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Mental Disorders and Disabilities Among Low-Income Children (2015)

Chapter: 2 The SSI Program for Children

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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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2

The SSI Program for Children

The Supplemental Security Income (SSI) program for children is an important and unique part of the country’s social safety net. The administration of this benefit program is complex; it is the product of numerous legislative, judicial, and regulatory decisions accumulating over the past 50 years. An understanding of the history and administration of SSI for children is essential background for understanding trends observed in the program. This chapter will provide background information on the SSI program for children and will discuss the committee’s approach to the use and interpretation of SSI program data. There are six sections in this chapter. The first section will provide a brief overview of the purpose and history of the SSI program for children. The second section is a list of key terms and definitions for this report. The third section provides a description of the process for determining whether an applicant is eligible to receive SSI benefits. The fourth section offers a description of the process for an applicant to appeal an unfavorable determination of eligibility, suspensions and terminations of benefits, and recurring reviews of disability. The fifth section gives a description of the SSI data, and of the sources of SSI data used in this report. The sixth and final section provides an explanation of how the committee approached the interpretation and use of the SSI data in order to be responsive to the committee’s task order.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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PURPOSE AND HISTORY OF THE SSI PROGRAM FOR CHILDREN

Purpose

SSI is a national needs-based public benefit program established in 1972 to provide assistance to individuals with limited income and resources who are age 65 or older, blind (any age), or disabled (any age). Funded through general tax revenues, the SSI program provides monthly cash benefits to recipients to meet basic needs for food, shelter, and clothing (SSA, 2014j). In 2014 the SSI program provided a maximum monthly cash benefit of $721.00 for an individual (SSA, 2014h). In September 2014, an average child SSI benefit was $632.24 (SSA, 2014i).

In order to receive benefits through the SSI program, an individual must (1) be age 65 or older, blind, or disabled; (2) be a U.S. citizen or have qualified alien status; (3) reside in one of the 50 states, the District of Columbia, or the Northern Mariana Islands1; (4) have limited income and resources; and (5) file an application (SSA, 2012b).

In addition to cash benefits, SSI eligibility may also grant eligibility for Medicaid. In 33 states and the District of Columbia, the SSI application is also the Medicaid application, so Medicaid eligibility starts during the same month as SSI eligibility (SSA, 2015c). Seven states and the Northern Mariana Islands require a separate application for Medicaid but use the same rules for the determination of eligibility as SSI (SSA, 2015c). Ten states require the completion of a different application with different standards to be eligible for Medicaid on the basis of disability and financial criteria (SSA, 2015c).

The following section discusses the history of the SSI program for children and, in particular, the evolution of the standard for eligibility.

History

Created by the Social Security Amendments of 1972 (Public Law 92-603), the SSI program came into effect in 1974 and was developed to replace disparate state-based benefit programs for the needy aged, blind, and disabled. The program was intended to provide another form of income support to particularly disadvantaged households.

The standard of eligibility for children has evolved in three distinct phases. From 1974 to 1990, the standard for children’s eligibility was essentially an extension of the adult standards; unlike the adult rules, however, the rules for children did not include an assessment of a child’s functioning comparable to the medical-vocational assessment of an adult’s

_________________

1 Effective January 9, 1978.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

employability. From 1990 to 1996, following an order by the Supreme Court in Sullivan v. Zebley, the Social Security Administration (SSA) wrote new childhood regulations that based the determination of disability on an individualized functional assessment (IFA). From 1996 to the present, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, Public Law 104-193) narrowed the definition of disability for children, including elimination of the IFA, and set new criteria for the determination of eligibility. Each of these phases is described in greater detail in the sections that follow.

Childhood Disability Eligibility Standards from 1974 to 1990

From 1974 to 1990 the Social Security Act set a “comparable severity standard” for the determination of a child’s eligibility for the SSI benefit program, meaning that the standard for determining whether a child was disabled enough to receive SSI benefits would be comparable to the adult standard for disability. Specifically, the statute stated that a child would be eligible for benefits “if he suffers from any medically determinable physical or mental impairment of comparable severity” to one that would disable an adult (SSA, 1991a).

The five sequential steps used in the adjudication of “adults” include (1) a determination of whether an applicant is currently engaged in “substantial gainful activity” (SGA; see definition in the Key Terms and Definitions section); (2) a medical screen to determine whether or not the applicant has a medically determinable impairment that is “severe” in that it has more than a minimal impact on basic work-related functional abilities and is not due to an acute condition of short duration; (3) further determination that the impairment meets or medically equals criteria articulated in the Listing of Impairments (Listings; see definition in the Key Terms and Definitions section) and meets the duration requirement; (4) an assessment of the applicant’s “residual functional capacity” (RFC) used to determine the ability to perform past relevant work; and (5) a determination of the applicant’s ability to do any work in the national economy using the same RFC and considering the applicant’s age, education, and work experience.

