Age-Sensitive Evaluation and Minimal Articulation in Child SSI: Seventh Circuit Holds That Preschool Toileting Accidents and Part-Time Skills-Coach Support Do Not Automatically Establish “Marked” Limitations

Introduction

This Seventh Circuit decision, Darlene Chrisman v. Frank Bisignano, Commissioner of Social Security (No. 24-1898, decided May 13, 2025), addresses a common but under-theorized problem in child Supplemental Security Income (SSI) adjudications: how to evaluate preschool-aged children with behavioral and developmental challenges in the functional-equivalence domains of “attending and completing tasks” and “caring for yourself.” The claimant, a four-year-old child, N.R.C., suffered from ADHD, reactive attachment disorder, separation anxiety, and toileting problems (constipation/encopresis), and received both medication (guanfacine) and extensive behavioral support, including regular sessions with a skills coach.

The administrative law judge (ALJ) denied benefits at step three after finding no listing met and no functional equivalence because the impairments were less than marked in the contested domains. The district court affirmed. On appeal, the Seventh Circuit likewise affirmed, concluding that the ALJ’s explanation—though not exhaustive—met the minimal articulation requirement and was supported by substantial evidence.

Key issues on appeal included: whether the ALJ ignored or inadequately addressed favorable evidence (notably, the child’s frequent toileting accidents and limited attention span), whether the need for a skills coach compelled a finding of a “marked” limitation in attending/completing tasks, and whether toileting issues in a preschooler compelled a “marked” limitation in caring for self. The case provides a clarifying statement on minimal articulation for child SSI reviews, age-sensitive analysis of toileting, and the probative weight of state-agency opinions when improvement with treatment and structured support is shown.

Summary of the Opinion

The Seventh Circuit, in a per curiam opinion, affirmed the ALJ’s denial of child SSI benefits to N.R.C. The court held:

The substantial evidence standard is “not high,” and the ALJ met the minimal articulation requirement by building a logical bridge between cited evidence and her findings (Biestek v. Berryhill; Warnell v. O’Malley).
With respect to “attending and completing tasks,” the ALJ acknowledged focus problems, teacher reports of serious issues, and the role of a skills coach. Crucially, the ALJ also considered that medication was helping and that the skills coach’s involvement was limited (approximately 6 hours/week at school and 2 at home), supporting a “less than marked” limitation.
With respect to “caring for yourself,” the ALJ recognized toileting accidents and regression but noted improvement over time, including with medication and physical therapy, and the differential between home and daycare settings. The ALJ permissibly relied on state-agency psychologists who specifically considered potty-training issues, supporting a “less than marked” limitation.
Although the ALJ “would have done better” to compare behaviors to a typical four-year-old explicitly, the omission did not warrant reversal given the holistic engagement with the record (Thorlton v. King).
Toileting accidents in a preschooler do not, by themselves, establish a “marked” limitation; age-sensitive standards and the regulatory recognition of developmental variability control (20 C.F.R. § 416.926a).

Detailed Analysis

Precedents Cited and Their Influence

Biestek v. Berryhill, 587 U.S. 97 (2019): Reiterated that the “substantial evidence” threshold is “not high.” The court uses Biestek to emphasize deferential review of ALJ factfinding.
Warnell v. O’Malley, 97 F.4th 1050 (7th Cir. 2024): Reinforces that ALJs need not discuss every piece of evidence; they must provide enough explanation to assess the validity of the findings. The opinion quotes Warnell’s articulation of the “logical bridge” requirement and “minimal” articulation standard, framing the measure for sufficiency.
Thorlton v. King, 127 F.4th 1078 (7th Cir. 2025): Emphasizes the prohibition on ignoring a “line of evidence” supporting disability, calls for holistic review, and—importantly—endorses affirmance despite less-than-ideal articulation where the ALJ’s decision shows engagement with favorable evidence. It also models the statement that an ALJ “would have done better” to make an explicit comparison to age norms, without making such a gap dispositive. This case is particularly impactful for child claims, where age-specific comparisons are often at issue.
L.D.R. v. Berryhill, 920 F.3d 1146 (7th Cir. 2019): Describes the stepwise child SSI framework and the court’s refusal to reweigh evidence or resolve conflicts on appeal.
Sanchez v. Barnhart, 467 F.3d 1081 (7th Cir. 2006): Restates the functional equivalence rule—extreme limitation in one domain or marked limitations in two.
Rice v. Barnhart, 384 F.3d 363 (7th Cir. 2004): Supports holistic reading of ALJ decisions; ALJs are not required to “formally tie” evidence to each domain or sub-activity, particularly where domains overlap.
Jozefyk v. Berryhill, 923 F.3d 492 (7th Cir. 2019): Establishes that the Appeals Council’s denial of review makes the ALJ’s decision final and reviewable.

