Supplemental Security Income
Preliminary Observations on Children with Mental Impairments Gao ID: GAO-12-196T October 27, 2011In Process
The numbers of children applying for and receiving SSI benefits due to a mental impairment has increased over the past decade and now comprise a growing majority of all child beneficiaries. While more than half of child applicants are denied each year, children with mental impairments, such as autism, have represented a growing share of those medically allowed for benefits--increasing from 60 to 67 percent between fiscal years 2000 and 2010. Factors including but not limited to the rising number of children living in poverty and increased diagnosis of certain mental impairments may have contributed to such growth. However, the relative effects of these and other factors on program growth are not fully known at this time. Generally, DDS officials reported that they rely on a combination of key medical and nonmedical information--such as medical records and teacher and parent assessments--in determining a child's medical eligibility and that they consider the totality of information related to the child's impairments, rather than one piece of information in isolation. For example, SSA and DDS officials said that they consider a child's use of prescribed medications in the context of other information including school records and teacher assessments, which are critical in evaluating the child's functioning over time. Yet, despite the importance of such nonmedical evidence, GAO's work shows that examiners sometimes face challenges in obtaining this information partly due to teachers' reluctance to complete the assessments. SSA is required to periodically review the medical eligibility of certain children receiving SSI benefits, but GAO's work shows that SSA has conducted significantly fewer childhood continuing disability reviews (CDR) in recent years. Between fiscal years 2000 and 2010, the number of childhood CDRs and age 18 reviews overall fell from more than 200,000 to about 126,000 (a 38 percent decrease), while childhood CDRs for those with mental impairments dropped from more than 84,000 to about 13,000 (an 84 percent decrease). SSA officials have acknowledged that the agency is not conducting childhood CDRs in a timely manner mostly due to resource constraints. However, SSA recognizes the importance of conducting CDRs and has recently estimated that the CDR process yields a savings-to-cost ratio of $12.50 to $1.
GAO-12-196T, Supplemental Security Income: Preliminary Observations on Children with Mental Impairments
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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Human Resources, Committee on Ways and
Means, House of Representatives:
For Release on Delivery:
Expected at 9:00 a.m. EDT:
Thursday, October 27, 2011:
Supplemental Security Income:
Preliminary Observations on Children with Mental Impairments:
Statement of Daniel Bertoni, Director: Education, Workforce, and
Income Security:
GAO-12-196T:
GAO Highlights:
Highlights of GAO-12-196T, testimony before the Subcommittee on Human
Resources, Committee on Ways and Means, House of Representatives.
Why GAO Prepared This Testimony:
The Social Security Administration‘s (SSA) Supplemental Security
Income (SSI) program provides cash benefits to eligible low-income
disabled individuals, including children, as well as certain others.
Children may generally qualify for SSI benefits if they meet certain
financial requirements and are deemed to have a qualifying medically
determinable physical or mental impairment of a specified duration or
severity that results in a functional limitation. In 2010, SSA paid
more than $9 billion to about 1.2 million disabled children. Over the
past decade, the overall number of children receiving SSI benefits has
continued to rise.
In this statement, GAO discusses initial observations from its ongoing
review and examines (1) the trends in the rate of children receiving
SSI benefits due to mental impairments over the past decade; (2) the
role that medical and nonmedical information, such as medication and
school records, play in the initial determination of a child‘s medical
eligibility; and (3) the steps SSA has taken to monitor the continued
medical eligibility of these children. To examine these issues, GAO
analyzed program data, interviewed SSA officials, conducted site
visits to SSA field offices and state disability determination
services (DDS) offices, and interviewed external experts. This work is
ongoing and GAO has no recommendations at this time. GAO plans to
issue its final report in April 2012.
What GAO Found:
The numbers of children applying for and receiving SSI benefits due to
a mental impairment has increased over the past decade and now
comprise a growing majority of all child beneficiaries. While more
than half of child applicants are denied each year, children with
mental impairments, such as autism, have represented a growing share
of those medically allowed for benefits”-increasing from 60 to 67
percent between fiscal years 2000 and 2010. Factors including but not
limited to the rising number of children living in poverty and
increased diagnosis of certain mental impairments may have contributed
to such growth. However, the relative effects of these and other
factors on program growth are not fully known at this time.
Figure: Number of Children under Age 18 Receiving Federally
Administered SSI Payments, by Mental and Physical Impairment Group,
December 2000–December 2010:
[Refer to PDF for image: stacked line graph]
Year: 2000;
Physical: 0.27 million;
Mental: 0.54 million;
Total: 0.81 million.
Year: 2001;
Physical: 0.28 million;
Mental: 0.57 million;
Total: 0.85 million.
Year: 2002;
Physical: 0.30 million;
Mental: 0.58 million;
Total: 0.88 million.
Year: 2003;
Physical: 0.31 million;
Mental: 0.61 million;
Total: 0.92 million.
Year: 2004;
Physical: 0.31 million;
Mental: 0.65 million;
Total: 0.96 million.
Year: 2005;
Physical: 0.32 million;
Mental: 0.69 million;
Total: 1.01 million.
Year: 2006;
Physical: 0.34 million;
Mental: 0.72 million;
Total: 1.06 million.
Year: 2007;
Physical: 0.35 million;
Mental: 0.74 million;
Total: 1.09 million.
Year: 2008;
Physical: 0.37 million;
Mental: 0.76 million;
Total: 1.13 million.
Year: 2009;
Physical: 0.38 million;
Mental: 0.79 million;
Total: 1.17 million.
Year: 2010;
Physical: 0.39 million;
Mental: 0.83 million;
Total: 1.22 million.
Source: GAO analysis of SSA data form the Supplemental Security Record.
[End of figure]
Generally, DDS officials reported that they rely on a combination of
key medical and nonmedical information”such as medical records and
teacher and parent assessments”in determining a child‘s medical
eligibility and that they consider the totality of information related
to the child‘s impairments, rather than one piece of information in
isolation. For example, SSA and DDS officials said that they consider
a child‘s use of prescribed medications in the context of other
information including school records and teacher assessments, which
are critical in evaluating the child‘s functioning over time. Yet,
despite the importance of such nonmedical evidence, GAO‘s work shows
that examiners sometimes face challenges in obtaining this information
partly due to teachers‘ reluctance to complete the assessments.
SSA is required to periodically review the medical eligibility of
certain children receiving SSI benefits, but GAO‘s work shows that SSA
has conducted significantly fewer childhood continuing disability
reviews (CDR) in recent years. Between fiscal years 2000 and 2010, the
number of childhood CDRs and age 18 reviews overall fell from more
than 200,000 to about 126,000 (a 38 percent decrease), while childhood
CDRs for those with mental impairments dropped from more than 84,000
to about 13,000 (an 84 percent decrease). SSA officials have
acknowledged that the agency is not conducting childhood CDRs in a
timely manner mostly due to resource constraints. However, SSA
recognizes the importance of conducting CDRs and has recently
estimated that the CDR process yields a savings-to-cost ratio of
$12.50 to $1.
