Opinion
Case No. 1:13-cv-674
09-23-2014
DEVON KNIGHT, O/B/O M.B., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
ORDER THAT: (1) THE ALJ'S NON-DISABILITY FINDING IS SUPPORTED BY SUBSTANTIAL EVIDENCE, AND AFFIRMED; AND (2) THIS CASE IS CLOSED
This is a Social Security disability benefits appeal. At issue is whether the administrative law judge ("ALJ") erred in finding M.B. "not disabled" and therefore not entitled to supplemental security income ("SSI"). (See Administrative Transcript at Doc. 9 ("Tr.") (Tr. 18-32) (ALJ's decision)).
I.
Plaintiff filed an application for SSI on behalf of M.B., a minor child, on August 26, 2010, alleging disability beginning on August 1, 2009. (Tr. 69, 140-146). Plaintiff claims that M.B. was disabled due to ADHD, separation anxiety, speech deficits, low intelligence, and frequent nosebleeds. (Doc. 12 at 2). Plaintiff's claim was denied initially and upon reconsideration. (Tr. 81-83, 88-94). Plaintiff then timely requested a hearing before an ALJ. (Tr. 95-97). The ALJ conducted a hearing on April 11, 2012, at which Plaintiff and M.B. appeared and testified. (Tr. 36-61). At the time of the hearing, M.B. was a 7 year old boy who was in the second grade. (Tr. 21). The ALJ issued an unfavorable decision on April 30, 2012. (Tr. 15-35).
The Appeals Council denied review, making the ALJ's decision the final determination of the Commissioner. (Tr. 14). Plaintiff then commenced this action in federal court for judicial review of the Commissioner's decision pursuant to 42 U.S.C. Sections 405(g) and 1383(c)(3).
The ALJ's "Findings," which represent the rationale of his decision, were as follows:
1. The claimant was born on July 30, 20014. Therefore, he was a preschooler on August 26, 2010, the date the application was filed, and is currently a school-age child (20 CFR 416.926a(g)(2)).(Tr. 21-32).
2. The claimant has not engaged in substantial gainful activity since August 26, 2010, the application date (20 CFR 416.924(b) and 416.971 et seq.).
3. The claimant has the following severe impairments: attention deficit hyperactivity disorder (ADHD) and an anxiety disorder (20 CFR 416.924(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 416.924, 416.925, and 416.926).
5. The claimant does not have an impairment or combination of impairments that functionally equals the severity of the listings (20 CFR 416.924(d) and 416.926(a)).
6. The claimant has not been disabled, as defined in the Social Security Act, since August 26, 2010, the date the application was filed (20 CFR 416.924(a)).
In sum, the ALJ concluded that M.B. was not under a disability as defined by the Social Security Regulations, and was therefore not entitled to SSI. (Tr. 32).
On appeal, Plaintiff argues that the ALJ erred by: (1) holding that M.B.'s speech/language impairment was "not severe"; (2) improperly weighing the evidence when determining that M.B.'s impairments did not functionally equal the Listings; (3) failing to give substantial weight to the opinion of treating therapist, Joanne Forsthoefel, when assessing M.B.'s limitations; and (4) improperly assessing the credibility of both M.B. and the Plaintiff. The Court will address each error in turn.
II.
The Court's inquiry on appeal is to determine whether the ALJ's non-disability finding is supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). In performing this review, the Court considers the record as a whole. Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978). If substantial evidence supports the ALJ's denial of benefits, that finding must be affirmed, even if substantial evidence also exists in the record upon which the ALJ could have found plaintiff disabled. As the Sixth Circuit has explained:
"The Commissioner's findings are not subject to reversal merely because substantial evidence exists in the record to support a different conclusion. The substantial evidence standard presupposes that there is a "zone of choice" within which the Commissioner may proceed without interference from the courts. If the Commissioner's decision is supported by substantial evidence, a reviewing court must affirm."Felisky v. Bowen, 35 F.3d 1027, 1035 (6th Cir. 1994).
