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Smith v. Colvin

United States District Court, E.D. Missouri, Southeastern Division

September 19, 2016

AMALIA SMITH, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the final decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security, denying the application of Plaintiff Amalia Smith (“Plaintiff”)[1] for Disabled Adult Child and Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. (the “Act”). The parties consented to the jurisdiction of the undersigned magistrate judge pursuant to 28 U.S.C. § 636(c). (Doc. 9). Because I find the decision denying benefits was not supported by substantial evidence, I will reverse the Commissioner's denial of Plaintiff's application and remand for further proceedings.

         I. Procedural Background

         On or around February 13, 2012, Plaintiff applied for Disabled Adult Child benefits and SSI, alleging that she had been unable to work since August 23, 2010. (Tr. 221, 223, 236). Plaintiff's applications were denied initially. (Tr. 145-46, 148-58). Plaintiff filed a request for hearing by an administrative law judge (ALJ). (Tr. 159). After a hearing, the ALJ found that Plaintiff was not under a disability as defined in the Act. (Tr. 13-27). On March 26, 2015, the Appeals Council denied Plaintiff's request for review. (Tr. 5-7). Plaintiff has exhausted all administrative remedies, and the decision of the ALJ stands as the final decision of the Commissioner of the Social Security Administration.

         II. Factual Background[2]

         A. Plaintiff's Statements and Testimony

         In a Function Report completed in February 2012, Plaintiff reported living in a trailer behind her parents' house. (Tr. 266). Plaintiff reported caring for a cat; doing laundry, cleaning, and yard work; drawing; writing books; playing video games; and sometimes reading. Plaintiff reported difficulty with memory completing tasks, concentrating, understanding, following instructions, and getting along with others. (Tr. 267-68, 271).

         On December 10, 2013, Plaintiff testified at a hearing before the ALJ. (Tr. 103-34). At the time, she was living in a residential care facility. (Tr. 105). She testified that in August 2012, she was hospitalized for fourteen days, and her parents would not allow her to return home. (Tr. 105). She stayed in a homeless shelter four three months, then returned to the hospital because she became suicidal, and then got into the residential care facility. (Tr. 106). She looked for some work while she was living at the homeless shelter, but she did not have any luck; she also held off looking for a job because of the disability hearing coming up. (Tr. 108-09). She has a high school education and thought about going to college, but her adoptive mother discouraged her from going. (Tr. 110-11).

         Plaintiff testified that she generally gets along with others, that she “can do just about anything in the house” such as cooking, laundry, and dishes, (Tr. 115); that she can go shopping, (Tr. 117-18); and that she enjoys playing videogames, drawing, writing, and hanging out with friends, (Tr. 119). She testified that she gets depressed a lot and does not want to get out of bed or do anything. (Tr. 122). She testified that her depression and anxiety would prevent her from working because if she was in a bad or upsetting mood, she would not be very productive at work and could be late, could not show up, or could snap at her boss. (Tr. 126). She also testified that she does not deal with stress well and will sometimes hold it in and then “explode on” someone. (Tr. 127). She also testified that she gets claustrophobia and anxiety when crowded around a lot of people, or when she has a lot of things on her mind. (Tr. 127-28).

         B. Medical Records

         Treatment records from February 2010 to June 2011 show that Plaintiff was diagnosed with Tourette's syndrome, attention deficit hyperactivity disorder, seasonal pattern depression, and mild recurrent major depression, and that she received several medications for these conditions (Tr. 318-41).

         Plaintiff's high school records from February 2012 show that Plaintiff had a grade point average of 3.16 on a 4.0 scale and was in regular education classes with no special instruction. (Tr. 347). Plaintiff's teacher completed a questionnaire indicating that she missed school often for illness; that Plaintiff had no problems acquiring and using information or attending and completing tasks; and that she had “a slight problem” (2 on a scale of 1 to 5) in several areas of interacting and relating with others, including playing cooperatively with other children, making and keeping friends, seeking attention appropriately, and relating experiences and telling stories. (Tr. 349-52).