View [hyperlink, http://www.gao.gov/products/GAO-12-196T]. For more
information, contact Daniel Bertoni at (202) 512-7215 or
bertonid@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss our preliminary observations
on children with mental impairments in the Supplemental Security
Income (SSI) program. Administered by the Social Security
Administration (SSA), SSI is a nationwide federal assistance program
that provides cash benefits to eligible low-income disabled
individuals, including children, as well as certain individuals who
are aged or blind. In 2010, SSA paid almost 8 million recipients about
$50 billion in SSI benefits, of which more than $9 billion was paid to
about 1.2 million disabled children. During the early and mid 1990s,
the SSI program experienced a period of unprecedented growth for
children due, in part, to legal developments that expanded program
eligibility for children with mental impairments. For example, from
the end of 1989 through 1996, the number of children receiving SSI
benefits more than tripled from 265,000 to about 955,000. Since that
time, the number of children receiving SSI benefits has continued to
rise, especially for those with mental impairments. Our prior work has
shown that accurately diagnosing some types of mental impairments is a
complex and often subjective process for SSA, which can sometimes be
vulnerable to fraud and abuse.
My statement today focuses on initial observations from our ongoing
review and examines (1) the trends in the rate of children receiving
SSI benefits due to mental impairments over the past decade; (2) the
role that medical and nonmedical information, such as medication and
school records, play in the initial determination of a child's medical
eligibility; and (3) the steps SSA has taken to monitor the continued
medical eligibility of these children. To examine these issues, we
collected agency data on the overall number of initial disability
determinations and allowances, the number and types of mental
impairments, and the number of continuing disability reviews of
children conducted by SSA. We assessed the reliability of the data
presented in this statement and found potential limitations with the
extent to which primary and secondary impairment codes within SSA's
831 disability files--the file that contains data on disability
determinations--may be complete. However, because the 831 disability
files are used by SSA to reflect the decisions made regarding medical
determinations, we determined that these data were sufficiently
reliable to describe certain trends among children in the SSI program.
In our ongoing work, we will conduct a case file review of a random,
generalizable sample of select SSI child mental impairments cases
decided in fiscal year 2010, which will potentially assist us in
better understanding the extent of this limitation. We also conducted
in-depth interviews with SSA management and line staff at SSA
headquarters and six SSA regions--Philadelphia, Pennsylvania; Boston,
Massachusetts; Atlanta, Georgia; Dallas, Texas; Chicago, Illinois; and
San Francisco, California. Our work included site visits to 9 field
offices within these regions, as well as 11 state disability
determination services (DDS) offices (state agencies under the
direction of SSA that perform medical eligibility determinations and
continuing disability reviews of SSI applicants). We selected these
sites on the basis of their geographic location, as well as the volume
of SSI applications and benefit allowances for children with mental
impairments. In addition, we interviewed numerous external experts
from the medical and disability advocacy communities and reviewed
relevant federal laws and regulations. We plan to issue our final
report in April 2012 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained will provide a
reasonable basis for our findings and conclusions based on our audit
objectives.
Background:
Since 1974, the SSI program, under Title XVI of the Social Security
Act, as amended,[Footnote 1] has provided benefits to low-income blind
and disabled persons, including adults and children[Footnote 2] as
well as certain aged individuals who meet financial eligibility
requirements and SSA's definition of disability. For children, a
disability is a medically determinable physical or mental impairment
that results in certain functional limitations, and is expected to
result in death or which has lasted or can be expected to last for a
continuous period of at least 12 months.[Footnote 3] Families of
children receiving SSI payments are generally required to use the
benefit to meet a child's current and future needs, including food,
clothing, and shelter.[Footnote 4] The maximum payment for a child
receiving SSI benefits is $674 per month regardless of the severity of
the child's impairment.[Footnote 5] As of December 2010, the average
monthly child benefit was $597.
To apply for benefits, the child's parent or guardian usually submits
an application to SSA either in person at a local SSA field office, by
telephone, or by mail. SSA's field offices are responsible for
processing these applications and for verifying the child's and legal
guardian's nonmedical eligibility requirements, including income,
resources, and living arrangement information. After initial
verification, the field office transmits the case file to their state
disability determination services office for a medical evaluation.
[Footnote 6] To aid in evaluating whether a child is medically
eligible, DDS offices review various medical and nonmedical
information about the child, such as physician notes, psychological
tests, school records, and teacher assessments.[Footnote 7] In certain
situations, such as when the evidence is not sufficient to support a
decision as to whether a child is disabled, the DDS may purchase a
consultative examination to assist in making the decision.[Footnote 8]
If there is evidence that indicates the existence of a mental
impairment, DDS makes every reasonable effort to ensure that a
qualified psychiatrist or psychologist has completed the medical
portion of the case review.[Footnote 9]
After it makes its initial determination, the DDS returns the case
file to the field office, where SSA completes any outstanding non-
disability case development, computes the benefit amount, and begins
paying benefits if the claimant was determined disabled. If the claim
is denied, a claimant has 60 days to request that SSA reconsider its
decision. If the claimant is dissatisfied with the reconsideration, he
or she may request a hearing before an administrative law judge, whose
decision may then be reviewed by SSA's Appeals Council. When these
administrative review options have been exhausted, the claimant may
request judicial review by filing an action in a federal district
court.[Footnote 10]
After SSA determines that a child is disabled, the agency is required
by law, in certain circumstances, to conduct periodic reviews, known
as a continuing disability review (CDR), to verify a child's continued
medical eligibility for receiving SSI benefits.[Footnote 11] SSA is
generally required to perform CDRs (1) during the first year after
birth for babies whose low birth weight is a contributing factor to
the determination of disability[Footnote 12] and (2) at least once
every 3 years for all other children under age 18 whose conditions are
considered likely to improve.[Footnote 13] DDS offices determine when
beneficiaries will be due for CDRs on the basis of their potential for
medical improvement, and select and schedule a review date--otherwise
known as a "diary date"--for each beneficiary's CDR. At the time of
these reviews, the child's representative payee generally must present
evidence that the child is and has been receiving medically necessary
and available treatment for his or her impairment. SSA is also
required to redetermine the eligibility of children against the adult
criteria[Footnote 14] for disability after they reach age 18.[Footnote
15]
Number of Children Applying for and Receiving SSI Benefits Due to
Mental Impairments Has Increased:
The numbers of children applying for and receiving SSI benefits due to
a mental impairment has increased over the past decade and now
comprise a growing majority of all child beneficiaries. While not all
such children who are deemed medically eligible ultimately meet SSI's
financial eligibility requirements,[Footnote 16] our preliminary
analysis of medical allowances suggests that the growth in the number
of child beneficiaries is roughly proportionate to the growth in the
number of applicants. Furthermore, SSA data showed that the agency has
denied a majority of child applicants each year.[Footnote 17] Between
fiscal years 2000 and 2010, the average medical allowance rates for
children with physical and mental impairments were about 37 and 46
percent, respectively (see figure 1).
Figure 1: SSI Applications and Allowances for Children under Age 18,
by Mental and Physical Impairment Group, Fiscal Years 2000-2010:
[Refer to PDF for image: 2 stacked line graphs]
Physical:
Year: 2000;
Applications: 145,350;
Allowances: 55,270 (38%).
Year: 2001;
Applications: 146,010;
Allowances: 56,720.
Year: 2002;
Applications: 151,540;
Allowances: 55,680.
Year: 2003;
Applications: 158,440;
Allowances: 57,960.
Year: 2004;
Applications: 160,540;
Allowances: 58,650.
