United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On April 9, 2010, Plaintiff filed an application for SSI in which she alleged her disability began on January 1, 1992. Tr. at 225-30. Her application was denied initially and upon reconsideration. Tr. at 126-130, 131-32. On November 20, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Todd D. Jacobson. Tr. at 36-76 (Hr'g Tr.). The ALJ issued an unfavorable decision on January 25, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 14-34. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 4-7. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on May 23, 2014. [ECF No. 1].
B. Plaintiff's Background and Medical History
Plaintiff was 25 years old at the time of the hearing. Tr. at 28. She received a special education certificate, but later obtained a diploma through adult education. Tr. at 42. She had no past relevant work ("PRW"). Tr. at 68. She alleges she has been unable to work since January 1, 1992. Tr. at 225.
2. Medical History
James K. Phillips, III, Ph.D. ("Dr. Phillips"), and Deborah L. Gladden, M.S., SSP, NCSP ("Ms. Gladden"), evaluated Plaintiff in March and April 1998. Tr. at 489-90. Dr. Phillips and Ms. Gladden indicated Plaintiff presented a complicated picture because she functioned within the average range in terms of conversation, relating style, and adaptive behavior. Tr. at 489. Plaintiff had achievement scores on the Woodcock-Johnson Psychoeducational Battery-Revised that ranged from 70 to 108 and were "approximately commensurate with the observational estimate of intellectual capacity." Id. However, Plaintiff's scores on the Wechsler Intelligence Scale for Children-III ("WISC-III"), the formal measurement for cognitive capacity, ranged from 58 to 69. Id. Dr. Phillips and Ms. Gladden indicated the discrepancy was the result of Central Auditory Processing Disorder, sensory integration problems, frustration, and performance anxiety. Id.
On July 7, 2006, Plaintiff presented to Piedmont Medical Center for a mental health evaluation. Tr. at 380. She complained of depressed mood, poor impulse control, sadness, anger/irritability, sleep disturbance, and feelings of guilt. Tr. at 391. Plaintiff stated she had yelled at a friend and family members. Tr. at 381. Plaintiff's mother indicated that Plaintiff had previously kicked out her windshield in anger and that she had recently kicked and slammed a door and thrown a phone. Tr. at 390. Plaintiff was instructed to follow up with Delfin F. Valite, M.D. ("Dr. Valite") the following morning. Tr at 383.
Plaintiff presented to Dr. Valite on April 7, 2009, and denied anxiety, depression, mania, obsessive thoughts, and symptoms of psychosis. Tr. at 423. Plaintiff was compliant with her medications and her behavior was stable and unremarkable. Id. Dr. Valite indicated a diagnosis of "bipolar I, most recent episode depressed severe." Id.
On August 28, 2009, Plaintiff and her mother presented to Dr. Valite. Tr. at 422. Plaintiff's mother reported her to be "poorly compliant" with her medications and to lack motivation and spend most of her time in front of the television. Id. She indicated Plaintiff procrastinated instead of performing her chores and relied on her family members for activities of daily living. Id. She noted Plaintiff became argumentative and oppositional when reminded to take medications or to engage in personal hygiene activities. Id. Dr. Valite indicated "in my opinion, she is a poor candidate to living independently and because of her mental illness and possible learning disability, she may not be able to keep a job that can sustain independent living." Id.
On November 19, 2009, Dr. Valite indicated Plaintiff was doing well. Tr. at 421. Plaintiff's mood was described as euthymic and stable and she denied symptoms of anxiety and psychosis. Id. Plaintiff reported taking her medication regularly and her behavior was stable. Id.
On April 16, 2010, Dr. Valite indicated Plaintiff showed a partial treatment response. Tr. at 420. Dr. Valite noted that Plaintiff's mother and grandmother had expressed concern over Plaintiff's perceived lack of motivation to stay healthy and concern for her personal hygiene. Id. Plaintiff reported significant arguments and misunderstandings with her mother. Id. Dr. Valite described Plaintiff as having a euthymic and stable mood. Id. Plaintiff denied symptoms of psychosis and anxiety. Id. Her self-care skills were impaired and she required assistance or cues to perform selfcare. Id. She reported outbursts of anger and impulsive behavior. Id. Dr. Valite indicated a diagnosis of "bipolar I, most recent episode depressed severe." Id.
On May 5, 2010, Dr. Valite wrote a letter indicating he had treated Plaintiff since July 2006 for bipolar disorder. Tr. at 426. Dr. Valite indicated Plaintiff was not emotionally stable. Id. He indicated that Plaintiff was "totally disabled and unable to work at this time or for the next 12 months." Id.
