may be the basis for adjudication.
Other widely used pediatric screening devices (such as the Denver Developmental, the “Draw-A-Person”, and the Peabody Picture Vocabulary Test) should be included whenever this information is available.
Chronic Brain Syndrome with arrest of developmental progression for six months or loss of previously acquired abilities.
Psychosis of Infancy and Childhood manifested by impaired relationships with others, impaired sense of reality, and one of the following:
Significant withdrawal or detachment, or
Bizarre behavior patterns, or
Strong need for maintenance of sameness, with intense anxiety, fear, and anger when change is introduced, or
Panic at threat of separation from parent.
Functional Non-Psychotic Disorders with symptom formation which renders the child unable to perform major daily age-appropriate activities, and one of the following:
Weight loss with malnutrition (see Section C 100.00).
Persistent inappropriate behavior (i.e. excessive preoccupation, withdrawal, or compulsive-ritualistic behavior).
Achievement of only those developmental milestones generally acquired by children up to one-half the child's chronologic age, or
I.Q. of 59 or less, or
I.Q. of 60-69, inclusive, with marked dependence, for age, upon others for basic personal needs (i.e., feeding, washing) and a physical or other mental impairment resulting in restriction of function and developmental progression.
Teratoma with recurrence; or
Malignant thymoma with recurrence; or
Ganglioneuroma with malignant change or recurrence.
Hepatoblastoma, argentaffinoma, or hepatic or biliary cell carcinoma; or
Metastatic malignant tumors to liver.
Teratocarcinoma, choriocarcinoma, or embryonal cell carcinoma; or
Seminoma not controlled by prescribed therapy.
Teratocarcinoma, choriocarcinoma, or adenocarcinoma; or
Granulosa or thecal cell tumors, or arrhenoblastoma, with
Onset at 24 months of age or later; or
Bone or marrow involvement; or
Not controlled by definitive therapy; or
Recurrent after definitive therapy.
Not controlled by prescribed therapy; or
Histologically benign tumors recurrent after radical surgery.
Teratocarcinoma or Choriocarcinoma: Occurring in any location except anterior mediastinum (see Section C 113.14A).
Bilateral involvement; or
Metastatic or extending beyond the orbit; or