Year: 2005;
Applications: 160,040;
Allowances: 58,430 (37%).
Year: 2006;
Applications: 158,730;
Allowances: 57,710.
Year: 2007;
Applications: 161,960;
Allowances: 58,600.
Year: 2008;
Applications: 162,690;
Allowances: 61,240.
Year: 2009;
Applications: 169,040;
Allowances: 64,200.
Year: 2010;
Applications: 179,350;
Allowances: 64,820 (36%).
Mental:
Year: 2000;
Applications: 187,050;
Allowances: 81,330 (43%).
Year: 2001;
Applications: 194,610;
Allowances: 92,540.
Year: 2002;
Applications: 217,390;
Allowances: 104,470.
Year: 2003;
Applications: 244,790;
Allowances: 117,700.
Year: 2004;
Applications: 255,350;
Allowances: 120,600.
Year: 2005;
Applications: 254,920;
Allowances: 117,540 (46%).
Year: 2006;
Applications: 242,410;
Allowances: 109,810.
Year: 2007;
Applications: 241,200;
Allowances: 106,350.
Year: 2008;
Applications: 250,080;
Allowances: 113,400.
Year: 2009;
Applications: 267,600;
Allowances: 123,670.
Year: 2010;
Applications: 298,260;
Allowances: 132,030 (44%).
Source: GAO analysis of SSA data from the 831 Disability Files.
Note: The information highlighted in this figure is based on the
primary impairment code recorded in the disability determination. Data
represented as "applications" reflect SSI benefit claims were an
initial disability determination was made each year. Some claims may
have more than one determination if selected for a quality review or
if the disability claim is updated during the same year. Such
determinations are reflected in the data presented above.
[End of figure]
SSA data show the number of child applicants with mental impairments
increased 60 percent between fiscal year 2000 and fiscal year 2010,
from 187,052 to 298,264, while the total number of SSI child
beneficiaries with mental impairments on the rolls grew 52 percent
from 543,000 to 827,000 (see figure 2).[Footnote 18] Our preliminary
research suggests that several factors may have contributed to the
increased number of child applicants and beneficiaries, including but
not limited to SSA's and child advocates' outreach efforts, improved
access to health insurance for children, the rising number of children
living in poverty, and increased diagnosis of certain mental
impairments. However, the relative effects of these and other factors
on program growth are not fully known at this time.
Figure 2: Number of Children under age 18 Receiving Federally
Administered SSI Payments, by Mental and Physical Impairment Group,
Dec. 2000-Dec. 2010:
[Refer to PDF for image: stacked line graph]
Year: 2000;
Physical: 0.27 million;
Mental: 0.54 million;
Total: 0.81 million.
Year: 2001;
Physical: 0.28 million;
Mental: 0.57 million;
Total: 0.85 million.
Year: 2002;
Physical: 0.30 million;
Mental: 0.58 million;
Total: 0.88 million.
Year: 2003;
Physical: 0.31 million;
Mental: 0.61 million;
Total: 0.92 million.
Year: 2004;
Physical: 0.31 million;
Mental: 0.65 million;
Total: 0.96 million.
Year: 2005;
Physical: 0.32 million;
Mental: 0.69 million;
Total: 1.01 million.
Year: 2006;
Physical: 0.34 million;
Mental: 0.72 million;
Total: 1.06 million.
Year: 2007;
Physical: 0.35 million;
Mental: 0.74 million;
Total: 1.09 million.
Year: 2008;
Physical: 0.37 million;
Mental: 0.76 million;
Total: 1.13 million.
Year: 2009;
Physical: 0.38 million;
Mental: 0.79 million;
Total: 1.17 million.
Year: 2010;
Physical: 0.39 million;
Mental: 0.83 million;
Total: 1.22 million.
Source: GAO analysis of SSA data form the Supplemental Security Record.
Note: The above figure does not include those diagnostic groups that
SSA reported as "unknown." SSA data showed that as of December 2000,
"unknowns' totaled 33,042 children (0.04 percent), and as of December
2010, 26,417 children (0.02 percent).
[End of figure]
While it is unclear how various factors are contributing to growth at
this time, SSA data show that since fiscal year 2000, children with
mental impairments have represented the majority of all child
applications and medical allowances for SSI benefits. For example, in
fiscal year 2010, about 62 percent of all SSI child applicants had a
mental impairment as a primary diagnosis, and about 67 percent of
those applicants were medically approved for benefits. For those
applicant children with mental impairments, SSA data also suggests
that the number of children found medically eligible for benefits has
increased for almost every mental impairment category--such as speech
and language delay and mood disorders--between fiscal years 2000 and
2010, with the exception of intellectual disability as most notable
(see figure 3).[Footnote 19]
Figure 3: Medical Allowances for SSI Children with Mental Impairments,
by Primary Impairment, Fiscal Year 2000-2010:
[Refer to PDF for image: multiple line graph]
Year: 2000;
Conduct/Oppositional Defiant/Personality disorders: 3,840;
Mental disorders: 5,050;
Autistic Disorder and other pervasive development disorders: 5,090;
Speech and language delays: 11,570;
ADD/ADHD Disorder: 13,860;
Intellectual disability: 26,370;
Other[A]: 15,550.
Year: 2001;
Conduct/Oppositional Defiant/Personality disorders: 4,900;
Mental disorders: 6,220;
Autistic Disorder and other pervasive development disorders: 6,590;
Speech and language delays: 13,360;
ADD/ADHD Disorder: 18,120;
Intellectual disability: 26,670;
Other[A]: 16,680.
Year: 2002;
Conduct/Oppositional Defiant/Personality disorders: 5,730;
Mental disorders: 7,490;
Autistic Disorder and other pervasive development disorders: 7,790;
Speech and language delays: 16,410;
ADD/ADHD Disorder: 21,560;
Intellectual disability: 27,180;
Other[A]: 18,330.
Year: 2003;
Conduct/Oppositional Defiant/Personality disorders: 6,210;
Mental disorders: 8,630;
Autistic Disorder and other pervasive development disorders: 9,010;
Speech and language delays: 19,810;
ADD/ADHD Disorder: 26,160;
Intellectual disability: 27,560;
Other[A]: 20,320.
Year: 2004;
Conduct/Oppositional Defiant/Personality disorders: 6,210;
Mental disorders: 9,680;
Autistic Disorder and other pervasive development disorders: 9,760;
Speech and language delays: 21,340;
ADD/ADHD Disorder: 28,740;
Intellectual disability: 24,600;
Other[A]: 20,270.
Year: 2005;
Conduct/Oppositional Defiant/Personality disorders: 5,800;
Mental disorders: 10,630;
Autistic Disorder and other pervasive development disorders: 9,840;
Speech and language delays: 21,610;
ADD/ADHD Disorder: 28,030;
Intellectual disability: 22,240;
Other[A]: 19,400.
Year: 2006;
Conduct/Oppositional Defiant/Personality disorders: 5,380;
Mental disorders: 11,610;
Autistic Disorder and other pervasive development disorders: 9,080;
Speech and language delays: 20,910;
ADD/ADHD Disorder: 25,960;
Intellectual disability: 19,160;
Other[A]: 17,720.
