Box ex rel. P.B.P. v. Colvin
| Decision Date | 08 February 2016 |
| Docket Number | No. 2:15 CV 10 DDN,2:15 CV 10 DDN |
| Parties | LORI BOX o/b/o P.B.P., Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Eastern District of Missouri |
This action is before the court for judicial review on the final decision of defendant Commissioner of Social Security denying the application of Lori Box on behalf of her son, P.B.P., for supplemental security income benefits under Title XVI of the Social Security Act. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). (Doc. 11.) For the reasons set forth below, the decision of the Administrative Law Judge (ALJ) is reversed and remanded for an award of a closed period of disability and resulting benefits.
Plaintiff P.B.P. was born on September 7, 2000. His mother filed an application for supplemental security income on his behalf on October 3, 2007. She alleged an onset date of September 1, 2007, asserting disability due to Attention Deficit Hyperactive Disorder (ADHD), impulsive explosive disorder (IED), and oppositional defiant disorder (ODD). (Tr. 86-88.) Plaintiff's claims were denied initially, and she requested a hearing before an ALJ. (Tr. 36-47, 55.)
On June 12, 2009, following a hearing, the ALJ issued a decision denying plaintiff's application. (Tr. 36.) The Appeals Council denied the request for review on February 22, 2010. (Tr. 527-28.) This district court remanded the case to the commissioner with instructions to the ALJ to consider all of the relevant evidence of P.B.P.'s impaired social functioning. (Tr. 473-523); Box v. Astrue, 2011 WL 4478563, No. 2:10 CV 28 FRB (E.D. Mo. Sept. 27, 2011).
On June 12, 2012, following a second hearing on May 14, 2012, the ALJ again denied benefits. (Doc. 532-46.) The decision was appealed to the Appeals Council, which remanded the case to the ALJ in order to address relevant, but ignored, evidence, as well as to evaluate several medical and educational opinions in the record. (Doc. 551-54.) On remand two additional hearings were held, and the ALJ found plaintiff was not disabled on September 26, 2013. (Doc. 351-77.)The Appeals Counsel denied review on February 12, 2014. (Doc. 345-47.) Thus, the ALJ decision dated September 26, 2013 stands as the final decision of the Commissioner.
In 2007, P.B.P. was enrolled in the Kansas City Center School District and had speech problems which were exacerbating his other behavioral problems. Plaintiff had a break down on the first day of school and had a suicidal ideation on the second day of school. (Tr. 130, 217-21.)
On September 9, 2007, P.B.P. was admitted to the Research Psychiatric Center in Kansas City following a break down at school. His Global Assessment Function (GAF)1 score at time of admission was 43.2 He was admitted due to his anger and aggressive outbursts while at school. He was able to complete his assigned school work whileadmitted. He also participated in individual and group counseling sessions. (Tr. 211-14, 240-48.)
Between September 18, 2007 and November 11, 2007, P.B.P. saw Dr. Lee T. Weng, M.D., five times. Plaintiff was prescribed Ritalin for ADHD and Risperdal for depression and anxiety symptoms. Dr. Weng added Adderall for ADHD on November 14, 2007. (Tr. 215, 255-56.)
On November 16, 2007, P.B.P. was admitted to Two Rivers Psychiatric Hospital in Kansas City, Missouri for anger and aggression and in order to stabilize his mood. His school, Boone Elementary, provided the hospital with an evaluation. He has fair attendance but his aggression toward adults and his unsafe behavior has resulted in suspensions. He is immature, impulsive, cannot accept consequences, has extreme anxiety and obsessive tendencies, and threatens suicide. His behavior has improved with medication. Two Rivers prescribed him Risperdal and Adderall. He was discharged on November 19, 2007. (Tr. 208-10, 285-87.)
P.B.P.'s school conducted a revaluation of his Individual Education Plan (IEP) on December 4, 2007, because of his recent aggression and outburst problems. Plaintiff is deficient in basic reading skills, as well as, reading and listening comprehension. He can be disruptive and defiant in class and teachers are concerned about his aggression, anxiety, depression, atypicality, and withdrawal. Plaintiff completed the Wechsler Intelligence Scale for Children-IV (WISC-IV) and was found to be average in verbal comprehension and perceptual reasoning, but low average in his working memory and processing speed. His full scale IQ was 87, indicating his intelligence is in the low average range. P.B.P. had been diagnosed with a mood disorder (not otherwise specified), and attention deficit disorder. He was prescribed Risperdal and Adderall. (Tr. 694-703.)
