United States District Court, D. New Jersey
JOSE L. LINARES, District Judge.
Before the Court is Plaintiff Janeth Cadavid ("Plaintiff')'s appeal on behalf of her minor child, M.C. ("Claimant"), seeking review of a final determination by Administrative Law Judge ("ALJ") Richard West denying her application for Supplemental Security Income ("SSI") benefits. The Court resolves this matter on the parties' briefs pursuant to Local Civil Rule 9.1(f) For the reasons set forth below, the Court remands the final decision of the Commissioner of Social Security.
A. Claimant's Medical and Educational Records
Claimant was born on November 26, 1996, and suffers from a learning disability, mood disorder, and intermittent explosive disorder. (R. at 197, 367). According to Plaintiff, the existence of Claimant's learning disability first became clear around 2005. ( Id. at 53).
A January 2005 educational assessment prepared by Jessie Cochran, a learning disabilities teacher consultant, corroborates Plaintiff's testimony. ( Id. at 97-101). At that time, Claimant was eight years old and in the second grade. ( Id. at 97). Plaintiff noted that Claimant did not want to study or do anything while at home, and that she had to beg him to work. ( Id. at 98). According to Claimant's second grade teacher, Claimant did not retain information, worked more slowly than others, rarely raised his hand in class, could be disruptive in class, was generally shy and withdrawn, and suffered academically. ( Id. at 97). In her assessment, Cochran observed that Claimant did not appear to pay attention to his second grade teacher. ( Id. at 98). For example, when Claimant's second grade teacher asked Claimant and his classmates to remove a sheet of paper from their desks, Claimant did not do so. ( Id. ). Instead, Claimant talked to his neighbor. ( Id. ). Cochran administered the Woodcock-Johnson Pyscho-Educational Battery 111 to Claimant, a comprehensive set of tests for measuring scholastic aptitudes and achievement. ( Id. at 99). Claimant scored in the very low range for his age in reading, the low average range for his age in writing, and the average range for his age in mathematics and academic knowledge. ( Id. at 99-101). Overall, Claimant scored in the low average range for total achievement. ( Id. at 99).
In February 2005, Zenaida Arvelo, a school social worker, examined Claimant, preparing a social evaluation report and speech and language report. ( Id. at 93-96, 327-29). The speech and language report revealed that Claimant had difficulty reading and retaining information, worked very slowly, required extra time to complete assignments and tests, could not focus, and required one-on-one assistance to complete class work. ( Id. at 327-29). Both reports commented that although Claimant was described as happy and friendly, he could be aggressive towards Plaintiff-he struck her when upset-and explosive at times. ( Id. at 94, 328-29). Both reports also commented that Plaintiff had a very serious character and could be both stubborn and temperamental. ( Id. at 94, 329). According to both reports, while Claimant was respectful of adult authority, he tended to resist discipline. ( Id. ). To improve Claimant's academic performance, both reports recommended placing Claimant in a small class environment where he could receive one-on-one in class support. ( Id. at 95, 328).
Also in February 2005, Diane Peneno, a certified school psychologist, conducted a psychological assessment of Claimant. ( Id. at 67-74). While conducting the assessment, Peneno observed that Claimant was polite, initiated some conversation, appeared to process information slowly, and did not display any emotion-he appeared to have a flat affect and did not smile. ( Id. at 67-68). The assessment included the administration of the Wechsler Intelligence Scale for Children - Fourth Edition ("WISC-IV"), an intelligence test used to assess the general thinking and reasoning skills of children aged six to sixteen years. ( Id. at 68-71). The WISC-IV provides scores in four areas-(1) verbal comprehension, (2) perceptual reasoning, (3) working memory, and (4) processing-as well as a full-scale IQ ("FSIQ") score. ( Id. at 68). According to the WISC-IV, Claimant's verbal comprehension and perceptual reasoning scores were in the average range. ( Id. at 68-70). However, Claimant's working memory score-a measurement of Claimant's attention, concentration, and mental reasoning skills-was in the borderline range and his processing speed score was in the low average range. ( Id. at 68, 70). Claimant's FSIQ score, a 91, suggested that Claimant's general cognitive ability was within the average range of intellectual functioning. ( Id. at 68).
