Primary diagnosis: Organic mental disorders (chronic brain syndrome).

Secondary diagnosis: None established (Medical Evidence in File, But Insufficient to Establish Diagnosis).

The claimant was a 13 ½ -year-old boy.
Alleged disability: major head trauma and speech issues. His mother indicated that the claimant had a learning disability, had a current individualized education program (IEP), and received speech therapy in school. He had been disabled since he was 16 months old. He attended 6th grade.

Decision under Review:
Per the Disability Determination (03/10/2016), the claimant’s disability began on 03/02/2015. The primary diagnosis was organic mental disorders (chronic brain syndrome). The secondary diagnosis was none established (medical evidence in file, but insufficient to establish diagnosis). …show more content…
The claimant was “extremely challenged” with communication. He had “significant expressive language delays.” He had difficulty with reading, spelling, writing, and mathematics. Per his test scores, his skills were from “below kindergarten” to “1st grade and 2 months” levels. His visual skills were also in the low average range. He required constant assistance to complete most academic tasks. He was classified as a student with a traumatic brain injury.

Because of the claimant’s mental challenges, multiple tests were administered to assess his intellectual abilities. The scores indicated that he was in the “very poor” range of intellectual functioning. His OT test scores were in the “low” and “well below average” range. He received special education services, speech/language therapy (ST), and OT. He also required special transportation.

Per medical records (2011), the claimant had a history of mental retardation, and anoxic brain