Effective Dates: 09/25/2020 - Present Previous | Next

TN 23 (09-20)

DI 22510.048 Pediatric Consultative Examination (CE) Report Content Guidelines for Mental Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric mental disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Identification

  1. 1. 

    The CE provider will include the claimant's name, date of birth, and/or claim number; and

  2. 2. 

    Indicate that the claimant and/or caregiver provided proof of identity by showing an original document proving age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record); or

  3. 3. 

    Provide a physical description of the claimant to verify that the person being examined is the claimant, except if the claimant's medical source with a treating relationship is the CE provider.

C. Medical History

1. Longitudinal medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Cite the specific medical records and any other documents reviewed during the course of the evaluation; and

  2. b. 

    Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.

2. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    The primary impairment(s) alleged for which the disability claim is being filed;

  2. b. 

    Onset, frequency, and duration of the impairment(s);

  3. c. 

    Current treatment plan including medicines and dosages, role of child and caregiver in administration of treatment plan, need for periodic adjustments in medication regimen;

  4. d. 

    Special therapy, equipment or devices;

  5. e. 

    Response to treatment and overall extent of control of the impairment(s); and

  6. f. 

    Source(s) of medical care including specialist(s) or specialty clinic(s).

3. Past medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Prenatal, delivery, and neonatal course; and

  2. b. 

    Other significant events including past illnesses, injuries, operations, hospitalizations, and urgent care encounters. When possible provide the dates of events and names of facilities that provided treatment.

4. Information about the child's development

The CE provider will describe and discuss, as appropriate:

a. For children who have not attained age 6, developmental milestones – the results of a formalized developmental screening test is one method to meet this requirement;

b. Early infant or preschool intervention services;

c. For children age 6 and older, usual daily activities; and

d. Current grade, type of class, limitations of activities, and need for special assistance or extra care.

5. Provide a list of current medications

a. The CE provider will list the name, dose, and frequency of medication(s), including both beneficial and adverse effects, and plans for continued drug administration, schedule, and extent of any therapy.

D. Infants and toddlers (birth up to age 3)

Information on the mental assessment for infants and toddlers must include the following:

  1. 1. 

    Motor coordination and responsiveness to visual, auditory, and tactile stimuli (birth to 12 months)

  2. 2. 

    Communicative behaviors, including pre-speech behaviors (for example, sucking, swallowing, imitation of sounds) and early language behaviors (for example, jargon, single words, phrases, turn-taking);

  3. 3. 

    Manner of relating to and interacting with parent or caregiver, and ability to separate from parent or caregiver;

  4. 4. 

    Manner of relating to and interacting with sibling or peer group, if observed;

  5. 5. 

    Any stereotypical movements;

  6. 6. 

    Perceptual functioning; and

  7. 7. 

    Other pathology.

E. Children age 3 and older

Information on the mental assessment for children age 3 and older must include the following:

  1. 1. 

    History, including adjustment in school and home (daily activities, social functioning, concentration, persistence, pace);

  2. 2. 

    Appearance and grooming;

  3. 3. 

    Behavior;

  4. 4. 

    Attention and concentration;

  5. 5. 

    Affect;

  6. 6. 

    Communicative abilities and behavior;

  7. 7. 

    Thought processes (with verbatim examples);

  8. 8. 

    Cognitive functioning, including psychological test findings;

  9. 9. 

    Any indication of self-injury; and

  10. 10. 

    Any indication of substance use.

F. Mental status examination for children age 12 and older

The mental status examination for individuals in this age range must include the information for children age 3 and older. The case facts emphasized will determine the specific areas of mental status during the examination, but the report must include a detailed description of the child's:

  1. 1. 

    Judgment and insight;

  2. 2. 

    Impulse control;

  3. 3. 

    Orientation;

  4. 4. 

    Memory; and

  5. 5. 

    Homicidal and suicidal ideation.

1. Diagnosis

The CE report should include the American Psychiatric Association standard nomenclature as set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

NOTE: The description of the claimant's mental status must not be an enumeration of the symptoms reported by the claimant (or other source); rather the description must be the examining source's description of the above item.

2. Prognosis

The CE report should include prognosis and recommendations for treatment, if indicated. The report should also include recommendations for any other medical evaluation (for example, neurological, general physical), if indicated.

G. Additional requirements for intellectual disability

The CE report must describe the following:

  1. 1. 

    Current documentation of IQ score by a standardized, well-recognized measure. Acceptable instruments will have a representative normative sample, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions (for example, the Wechsler scales);

  2. 2. 

    Summary of composite scores (for example, Full Scale IQ, Verbal Comprehension Index, Perceptual Reasoning Index) together with the individual subtest scores;

  3. 3. 

    Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that may have influenced the results, such as the child's attitude and degree of cooperation, the presence of visual, hearing, or other physical problems, and recent prior exposure to the same or similar test; and

  4. 4. 

    Consistency of the obtained test results with the child’s education and social adjustment, especially in the area of personal self-sufficiency.

H. Provide a medical opinion

The medical source should provide a medical opinion that includes the following:

1. Assessment of the child’s abilities and limitations based upon the child’s medical history, observations during the examination, and results of relevant signs or tests, or both;

2. Specify the nature and extent of the condition or disorder;

3. Discuss any apparent discrepancies in the medical history or in the examination findings; and

4. Specify any limitations in age-appropriate functioning that result from the condition or disorder, including the child’s ability to:

a. Acquire and use information;

b. Interact and relate with others;

c. Attend and complete tasks; and

d. Care for himself or herself.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510048
DI 22510.048 - Pediatric Consultative Examination (CE) Report Content Guidelines for Mental Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020