The claimant bears the ultimate burden to prove by sufficient evidence that he is entitled to disability benefits. 20 C.F.R. § 404.1512(a). That is, he must present sufficient evidence to show that, during the relevant time period, he suffered an impairment, or combination of impairments, expected to last at least twelve months, that left him unable to perform any job in the national economy. 42 U.S.C. § 423(d)(1)(A).
A.
The record reflects that:
M.B. has been a student in the North College Hill School District since kindergarten. (Tr. 204-214, 216, 267-311, 432-468). While still in pre-kindergarten, M.B.'s teacher referred him for an evaluation for IEP services because he failed a speech and language screening test. (Tr. 272). The initial testing, performed in May 2009, revealed that M.B. had a "significant delay in both receptive and expressive language development" (with his scores falling more than two standard deviations below the mean), and M.B. had "significant" delays in speech sound development. (Tr. 282). M.B. was placed into speech and language therapy at school, and he has continued to participate in those services though kindergarten, first grade, and second grade. (Tr. 293, 442, 452). By the second grade, M.B. had made some improvements in his speech and language disorders, but he continued to exhibit a "moderate" spoken language impairment (improving his spoken language scores on the Test of Language Development - Primary from 64 in 2009 to 77 in 2012). (Tr. 442). M.B.'s articulation was worse at the conversational level, as opposed to speaking words in isolation. (Id.)
The school psychologist who evaluated M.B. in February 2012 observed that M.B. "was difficult to understand while reading passages aloud," and she found that even though M.B. had average reading and math skills, he had "very low" written expression skills which were consistent with his speech and language errors. (Tr. 445). She observed that M.B. "worked very hard and diligently but seemed not to understand the writing task or directions." (Id.) M.B.'s report cards and progress reports demonstrate that with accommodations such as additional time for tests and class assignments, having tests and assignments read to him, alternative spelling lists, and a special reading group (among other services), M.B. was able, for the most part, to pass his classes. (Tr. 205206, 210-211, 461-462). However, M.B. was disruptive in class and was disciplined on a number of occasions. (See, e.g., Tr. 207, 216, Tr. 205 (comment included with the letter grade given for Art class in second grade is "needs to listen and follow directions" (Tr. 461) (comment included with the letter grade given for Physical Education is "Exhibits behavior or attitude which hinders performance").
M.B. began treatment at St. Aloysius Orphanage and Educational Center in April 2010, and he has been treated there regularly ever since. (Tr. 222-255, 312-406, 407- 431). While at St. Aloysius Orphanage, M.B. received psychiatric services from Drs. Kuschnir and Friedeman and weekly therapy services from Joanne Forsthoefel, NAPC. (Id.) At the initial Diagnostic Assessment in April 2010, M.B. was diagnosed with ADHD-combined type and Separation Anxiety Disorder, and he was assessed a GAF score of 43. (Tr. 238). He was noted to have aggressive episodes approximately two times per week. (Tr. 229). At an initial psychiatric evaluation in May 2010 conducted by Dr. Kuschnir, M.B. was observed to be very hyperactive with psychomotor agitation, fleeting eye contact, intrusive behaviors, an inability to sit still, and tangential thought processes. (Tr. 430). Dr. Kuschnir diagnosed M.B. with a history of Separation Anxiety Disorder, ADHD, and assigned a GAF score of 45-50. (Id.) During a Diagnostic Assessment update in July 2010, M.B. was found to have a GAF score of 43, with the highest GAF score in the previous year being 45. (Tr. 225).
The Global Assessment of Functioning ("GAF") is a numeric scale (0 through 100) used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. A score of 41-50 indicates serious symptoms or any serious impairment in social, occupational, or school functioning.
In mid to late 2010, Plaintiff reported that she gave M.B. his medications on an "as-needed" basis, but after Dr. Kuschnir explained in October 2010 the proper way of administering the medication, M.B.'s use of prescribed medication "significantly improved." (Tr. 316, 341-342, 362, 412). In fact, the last mention in the records of the possibility that M.B. was not receiving his medications in the manner recommended by his psychiatrists was in January 2011, when Plaintiff was recovering from surgery and M.B.'s father was caring for him. However, M.B. continued to display hyperactive behaviors. For example, in July 2011, Dr. Friedeman observed that M.B. "has his aggression problems more under control than his brother, but he does continue to be very active." (Tr. 386). Dr. Friedeman recommended switching the Metadate to Vyvanse and recommended that M.B. return for a psychiatry appointment approximately two months later. (Id.) By the following appointment in September 2011, M.B. had run out of his medication and his mother had been unable to obtain the Vyvanse. (Tr. 329).