On June 29, 2010, Plaintiff attended a psychological consultative evaluation with A. Nicholas DePace, Ph. D. ("Dr. DePace"). Tr. at 427-31. Dr. DePace noted that Plaintiff appeared to put forth good effort and concluded that the test results obtained were felt to represent an accurate assessment of her level of functioning. Tr. at 429. On the Wechsler Adult Intelligence Scale-Fourth Edition ("WAIS-IV"), Plaintiff obtained a full scale IQ score of 66, a verbal comprehension score of 63, a perceptual reasoning score of 82, a working memory score of 77, and a processing speed score of 62. Id. Dr. DePace indicated "these scores are felt to represent an accurate assessment of her current level of functioning." Id. On the Wide Range Achievement Test-Third Edition ("WRAT-3"), Plaintiff's reading score was at a high school level, her spelling score was at a seventh grade level, and her arithmetic score was at a fourth grade level. Tr. at 430. Dr. DePace noted these scores were higher than anticipated given Plaintiff's full scale IQ score and suggested she "worked very hard in school." Id. Dr. DePace noted Plaintiff's full scale IQ score was likely not the best measure of her global intellectual abilities and that her non-verbal abilities were significantly stronger than her verbal abilities and approached the criteria necessary to make a diagnosis of a mixed receptive-expressive language disorder. Id. Dr. DePace indicated the following regarding Plaintiff's abilities:
With regard to activities of daily living, Ms. Lyles reports that she continues to receive some assistance in the management of some higherorder activities of daily living, including managing her own money and she is yet to drive, although she has earned the opportunity to try for her license. She is reported to have numerous age-appropriate friends and was socially appropriate here today. At times, she may be distractible and may seem to lack confidence in engaging in new activities. She does however appear to be able to perform three-step commands, particularly if given an opportunity to repeat them on a couple of occasions. Her concentration appears to be in the Borderline range. Her tolerance for frustration appeared to be fairly appropriate here today. She appeared to put forth appropriate effort during this evaluation.
Tr. at 430-31.
On August 4, 2010, state agency consultant Philip Rosenshield, Ph. D. ("Dr. Rosenshield"), considered Listing 12.02 for organic mental disorders and indicated Plaintiff had receptive-expressive language disorder. Tr. at 434. Dr. Rosenshield assessed Plaintiff to have moderate restriction of activities of daily living, mild difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 441. Dr. Rosenshield completed a mental residual functional capacity assessment in which he indicated Plaintiff was markedly limited with respect to her abilities to understand and remember detailed instructions and carry out detailed instructions. Tr. at 445. Dr. Rosenshield indicated "[t]he claimant is capable of concentrating sufficiently well to perform simple work tasks in a timely manner without special supervision and adapt to changes in the work setting. Tr. at 447. He further indicated "[s]he has the capacity to interact appropriately with coworkers, supervisors and the general public." Id.
On September 7, 2010, Dr. Valite noted Plaintiff was somewhat improved. Tr. at 451. Plaintiff reported she continued to be upset over "little things." Id. Plaintiff denied symptoms of psychosis, mania, and suicidal thoughts. Id.
On January 6, 2011, state agency consultant Larry Clanton, Ph. D., considered Listings 12.02 for organic mental disorders and 12.04 for affective disorders. Tr. at 453. Dr. Clanton indicated Plaintiff's test results supported language disorder, not a mental retardation diagnosis. Tr. at 454. Dr. Clanton also indicated Plaintiff had bipolar disorder. Tr. at 456. He indicated Plaintiff had mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 463. Dr. Clanton indicated Plaintiff's mental symptoms and impairments were severe, but would not preclude the performance of simple, repetitive work tasks in a setting without ongoing interaction with the public. Tr. at 465. Dr. Clanton indicated Plaintiff's abilities to understand and remember detailed instructions, carry out detailed instructions, interact appropriately with the general public, and set realistic goals or make plans independently of others were moderately limited. Tr. at 467-68.
Plaintiff presented to Dara Josiah-Howze, M.D. ("Dr. Josiah-Howze"), for an initial assessment on June 19, 2012. Tr. at 514. She reported that her mother had little time for her and that her stepfather was verbally abusive. Id. She indicated she became angry and cried when she thought of her stepfather. Id. Dr. Josiah-Howze indicated Plaintiff was irritable, had experienced/witnessed trauma, had instrusive distressing recollections, had recurrent dreams, experienced irritability, was fearful/anxious, and had poor impulse control. Tr. at 517, 519. However, she also indicated Plaintiff was appropriately dressed and groomed, was cooperative, made good eye contact, spoke with normal rate, amplitude, and prosody, was talkative, had a linear and goal-directed thought process, and had normal and future-oriented thought content. Tr. at 519.
