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Gatti v. Colvin

United States District Court, N.D. Illinois, Western Division

September 2, 2016

Alene Gatti, o/b/o A. G-F., a minor Plaintiff,
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.


          Iain D. Johnston, United States Magistrate Judge.

         Alene Gatti (the “mother”), on behalf of her minor daughter (“plaintiff”), brings this action under 42 U.S.C. §405(g), challenging the denial of social security disability benefits to plaintiff. For the reasons explained below, the decision is affirmed.


         Plaintiff was born on December 6, 2012. R. 19. The pregnancy was complicated due to the mother's increased blood pressure and medications she was taking for bipolar disorder and diabetes. After birth, plaintiff was placed in the intensive care unit because of feeding difficulties and remained there for 24 days. R. 259. Less than a year later, on October 25, 2013, the mother filed an application for supplemental security income on plaintiff's behalf. Since her birth, plaintiff has been seen by a number of treating doctors, as well as agency consultants.

         Relevant to this appeal, in the fall of 2013, plaintiff's doctors at the Crusader Clinic referred her to Dr. Carl E. Stafstrom for a neurology consultation. He worked at the University of Wisconsin and saw plaintiff twice, once in September and November, and then submitted a report (Ex. 5F) upon which the ALJ relied heavily. Given this fact and also because the report provides a helpful summary, the Court will quote from it at length:

At the last visit, we suggested that [plaintiff] might benefit from physical therapy. However, mom states that [plaintiff] was evaluated 3 times by Birth to 3, and all 3 times [plaintiff] did not qualify for services. Mom has attempted to get Social Security for [plaintiff], but she has been denied. She is wondering if there is anything that we have to offer her to help get Social Security approved or what kind of therapies would be beneficial for [plaintiff].
Developmentally, [plaintiff] has made wonderful progress. She is crawling well. She can pull to stand, which she started doing around 10 months of age. She does occasionally cruise, holding on to furniture. She has not yet taken any steps on her own, though she will walk while holding onto someone's hands. She does reach for objects and continues to bring lots of objects to her mouth. She babbles frequently and grandpa states that he occasionally thinks she may be saying grandpa or bye. She appears to recognize faces and voices well.
Overall, [plaintiff] has been very healthy, without any significant illnesses. Mom is concerned that [plaintiff] may have asthma. [Plaintiff's] appetite is good and she continues to grow well and track along her growth curve. She has some constipation, which has improved with a stool softener. She also has intermittent abdominal pain. She is currently drinking whole milk and taking table foods. [Plaintiff] sleeps well at night, although there are some nights where she will wake 2-3 times per night. When she wakes up, she either wants to eat or just wants to be held. A complete review of systems was performed and is otherwise negative except as noted above.
* * *
ASSESSMENT AND RECOMMENDATIONS: [Plaintiff] is a beautiful and social 11-month-old girl with mildly decreased truncal tone and mildly increased lower extremity tone, consistent with a diagnosis of very mild cerebral palsy. She appears to be developing very nicely, and we think she will continue to reach milestones appropriately. However, we do believe she would benefit from physical therapy to help with her differences in tone. It would be reasonable for mom to attempt another evaluation by Birth to 3, to see if [plaintiff] qualifies for services, although we do feel as though [plaintiff] will likely do well even without physical therapy. Her head flailing and arm stiffening movements are not likely to be seizures. She has had a normal EEG and MRI in the past. The description of her movements seems very consistent with a mildly exaggerated startle response. We do not believe that [plaintiff] needs any further testing at this time; Grandpa agrees that [plaintiff] is an essentially normal child. The family will keep in touch with us, if any further concerns arise. No set followup was scheduled, but we would be happy to see [plaintiff] in followup, if new concerns arise.

R. 250-251.

         On November 6, 2013, an agency doctor, Victoria Dow, issued a report. Ex. 4A. It does not appear that she examined plaintiff. Her report was prepared after plaintiff's first visit to Dr. Stafstrom but before the second visit. Dr. Dow found that plaintiff only had marked limitations in one domain, which was the sixth domain for health and physical well-being. Her conclusions seem to rest solely on notes from plaintiff's first visit to Dr. Stafstrom. Here is her analysis, which was set forth in two places and which seems to be mostly a regurgitation of Dr. Stafstrom's notes:


U of W
9/20/13 Initial Pediatric Neurology Consult normal MRI of the brain; no developmental regression; rolled over at 7 months, sat up unassisted at 8 months and currently crawling; weight 13 lbs, less than 3rd%; cognitively bright and ...

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