United States District Court, W.D. Arkansas, Fort Smith Division
LAURAN M. CROWDER PLAINTIFF
ANDREW M. SAUL,  Commissioner, Social Security Administration DEFENDANT
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
Lauran Crowder, brings this action pursuant to 42 U.S.C.
§ 405(g), seeking judicial review of a decision of the
Commissioner of the Social Security Administration
(Commissioner) denying her claim for supplemental security
income (SSI) under the provisions of Title XVI of the Social
Security Act (Act). In this judicial review, the Court must
determine whether there is substantial evidence in the
administrative record to support the Commissioner's
decision. See 42 U.S.C. § 405(g).
protectively filed an application for SSI on September 10,
2015, alleging an inability to work since September 10, 2015,
due to mental illness. (Tr. 150, 166). The first
administrative video hearing was held on November 21, 2016.
(Tr. 83-119). Plaintiff testified via video from
Russellville. (Tr. 87-98). John Richard Cowell,
Plaintiff's uncle, also testified. (Tr. 99-111). Deborah
Steele, Vocational Expert (VE), also testified via telephone.
(Tr. 111-118). A supplemental hearing was held on October 31,
2017. (Tr. 122-143). Plaintiff and her attorney appeared, and
Plaintiff was the only witness. (Tr. 128-145).
written opinion dated April 30, 2018, the ALJ found that
Plaintiff had the following severe impairments: borderline
intellectual functioning; specific learning disability;
attention-deficit hyperactivity disorder (ADHD); major
depressive disorder; unspecified anxiety disorder;
oppositional defiant disorder (ODD); and post-traumatic
stress disorder (PTSD). (Tr. 19). However, after reviewing
the evidence in its entirety, the ALJ determined that the
Plaintiff's impairments did not meet or equal the level
of severity of any listed impairments described in Appendix 1
of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr.
19-22). The ALJ found Plaintiff retained the residual
functional capacity (RFC) to perform a full range of work at
all exertional levels but with the following non-exertional
limitations: Plaintiff was “able to perform unskilled
work where interpersonal contact with coworkers and
supervisors is only incidental to the work performed, there
is no contact with the public, the complexity of tasks is
learned and performed by rote with few variables and little
use of judgment, and the supervision required is simple,
direct, and concrete.” (Tr. 22-33). Plaintiff had no
past relevant work; however, with the help of a VE, the ALJ
determined that there were jobs that existed in significant
numbers in the national economy that Plaintiff could perform,
such as cook helper, kitchen helper, sweeper cleaner, bin
filler, gasket attacher/gluer, ordnance check weigher, and
paper label assembler. (Tr. 33-34). Ultimately, the ALJ
concluded that Plaintiff had not been under a disability
within the meaning of the Social Security Act since September
10, 2015, the date the application was filed. (Tr. 34).
Plaintiff requested a review of the hearing decision by the
Appeals Council, which denied that request on October 29,
2018. (Tr. 1-7). Plaintiff filed a Petition for
Judicial Review of the matter on December 21, 2018. (Doc. 1).
Both parties have submitted briefs, and this case is before
the undersigned for report and recommendation. (Docs. 11,
Court has reviewed the transcript in its entirety. The
complete set of facts and arguments are presented in the
parties' briefs and are repeated here only to the extent
hearing before the ALJ on November 21, 2016, Plaintiff
testified that she was born in 1997 and graduated from high
school. (Tr. 89). Plaintiff was in special education classes
in high school for Math and English. (Tr. 89). Testimony
showed that Plaintiff did not have any past relevant work.