In Therapist Forsthoefel's progress notes, it was often noted that M.B. had difficulty sitting through a therapy session, especially in 2010. (Tr. 387, 392, 394, 396). M.B. was somewhat better at sitting through sessions in 2011, but he continued to be easily distractible. (Tr. 321, 324, 327, 331, 334, 346, 353, 355, 358, 360, 367, 369, 371, 373, 383, 385). M.B. also continued to have behavioral problems at school and at home. In fact, in September 2011, Plaintiff and M.B. told Therapist Forsthoefel about an incident where M.B. beat up another child and the child had to go to the hospital. (Tr. 327). In January and February 2012, M.B. had several disciplinary incidents with his school. (Tr. 207, 216).
Dr. Lester conducted a psychological consultative examination of M.B. in December 2010. (Tr. 256-262). At that time, M.B. took Clonidine and Tenex regularly, but he continued to experience hyperactivity and distractibility. Dr. Lester found M.B. to be only 70-80% intelligible in speech patterns. (Tr. 259-260). Dr. Lester estimated that M.B.'s intelligence was in the low average to upper borderline range. (Tr. 260). Dr. Lester diagnosed M.B. with ADHD combined type in partial remission, anxiety disorder NOS, estimated that he was performing in the upper level of borderline intelligence, assigned a GAF score of 60, and opined that M.B. was performing at approximately three-fourths the level of his peers. (Tr. 261).
A score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning.
A speech therapist, Ruth Quinn, performed a speech and language consultative examination in December 2010. (Tr. 263-266). She believed that M.B.'s speech was 80% intelligible, but she noted that a "fast rate of speech reduces intelligibility." (Tr. 263). Ms. Quinn opined that M.B. had only a "mild" speech and language disorder. (Tr. 266).
In March 2012, Therapist Forsthoefel completed an ADHD Residual Functional Capacities Questionnaire, in which she opined that M.B. has "marked" limitations in attending and completing tasks and in communicative functioning, and at least "moderate" limitations in a number of other areas, including social functioning and cognitive development. (Tr. 469-473).
A North College Hill Elementary School form from 2012 indicates that M.B.'s spoken language score was 77, which showed moderate language impairment. (Tr. 23). His score of 85 on the GFTA showed articulation abilities in the average range. (Id.) He had made progress with his speech and language skills and had average reading and math skills. (Id.)
B.
First, Plaintiff maintains that the ALJ erred in holding that M.B.'s speech/language impairment was "not severe."
A child under age eighteen will be considered disabled if he has a "medically determinable physical or mental impairment, which results in marked and severe functional limitations." 42 U.S.C. § 1382c(a)(3)(C)(i). Childhood disability claims involve a three-step process evaluating whether the child claimant is disabled. 20 C.F.R. § 416.924. First, the ALJ must determine whether the child claimant is working. If not, at step two the ALJ must decide whether the child claimant has a severe mental or physical impairment. Third, the ALJ must consider whether the claimant's impairment(s) meet or equal a listing under 20 C.F.R. Part 404, Subpart P, Appendix 1.
A child claimant medically equals a Listing when the child's impairment is "at least equal in severity and duration to the criteria of any listed impairment." 20 C.F.R. § 416.926(a). Yet, in order to medically equal a Listing, the child's impairment(s) must meet all of the specified medical criteria. "An impairment that manifests only some of those criteria, no matter how severely, does not qualify." Sullivan v. Zebley, 493 U.S. 521, 530-32 (1990).
A child claimant will also be deemed disabled when he or she functionally equals the Listings. The regulations provide six domains that an ALJ must consider when determining whether a child functionally equals the Listings. These domains include:
(1) Acquiring and using information;20 C.F.R. § 416.926a(b)(1).
(2) Attending and completing tasks;
(3) Interacting and relating with others;
(4) Moving about and manipulating objects;
(5) Caring for yourself; and
(6) Health and physical well-being.