Year: 2007;
Conduct/Oppositional Defiant/Personality disorders: 5,17;
Mental disorders: 12,93;
Autistic Disorder and other pervasive development disorders: 8,91;
Speech and language delays: 21,14;
ADD/ADHD Disorder: 24,63;
Intellectual disability: 17,15;
Other[A]: 16,430.
Year: 2008;
Conduct/Oppositional Defiant/Personality disorders: 5,250;
Mental disorders: 15,810;
Autistic Disorder and other pervasive development disorders: 9,200;
Speech and language delays: 22,950;
ADD/ADHD Disorder: 26,310;
Intellectual disability: 17,180;
Other[A]: 16,700.
Year: 2009;
Conduct/Oppositional Defiant/Personality disorders: 5,550;
Mental disorders: 18,230;
Autistic Disorder and other pervasive development disorders: 9,870;
Speech and language delays: 26,840;
ADD/ADHD Disorder: 27,670;
Intellectual disability: 17,830;
Other[A]: 17,680.
Year: 2010;
Conduct/Oppositional Defiant/Personality disorders: 5,790;
Mental disorders: 20,320;
Autistic Disorder and other pervasive development disorders: 10,590;
Speech and language delays: 29,150;
ADD/ADHD Disorder: 30,110;
Intellectual disability: 17,680;
Other[A]: 18,390.
Source: GAO analysis of SSA data from the 831 Disability Files.
Note: The information highlighted in this figure is based on the
primary impairment code recorded in the disability determination.
[A] The "other" category includes borderline intellectual functioning;
learning disorders; developmental and emotional disorders in newborns
and younger infants; psychoactive substance dependence disorder;
somatoform disorders/eating and tic disorders; anxiety disorders;
schizophrenic, delusional, schizoaffective and other psychotic
disorders; and organic mental disorders.
[End of figure]
As part of our preliminary work, we examined individual mental
impairments to determine which impairments had the highest number of
applications and medical allowances. SSA's data on disability
determinations is based on the primary impairment as designated by the
DDS.[Footnote 20] SSA's policy operations manual directs DDS examiners
to code the primary impairment as the most severe condition that
rendered the child disabled. In instances where multiple impairments
are present, the secondary impairment is generally the next most
severe following the primary. However, SSA officials have acknowledged
that primary impairment codes are sometimes missing or inaccurately
coded.[Footnote 21] In addition, the primary impairment code listed
may be only one of several impairments that led DDS examiners to find
the child medically eligible for benefits. In our ongoing review, we
plan to conduct an in-depth case file review to determine the extent
to which a secondary impairment was present for the most prevalent
impairments and the extent to which the secondary impairment, or
combination of impairments, influenced the eligibility decision. SSA
data show that for fiscal year 2010, the three most prevalent primary
mental impairments among medical allowances were for (1) attention
deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD),
(2) speech and language delay, and (3) autistic disorder and other
pervasive development disorders (autism). The following information
provides a brief summary of each of these three impairments as they
compare to the incidence of all mental impairments, as well as in
terms of the proportion of applications and medical allowances:
ADD/ADHD. Between fiscal years 2000 to 2010, applications for this
condition as a primary impairment more than doubled, from about 55,000
to 113,000. Also, the number of children found to be medically
eligible increased by more than 100 percent, from 13,857 to 30,108
(see figure 4). By December 2010, about 212,000 such children were
receiving SSI benefits, and they comprised 26 percent of child
recipients with mental impairments.
Figure 4: Applications and Medical Allowances for Children with
Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder as
a Primary Impairment, Fiscal Year 2000-2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2000;
Allowances: 13,857 (25%);
Applications: 41,347.
Year: 2001;
Allowances: 18,124 (32%);
Applications: 39,267.
Year: 2002;
Allowances: 21,558 (33%);
Applications: 44,509.
Year: 2003;
Allowances: 26,162 (33%);
Applications: 53,268.
Year: 2004;
Allowances: 28,739 (32%);
Applications: 60,176.
Year: 2005;
Allowances: 28,026 (31%);
Applications: 62,865.
Year: 2006;
Allowances: 25,959 (30%);
Applications: 61,808.
Year: 2007;
Allowances: 24,632 (28%);
Applications: 63,607.
Year: 2008;
Allowances: 26,305 (28%);
Applications: 66,568.
Year: 2009;
Allowances: 27,669 (28%);
Applications: 71,824.
Year: 2010;
Allowances: 30,108 (27%);
Applications: 83,338.
Source: GAO analysis of SSA data from the 831 Disability Files.
Note: The information highlighted in this figure is based on the
primary impairment code recorded in the disability determination. Data
represented as "applications" reflect SSI benefit claims where an
initial disability determination was made within each year.
[End of figure]
While children with ADD/ADHD represent the single largest primary
diagnostic group, SSA data show that the majority of ADD/ADHD
applications over the years have been medically denied. Some of the
examiners we interviewed said that they rarely find a child medically
eligible for benefits solely on the basis of an ADD/ADHD impairment
alone, but more commonly in combination with another impairment, such
as asthma or oppositional defiant disorder. Nevertheless, SSA
officials suggested that the increase in both applications and medical
allowances for children with ADD/ADHD might be attributable to an
increase in diagnosis over the last decade, and cited a National
Institute of Health survey finding that ADHD diagnoses had increased,
on average, by 3 percent from 1996 to 2006 and by 5.5 percent, on
average, from 2003 to 2007.[Footnote 22] SSA officials also noted a
2008 medical study reporting that ADHD is one of the most commonly
diagnosed childhood neurobehavioral disorders.[Footnote 23]
Speech and language delay. During the last decade, both applications
and medical allowances for children with speech and language delay
have increased overall, but the proportion of applicants found
medically eligible has remained relatively stable over time. Between
fiscal years 2000 to 2010, applications for this impairment more than
doubled, from 21,615 to 49,664 while the number of children found to
be medically eligible nearly tripled, from 11,565 to 29,147 (see
figure 5). As of December 2010, about 174,000 (21 percent) children
with mental impairments were receiving benefits due to a speech and
language delay. While some DDS officials expressed the view that
increases could be attributed to increased school testing and
screening programs, SSA officials said further study was needed to
better understand these particular increases.
Figure 5: Applications and Medical Allowances for Children with Speech
and Language Delay as Primary Impairment, Fiscal Year 2000-2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2000;
Allowances: 11,565 (54);
Applications: 10,050.
Year: 2001;
Allowances: 13,358 (56%);
Applications: 10,386.
Year: 2002;
Allowances: 16,407 (58%);
Applications: 11,753.
Year: 2003;
Allowances: 19,812 (60%);
Applications: 13,279.
Year: 2004;
Allowances: 21,342 (60%);
Applications: 14,251.
Year: 2005;
Allowances: 21,613 (59%);
Applications: 14,900.
Year: 2006;
Allowances: 20,905 (59%);
Applications: 14,709.
Year: 2007;
Allowances: 21,137 (58%);
Applications: 15,018.
Year: 2008;
Allowances: 22,946 (59%);
Applications: 15,914.
Year: 2009;
Allowances: 26,841 (61%);
Applications: 17,050.
Year: 2010;
Allowances: 29,147 (59%);
Applications: 20,517.
Source: GAO analysis of SSA data from the 831 Disability Files.
Note: The information highlighted in this figure is based on the
primary impairment code recorded in the disability determination. Data
represented as "applications" reflect SSI benefit claims where an
initial disability determination was made within each year.