Boone Elementary School performed an evaluation on March 10, 2008, of P.B.P when he was in the first grade. In the domain of acquiring and using information he has very serious problems in reading and comprehending written material and serious problems in providing organized oral explanations and descriptions. In the domain ofattending and completing tasks P.B.P. has serious problems with multi-step tasks and obvious or slight problems in all other categories. He has problems hourly in changing from task to task. In the domain of interacting and relating with others P.B.P. has very serious problems with expressing his anger appropriately, respecting and obeying authority figures, relating experiences and telling stories, and using language appropriate to the situation. He had no problem making or maintaining friendships. He is on a behavior modification plan. In the domain of moving about and manipulating objects, he has no problems. In caring for himself, he cannot handle frustration, or use appropriate skills to calm himself. He has serious problems asking for help, being patient, and appropriately asserting emotional needs. (Tr. 112-18.)
On March 27, 2008, a state-appointed psychiatrist, Jamie C. Prestage, Ph.D., performed an evaluation of P.B.P. by using medical records as well as conducting an in-person interview. P.B.P.'s behavioral problems began in December 2006 and he has been previously diagnosed with ADHD and a mood disorder. He has been hospitalized two times and is currently on Risperdal, amphetamines (for ADHD), and Depakote (for mania). His Slossen Intelligence Test score was 90. He receives special education and has been suspended four times this school year. Plaintiff scored a 92 on the Asperger Syndrome Diagnostic Scale, which indicates a probability of Asperger Syndrome. Dr. Prestage diagnosed him with Asperger Syndrome, mood disorder (not otherwise specified), anxiety disorder (not otherwise specified), and ADHD. (Tr. 132-35.)
On May 21, 2008, P.B.P.'s paraprofessional provided an assessment of him. She wrote that P.B.P. must be right 100% of the time. Test taking is very stressful, because if plaintiff is not right he will have a meltdown. While he does intimidate other students, she assessed he does so without the real intention to harm others. He obsesses about things and continues to do the activity until he gets it right or has a complete meltdown. (Tr. 132-35.)
On June 25, 2008, an APRN saw P.B.P. at Comprehensive Psychiatric Associates assessed his GAF at 50,3 and was considering lessening his medications in order to see his baseline without medications. On July 17, 2008, plaintiff was taking Depakote, but his mother lost the prescription. He continued to take Risperdal and Adderall. (Tr. 290-92.)
Plaintiff's report card for quarters 3 and 4 of the first grade indicated he had Cs in reading, but As and Bs in math. His social development was below expectations. (Tr. 169-71.)
On September 10, 2008, P.B.P. had a breakdown at school. He threw desks and chairs in a room with other children. Then he crawled around on the floor and licked the carpet. (Tr. 222-25.)
After not being able or refusing to do a math problem on September 18, 2008, P.B.P. had a breakdown and threw himself on the floor. He had to be taken home early by his grandfather. (Tr. 225-27.)
On September 24, 2008, Sultanan Jahan, M.D., provided a second opinion that diagnosed P.B.P. with ADHD, IED, and a mood disorder. He was on Depakote and amphetamines. His GAF was 56.4 (Tr. 333-37.)
On October 21, 2008, plaintiff's IEP was reassessed. The report noted a "vast improvement in his ability to function in the regular education classroom." His WISC-IV IQ score was 87, with verbal comprehension at 96, perceptual reasoning at 94, working memory at 80, and processing speed at 84. (Tr. 182-92.)
On November 12, 2008, Ellen A. Horwitz, Ph.D., at the University of Missouri performed a psychological assessment. P.B.P.'s current medications were Adderall, Risperdal, and Depakote. He was diagnosed with ADHD and IED. He was twice hospitalized for three to five days in 2007. The school does have a specialized plan forP.B.P. when he begins to have a meltdown. P.B.P.'s IQ was 87, indicating a low average IQ. He was normal on the hyperactivity scale. He had two meltdowns during the testing, but completed all of the examinations. Dr. Horwitz diagnosed plaintiff with ADHD, IED, and a mood disorder (not otherwise specified). P.B.P.'s GAF was 48. (Tr. 297-309.)
On January 8, 2009, plaintiff was suspended for three days due to out of control defiance to school authority figures. (Tr. 228.)
On January 23, 2009, plaintiff was seen by Dr. Jahan at Burrell Behavior Health Clinic for a psychological assessment follow-up. Dr. Jahan began the process to gradually eliminate plaintiff's ADHD prescriptions, Risperdal and Adderall. Plaintiff admitted he has problems controlling his anger. His last episode, January 8, 2009, resulted in plaintiff's suspension and an apology to his classmates for his disruptive behavior. (Doc. 294-96, 316-19.)
Plaintiff saw Dr. Jahan...
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