When Claimant entered the sixth grade in September 2008, his school prepared an Individualized Education Program ("IEP") for him. ( See id. at 281-316). Claimant's sixth grade IEP noted that Claimant then functioned at the second grade level in language arts and at the fourth grade level in math, science, and social studies. ( Id. at 286, 288). With regard to Claimant's ability to read, the IEP noted that Claimant had lost his motivation to read, only read books with illustrations, and struggled with unfamiliar words. ( Id. at 286-87). Not only had Claimant lost his motivation to read, according to the IEP, but he had also lost his motivation to complete his homework and class assignments. ( Id. at 287). However, the IEP noted that Claimant had increased motivation when he received one-on-one instruction or worked with his peers. ( Id. at 288). The IEP further noted that Claimant could be defiant and stubborn, had trouble responding to authority, and demonstrated inappropriate behavior. ( Id. at 287, 289).
To enable Claimant to participate in the general education curriculum, Claimant's sixth grade IEP granted Claimant frequent breaks, preferential seating, and additional time to process information and complete assignments and tests. ( Id. at 283, 312). Additionally, the IEP noted that directions and instructions should be clarified, repeated, and reworded when delivered to Claimant. ( Id. ). The IEP granted these special accommodations to Claimant along with others in math, science, language arts, and social studies. ( Id. at 312).
In October 2008, Dr. Maria Padron conducted a psychiatric evaluation of Claimant at Trinitas Hospital in Elizabeth, New Jersey. ( Id. at 354-61). Claimant was referred to Trinitas by his pediatrician, Dr. Lozano, because of his aggressive behavior-shortly before the evaluation, Claimant fought with a peer. ( Id. at 354, 259). Claimant's teacher prepared a questionnaire prior to the evaluation. ( Id. at 356-57). The questionnaire noted that Claimant had a peculiar way of relating to others, tended not to make good eye contact, had significant language problems, had some excessive preoccupations, and got upset over small changes in routine. ( Id. at 357). The questionnaire also noted that Claimant exhibited multiple signs of ADHD and some signs of impulsivity. ( Id. ).
At the time of intake, Dr. Padron noted that Claimant did not make eye contact and was angry. ( Id. at 358). She found that Claimant had poor impulse control and moderately impaired judgment. ( Id. at 359). She assigned Claimant a Global Assessment of Functioning ("GAF") score of sixty. and diagnosed Claimant with the following: Impulse Control Disorder, Learning Disability - not otherwise specified, and Speech Articulation Disorder. ( Id. at 360). In doing so, Dr. Padron ruled out Mood Disorder. ( Id. ). Dr. Padron recommended that Claimant take Trileptal to treat his impulsivity. ( Id. ). She later recommended that Claimant take Abilify to treat his irritability and doubled his dosage of Trileptal. ( Id. at 360-61). Plaintiff subsequently informed Dr. Padron that Claimant was listening better and was less angry. ( Id. at 361).
While treating Claimant from November 2008 to January 2010, Dr. Pardon prepared Psychiatric Drug Management Notes. ( Id. at 404-19). In February 2009, Dr. Padron noted that Claimant had not improved as expected, and, as a result, increased his dosage of Abilify. ( Id. at 407). The following month, Dr. Padron noted that Claimant had one episode of aggressive behavior towards a relative, and rated Claimant's aggression as an eight out of ten. ( Id. at 408). In April 2009, Dr. Padron prescribed Claimant Cogentin and again increased Claimant's dosage of Abilify. ( Id. at 409). In May 2009, Dr. Padron found that Claimant was doing much better, and that he had no aggressive behavior. ( Id. at 411). However, in September 2009, Dr. Padron noted that although she had received no complaints from Claimant's school, he was still angry. ( Id. at 415).
That same month, when Claimant was in the seventh grade, Dr. Ernesto L. Perdomo performed a consultative psychological evaluation of Claimant. ( Id. at 364-67). Plaintiff told Dr. Perdomo that Claimant was very aggressive, threw things, fought a lot, had severe mood swings, was depressed, and locked himself in his bedroom to be left alone. ( Id. at 264). Nonetheless, Dr. Perdomo observed that Claimant was sociable, calm, and cooperative throughout the evaluation. ( Id. at 366). With regard to Claimant's functional capacity, Dr. Perdomo noted that Claimant had difficulty reading-Claimant was unable to read a letter during the examination-and attended special education full time. ( Id. ). Yet, Dr. Perdomo noted that Claimant was able to understand and follow directions of moderate complexity, for example, a four-step instruction. ( Id. ). Dr. Perdomo diagnosed Claimant with the following: Mood Disorder - not otherwise specified, ...