To establish functional equivalency to the Listings, the claimant must exhibit an extreme limitation in at least one domain, or a marked impairment in two domains. 20 C.F.R. § 416.926a(d). In addition to considering the treating physician's opinions, the ALJ must also account for the opinions of the non-examining sources and other medical opinions in the record. 20 C.F.R. § 416.927(e)(2)(i-ii). Additionally, the regulations require the ALJ to consider certain other evidence in the record such as information from the child's teachers, 20 C.F.R. § 416.926a(a), and how well the child performs daily activities in comparison to other children the same age. 20 C.F.R. § 416.926a(b)(3)(i-ii).
"We will find that you have an 'extreme' limitation in a domain when your impairment(s) interferes very seriously with your ability to independently initiate, sustain, or complete activities ... [it] also means a limitation that is 'more than marked.' 'Extreme' limitation is the rating we give to the worst limitations. However, 'extreme limitation' does not necessarily mean a total lack or loss of ability to function. It is the equivalent of the functioning we would expect to find on standardized testing scores that are at least three standard deviations below the mean." 20 C.F.R. § 416.926a(e)(3)(i).
"We will find that you have a 'marked' limitation in a domain when your impairment(s) interferes seriously with your ability to independently initiate, sustain, or complete activities ... [it] also means a limitation that is 'more than moderate' but 'less than extreme.' It is the equivalent of the functioning we would expect to find on standardized testing with scores that are at least two, but less than three, standard deviations below the mean." 20 C.F. R. § 416. 926a(e)(2)(i).
When a treating source opinion is not entitled to controlling weight, the regulations provide that the ALJ must consider several factors when determining what weight to give the opinion. 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). The factors include: the examining relationship, the treating relationship (its length, frequency of examination, and its nature and extent), the supportability by clinical and laboratory signs, consistency, specialization, and other enumerated criteria. 20 C.F.R. § 404.1527(d), 416.927(d).
Here, the ALJ found that M.B. had the severe impairments of attention deficit hyperactivity disorder ("ADHD") and an anxiety disorder. (Tr. 21). He then considered all of the evidence and reasonably evaluated the combined effects of M.B.'s severe and non-severe impairments to determine that M.B.'s impairments did not functionally equal a Listing.
The ALJ's determination that M.B.'s speech/language impairment was non-severe was reasonable and supported by substantial evidence. During a consultative exam in December 2010, a speech language pathologist determined that M.B. had only "a mild speech and language disorder." (Tr. 264-66). She found that M.B. was 80-85% intelligible and that his prognosis was very good with continued interviewing. (Id.) A consulting psychologist examined M.B. in the same year and found that he had "some difficulties with articulation and intelligibility," but was performing at "three-quarters of his age appropriate level." (Tr. 260). The state reviewing medical experts, including speech and language pathologists, opined that M.B.'s speech and language problems were only a secondary issue. (Tr. 65-66, 77). A school evaluation from 2012 shows that M.B. had a "moderate language impairment," average reading skills, and performed within the average range in his rate of learning, although he also had very low written expression skills. (Tr. 440, 442, 446).
The ALJ noted that the records showed Plaintiff had undergone significant improvement in his speech and language disorder due to therapy and to the extent he had improved, determined that M.B.'s speech/language impairment was not severe. (Tr. 23). While M.B. continues to have a speech/language delay, testing has shown that his intellectual abilities are in the average range and his grades are fairly good. (Tr. 26). Accordingly, the records do not support a finding that M.B. has a severe limitation in speech/language.
C.
Next, Plaintiff argues that the ALJ improperly weighed the evidence when determining that M.B.'s impairments did not functionally equal the Listings.
Plaintiff maintains that M.B. meets Listings 112.11 and 112.06.
Listing 112.11, Attention Deficit Disorder, is "[m]anifested by developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity." 20 C.F.R. pt. 404, Subpt. P, App. 1 The required level of severity is met when the requirements in both A and B are satisfied.
