Concentration, persistence or pace (i.e., the B3 criterion) refers to the ability
to sustain focused attention sufficiently long to permit the timely completion of
tasks commonly found in work settings. For example, concentration may be reflected
in terms of ability to complete tasks in everyday household routines. Deficiencies
in concentration, persistence or pace are best observed in work and work-like settings.
Major deficits in this area can often be assessed through direct psychiatric examination
and/or psychological testing, although mental status examination or psychological
test data alone should not be used to describe concentration and sustained ability
to adequately perform work-like tasks.
On mental status examinations, concentration is assessed by tasks such as having the
individual subtract serial sevens from 100. In psychological tests of intelligence
or memory, concentration is assessed through tasks requiring short-term memory or
through tasks that must be completed within established time limits. In work evaluations,
concentration, persistence, or pace are assessed through such tasks as filing index
cards, locating telephone numbers, or disassembling and reassembling objects. Strengths
and weaknesses in areas of concentration can be discussed in terms of frequency of
errors, the time it takes to complete the task, and extent to which assistance is
required to complete the task.
Deterioration or decompensation in work or work-like settings (i.e., the B4 criterion)
refers to failure to adapt to stressful circumstances which cause the individual either
to withdraw from that situation or to experience exacerbation of signs and symptoms
or experience deterioration in previously attained adaptive skills. Stresses common
to the work environment include decisions, attendance, schedules, completing tasks,
interaction with supervisors, interaction with peers, etc.
Great care should be exercised in making assumptions about the inability to sustain
attention or pace under the stress of competitive employment for a normal workday
or workweek based on short term mental status or psychological testing by a clinician.
The ability to sustain activity over the workweek must be assessed by evaluating all
the evidence with emphasis on past work attempts, workshop or rehabilitation reports,
if available, and the current functioning of the individual at home and in other social
or educational activities performed over a sustained period.
Individuals may be able to sustain attention and persist at simple tasks but may have
difficulty with complicated tasks. Deficiencies of concentration, task persistence,
or pace which are apparent only in performing complex procedures or tasks would not
satisfy the intent of the “B3” criterion. Even when these deficiencies are seen in combination with another “B” criterion the individual could not be reliably considered unable to engage in substantial
The “B4” criterion is derived from the longitudinal history of the disorder. To satisfy the
criterion it must be shown that the individual experienced an exacerbation in signs
and symptoms of sufficient duration and intensity which would ordinarily require increased
treatment and/or a less stressful situation. Increases in signs and symptoms and their
effect on function may be demonstrated by significant alterations in medication or
the need for a more structured psychological support system (e.g., hospitalization,
placement in a halfway house or a highly structured and directing household, etc.).
The key here is that we are measuring the significance of episodes of deterioration
and decompensation, as shown by the increase in symptoms or signs and the need to
seek new or additional treatment or withdraw from the stress-provoking environment.
Generally, to fulfill this criterion, the file should document the three significant
episodes of deterioration or decompensation, each of which is at least 2 weeks or
longer, during the most recent adjudicative year.
In circumstances in which the individual has more frequent but less marked (in terms
of duration and effect) episodes of decompensation or deterioration, medical judgment
must be used to determine if the duration and effect are equivalent to that described
above. If so, the portion of the listing will be considered to be fulfilled. The listing
could also be fulfilled if fewer than 3 significant episodes have occurred and the
episodes have been of longer than 2 weeks duration.
For the B3 criterion (deficiencies in concentration, persistence, or pace) and B4
criterion (episodes of deterioration or decompensation), documentation must be sufficient
to permit an assessment of their frequency, duration, and effect on the claimant's
function. If such documentation cannot be derived from recent work history or work
attempts (i.e., the individual has never worked or does not have any recent work attempts),
these criteria should be developed and evaluated based upon the individual's ability
to function within situations simulating work-like tasks, e.g., hobbies, day-care