A. Introduction

To assure a comprehensive assessment of mental RFC, the SSA-4734-F4-SUP requires the medical or psychological consultant (MC/PC) first to record preliminary conclusions about the effect of the impairment(s) on each of four general areas of mental function (described in B.1-4 below), then to prepare a narrative statement of mental RFC.

B. Operating Policy

The MC is to analyze each of the mental activities within the following four general mental functional areas and to indicate on the SSA-4734-F4-SUP:

• Whether the evidence is sufficient to permit assessment or, if not, the evidence needed.

• The extent to which the individual can still perform and sustain specific mental activities and mental functions.

1. UNDERSTANDING AND MEMORY

1. Understanding and memory can be evaluated through evidence from the mental status examination(s) or from elements of standardized psychological tests (such as IQ tests) that assess the ability to understand and remember, as well as evidence available from other medical and nonmedical sources, e.g., reports of prior work attempts or work evaluations.

2. The ability to understand and remember may be at least partially assessed through answers to some of the following questions:

   • Is the individual able to complete forms, respond to two or three-step instructions for filling out applications, or follow instructions given by someone?

   • Did the individual have difficulty in the process of filing for disability, going for examinations, or remembering appointments?

   • Is there any history of work or school failures due to inability to remember and understand?

   • Was the individual involved in special educationor training programs? (These might indicate some impairment of the ability to understand and remember.)

   • Is there any evidence that the claimant requires supervision or assistance to perform activities of daily living because of problems with understanding or remembering?

   • Did the individual come to appointments without supervision, finding his/her own way without unusual supervision?

2. SUSTAINED CONCENTRATION AND PERSISTENCE

1. The individual's ability to sustain ongoing mental performance for a full workday is essential. These may be evaluated through:

   • Medical history and reports, and

   • Reports of performance at past work, recent work attempts, recreational or volunteer activities, or vocational evaluations.

2. Limitationsin these areas may be demonstrated in typically less demanding settings, such as sheltered work, vocational training, or school (i.e., in any situation demanding performance of tasks requiring concentration or task persistence).

3. Use care in inferring an individual's ability to sustain the mental demands of work in a competitive setting from his/her performance in a less demanding setting, such as sheltered work.

   NOTE: Discussion with the disability examiner of the performance required in competitive work environments may clarify this distinction.

3. SOCIAL INTERACTION

The items in this subsection deal with socially acceptable behavior and the individual's capacity to relate to others in a work setting. To assess these factors, important considerations are:

• Historical information about interpersonal interactions with others, particularly in an employment or work-like setting.

• Indications, on mental status examinations or psychological testing, of withdrawal, bizarre or unusual behavior, emotional lability, paranoid ideas, or faulty insight and judgment.

• Observed behavior, in terms of how the individual relates to various interviewers or behaves when exposed to a stressful circumstance or situation.

4. ADAPTATION

Adaptive functions reflect the individual's ability to integrate other areas of functioning.

1. The items in this section pertain to the individual's ability to:

   • plan,

   • respond to changes,

   • deal appropriately with mental demands (stress),

   • avoid hazards and maintain safe behavior,

   • follow rules,

   • adhere to schedules and to time constraints, and

   • travel.

2. The area of mental demands of work (“stress”) is difficult to assess. Some mentally impaired individuals may be unusually sensitive to changes in their environment and may become anxious, depressed, confused, or even psychotic when confronted with seemingly slight mental demands.

   “Stress” is a highly individualized phenomenon and can only be assessed with regard to each individual's experiences and limitations. Even work activities usually considered to entail low stress may produce adverse responses in some individuals.

3. Data in the medical file may demonstrate sensitivity to change, e.g., resistance to try a new activity, treatment or medication, or exacerbation of symptoms when a therapist leaves, changes schedule, or goes on vacation.

4. Most health care settings have rules, schedules, and hazards. Limitations in conforming to acceptable behavior may sometimes emerge in the reports from hospital, or clinics.