A. Medically documented findings of all three of the following:
(1) Marked inattention; (2) Marked impulsiveness; and (3) Marked hyperactivity; and
Plaintiff argues that M.B.'s speech/language impairment, ADHD, and anxiety created marked limitations in acquiring and using information, attending and completing tasks, and interacting and relating with others. First, the ALJ acknowledged that M.B. had marked limitations in attending and completing tasks. (Tr. 27). In the other two domains at issue, however, the ALJ reasonably determined that M.B. had less than marked limitations. (Tr. 25-27, 28-29). There are no medical opinions in the record suggesting that M.B. had marked limitations in either of these domains. Even Ms. Forsthoefel, M.B.'s treating therapist, opined that M.B. had no more than moderate limitations in areas relating to acquiring and using information and interacting and relating with others, despite his speech/language difficulties. (Tr. 471-73).
Acquiring and using information concerns how well a child is able to acquire or learn information, and how well a child uses the information he has learned. 20 C.F.R. § 416.926a(g).
The interacting and relation to others domain considers how well a child is able to initiate and sustain emotional connections with others, develop and use the language of the community, cooperate with others, comply with rules, respond to criticism, and respect and take care of the possessions of others. 20 C.F.R. § 416.926a(i).
Ms. Forsthoefel is a therapist and therefore not an acceptable medical source. 20 C.F.R. § 404.1527(a)(2). The Sixth Circuit does not require an ALJ to explicitly discuss his evaluation of evidence form non-acceptable medical sources. Ealy v. Comm'r of Soc. Sec., 594 F.3d 504, 514 (6th Cir. 2010) (requirement to provide good reasons for the weight given to opinions "only applies to treating sources."). Still, the ALJ did evaluate Ms. Forsthoefel's opinion as discussed infra at Section II.D.
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As far as acquiring and using information, despite M.B.'s speech/language impairments, testing showed that his intellectual abilities were in the average range and his grades were fairly good. (Tr. 26-27, 205-06, 210, 442-43). In fact, Ms. Forsthoefel opined that M.B.'s cognitive development was only moderately impaired and that he had average intellectual skills despite the fact that he had a marked speech impairment. (Tr. 471-472). The ALJ reasonably weighed the evidence and these medical opinions and determined that M.B. had less than marked limitations in acquiring and using information. (Tr. 26-27).
The ALJ also found that M.B. had less than marked limitations in interacting and relating with others. (Tr. 28-29). First, all of the medical opinions in the record stated that M.B. had less than marked limitations in this domain. The state agency reviewing opinions found that despite his problems with speech and the fact that he fought with other children, M.B. was less than markedly impaired in this domain. (Tr. 65-66, 76). A consultative examiner, Dr. Lester, examined M.B. in 2010 and determined that M.B. had only mild to moderate difficulties getting along with peers. (Tr. 257-62). Moreover, while Ms. Forsthoefel acknowledged that M.B. had some difficulties with his peers, getting along with others, and had limited ability to accept criticism and consequences, she opined that M.B. was only moderately limited in his social development and his personal/behavioral development. (Tr. 472). Additionally, the record reflects that M.B. has only been suspended from school once, and that the suspension form indicated that M.B.'s behavior had been improving. (Tr. 29). In fact, M.B. received tickets from school for good behavior, which included sharing with peers. (Id.) This is hardly dispositive evidence that M.B. had marked limitations in interacting and relating with others. The ALJ also considered the fact that the record indicates M.B. was not consistently given his medications as directed, and that when he took his medications, they helped his behavior. (Tr. 250, 257-62, 329, 383, 397).
"Discretion is vested in the ALJ to weigh all the evidence," and he did not abuse that discretion in this instance. Collins v. Comm'r of Soc. Sec., 357 F. App'x 663, 668 (6th Cir. 2009). Accordingly, the ALJ did not commit reversible error in weighing the record evidence and was justified in determining that M.B. was less than markedly limited in his ability to acquire and use information and interact and relate with others, and as a result did not have an impairment or combination of impairments that functionally equaled the severity of the listings. Her v. Comm'r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999) ("Even if the evidence could also support another conclusion, the decision of the Administrative Law Judge must stand if the evidence could reasonably support the conclusion reached.").
D.
Plaintiff also maintains that the ALJ erred in not giving substantial weight to the opinion of the treating therapist, Joanne Forsthoefel, when assessing M.B.'s limitations.