to the relevant time period, Plaintiff was treated for upper
respiratory infections, influenza, ear infections, abdominal
pain from an ovarian cyst and dysmenorrhea, gastritis,
gastroenteritis, depression, violent behavior, cystitis,
dermatitis, cellulitis, urinary tract infection, right
shoulder pain, strained tendon in foot/ankle, headaches,
ADHD, oppositional and disruptive behaviors, trauma-related
problems, learning issues, cognition issues, and memory
early as December of 2009, Plaintiff had a doctor visit at
Dayspring Behavioral Health. (Tr. 889). Records indicated
that she had a history of oppositional defiant disorder,
impulse control disorder, ADHD, and adjustment disorder with
depressed mood, and she was on medication at the time for the
conditions. (Tr. 889). Dayspring records showed that
Plaintiff's mother reported some improvement on the
medication, such as a stabilization in Plaintiff's grades
in February of 2011, an increase in calm behavior in November
of 2010, and an improvement in her attention span in June of
2010. (Tr. 981-982, 984). Plaintiff underwent counseling and
made some progress toward her goals but continued to struggle
with oppositional defiance disorder and difficulty with
authority and following rules. Her GAF scores remained
between 38 and 55 during her services with Dayspring. She was
discharged from Dayspring in October of 2012, and she was
encouraged to continue working toward her goals and resume
services with another outpatient mental health agency. (Tr.
December of 2011, until May of 2012, Plaintiff was inpatient
at Pinnacle Point for labile moods, violent and aggressive
behavior, combativeness with siblings, belligerent behavior,
destructive behavior, and noncompliance with medication. (Tr.
1089). While at Pinnacle Point, Plaintiff was involved in
individual, group and family treatment, as well as
recreational therapy and educational classes. (Tr. 1091). At
discharge, Plaintiff was no longer exhibiting or verbalizing
ongoing depressive or aggressive symptoms and denied
homicidal or suicidal ideation. Plaintiff was to follow up
with her Dayspring mental health professionals. (Tr. 1091).
Her discharge diagnosis was mood disorder, disruptive
behavior disorder, and ADHD with a GAF score of 42. (Tr.
medical record also indicated that Plaintiff was admitted to
BridgeWay in July of 2012 for six days. (Tr. 994). Intake
notes revealed that Plaintiff had also been hospitalized in
the past at Youth Villages (a residential setting) due to her
impulsive and aggressive behaviors. (Tr. 997). Plaintiff was
showing severe aggression toward her developmentally delayed
brother and also throwing things at her mother. She was also
noncompliant with her medications. (Tr. 994). Plaintiff
reported at intake that Plaintiff had hit one brother in the
eye with an object and that she was showing aggression toward
her brothers. (Tr. 994-995). She admitted to not taking her
medication and stated that her mood was usually
“good” but that she did experience anger on a
daily basis. (Tr. 995). Records indicated that Plaintiff
attend group sessions while at BridgeWay; that she completed
daily self-inventories and assignments on anger; and that she
completed a risk assessment. During inpatient, Plaintiff was
noted to be sleeping well, not displaying any aggression,
tolerating her medication, and in agreement to complying with
her medication as an outpatient. (Tr. 995). Plaintiff's
diagnosis upon discharge was disruptive behavior disorder,
sexual abuse as a child, history of ADHD and a GAF score of
45. (Tr. 996).
September 11, 2012, Plaintiff underwent a psychoeducational
evaluation by Jo Ella Peever, M.Ed., which showed that
Plaintiff's overall level of achievement was very low;
her math score was low average; her reading and written
expression were in low range; and she had a significant
deficit in the area of visual perception. (Tr. 679). Her
adaptive behavior and functional skills assessment both
indicated areas of statistical significance and were within
expected ranges. She demonstrated specific learning
disabilities in basic reading skills, reading comprehension,
reading fluency, math calculation skills, and written
expression. (Tr. 679).