Legal Reasoning and Application

1) Governing Standards

The court applied the familiar child SSI framework. The ALJ proceeded through the child-specific evaluation (20 C.F.R. § 416.924): no substantial gainful activity; severe impairments (ADHD, reactive attachment disorder, separation anxiety, constipation/encopresis, anxiety, personality disorder); no listing met (considering Listings 112.06, 112.08, 112.11); and no functional equivalence under § 416.926a.

To show functional equivalence, the claimant must demonstrate either an “extreme” limitation in one domain or “marked” limitations in two domains (20 C.F.R. § 416.926a(d)). Chrisman challenged the “less than marked” findings in two domains: (i) attending and completing tasks (§ 416.926a(h)) and (ii) caring for yourself (§ 416.926a(k)).

On review, the Seventh Circuit emphasized:

Substantial evidence review is deferential and does not permit reweighing evidence.
The ALJ must build a logical bridge but need not discuss every piece of evidence; minimal articulation suffices if meaningful review is possible.
Holistic review applies, and overlapping domains do not require mechanical tying of each fact to each sub-criterion.

2) Attending and Completing Tasks

Regulatory guideposts for preschoolers include paying attention when spoken to directly, sustaining attention in play/learning, transitioning when prompted, waiting one’s turn, and involved tasks like puzzles, dressing, and feeding (20 C.F.R. § 416.926a(h)(2)(iii)).

Evidence considered by the ALJ, as highlighted by the court:

Teacher questionnaire (May 2021) noting “very serious” problems with following instructions, transitions, taking turns, and a “very minimal” attention span; the ALJ deemed this “partially persuasive,” recognizing it did not reflect contemporaneous improvement with a skills coach and medication.
Extensive skills-coach notes: regular sessions, progress described as “some” or “good” with regressions at times; the ALJ detailed these notes across four paragraphs and considered the timing and scope of support.
Medication efficacy: Guanfacine was “helping,” a point corroborated by state-agency psychologists and treating sources; this was central to the “less than marked” conclusion.
Functional abilities: ALJ credited testimony and notes that the child could dress and feed herself—activities tied to the domain’s regulatory examples—and that she could sustain attention on preferred activities, though often requiring redirection.
Intensity of support: The skills coach’s services—about 6 hours/week at school and 2 hours/week at home—did not amount to a full-time aide or “highly structured environment” sufficient, by itself, to convert limitations into “marked.” The ALJ correctly understood the scope of support and the child’s functioning outside those hours (regular daycare, care by guardian).

Holding: Considering medication response, partial but real gains, and the limited intensity of structured support, the ALJ’s finding of a “less than marked” limitation in attending and completing tasks was supported by substantial evidence and adequately articulated.

3) Caring for Yourself

This domain captures the child’s ability to regulate emotions and meet physical needs independently (feeding, dressing, toileting, bathing) at age-appropriate levels (20 C.F.R. § 416.926a(k)(1)(i)-(ii); (k)(2)(iii)).

Evidence and reasoning:

The ALJ acknowledged frequent toileting accidents and regression from being fully potty trained, including testimony about deliberate soiling when angry, and noted counseling-center notes (including the child’s description of a “monster” telling her to “poop on [herself]”).
Medical evaluations: Pediatric and GI assessments suggested behavioral etiology; physical therapy showed improvement with successful bowel movements after about a month; medication ameliorated behaviors.
Setting-specific functioning: Crucially, pediatric records and testimony indicated fewer or no problems at daycare compared to home, indicating the limitation was not uniformly severe across settings.
Longitudinal trajectory: Records documented improvement over time, described as “some” or “good progress,” eventually “doing better going to the bathroom on her own.”
State-agency opinions: Both psychologists recognized potty-training issues but assessed limitations as “less than marked,” and the ALJ reasonably found those opinions persuasive in light of the record (20 C.F.R. § 416.913a(b)(1)).

Age-sensitivity was pivotal. Chrisman relied on cases involving much older children with daily incontinence to argue for a “marked” limitation. The Seventh Circuit distinguished those authorities, emphasizing that age is a required consideration (20 C.F.R. § 416.926a(b)), and that the regulations expressly recognize a “range of development and functioning” among children of the same age (20 C.F.R. § 416.926a(b)(1)). For a preschooler, episodic toileting accidents, particularly when improving and often absent in structured settings, do not automatically equate to a marked limitation.

The court candidly observed the ALJ “would have done better” to directly compare N.R.C.’s behaviors to age norms, but found the articulation gap harmless in context (Thorlton), given the ALJ’s engagement with the evidence, recognition of improvement, and reliance on consistent state-agency assessments.