[End of figure]
Autism. Between fiscal years 2000 and 2010, autism applications more
than quadrupled from 5,430 to 23,203, and medical allowances increased
similarly from 5,050 to 20,319 (see figure 6). As of December 2010,
about 95,000 (11 percent) children with mental impairments were
receiving SSI benefits due to autism. DDS examiners have generally
found the vast majority of those children applying for SSI on the
basis of autism medically eligible for benefits. SSA officials
attributed the increase in the number of autism applications and
medical allowances over the years to greater incidence of autism among
children and explained that some children who may have previously been
diagnosed as intellectually disabled are instead being diagnosed as
autistic. According to one study SSA cited, the prevalence of autism
in children has increased from 0.6 per 1,000 live births in 1994 to
3.1 per 1,000 live births in 2003, while the prevalence of
intellectual disability decreased by 2.8 per 1,000 live births in 2003
[Footnote 24].
Figure 6: Applications and Medical Allowances for Children with Autism
as a Primary Impairment, Fiscal Year 2000-2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2000;
Allowances: 5,050 (93%);
Applications: 0,380.
Year: 2001;
Allowances: 6,220 (94%);
Applications: 0,370.
Year: 2002;
Allowances: 7,490 (94%);
Applications: 0,490.
Year: 2003;
Allowances: 8,630 (93%);
Applications: 0,640.
Year: 2004;
Allowances: 9,680 (92%);
Applications: 0,810.
Year: 2005;
Allowances: 10,630 (92%);
Applications: 0,890.
Year: 2006;
Allowances: 11,610 (92%);
Applications: 1,070.
Year: 2007;
Allowances: 12,930 (90%);
Applications: 1,420.
Year: 2008;
Allowances: 15,810 (90%);
Applications: 1,670.
Year: 2009;
Allowances: 18,230 (90%);
Applications: 2,130.
Year: 2010;
Allowances: 20,320 (88%);
Applications: 2,880.
Source: GAO analysis of SSA data from the 831 Disability Files.
Note: The information highlighted in this figure is based on the
primary impairment code recorded in the disability determination. Data
represented as "applications" reflect SSI benefit claims where an
initial disability determination was made within each year.
[End of figure]
Examiners Report Using a Combination of Key Information Sources in
Determining Medical Eligibility:
In our preliminary work, DDS officials reported that they rely on a
combination of key medical and nonmedical information--such as medical
records, prescribed medications, school records, and teacher and
parent assessments--in determining a child's medical eligibility.
[Footnote 25] Several DDS officials said that when making a
determination, they consider the totality of information related to
the child's impairments, rather than one piece of information in
isolation.[Footnote 26] With regard to the medical information used by
examiners, SSA generally requires DDS examiners to assist children and
their parents or guardians in obtaining medical records in an effort
to develop at least a 1-year-long medical history prior to applying
for benefits.[Footnote 27] According to many of the DDS officials we
interviewed, examiners attempt to obtain medical evidence, such as
psychological tests, physician's notes, and mental health records, for
children with alleged mental impairments. If such evidence is not
available or existing evidence is inconclusive, some DDS officials we
spoke with said that they will purchase a consultative examination for
the child. This examination is intended to provide the additional
medical evidence, such as results of a physical examination and
laboratory findings, needed for a determination. However, many DDS
officials told us that such examinations are only a "snap-shot" in
time and do not provide a longitudinal view of the child's functioning
over time. For this reason, some DDS officials said that information
from a treating source with a long-standing relationship with the
child, such as a physician, is more useful.
In response to concerns among many about the role medication plays in
the determination process, we asked SSA and DDS officials how
information about a child's use of prescribed medications is used, and
they told us it is generally given no more weight than any other
medical or nonmedical information in determining a child's medical
eligibility.[Footnote 28] Several DDS officials told us that when
making determinations for children with mental impairments, medication
is considered in the context of other sources of information as "just
one piece of the puzzle." To the extent that medication improves
functioning, some DDS officials told us they could potentially find
that the child is not disabled under program rules. Despite this fact,
certain field office and DDS officials acknowledged they believe some
parents are under the impression that medicating their children will
improve their likelihood of being found eligible for benefits.
However, other DDS officials said they think a number of parents may
avoid medicating their child prior to a consultative examination so
that the child misbehaves and appears more disabled.
To better understand the role of prescribed medications, in March
2011, SSA conducted an analysis to determine the effect reported use
of medications has on determinations for children with three different
mental impairments and concluded that no effect existed. To conduct
this review, SSA compiled reports of medication usage for all fiscal
year 2010 initial determinations for children with ADD/ADHD,
oppositional/defiant disorder, or conduct disorder impairments.
[Footnote 29] For each impairment, SSA calculated the share of
allowance and denial decisions for those claims with and without
related medications. SSA subsequently noted that for the children
examined, those with reports of related medication were more likely to
be denied than to be allowed. Although SSA's analysis indicates that
allowance and denial rates were similar for children with ADD/ADHD who
were and were not taking related medications, children with related
medications were somewhat more likely to be allowed for oppositional/
defiant disorder and conduct disorder than those without medications.
Because only about one-third of those allowed for these three
impairments had reports of related medication, SSA concluded that
medication usage does not affect the allowance of child claims for
these impairments. However, SSA's analysis did not control for other
factors, such as DDS location or claimant age, which may also affect
allowance rates. Without a more in-depth analysis, the effect of the
underlying causes of such differences is unknown. Although we did not
independently validate SSA's findings, as part of our ongoing review,
we plan to conduct a case file review of a random, generalizable
sample of initial determinations decided in fiscal year 2010 for the
most prevalent mental impairments--ADD/ADHD, speech and language
delay, and autism. As part of this effort, we will identify what
sources DDSs reported using to determine the child's medical
eligibility and how they reported weighing various sources if material
inconsistencies could not be resolved. This case file review should
allow us to verify testimonial evidence from interviews with field
office and DDS officials.
In addition to medical evidence, SSA policy directs DDS offices to use
available evidence from nonmedical sources to evaluate the severity of
the child's impairment and functioning as part of the eligibility
determination. These sources include parents, day care providers,
teachers, and others knowledgeable about the child's day-to-day
behavior and activities. SSA field office staff may also provide
observations about the child, if the child is present when the parent
submits the application, in person, and the field office may notify
the DDS if multiple siblings apply for benefits at the same time.
Several DDS officials told us school records and teacher assessments
(standardized questionnaires)[Footnote 30] are especially critical,
because these assessments provide information on the child's
functioning over time and are generally more objective than parent
assessments. Because parents may be unable to accurately assess the
extent of their child's impairment, nearly all the DDS officials we
interviewed said that information from the school, including the
teacher assessment, was critical for making accurate determinations.
According to some DDS officials, parents may primarily observe their
child in an unstructured home environment after the child's
medications have worn off, and they may not know what behaviors are
developmentally normal, whereas teachers are generally in a position
to compare the child to other children and provide neutral
observations on how the child relates to peers, responds to
medication, and performs in school. Several DDS officials told us that
they compare all the information they collect to identify
inconsistencies and decide how much weight to assign the various
sources. For example, some officials told us examiners assess the
credibility of parents' assessments of children's functioning by
comparing it to physicians' and teachers' statements.
