Functional Capacity Disability for Child – Teacher Form

A child’s ability to function can be analyzed by teachers, counselor’s and therapists in addition to Ph. D. psychologists and MD’s or D.O.’s. At ages six to eleven a child’s diagnosed condition must be tied to the child’s functional limitation. Often a teacher is best able to to provide relevant information regarding the child. If teacher completes the form it may be important to have access to at least the child’s diagnosis. See SSA Child Mental Disorders.

Students with Disabilities Assessed by Teachers with Forms

A teacher spends an entire year with a student. Often there is no one better qualified than a teacher to report to the SSA on the impact the disability has upon the student’s life in terms of interaction with peers, concentration, and ability to participate in activities. Often teachers are considered only in terms of their ability to assess an intellectual impairment, however, other facets of the claimant’s life are observed by teachers as well. While a teacher CANNOT provide a diagnosis, a teacher can provide their assessment of a student’s disability.

SSA Form: Teacher Questionnaire

The SSA has developed form for teachers: Teacher Questionnaire Form Form SSA-5665-BK (09-2011) ef (09-2011).  Remember, there is no better advocate for a child that the parent. Be sure to take the SSA Form to the child’s teachers, counselors and trainers.

Whole Child Approach

The Whole Child Approach record format for the SSA is here for your review with insights and suggestions. However, you may link to the original.

The Whole Child Approach includes each element:

Mental Impairment

Intellectual Disabilities

Developmental Disabilities

Title XVI requires the childhood disability be evaluated under the function equivalence rule or The ‘‘Whole Child’’ Approach

Functional Capacity Analysis for Child

This form begins with the standard identifying information.

Name: SSN: D.O.B.

Please state your relationship to the child and the length of that relationship.

Diagnosed Impairment(s):

The analysis which follows requests an evaluation of the severity of a child’s functional limitation in six broad areas of functioning. This information is used to determine whether the child’s limitations are functionally equivalent to the impairments listed in the Social Security regulations. The mental disability or intellectual disability of the child can be analyzed with standardized tests.  It is important to be certain the documentation is in the record before the hearing on disability.

Overview of Child’s Functional Capacity for Age Appropriate Activities

What age-appropriate activities is the child able to perform?

What age-appropriate activities is the child unable to perform?

Which of the child’s activities are restricted compared to other children the same age who do not have impairments?

Where does the child have difficulty with activities and please consider all environments with which you are familiar and note those with which you are not familiar including but not limited to home, childcare, school or in the community?

Does the child have difficulty independently initiating, sustaining or completing the activities?

What kind of help does the child need to do his or her activities, how much help, and how often is it needed?

Definitions of Limitation Level

None: No interference with functioning in that area and child functions in an age-appropriate manner

Moderate: More than slight interference, but less than a marked restriction

Marked: Serious interference with the child’s ability to function independently, appropriately, and effectively in an age appropriate manner = A marked limitation requires episodes of illness or exacerbations that occur an average of three times a year, lasting two weeks or more, or the equivalent.

Extreme: Very serious limitation in functioning to no meaningful functioning in that area (reserved for only the worst limitations)

The examples given are intended only to provide an illustration of typical functioning in that area, particular to the child’s age group. They are taken directly from the Social Security Administration’s policy interpretation rulings.

When making this determination, the child’s level of functioning should be considered in relation to children the same age who do not have impairments.

Child’s Ability to Acquire and Use Provided Information

A mental or intellectual disability impairs the child’s ability to think, acquire and use information, visual and verbal reasoning, problem solving, and idea development. This includes perceptual, sensorimotor, language and memory processes necessary to learn.

Examples of Typical Functioning: Learns to read, write, and do simple arithmetic; becomes interested in new subjects and activities (for example, science experiments and stories from history); demonstrates learning by producing oral and written projects, solving arithmetic problems, taking tests, doing group work, and entering into class discussions; applies learning in daily activities at home and in the community (for example, reading street signs, telling time, and making change); and uses increasingly complex language (vocabulary and grammar) to share information, ask questions, express ideas, and respond to the opinions of others.

Attending and Completing Tasks

Attending to and completing tasks is an important feature of a child’s disability.  The child’s level of alertness, ability to work at an appropriate pace, allay impulses, and initiate, sustain and change focus. This includes the capacity to focus on certain stimuli and ignore others.

Examples of Typical Functioning: Focuses attention in a variety of situations in order to follow directions, completes school assignments, and remembers and organizes school-related materials; concentrates on details and avoids making careless mistakes; changes activities or routines without distracting self or others; sustains attention well enough to participate in group sports, read alone, and complete family chores; and completes a transition task without extra reminders or supervision (for example, changing clothes after gym or going to another classroom at the end of a lesson).

Interacting and Relating with Others

All aspects of social interaction and relationships with groups and individuals, as well as the speech and language skills necessary to communicate effectively. This includes the ability to respond to emotional and behavioral cues and form intimate relationships.

Examples of Typical Functioning: Develops more lasting friendships with same-age children; increasingly understands how to work in groups to create projects and solve problems; increasingly understands another’s point of view and tolerates differences (for example, playing with children from diverse backgrounds); attaches to adults other than parents (for example, teachers or club leaders), and may want to please them to gain attention; and shares ideas, tells stories, and speaks in a manner that can be readily understood by familiar and unfamiliar listeners.

Caring for Yourself

The child’s ability to care for one’s physical needs and maintain a healthy emotional state. This includes the ability to care for one’s own health and safety and to cooperate with others to meet one’s needs. Incorporate the concept that the child should be developing an increasing sense of independence and competence.

Examples of Typical Functioning: Recognizes circumstances that lead to feeling good and bad about himself; begins to develop understanding of what is right and wrong, and what is acceptable and unacceptable behavior; demonstrates consistent control over behavior and avoids behaviors that are unsafe; begins to imitate more of the behavior of adults she knows; and performs most daily activities independently (for example, dressing, bathing), but may need to be reminded.

The child’s ability to perform physical functions like sitting, standing, balancing, shifting weight, bending, crawling, running, and transferring. This includes the ability to hold, carry and manipulate objects, as well as the capacity to plan, remember and execute movements. Consider the child’s coordination, dexterity and integration of sensory input.

Examples of Typical Functioning: Uses developing gross motor skills to move at an efficient pace at home, at school, and in the neighborhood; uses increasing strength and coordination to participate in a variety of physical activities for example, running, jumping, and throwing, kicking, catching and hitting balls; applies developing fine motor skills to use many kitchen and household tools independently for example, scissors; writes with a pen or pencil.

Health and Physical Well Being: Cumulative Effects

Cumulative effects of physical and/or mental impairments should be considered in their total impact on the child. This includes the effects of chronic illness, including shortness of breath, reduced stamina, pain and poor growth. Consider the impact of therapies, medications and exacerbations. A marked limitation requires episodes of illness or exacerbations that occur an average of three times a year, lasting two weeks or more, or the equivalent.

Examples of Limitations: Psychomotor retardation; seizure or convulsive activity; Weakness; dizziness; agitation; lethargy; recurrent infections; changes in weight; insomnia; need for frequent treatment or therapy; need for intensive medical care to maintain level of health.

Consider the Medication and unacceptable side effects of medication including stomach cramps, dizziness, headaches, daytime drowsiness.  Medication may itself contribute to a child’s ability to function rendering them disabled.

 A Child’s Advocate

It is best to manage the documentation to make certain each facet of the disability is documented.  Resolve inconsistencies and present the strongest case possible.  There is no better advocate for a child than their parent.