4) Articulation, Holistic Review, and Overlapping Domains

The court reaffirmed that:

Minimal articulation is sufficient where the ALJ’s narrative enables meaningful appellate review (Warnell).
ALJs are not obliged to “formally tie” each piece of evidence to each domain criterion, especially where domains overlap (Rice; 20 C.F.R. § 416.926a(c), (f)(3)).
So long as the ALJ does not ignore an entire line of favorable evidence and grapples with the material counterpoints, the decision will be read holistically and affirmed if supported by substantial evidence (Thorlton; L.D.R.).

Impact and Practical Implications

Doctrinal Clarifications

Minimal articulation reaffirmed in child SSI: The court signals continued tolerance for succinct ALJ explanations so long as they acknowledge key favorable evidence and state clear reasons tethered to the record.
Age-sensitive analysis in “caring for yourself”: Preschools’ toileting variability is recognized; accidents and regression, without more, do not compel a “marked” finding. Explicit age-norm comparisons are best practice but not jurisdictionally mandatory if the ALJ’s reasoning is otherwise clear.
Structured supports and intensity matter: The mere presence of a skills coach is not dispositive. The frequency and duration of assistance, the child’s functioning outside the supported setting, and the effectiveness of treatment are all highly probative.
Cross-setting severity is critical: Differences between daycare/school and home functioning can be outcome-determinative in assessing both attention-related and self-care domains.
State-agency opinions remain central: Where consistent with the longitudinal record, non-examining agency psychologists’ assessments can carry persuasive weight, even amid mixed evidence and intermittent regressions.

Guidance for Future Cases

For claimants and counsel:
- Document cross-setting severity. Evidence that limitations persist across school/daycare and home strengthens a “marked” argument.
- Quantify structured supports. Demonstrate duration, frequency, and necessity of aides or coaches and whether the child can function without them.
- Address treatment response. If medication or therapy is ineffective, document objective markers of non-response. If side effects impair functioning (e.g., constipation), tie them to domain criteria.
- Use age norms. Provide developmentally anchored expert opinions comparing the child’s functioning to typical peers.
For ALJs:
- Make explicit, age-appropriate comparisons where feasible, particularly in “caring for yourself.” While not required, it fortifies the logical bridge.
- Discuss intensity and scope of structured supports, and the claimant’s functioning in unsupervised or less-structured settings.
- Explain how longitudinal improvement and treatment efficacy inform the “less than marked” conclusion.

Complex Concepts Simplified

Substantial Evidence: A deferential standard. The question is not whether the court agrees with the ALJ, but whether a reasonable mind could accept the evidence as adequate to support the conclusion; the threshold is “not high.”
Logical Bridge / Minimal Articulation: The ALJ must explain enough to connect the evidence to the findings. She need not cite every record but must address the key points, including significant contrary evidence.
Functional Equivalence: In lieu of meeting a listed impairment, a child can be found disabled if functioning is severely limited—either “extreme” in one domain or “marked” in two of the six domains (20 C.F.R. § 416.926a(d)).
Domains:
- Attending and Completing Tasks (§ 416.926a(h)): Focus, persistence, transitions, following directions, and task completion at age-appropriate levels.
- Caring for Yourself (§ 416.926a(k)): Emotional regulation and independent management of physical needs (feeding, dressing, toileting, bathing) appropriate to age.
Marked vs. Extreme:
- Marked: More than moderate but less than extreme; seriously interferes with functioning.
- Extreme: Very serious interference; the highest level of limitation.
Age-Sensitive Assessment: Children develop at different rates; the regulations require considering the child’s age and recognize variability in what children of the same age can consistently do (20 C.F.R. § 416.926a(b)(1)).
Structured Setting/Supports: The type, frequency, and duration of supports (e.g., skills coaching) help gauge how independently the child can function; limited part-time support is different from a near-constant aide.

Conclusion

Chrisman v. Bisignano reinforces three important points in child SSI adjudications: (1) the ALJ’s burden to explain is modest—minimal articulation, read holistically, suffices if the record shows the ALJ grappled with material favorable evidence; (2) age matters—preschool toileting regressions and behavioral outbursts do not automatically amount to “marked” limitations in caring for oneself; and (3) the scope and effectiveness of structured support and treatment can tip the scale—documented improvement with medication and part-time skills-coach support supported “less than marked” findings in attending/completing tasks and caring for self.

While the court encouraged more explicit age-norm comparisons, it declined to impose a rigid articulation requirement. Going forward, claimants should marshal cross-setting evidence, quantify the intensity of supports, and address treatment response to meet the demanding “marked” threshold. ALJs, for their part, should continue to synthesize teacher reports, therapy notes, agency opinions, and longitudinal outcomes into a concise narrative that shows engagement with the entire record. The decision thus offers pragmatic guidance: in child SSI cases, developmentally tailored analysis and careful attention to the intensity and efficacy of supports are the fulcrum on which functional-equivalence findings will turn.