Despite the importance of nonmedical information in determining a
child's medical eligibility, our preliminary work shows that examiners
sometimes face challenges obtaining complete information. For example,
some DDS offices reported difficulty obtaining school records or
teacher assessments, which they partly attributed to school and
teacher concerns about the time involved to compile this information,
potential liability issues, or confusion about how such information is
used in the disability decision-making process. In addition, DDS
examiners told us that they do not routinely receive information on
multiple siblings receiving SSI benefits within the same household
even though they are directed to be alert for such cases. SSA's policy
operations manual states that disabilities may occur in more than one
member of a family or household, but notes prior case experience has
shown this type of situation is an indicator of potential fraud or
abuse, particularly where certain mental impairments are involved. For
example, SSA recently investigated a case in which parents applied for
SSI benefits on behalf of their four children, alleging that they all
suffered from ADHD and conduct issues.[Footnote 31] However,
investigators found that the school guidance counselor had never
observed the children exhibiting symptoms of ADHD despite seeing them
daily and that a doctor had rescinded an order authorizing the school
to administer ADHD medication to the children. In this instance, SSA
subsequently denied the siblings' applications for SSI benefits. Based
on our interviews, it appears that SSA field offices do not
consistently notify DDS examiners when an applicant's siblings are
already receiving SSI benefits, nor are they always made aware of
concurrent sibling applications. Without such information, DDS
examiners may be limited in their abilities to identify potential
fraud or abuse in the program.
SSA Has Conducted Significantly Fewer CDRs for SSI Children with
Mental Impairments:
SSA is required to periodically review the medical eligibility of
certain individuals,[Footnote 32] though our preliminary work shows
that SSA has conducted significantly fewer CDRs for children receiving
SSI benefits in recent years, including those with mental impairments.
Between fiscal years 2000 and 2010, childhood CDRs for those
recipients under age 18 and age 18 redeterminations overall fell from
more than 200,000 to about 126,000 (a 38 percent decrease), and more
specifically, childhood CDRs for those with mental impairments
declined from more than 84,000 to about 13,000 (an 84 percent
decrease) (see figure 7). SSA officials attribute the decrease in CDRs
overall primarily to resource limitations and a greater emphasis on
processing initial claims and reducing the backlog of requests for
appeals hearings in recent years. While SSA did increase the number of
CDRs it performed after receiving additional funding specifically
targeted for CDRs between fiscal years 1996 and 2002, CDRs decreased
once the funding expired.
Figure 7: Number of Childhood CDRs Conducted for SSI Recipients under
Age 18, by Primary Impairment, Fiscal Years 2000-2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2000;
Mental impairment CDRs: 84,010;
Physical impairment CDRs: 66,860.
Year: 2001;
Mental impairment CDRs: 67,010;
Physical impairment CDRs: 37,910.
Year: 2002;
Mental impairment CDRs: 112,530;
Physical impairment CDRs: 63,970.
Year: 2003;
Mental impairment CDRs: 90,430;
Physical impairment CDRs: 44,300.
Year: 2004;
Mental impairment CDRs: 68,440;
Physical impairment CDRs: 47,050.
Year: 2005;
Mental impairment CDRs: 41,280;
Physical impairment CDRs: 33,820.
Year: 2006;
Mental impairment CDRs: 13,610;
Physical impairment CDRs: 14,080.
Year: 2007;
Mental impairment CDRs: 2,980;
Physical impairment CDRs: 4,630.
Year: 2008;
Mental impairment CDRs: 3,310;
Physical impairment CDRs: 6,670.
Year: 2009;
Mental impairment CDRs: 7,980;
Physical impairment CDRs: 15,170.
Year: 2010;
Mental impairment CDRs: 13,090;
Physical impairment CDRs: 25,990.
Source: GAO analysis of SSA data from the CDR Waterfall Files.
[End of figure]
SSA has conducted fewer childhood CDRs in recent years. As of August
1, 2011, SSA had not yet conducted CDRs for about 434,000 SSI
recipients under age 18 with mental impairments who had reached their
scheduled CDR date (see figure 8).[Footnote 33] Of these recipients,
about 343,000 (79 percent) had exceeded the scheduled date by at least
a year, with about 205,000 (47percent) exceeding their date by 3 years
and 24,400 (6 percent) exceeding by 6 years. SSA data also indicate
that while age 18 redeterminations are conducted in a more timely
manner, about 8 percent of these reviews are also overdue by 3 years
or more.[Footnote 34] In September 2011, SSA's Office of the Inspector
General also reported that SSA had not completed all childhood CDRs
and age 18 redeterminations in a timely manner. When reviews of
benefits are delayed or not conducted, some beneficiaries may receive
benefits for which they are no longer eligible. The Inspector General
estimated that SSA had paid about $1.4 billion in SSI benefits to
approximately 513,000 recipients under age 18 who should not have
received them.[Footnote 35] SSA has recently estimated that the CDR
process yielded a savings-to-cost ratio of roughly $12.50 to $1 in
fiscal year 2009, and that those CDRs conducted for adults and
children combined in fiscal year 2009 will save federal programs an
estimated $4.6 billion.[Footnote 36]
Figure 8: Pending Childhood CDRs and Age 18 SSI Redeterminations for
Recipients with Mental Impairments, by Time Lapsed, as of August 1,
2011:
[Refer to PDF for image: vertical bar graph]
Years from scheduled date: Less than 1;
CDRs: 90,090;
Age 18 recommendations: 27,680.
Years from scheduled date: Less than 2;
CDRs: 72,280;
Age 18 recommendations: 5,130.
Years from scheduled date: Less than 3;
CDRs: 67,130;
Age 18 recommendations: 1,780.
Years from scheduled date: Less than 4;
CDRs: 70,730;
Age 18 recommendations: 1,110.
Years from scheduled date: Less than 5;
CDRs: 62,760;
Age 18 recommendations: 650.
Years from scheduled date: Less than 6;
CDRs: 46,800;
Age 18 recommendations: 510.
Years from scheduled date: 6 or more;
CDRs: 24,400;
Age 18 recommendations: 830.
Source: GAO analysis of SSA data from the CDR Waterfall Files.
[End of figure]
Of those reviews conducted for child recipients in recent years, the
vast majority were for age 18 redeterminations and low-birth weight
babies. SSA is generally required by law to conduct age 18
redeterminations, within 1 year after a child turns 18, and within 12
months after the birth of a child who was allowed benefits because of
low birth weight. In fiscal year 2010, 87 percent of CDRs conducted
for child recipients were done in these two areas, and SSA
subsequently terminated benefits for about 52 percent of age 18
recipients and 60 percent of low birth weight recipients. The
remaining 13 percent of CDRs conducted were mostly reviews of children
with mental impairments. Of those CDRs conducted for children under
age 18 with mental impairments, SSA terminated benefits for about 24
percent of recipients in fiscal year 2010, and personality disorders
[Footnote 37] and speech and language delay had the highest cessation
rates (34 and 33 percent, respectively).