Under the regulations, as a therapist, Ms. Forsthoefel is not an "acceptable medical source." 20 C.F.R. § 404.1513(a)(1)-(5). While Social Security Regulation 06-03p recognizes that "non-medical sources" who had contact with a claimant in their professional capacity are valuable sources of evidence for assessing impairment severity and functioning, the regulation also permits the ALJ to give greater weight to "acceptable medical sources" who are recognized as more-qualified healthcare professionals. (Id.) However, the opinions of "non-medical sources" must be weighed and evaluated with the criteria set forth in 20 C.F.R. § 404.1527. The factors the ALJ must consider include the consistency of the opinion with the other evidence of record and the degree to which the source presents relevant evidence to support that opinion. See 20 C.F.R. § 404.1527.
While Ms. Forsthoefel's assessment notes significant behavioral problems, her records also show that M.B. had been improving when he was on medication. (Tr. 25). Accordingly, given the inconsistency in Ms. Forsthoefel's opinion, it was appropriate for the ALJ to only give her opinion some weight.
E.
Finally, Plaintiff argues that the ALJ improperly assessed M.B.'s credibility. The ALJ's credibility determination is given great weight and deference. Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 476 (6th Cir. 2003) ("Upon review, we are to accord the ALJ's determinations of credibility great weight and deference particularly since the ALJ has the opportunity, which we do not, of observing a witness's demeanor while testifying.").
The ALJ found that M.B. and his mother were only partially credible because Plaintiff's testimony was inconsistent with the record. See SSR 96-7p ("One strong indication of the credibility of an individual's statements is their consistency, both internally and with other information in the case record."). Specifically, the ALJ found that Plaintiff exaggerated her son's behavioral problems. (PageID 62). For example, Plaintiff testified that she must leave work to pick up M.B. from school due to his behavioral problems. However, there is no evidence that M.B. has ever been expelled from school, and he was only suspended once. In fact, an in-school suspension form from January 2012 notes that M.B.'s behavior was improving and his grades were fairly good. (Id.) The record also indicates that M.B.'s behavior is better when he is on his prescribed medication, but that Plaintiff often fails to properly administer the medication. (Id.)
Accordingly, the evidence supports the ALJ's credibility determinations.
III.
For the foregoing reasons, Plaintiff's assignments of error are unavailing. The ALJ's decision is supported by substantial evidence and is affirmed.
IT IS THEREFORE ORDERED THAT the decision of the Commissioner that M.B. was not entitled to supplemental security income is found SUPPORTED BY SUBSTANTIAL EVIDENCE, and AFFIRMED.
The Clerk shall enter judgment accordingly, and as no further matters remain pending for the Court's review, this case is CLOSED. Date: 9/23/14
s/ Timothy S. Black
Timothy S. Black
United States District Judge
B. At least two of the appropriate age-group criteria in paragraph B2. The appropriate age-group criteria found in B(2) are:
(a) Marked impairment in age-appropriate cognitive/communicative function; or20 C.F.R. pt. 404, Subpt. P, App. 1.
(b) Marked impairment in age-appropriate social functioning; or (c) Marked impairment in age-appropriate personal functioning; or (d) Marked difficulties in maintaining, concentration, persistence, or pace.
Listing 112.06, Affective Disorders, requires both A and B to be satisfied.
A. Medically documented findings of at least one of the following:
(1) Excessive anxiety manifested when the child is separated, or separation is threatened, from a parent or parent surrogate; or (2) Excessive and persistent avoidance of strangers; or (3) Persistent unrealistic or excessive anxiety and worry (apprehensive expectation), accompanied by motor tension, autonomic hyperactivity, or vigilance and scanning; or (4) A persistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity, or situation; or (5) Recurrent severe panic attacks, manifested by a severe unpredictable onset of intense apprehension, fear, or terror, often with a sense of impending doom, occurring on the average of at least once a week; or (6) Recurrent obsessions or compulsions which are a source of marked distress; or (7) Recurrent and intrusive recollections of a traumatic experience, including dreams, which are a source of marked distress; andB. At least two of the appropriate age-group criteria cited supra in paragraph B2 of 112.02.