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Williams v. Colvin

United States District Court, E.D. Virginia, Alexandria Division

March 2, 2016

JACQUELINE WILLIAMS, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

REPORT AND RECOMMENDATION

IVAN D. DAVIS, Magistrate Judge.

This matter is before the Court on the parties' cross-Motions for Summary Judgment. (Dkt. Nos. 17, 19.) Pursuant to 42 U.S.C. § 405(g), Jacqueline Williams ("Plaintiff or "Ms. Williams"), on behalf of the minor claimant ("D.M.S." or "Claimant"), seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner" or "Defendant") denying her grand-niece's claim for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("the Act"), 42 U.S.C. §§ 1381-1383f. For the following reasons, the undersigned recommends that Plaintiffs Motion for Summary Judgment be DENIED and Defendant's Motion for Summary Judgment be GRANTED.

I. PROCEDURAL BACKGROUND

On December 22, 2011, Plaintiff, maternal great-aunt and legal guardian to D.M.S., protectively filed an application for SSI benefits, alleging her grand-niece's disability since September 1, 2007 due to attention deficit hyperactivity disorder ("ADHD"), fetal alcohol syndrome ("FAS"), and attachment disorder. (Administrative Record ("R.") 10, 37.) Plaintiffs initial claim was denied on April 30, 2012 and again upon reconsideration on July 10, 2012. ( Id. at 58-62, 64-67.) Plaintiff then requested a hearing in front of an Administrative Law Judge ("ALJ") on July 15, 2012. ( Id. at 68.)

On July 18, 2013, ALJ Eugene Bond conducted a hearing at which Plaintiff and D.M.S. testified. ( Id. at 25-26.) At the hearing, Plaintiff amended D.M.S.'s alleged onset date to December 22, 2011. ( Id. at 24.) On July 29, 2013, the ALJ issued his decision finding that D.M.S. was not disabled within the meaning of the Act. ( Id. at 7-23.) On August 12, 2014, the Appeals Council for the Office of Disability and Adjudication ("Appeals Council") denied Plaintiffs request for review of the ALJ's decision, rendering the ALJ's decision the final decision of the Commissioner for purposes of review under 42 U.S.C. § 405(g). ( Id. at 1-5.) Having exhausted her administrative remedies, Plaintiff filed the instant suit challenging the ALJ's decision on October 15, 2014. (Dkt. No. 1.) Cross-Motions for Summary Judgment were filed, and this matter is ripe for disposition. (Dkt. Nos. 17, 19.)

II. FACTUAL BACKGROUND

Claimant D.M.S. was born on May 4, 2004 and was 7 years old at the time of her alleged onset date, December 22, 2011. (R. 13, 37.) D.M.S. lives with her younger sister and her greataunt, Ms. Williams, who has had legal custody of D.M.S. since June 5, 2008. ( Id. at 29-30, 134-37.) D.M.S. has two more siblings who live with other family members. ( Id. at 32.) As a young child, D.M.S. suffered from abuse and neglect by her parents, including an incident when she was nearly drowned by her mother when she was 3 years old. ( Id. at 30-31, 183, 282.) On the date of the hearing before ALJ Bond, D.M.S. was 9 years old. ( Id. at 25.)

A. Medical History

1. Medical Records and Treatment Notes

In early 2011, Dr. Moheb Andrawis, D.M.S.'s pediatrician, referred D.M.S. to Dr. Tauen Chang for a neurological evaluation. (R. 335.) In February 2011, Dr. Chang examined D.M.S. ( Id. at 349.) Dr. Chang determined that D.M.S. had been exposed to drugs and alcohol in utero. ( Id ) He also stated that there were no reported cognitive issues as a result of D.M.S.'s near drowning. ( Id. ) Lastly, Dr. Chang determined that D.M.S. may have attention deficit disorder. ( Id. ) Dr. Chang prescribed a trial course of Focalin at a dose of 5 milligrams per day and recommended an Individualized Education Program ("IEP") assessment. ( Id. )

In May 2011, D.M.S. saw Dr. Chang again. ( Id. at 346-47.) Dr. Chang diagnosed D.M.S. with FAS and ADHD. ( Id. at 346.) Because Ms. Williams and D.M.S.'s teachers reported improvement in attention which waned in the late afternoon, Dr. Chang increased D.M.S.'s Focalin dosage to 7.5 milligrams per day. ( Id. ) In October 2011, D.M.S.'s Focalin dosage was increased again, this time to 10 milligrams per day. ( Id. at 354.)

D.M.S. visited Dr. Andrawis again in January 2012 for treatment of ADHD and influenza. ( Id. at 353.) Dr. Andrawis noted that the increased Focalin dosage was helpful and that D.M.S.'s school performance was improving. ( Id ) Dr. Andrawis also noted that D.M.S. appeared well developed and well nourished but that she was hyper in the exam room, that she could not sit still, and that she "follow[ed] orders with difficulty." ( Id ) Dr. Andrawis refilled D.M.S.'s Focalin prescription at 10 milligrams per day. ( Id )

In June 2012, Dr. Loan Kline saw D.M.S. and reported that she was doing well on the 10 milligram dose of Focalin. ( Id. at 367.) Ms. Williams reported that D.M.S. was not eligible for an IEP and that she was advancing from the second to third grade but that she had problems completing homework. ( Id. ) Dr. Kline refilled D.M.S.'s Focalin prescription at 10 milligrams a day as a treatment for D.M.S.'s ADHD. ( Id ) As of February 2013, Dr. Kline had increased D.M.S.'s Focalin dosage to 15 milligrams per day. ( Id. at 265.)