SSA and DDS officials have acknowledged that the agency is not
conducting reviews for child recipients in a timely manner, and in
some cases, they have not conducted required childhood CDRs prior to a
child's age 18 redeterminations. SSA officials said that they would
like to conduct additional childhood CDRs, but added that due mostly
to funding constraints they are not able to do so. From 1996 to 2002,
Congress provided funding to SSA to conduct additional CDRs for both
Social Security disability and SSI beneficiaries. Since this funding
expired, the number of CDRs SSA has conducted overall has dramatically
declined.[Footnote 38] The recently enacted Budget Control Act of
2011[Footnote 39] authorized an increase in funding for CDRs and
redeterminations under both the SSI and the Social Security Disability
Insurance programs, starting with an additional $623 million in fiscal
year 2012 and reaching an additional $1.3 billion in each of fiscal
years 2017 to 2021. At the time of this statement, SSA was evaluating
how to use this funding for CDRs, should it be appropriated, and it is
not yet known to what extent the agency would (a) increase the number
of childhood CDRs in the future or (b) target such CDRs toward those
mental impairments with the highest cessation rates.
Mr. Chairman and Members of the Subcommittee, this concludes my
prepared statement. I will be happy to respond to any questions.
GAO Contact and Staff Acknowledgments:
For further information related to this statement, please contact me
at (202) 512-7215. Individuals who may key contributions to this
statement include Jeremy Cox, Assistant Director, James Bennett,
Edward Bodine, Sue Bernstein, David Chrisinger, Alex Galuten, Monika
Gomez, Jason Holsclaw, Kristen Jones, Sheila McCoy, Luann Moy, and
Paul Wright.
[End of section]
Appendix I: Listings for Mental Disorders for Children under Age 18:
The structure of the mental disorders listings for children under age
18 parallels the structure for the mental disorders listings for
adults but is modified to reflect the presentation of mental disorders
in children. Under federal regulations, when a child is not performing
substantial gainful activity and the impairment is severe, SSA is
required to examine whether the child's impairment meets, medically
equals, or functionally equals any of the impairments contained in the
listings. The actual listings go into further detail about the level
of severity necessary for this step of the determination, but the
general listings for mental disorders in children are arranged in 11
diagnostic categories.[Footnote 40] These categories include:
Organic mental disorders: Abnormalities in perception, cognition,
affect, or behavior associated with dysfunction of the brain. The
history and physical examination or laboratory tests, including
psychological or neuropsychological tests, demonstrate or support the
presence of an organic factor judged to be etiologically related to
the abnormal mental state and associated deficit or loss of specific
cognitive abilities, or affective changes, or loss of previously
acquired functional abilities.
Schizophrenic, delusional (paranoid), schizoaffective, and other
psychotic disorders: Onset of psychotic features, characterized by a
marked disturbance of thinking, feeling, and behavior, with
deterioration from a previous level of functioning or failure to
achieve the expected level of social functioning.
Mood disorders: Characterized by a disturbance of mood (referring to a
prolonged emotion that colors the whole psychic life, generally
involving either depression or elation), accompanied by a full or
partial manic or depressive syndrome.
Mental retardation: Characterized by significantly sub-average general
intellectual functioning with deficits in adaptive functioning
[Footnote 41].
Anxiety disorders: In these disorders, anxiety is either the
predominant disturbance or is experienced if the individual attempts
to master symptoms; e.g., confronting the dreaded object or situation
in a phobic disorder, attempting to go to school in a separation
anxiety disorder, resisting the obsessions or compulsions in an
obsessive compulsive disorder, or confronting strangers or peers in
avoidant disorders.
Somatoform, eating, and tic disorders: Manifested by physical symptoms
for which there are no demonstrable organic findings or known
physiologic mechanisms; or eating or tic disorders with physical
manifestations.
Personality disorders: Manifested by pervasive, inflexible, and
maladaptive personality traits, which are typical of the child's long-
term functioning and not limited to discrete episodes of illness.
Psychoactive substance dependence disorders: Manifested by a cluster
of cognitive, behavioral, and physiologic symptoms that indicate
impaired control of psychoactive substance use with continued use of
the substance despite adverse consequences.
Autistic disorder and other pervasive developmental disorders:
Characterized by qualitative deficits in the development of reciprocal
social interaction, in the development of verbal and nonverbal
communication skills, and in imaginative activity. Often, there is a
markedly restricted repertoire of activities and interests, which
frequently are stereotyped and repetitive.
Attention deficit hyperactivity disorder: Manifested by
developmentally inappropriate degrees of inattention, impulsiveness,
and hyperactivity.
Developmental and emotional disorders of newborn and younger infants
(birth to attainment of age 1): Developmental or emotional disorders
of infancy are evidenced by a deficit or lag in the areas of motor,
cognitive/communicative, or social functioning. These disorders may be
related either to organic or to functional factors or to a combination
of these factors.
According to SSA, these listings are examples of common mental
disorders that are severe enough to find a child disabled. When a
child has a medically determinable impairment that is not listed, an
impairment that does not meet the requirements of a listing, or a
combination of impairments none of which meets the requirements of a
listing, SSA will make a determination whether the child's
impairment(s) medically or functionally equals the listings.[Footnote
42] This determination can be especially important in older infants
and toddlers (age 1 to attainment of age 3), who may be too young for
identification of a specific diagnosis, yet demonstrate serious
functional limitations. Therefore, the determination of equivalency is
necessary to the evaluation of any child's case when the child does
not have an impairment that meets or medically equals a listing.
[End of section]
Footnotes:
[1] Pub. L. No. 92-603, § 301, 86 Stat. 1329, 1465.
[2] For purposes of the SSI program, the term "child" means an
individual who is neither married nor (as determined by the
Commissioner of Social Security) the head of a household, and who is
(1) under the age of 18, or (2) under the age of 22 and (as determined
by the Commissioner of Social Security) a student regularly attending
a school, college, or university, or a course of vocational or
technical training designed to prepare him for gainful employment. 42
U.S.C. § 1382c(c).
[3] 42 U.S.C. § 1382c(a)(3)(C)(i) and 20 C.F.R. § 416.906.
[4] Typically, a disabled child's SSI benefit is paid on behalf of the
child to a "representative payee," such as a parent or guardian. The
"representative payee" is responsible for using benefits received only
for the child's use and benefit in a manner and for the purposes he or
she determines, consistent with SSA guidelines, to be in the child's
best interests. 20 C.F.R. § 416.635(a).
[5] All but five states and the Commonwealth of the Northern Mariana
Islands supplement federal SSI benefits with additional payments.
Fourteen states and the District of Columbia have state supplements
that are either partially or wholly administered by SSA, and 31 states
self administer their supplements.
[6] The medical evaluation is conducted under applicable legal
requirements and SSA policy and assesses whether the child has a
physical or mental impairment that is severe and that meets or
medically or functionally equals impairments that are included in
SSA's listing of impairments, and that meets the duration requirement.
If these requirements are met, the child is found to be disabled for
purposes of SSI. 20 C.F.R. § 416.924(a). The listing of impairments
for children describes the impairments that cause marked and severe
functional limitations. (See appendix I for additional information
about the listing of mental disorders for children.) If a child has a
severe impairment that does not meet or medically equal any listing,
DDS will decide whether the impairment results in limitations that
"functionally equal" the listings. Under functional equivalence, a
child can be found medically eligible for benefits if the child's
impairment limits his or her functional ability to the same degree as
described in the listed impairment. Functional equivalence is based on
the principle that it is the functional limitations resulting from an
impairment that make the child disabled, regardless of the particular
medical cause. It was added as a basis for eligibility for children in
response to the U.S. Supreme Court's decision in Sullivan v. Zebley,
493 U.S. 521, that SSA's use of medical listings of impairments for
children--without conducting a functional analysis--was incomplete.