         On April 4, 2012, Plaintiff underwent a consultative psychological evaluation by Dr. John O. Wood, Psy. D. (Tr. 374-76). Plaintiff reported some problems with depression and anxiety, distractibility, sustaining attention, and maintaining concentration. (Tr. 374). Plaintiff reported exhibiting odd motor movements. (Tr. 374). Plaintiff reported generally eating meals with parents, spending time at home studying for school, helping with household chores, reading books, playing video games, writing poems and stories, and hanging out with friends at school. (Tr. 375). Dr. Wood found that Plaintiff's eye contact was fair, that Plaintiff spoke at times in a somewhat soft and v manner, that Plaintiff's mood and affect were generally appropriate and congruent, and that Plaintiff was cooperative and agreeable during the examination. (Tr. 375). Dr. Wood performed some testing and found some deficits in delayed recall and attention. (Tr. 375). Dr. Wood assessed attention deficit hyperactivity disorder (by history), Tourette's disorder (by history), and depressive disorder. (Tr. 375). He assigned Plaintiff a Global Assessment of Functioning (“GAF”) score of 65, indicating mild symptoms.[3] (Tr. 376). He found that Plaintiff was capable of understanding and remembering simple instructions and that when on medication, Plaintiff's ability to maintain attention and concentration on simple tasks was adequate. (Tr. 376).

         In early August 2012, Plaintiff was hospitalized for approximately two weeks for depression with some vague suicidal ideations. (Tr. 384). Plaintiff reported difficulty with being made fun of at school. (Tr. 388). Plaintiff reported that she had not been taking medications as prescribed due to an inability to pay for them. (Tr. 389). Plaintiff's mood and affect improved as the course of the hospitalization progressed, with a GAF score at admission of 31 and a GAF score at discharge of 55.[4] (Tr. 384). At discharge, Plaintiff's mother refused to take her back, and a social worker found Plaintiff a place at a shelter. (Tr. 386).

         On August 23, 2012, Plaintiff underwent a psychiatric evaluation by Courtney Johnson, M.D. Dr. Johnson reviewed Plaintiff's medical and social history and noted a history of depressive symptoms and at least one suicide attempt. (Tr. 412). She noted that Plaintiff's depressive symptoms resolved once she stopped living with her adoptive parents. (Tr. 412). Dr. Johnson stated that “[a]lthough it appears that the patient may have met criteria for major depressive disorder, the fact that his depressive symptoms are associated with external stressor and quickly remitted in the presence of that particular stressor being removed is concerning for adjustment disorder, with mixed anxiety and depressed mood.” (Tr. 412). She noted that a history of fighting, difficulty paying attention, and problems with memory was concerning for ADHD, which should be further evaluated. (Tr. 412). She assigned a GAF score of 41-50[5] and continued Plaintiff's medications. (Tr. 413-14).

         On October 21, 2012, Plaintiff was admitted to the hospital with depression and suicidal thoughts. (Tr. 426). Plaintiff reported that she had not been taking medications due to an inability to afford them, but it was noted that she was now on Medicaid. (Tr. 432). Plaintiff reported that when the people at the Amen Center (the shelter where Plaintiff was living) found out about her sexual orientation, “it got bad, ” and Plaintiff became suicidal. (Tr. 426, 432). Plaintiff reported contemplating suicide every day. (Tr. 432). Plaintiff's medications were adjusted. (Tr. 433). Plaintiff's GAF was 35 upon admission and was 55 at discharge five days later. (Tr. 432). Plaintiff was found a place at the Lou Masterman Residential Care Facility. (Tr. 434).

         Between approximately October 25, 2012, and at least December 10, 2013, Plaintiff lived at the residential care facility. (Tr. 434-35, 105). Medical records during this period show that Plaintiff complained of symptoms including depression or low mood, (Tr. 397, 476, 480, 484, 485); a chronic intermittent passive death wish, (Tr. 468, 476); gender identity issues, (Tr. 397, 418, 420, 468, 488); anxiety, (Tr. 418); and poor distress tolerance, (Tr. 420, 421, 479). Plaintiff's diagnoses included depressive disorder, r/o panic disorder without agoraphobia; Asperger's Syndrome; gender identity disorder; borderline personality disorder; a history of Tourette's Disorder; a history of ADHD; and a history of pervasive developmental disorder. (Tr. 418, 421, 467, 468, 472, 474, 475, 478, 479, 482, 483, 484, ...

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