2. Psychological Records and Assessments

In April 2010, D.M.S. began seeing Dr. Debra Nygaard, a psychologist at the Youth and Family Unit of the Alexandria Community Services Board, due to oppositional and aggressive behavior reported by Ms. Williams. (R. 282.) Dr. Nygaard diagnosed D.M.S. with post-traumatic stress disorder ("PTSD"). ( Id. at 303.) Dr. Nygaard also found that D.M.S. had been abused and neglected before coming into Ms. Williams's care. ( Id. ) Dr. Nygaard attributed D.M.S.'s aggressive and defiant symptoms, including getting into fights, having angry moods, and being violent with others, to her history of abuse and neglect. ( Id. ) In August 2010, D.M.S. was discharged from the Youth and Family Unit program because she became "more stable behaviorally and emotionally" and because Ms. Williams wanted to focus treatment on D.M.S.'s sister. ( Id. at 306.)

In November 2011, D.M.S. began seeing Sally Bird, LCSW. ( Id. at 224, 260.) Ms. Bird treated D.M.S. in individual therapy and as part of family therapy which also included her sister and Ms. Williams. ( Id. at 260.) D.M.S. began seeing Ms. Bird due to behavior difficulties at home and school and anxiety and depression. (R. 228.) Soon after D.M.S. began seeing Ms. Bird, Ms. Williams reported to Ms. Bird that D.M.S. attempted to hit her sister with a wooden chair. ( Id. at 240.) Ms. Bird helped Ms. Williams implement a rewards-based behavior modification plan for both D.M.S. and her sister. ( Id. at 228-40.) In January 2012, Ms. Bird reported that although D.M.S. and her sister still fought, they no longer fought physically. ( Id. at 232.)

By May 2012, Ms. Bird reported that D.M.S. had no outstanding problems in school. ( Id. at 260.) However, Ms. Bird reported that D.M.S.'s fighting with her sister persisted and that the girls were, once again, violent with each other. ( Id. ) Ms. Bird reported that, although the behavior modification plan was effective, when the program ended, the girls began to fight again "as forcefully as before." ( Id )

In late 2012, D.M.S. stopped seeing Ms. Bird because Ms. Williams was unable to obtain leave from work to take D.M.S. to therapy. ( Id. At 270.) D.M.S. began seeing Ms. Bird again in February 2013. ( Id ) In March 2013, Ms. Bird reported that D.M.S. was having trouble in school and fighting with and trying to control her sister and other children. ( Id. ) Ms. Bird reported that D.M.S. was doing well in play therapy and that Ms. Williams agreed to implement another rewards-based behavior modification system. ( Id. ) Ms. Bird reported that D.M.S.'s diagnosis was PTSD. ( Id. )

B. School Records

1. First Grade

In March 2011, before D.M.S.'s alleged onset date, Milann Polite, D.M.S.'s first grade teacher, completed a Teacher Questionnaire concerning D.M.S.'s functioning. ( Id 199-206.) Ms. Polite reported that D.M.S. was performing at grade level 1.1 in reading, math, and written language and that D.M.S. did not receive any special education services. ( Id. at 199.) Ms. Polite reported that D.M.S. had problems functioning in the domains of Acquiring and Using Information and Attending and Completing Tasks. ( Id. at 200-01.)

In the domain of Acquiring and Using Information, Ms. Polite reported that D.M.S. had obvious problems understanding vocabulary, reading and/or comprehending written material, comprehending and doing math problems, expressing ideas in written form, recalling and applying material, and applying problem solving skills in class discussions. ( Id. at 200.) Ms. Polite reported that D.M.S. had slight problems understanding and participating in class discussions, providing explanations and descriptions, and learning new material. ( Id ) Ms. Polite did not report any serious or very serious problems in the domain of Acquiring and Using Information. ( Id )

In the domain of Attending and Completing Tasks, Ms. Polite reported that D.M.S. had obvious problems focusing long enough to finish tasks, carrying out multi-step instructions, completing assignments, working without distracting herself or others, and working at a reasonable pace/finishing on time. ( Id. at 201.) Ms. Polite reported that D.M.S. had slight problems with paying attention when spoken to directly, sustaining attention during play and sports activities, carrying out single-step instructions, waiting to take turns, changing from one activity to another without being disruptive, organizing her own things and school materials, and completing work accurately. ( Id ) Ms. Polite did not report any serious or very serious problems in the domain of Attending and Completing Tasks. ( Id. )

Ms. Polite reported that she had not observed problems in the domains of Interacting and Relating with Others, Moving About and Manipulating Objects, or Caring for Himself or Herself. ( Id. at 202-04.) Ms. Polite also reported that D.M.S.'s medication changed her functioning, making her "able to maintain focus for longer durations." ( Id. at 205.)

Also in March 2011, PreeAnn Johnson of James K. Polk Elementary School completed a Request for Administrative Information form. ( Id. at 219-20.) Ms. Johnson stated that although the child study team had decided that D.M.S. had areas of weakness, the team did not suspect that she had a disability that had a significant effect on her education. ( Id. at 19.) However, because "parent" shared her desire for an assessment, Ms. Johnson reported that the school would ...


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