On July 5, 2012, Plaintiff reported to Dr. Josiah-Howze that she had a nightmare the previous night and cried for an hour after waking. Tr. at 513. Dr. Josiah-Howze indicated Plaintiff was tolerating Abilify and would start therapy soon. Id. She described Plaintiff as appropriately dressed with adequate grooming and hygiene. Tr. at 515. She noted Plaintiff was cooperative, had good eye contact, had normal motor activity, spoke at a normal rate, had a normal thought process and content, and was anxious. Id. Dr. Josiah-Howze described Plaintiff's insight/judgment as impaired. Tr. at 516. She diagnosed PTSD and assessed a GAF score of 50. Id.
On September 26, 2012, Plaintiff reported to Sherita Davis, M. Ed., LPC ("Ms. Davis"), that her anger was triggered by contact with previous friends, conflicts with family, and negative thoughts about herself. Tr. at 526. Ms. Davis noted that Plaintiff had recently experienced anger outbursts directed toward members of her family. Id. On October 10, 2012, Plaintiff reported to Ms. Davis that she had recently experienced several nightmares. Tr. at 524. However, by October 24, 2012, Ms. Davis indicated Plaintiff's nightmares had decreased. Tr. at 523. On October 31, 2012, Plaintiff and Ms. Davis explored distorted thoughts Plaintiff had about herself. Tr. at 522. Ms. Davis described Plaintiff's mood as a calm and her affect as appropriate. Id. On November 14, 2012, Plaintiff and Ms. Davis discussed Plaintiff's efforts to control her emotions and Ms. Davis noted Plaintiff had not experienced any anger outbursts since her last session. Tr. at 521. Ms. Davis described Plaintiff's mood as calm and her affect as appropriate. Id.
3. Educational History
School psychologist Bryan D. Greeson, MA/CAS, NCSP ("Mr. Greeson"), evaluated Plaintiff on November 22, 1994, when Plaintiff was seven years old. Tr. at 337-41. Mr. Greeson indicated the test results were considered "to be a valid estimate of" Plaintiff's "intellectual potential as related to a language-based educational setting." Tr. at 338. Results of the WISC-III indicated Plaintiff was functioning in the educable mentally disabled range. Id. She had a verbal IQ of 66, a performance IQ of 55, and a full scale IQ of 57. Id. Plaintiff scored in the tenth percentile for reading and below the first percentile for spelling and arithmetic on the Wide Range Achievement Test-Revised ("WRAT-R"). Tr. at 339. Her scores were in the fourteenth percentile for basic reading, the ninth percentile for spelling and math reasoning, the fifth percentile for numerical operations, and the fourth percentile for total mathematics. Id. Results of the Developmental Test of Visual-Motor Integration ("VMI") suggested Plaintiff had a developmental age of five years, four months. Tr. at 340. Mr. Greeson interpreted the tests to indicate Plaintiff's limited abilities were not restricted only to the educational environment. Id. He recommended Plaintiff be served in the educable mentally disabled resource program. Id.
Mr. Greeson reevaluated Plaintiff on September 3, 1998, when she was ten years and nine months old. Tr. at 352-45. He indicated testing presented a valid estimate of Plaintiff's academic achievement and visual-motor development. Tr. at 343. Mr. Greeson referenced WISC-III results dated March 4, 1998, in which Plaintiff was assessed as having a verbal IQ of 69, a performance IQ of 58, and a full scale IQ of 60. Id. The Wechsler Individual Achievement Test ("WIAT") was administered on September 3, 1998, and its results indicated Plaintiff was performing on a high first grade level in basic reading, a first grade level in math reasoning, a third grade level in spelling, a high first grade level in reading comprehension, a high second grade level in numerical operations, and a kindergarten level in listening comprehension and written expression. Id. Plaintiff's total reading was on a high first grade level; her total mathematics was on a second grade level; and her total writing was on a high second grade level. Id. Plaintiff's scores were equivalent to an age of seven years to seven years, five months and a mid-first grade level on the Bender Visual-Motor Gestalt Test, which suggested she had significant visualmotor difficulties. Tr. at 343-44. On the Vineland Adaptive Behavior Scales Test, Plaintiff's adaptive behavior composite ("ABC") score fell within the borderline to educable mentally disabled range. Tr. at 344. Mr. Greeson noted that Plaintiff continued to be functioning in the educable mentally disabled range of academic aptitude. Id.
On April 3, 2001, Plaintiff was assessed as reading and engaging in written expression on a fourth grade level and performing math on an early fifth grade level. Tr. at 346-47. Plaintiff's teachers observed that Plaintiff had progressed in writing, but had difficulty with creativity, grammar, and spelling. Tr. at 347. Plaintiff was described as very cooperative and participating and behaving well, but lacking higher-level reasoning skills. Id.
On March 25, 2004, Plaintiff was reading and performing math on a fourth grade level and engaging in written expression on an early fifth grade level. Tr. at 351. Her writing mechanics had improved, but she needed improvement in vocabulary and sentence structure. Id. Plaintiff demonstrated weakness in reading comprehension and math applications, but showed strength in math calculation skills and oral ...