October 2, 2012, Jane Barrett, the speech pathologist at
Plaintiff's school, completed testing on Plaintiff, which
showed that Plaintiff's global language skills were
within the average range for her age. (Tr. 658-662).
medical record also showed that Plaintiff was receiving
individual psychotherapy services as early as August of 2014
at Counseling Associates, Inc. for major depressive disorder,
oppositional defiant disorder, and relational problems;
however, Plaintiff was discharged on July 24, 2015 for lack
of contact with Plaintiff. (Tr. 870).
the relevant time period, the medical record showed that on
September 23, 2015, Stephanie Houston, Plaintiff's
resource teacher, completed a teacher questionnaire. (Tr.
648-655). Ms. Houston indicated that based on her daily
interaction with Plaintiff, she had an obvious problem in the
area of acquiring and using information. (Tr. 649).
Specifically, she struggled with working alone, required
extra help, and needed a lot of structure and support
overall. (Tr. 649). Ms. Houston noted that Plaintiff had a
serious problem with attending and completing tasks and had
to be kept on task and focused regularly. (Tr. 650).
Plaintiff had a slight problem overall in interacting and
relating to others. (Tr. 651). Plaintiff did not have any
issues with moving about and manipulating objects. (Tr. 652).
Lastly, Ms. Houston suggested that Plaintiff had a serious to
very serious problem in the area of caring for herself. (Tr.
October 26, 2015, Andrea Edgmon, a social worker, completed a
Function Report on Plaintiff's behalf. (Tr. 330-337).
Edgmon reported that Plaintiff had limited adaptive living
skills; that she had issues regarding interaction with
others; that she would get angry and frustrated easily: that
she had to be prompted to bathe; that she had no money
management skills; and that she had no ability to follow
complex directions. (Tr. 330). She noted that Plaintiff lived
alone, but that she would get herself up, take the bus to and
from school, occasionally have a friend pick her up to go to
church, and stay around the camper until bedtime. (Tr. 330).
She stated that Plaintiff would wear improper or ill-fitting
clothing; that she would only bathe once a week unless
prompted; and that she did not care for her hair or shave.
(Tr. 331). Plaintiff could prepare simple meals, and she was
able to physically do housework. (Tr. 332). Ms. Edgmon noted
that while Plaintiff did not drive and was unable to manage
money, she was able to shop in stores for food and personal
items. (Tr. 333). Plaintiff was social in that she liked to
watch movies, go to church, and hang out with her little
sister. (Tr. 334). However, she had trouble getting along
with others, including verbal outbursts, becoming easily
agitated, and displaying oppositional behavior. (Tr. 335).
She could pay attention for five to ten minutes, could not
finish what she started, and would get confused with
instructions. (Tr. 335). Ms. Edgmon noted that Plaintiff was
not on any medication at the time she completed the report.
October 28, 2015, Plaintiff underwent a mental diagnostic
evaluation by Dr. Steve Shry, Ph.D. (Tr. 693-695). Initially,
Plaintiff's social worker, who was also interviewed,
reported Plaintiff's issues with independent living, poor
decision making, and anger management. Dr. Shry noted
Plaintiff's diagnosis of major depressive disorder and
oppositional defiant disorder through Counseling Associates.
Plaintiff denied inpatient treatment, said she was not
currently on medication, and reported a lack of medical
insurance and financial resources. (Tr. 693). Dr. Shry
observed that Plaintiff was pleasant but passive and
non-spontaneous; was cooperative; had a normal and stable
mood; had a normal speech pattern; affect was mood congruent;
had a normal range of expression; had liner and relevant
responses; had well-connected and goal directed associations;
and had no evidence of psychotic process. (Tr. 693-694). Dr.
Shry noted that Plaintiff was oriented to time, place and
person; that she did not appear to demonstrate any unusual
mannerisms or behaviors; that she was able to cite basic
biographical information, but incorrectly cited other
information; that she had received psychiatric treatment but
was not on any mediation; and that she appeared to meet the
diagnostic criteria for specific learning disorder and
borderline intellectual functioning (Tr. 694-695). Dr. Shry
concluded that Plaintiff was poorly groomed but was pleasant
and did not appear to be impaired in her ability to
communicate and interact in a socially adequate manner. (Tr.