[7] 20 C.F.R. § 416.913.
[8] 20 C.F.R. § 416.919a(b). A consultative examination is a physical
or mental examination or test purchased from a treating source or
another medical source, including a pediatrician, for an individual at
SSA's request and expense. 20 C.F.R. § 416.919.
[9] 20 C.F.R. § 416.903(e).
[10] For more information about the administrative review process for
disability determinations, see 20 C.F.R. § 416.1400 et seq.
[11] SSA conducts two types of reviews to ensure that participants are
eligible for benefits--CDRs and redeterminations. CDRs verify
claimant's medical eligibility, while SSI redeterminations verify
their financial eligibility and ensure that the beneficiary is
receiving the right amount of SSI benefits. 20 C.F.R. §§ 416.989 and
416.204.
[12] 42 U.S.C. § 1382c(a)(3)(H)(iv).
[13] 42 U.S.C. § 1382c(a)(3)(H)(ii)(I).
[14] Adults are considered disabled if they are unable to engage in
substantial gainful activity by reason of a medically determinable
physical or mental impairment expected to result in death or last at
least 12 months. 42 U.S.C. § 1382c(a)(3)(A).
[15] 42 U.S.C. § 1382c(a)(3)(H)(iii).
[16] Although a child may be found medically eligible for benefits due
to a physical or mental impairment, SSA must verify the child's
financial and other non-medical eligibility. If these other criteria
are not met, the child will not receive SSI benefits.
[17] Data and references to "applications" or "applicants" throughout
this statement reflect SSI benefit claims where an initial disability
determination was made each year. Some claims may have more than one
determination if selected for a quality review or if the disability
claim is updated during the same year.
[18] The number of adults receiving SSI benefits has also steadily
increased over the past decade. As of December 2010, 6.7 million
adults were receiving SSI disability benefits up from 5.8 million as
of December 2000.
[19] In accordance with Rosa's Law, "intellectual disability" has
generally replaced the term "mental retardation." Pub. L. No. 111-256,
124 Stat. 2643.
[20] The recorded primary impairment code identifies the primary
impairment used in the medical determination for an individual's
eligibility for Title XVI disability benefits. It appears in the
Social Security Administration's 831 and 832/833 Disability files.
[21] According to SSA officials, the error rate for impairment coding
is estimated between 5 to 6 percent.
[22] Centers for Disease Control and Prevention/National Survey of
Children's Health, "National Health Interview Survey, 2004-2006."
[23] Pastor, P.N., Reuben, C.A., "Diagnosed attention deficit
hyperactivity disorder and learning disability: United States, 2004-
2006" Vital Health Stat 2008; 10 (237).
[24] Shattuck, P.T., "The contribution of diagnostic substitution to
the growing administration prevalence of autism in the U.S. Special
Education data." Pediatrics. 2006 117: 1028-1037.
[25] See 20 C.F.R. § 416.913.
[26] See 20 C.F.R. § 416.924(a).
[27] 20 C.F.R. § 416.912(d).
[28] SSA regulations require that, when evaluating the effect of a
child's impairment on his or her functioning, examiners consider the
effects of treatment, including medication, the child is receiving.
Specifically, they are required to consider the effects of medication
on the child's symptoms, signs, laboratory findings, and functioning.
If it appears that the child's symptoms are reduced by medications,
they are required to consider (1) any functional limitations that
persist, despite the medication; (2) whether the medications create
any side effects that cause or contribute to the child's limitations;
(3) the frequency of the child's need for medication; (4) changes in
the child's medication or the way it is prescribed; and (5) any
evidence over time of how the medication helps or does not help the
child to function compared to other children the same age who do not
have impairments. 20 C.F.R. § 416.924a(b)(9)(i).
[29] SSA excluded from its analysis any medications that were not
related to the three impairments. For example, a claim for a child
with ADD/ADHD who was only taking asthma medication would not be
classified as having a related medication.
[30] The standardized SSA teacher questionnaire includes checkboxes
and multiple choice questions and is organized into sections that
cover broad domains of functioning, such as acquiring and using
information and attending and completing tasks.
[31] SSA's Office of Operations and the Office of the Inspector's
General Cooperative Disability Investigations Unit, which is
responsible for investigating questions of fraud in SSA's disability
programs, conducted this investigation.
[32] Under Title XVI of the Social Security Act, SSA is required to
(1) perform CDRs at least every 3 years on all children recipients
under age 18 whose impairments are likely to improve (or, at the
Commissioner's option, recipients whose impairments are unlikely to
improve) (42 U.S.C. § 1382c(a)(3)(H)(ii)(I)) and (2) redetermine,
within 1 year of the individual's 18TH birthday, the eligibility of
any individual who was eligible for SSI childhood payments in the
month before attaining age 18, by applying the criteria used in
determining initial eligibility for individuals who are age 18 (42
U.S.C. § 1382c(a)(3)(H)(iii)).
[33] About 845,000 child recipients with mental impairments were
receiving SSI benefits as of Aug. 1, 2011.
[34] SSA informed us that 95.6 percent of the age 18 redeterminations
are released to the field offices for processing by SSA headquarters
within 2 months of the recipients' 18TH birthday, and most all of them
were released by no later than their 19TH birthday.
[35] The Inspector General estimated that SSA did not complete 79
percent of childhood CDRs and 10 percent of age 18 redeterminations on
the basis of the results of 275 cases of physical and mental
impairments they reviewed. (Social Security Administration Office of
the Inspector General, "Follow-Up: Childhood Continuing Disability
Reviews and Age 18 Redeterminations" (A-01-11-11118), Sept. 23, 2011.)
[36] This estimate represents the combined savings to the SSI,
Disability Insurance, Medicare, and Medicaid programs from CDRs
conducted for the SSI and Disability Insurance programs, as in some
cases eligibility for those programs confers eligibility for certain
Medicare or Medicaid benefits, as well.
[37] Personality disorders are manifested by pervasive, inflexible,
and maladaptive personality traits, which are typical of the child's
long-term functioning and not limited to discrete episodes of illness.
20 C.F.R. pt. 404, subpt. P, appendix 1
[38] In part to reduce the CDR backlog, the Obama Administration
proposed to increase the overall number of CDRs for adults and
children in the SSI program in fiscal year 2012. The proposed fiscal
year 2012 budget requests $562 million for conducting, in part, SSI
CDRs and SSI redeterminations (for child and adult recipients
combined), an increase of $298 million over FY 2011. SSA estimates
that if granted, this level of funding would result in almost $4.2
billion in savings to the SSI program alone over the next 10 years.
[39] Pub. L. No. 112-25, sec. 101, § 251(b)(2)(B), 125 Stat. 240, 243-
44.
[40] For purposes of this appendix, we have provided basic information
about the 11 mental disorders for children included in SSA's listings.
For additional information about these listings, refer to 20 C.F.R.
pt. 404, subpt. P, appendix 1.
[41] Although for most purposes SSA refers to intellectual
disabilities rather than mental retardation, its medical listings have
not been updated to reflect this change.
[42] See 20 C.F.R. §§ 416.926 and 416.926a.
[End of section]
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