United States District Court, Western District of Missouri, Southern Division
TAMMY WOODS O.B.O. T.J., a minor child, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
NANETTE K. LAUGHREY United States District Judge.
Before the Court is Tammy Woods' appeal of the Commissioner of Social Security's final decision denying her minor son's application for supplemental security income under Title XVI of the Social Security Act. [Doc. 8]. For the following reasons, the Commissioner's decision is reversed, and the case is remanded for further consideration consistent with this Order.
A. was born in November 1996. On T.J.'s behalf, Ms. Woods filed an application for supplemental security income under Title XVI of the Social Security Act on November 29, 2011, alleging disability due to epilepsy and mental impairments including bipolar disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), aggression, and depression. [Tr. 186].
A. Medical and Disciplinary History
T.J. has a history of behavioral problems. In the 2005-2006 school year, T.J. was disciplined eighteen times between October and March. In March 2010, T.J. was suspended from school for ten days for making threats to other students. [Tr. 293]. In September 2010, T.J. tried to run away from school and refused to go back to his classroom. He was eating paper and pencil lead. [Tr. 292]. His mother and the police were called, he was suspended for the rest of the day, and he was referred to the juvenile office. Id. On at least three occasions in 2011, T.J. was disciplined for disrupting class, inappropriate contact with another student, choking another student, threatening to kill a student, making inappropriate sexual comments to a student, pushing teachers, destroying school property, and throwing a chair at his teacher. [Tr. 79, 203]. On the last occasion in 2011, T.J. was suspended for a substantial period of time and at one point faced charges for assaulting a teacher and destroying school property. [Tr. 472]. He was hospitalized for inpatient care at Heartland Center for Behavioral Change from September 28 to October 5, 2011. In December 2011, a nurse noticed T.J. constantly picking at and aggravating his two year old brother. [Tr. 463]. In February 2013, Dr. Harcharan Bains, M.D., who controlled T.J. mental health medication since October 2011, wrote that T.J. was easily irritated by his little brother, has verbal outbursts toward him, plays rough with him, and takes things from him. [Tr. 521]. At his hearing in May 2013, T.J. testified that his first year of high school went "pretty good, " [Tr. 44], but that he got into five physical fights with five different people that year. [Tr. 46-50].
Medical records from Dr. Bains reveal periods of improvement and regression. In November 2011, January, March, June, July, August, September, and October 2012, and March 2013, T.J.'s records documented improved mood and depression and unremarkable findings. [Tr. 454, 460, 466, 528, 531, 537, 540, 543, 576]. In October, November, and December 2011, March, May, August, and December 2012, and January and February 2013, T.J. or his mother reported an increase in or the return of mood swings, crying spells, verbal outbursts and aggression, physical aggression, or depression. [Tr. 448, 451, 457, 463, 468, 471, 521, 524, 526, 534]. Some of those same records revealed improvements in one area and the return of behaviors in another area. For instance, in February 2013, T.J.'s depression was improved, his grades were good, and he did not experience mood swings, but he was tearful and had verbal outbursts toward his little brother. [Tr. 521]. Between October 2011 and March 2013, Dr. Bains increased or altered T.J.'s medication eight times. [Tr. 448, 451, 457, 463, 468, 471, 521, 537]. Dr. Bennett, T.J.'s primary care physician, saw T.J. for follow-up appointments related to his mental impairments and a variety of illnesses. From October 2011 through August 2012, Dr. Bennett consistently stated that T.J. was "doing okay." [Tr. 421, 423, 425, 427, 431, 433, 558, 564].
B. Medical and Non-Medical Opinions
The record contains opinions from T.J.'s primary care physician, therapist, eighth grade special education teacher, ninth grade special education teacher, and a combined opinion from a non-examining psychologist and non-examining pediatrician.
Dr. Michael Bennett, M.D., is T.J.'s primary care physician. He primarily treated T.J.'s mental impairments from February 2011 until October 2011, when Dr. Harcharan Bains, M.D., took over management of T.J.'s mental health medication. However, Dr. Bennett continued to see T.J. throughout 2011 and 2012, treating him on approximately twenty occasions for depression, bipolar disorder, ADHD, and various illnesses.
Alicia Humes, LMSW, also treated T.J. through therapy. Although there are limited records regarding her treatment relationship with him, it appears that Ms. Humes treated T.J. from at least September 2011 through March 2013. [Tr. 569-73]. T.J.'s mother testified that Ms. Humes was currently "kind of leaving it at [T.J.'s] call . . . because summer is coming." [Tr. 90]. She testified that T.J. had seen Ms. Humes two weeks prior and two weeks prior to that. Id. She testified that T.J. saw Ms. Humes on a biweekly basis or "at least two or three times a month." Id.
Ms. Pam Kistenmacher was T.J.'s special education teacher from approximately 2008 to 2012. [Tr. 195]. She taught T.J. communication arts and mathematics. Ms. Kristen Caldwell became T.J.'s special education teacher when he entered high school in the 2012-2013 school year. Though Ms. Humes and T.J.'s teachers are not "acceptable medical sources" whose opinions are entitled "controlling weight" under the regulations, they are nonetheless "other sources" whose opinions can be considered by the ALJ. 20 C.F.R. § 416.913.
In June 2012, Ms. Kistenmacher completed a Teacher Questionnaire. She stated that T.J. was in the eighth grade, but performed at a sixth or seventh grade level in reading, a seventh grade level in mathematics, and a fourth grade level in written language. [Tr. 195]. She noted that T.J. had been suspended from school for forty-five days for assaulting adults and destroying school property. [Tr. 198]. She stated T.J. had anger issues, but was "working on them positively." Id. Ms. Kistenmacher opined that T.J. had problems in "acquiring and using information, " "attending and completing tasks, " and "interacting and relating with others." [Tr. 196-99]. T.J. had no problem "moving about and manipulating objects" or "caring for himself." [Tr. 199-200]. She was unsure about his medication schedule. [Tr. 201].
In July 2012, non-examining consultants Dr. Stephen Scher, Ph.D., and Dr. Despine Coulis, M.D., completed a Childhood Disability Evaluation after reviewing T.J.'s school records and various medical records. [Tr. 496-99]. Dr. Bennett, Ms. Humes, and Ms. Kistenmacher individually completed Individual Functional Assessments in August 2012. Ms. ...