695). Dr. Shry opined that she could communicate in an
intelligible and effective manner; that she did not appear to
be significantly impaired in her ability to cope with the
typical demands of basic work like tasks when the tasks were
simple, but due to her learning disorder and her intellectual
functioning, she might be significantly impaired in this area
when tasks were complex; that she attended well and did not
seem impaired in her ability to attend and sustain
concentration on tasks; that she did not tolerate frustration
well and would likely demonstrate significant impairment in
her ability to sustain persistence when completing tasks when
under stress due to her intellectual function level; and she
did not appear to be impaired in her ability to complete
simple work like tasks within an acceptable time frame, but
could be impaired in this area if tasks were complex. (Tr.
November 30, 2015, Dr. Sheri L. Simon, Ph.D., a non-examining
medical consultant, completed a mental RFC assessment where
she determined that Plaintiff had the capacity for work where
interpersonal contact was incidental to work performed, e.g.
assembly work; complexity of tasks was learned and performed
by rote, few variables, little judgment; and supervision
required was simple, direct and concrete (unskilled). (Tr.
Ms. Debbie McBurney, completed a Communications Assessment on
Plaintiff on December 7, 2015, as part of an overall
psychological and speech and language evaluation at
Forrester-Davis Developmental Center. (Tr. 1284). Ms.
McBurney stated that Plaintiff “needed prompts”
when handling situations involving conflict or anger, but
that she was able to independently handle the majority of
various types of social communication and interaction. (Tr.
1284-1287). Other instructors noted Plaintiff's need for
prompts in areas of exercise, nutrition, and some social
community. (Tr. 1295-1299).
March 25, 2016, Dr. Kay M. Gale, a non-examining medical
consultant, completed a mental RFC assessment where she
affirmed Dr. Simon and determined that Plaintiff had the
capacity for work where interpersonal contact was incidental
to work performed, e.g. assembly work; complexity of tasks is
learned and performed by rote, few variables, little
judgment; and supervision required was simple, direct and
concrete (unskilled). (Tr. 180).
April 13, 2016, Plaintiff resumed counseling at Counseling
Associates with Dr. Mervin Leader. (Tr. 1115).
Plaintiff's Intake Assessment indicated problems with
physical, emotional and sexual abuse resulting in trauma.
(Tr. 1115). Plaintiff reported that she was currently
residing with her aunt and uncle because she was unable to
get along with her mother. (Tr. 1116). She stated that she
attended church services with her family, but she did not
interact with her peers outside of school. The examiner noted
that Plaintiff had a cooperative attitude, was well-groomed,
had a normal mood, intact short-term memory, fair judgment
and insight, appropriate behavior and affect, and posed no
risk of violence. (Tr. 1116). Plaintiff was diagnosed with
PTSD. (Tr. 1116).
Plaintiff's counseling session on April 20, 2016, Dr.
Leader noted that her judgment and insight were fair. (Tr.
1117). On April 27, 2016, Plaintiff opened up to Dr. Leader
about her history of sexual abuse and her sexual abuse of her
brothers. She explained that she had worked through the abuse
in counseling and did not need further treatment for that
issue. (Tr. 1118). At her May 11, 2016, session,
Plaintiff's uncle reported to Dr. Leader that he was
concerned about Plaintiff's attention seeking behavior
and that she had been messaging men and giving them her
personal information. (Tr. 1120). At her May 19, 2016,
session, she reported that she had been staying with her
mother for a week and that it was going “fairly
well.” (Tr. 1119). Plaintiff was also excited about her
upcoming graduation. (Tr. 1119).
Plaintiff's June 2, 2016, session with Dr. Leader,
Plaintiff's uncle joined her, and they discussed her
relationship with her mother. (Tr. 1121). At her June 6,
2016, session Plaintiff and Dr. Leader discussed choosing her
battles with those around her, and Dr. Leader's ...