The child disability determination of impairment severity was based on the adult standard. In practice, the adult standard had other steps for determining impairment severity beyond the medical criteria in the listings. When an adult’s impairment did not meet or equal the medical criteria in the listings, his or her RFC was considered in steps 4 and 5. These steps included a functional assessment and compared it to the physical and mental demands of the adult’s past relevant work. Children were not evaluated using a functional assessment and instead were evaluated using medical criteria alone.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

In 1983 a class-action complaint was filed in Pennsylvania to challenge the listings-only, medical criteria–based policy of evaluating disability for children. The complaint alleged that children were held to a stricter standard than adults because functional assessments, which were used for adult disability claims, were not used for child disability claims. When the Third Circuit Court found the statute’s “comparable severity standard to be too restrictive and preclusive of an individualized assessment of a child’s functional impairment,” the SSA filed a petition requesting a review by the Supreme Court (SSA, 1992). In Sullivan v. Zebley, decided in 1990, the Supreme Court held that the listings-only policy for determining disability in children was inconsistent with the statutory standard of “comparable severity” to adult standards in the Social Security Act and therefore required functional assessments for children when determining disability (SSA, 1992). The Supreme Court subsequently ordered SSA to conduct “individualized functional analysis contemplated by the statute and provided to adults” (SSA, 1991b).

Childhood Disability Eligibility Standards from 1990 to 1996

In following the Supreme Court’s order, the SSA wrote new regulations that based the determination of disability for children on an IFA. The IFA assessed a child’s day-to-day functioning in several domains while considering the child’s age. If an IFA showed that impairments substantially reduced a child’s ability to function independently, appropriately, and effectively in an age-appropriate manner and also that the impairments met the duration requirement, then the SSA would find that the child had an impairment of comparable severity to one that would disable an adult. The child would then be determined eligible for benefits.

At around the same time as the Sullivan v. Zebley decision in 1990, the SSA published updated medical listings for adult and child mental disorders. In the revised listings for children, seven new listings were added:

  • anxiety disorders (112.06);
  • somatoform, eating, and tic disorders (112.07);
  • personality disorders (112.08);
  • psychoactive substance dependence disorders (112.09);
  • autistic disorder and other pervasive developmental disorders (112.10);
  • attention deficit hyperactivity disorder (112.11); and
  • developmental and emotional disorders of newborn and younger infants (112.12) (Cowles, 2005).
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

In the early 1990s, following the Sullivan v. Zebley ruling which allowed for the consideration of a child’s functioning and SSA’s publication of seven new mental disorder listings, an increase in child SSI beneficiaries was observed. Between 1991 and 1996, SSI child beneficiaries more than doubled from 397,000 to 955,000, with a portion of awards being given to children with mental disorders (SSA, 2006b; Tambornino et al., 2015).

Childhood Disability Eligibility Standards from 1996 to the Present

In 1996, as part of a series of welfare reform legislative actions, Congress passed the PRWORA, which changed the statutory standard for childhood eligibility for SSI benefits from “comparable severity” to “marked and severe functional limitations,” eliminated reference to “maladaptive behavior” in the childhood mental listings, and eliminated the “individualized functional assessment” (SSA, 2012a).

The PRWORA created a new definition of disability for children and mandated changes to the disability determination process for children (SSA, 1997). The “comparable severity” portion of the act was replaced with the new definition: “An individual under the age of 18 shall be considered disabled for the purposes of this title [XVI] if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months” (SSA, 1997).

The SSA implemented interim final rules in 1997 for the determination of eligibility for children, which established a three-step sequential evaluation process:

  • Step 1: Is the child working and performing SGA?
  • Step 2: Does the child have a severe medically determinable impairment?
  • Step 3: Does the severe impairment meet a listing, medically equal a listing, or functionally equal the listings?

Following these changes to the disability determination process and the stricter definition of disability, a temporary decline in the number of awards for new beneficiaries was observed (Bazelon Center, 2012).

Additionally, after PRWORA was passed, existing child SSI recipients who were originally evaluated using IFAs were reevaluated for eligibility based on the new criteria. Reevaluations for these recipients led to the termination of SSI payments for more than 90,000 children, further decreasing the number of beneficiaries (Coe and Rutledge, 2013). SSI awards for children with mental disorders began rising again after 1997 (SSA, 2006b).

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

KEY TERMS AND DEFINITIONS

The following set of definitions for the key administrative terms and procedures used in the SSA’s determination of an applicant’s eligibility for SSI benefits will be used throughout the remainder of this chapter and report. SSA field offices (FOs), located in communities throughout the country, administer the nondisability criteria of citizenship or alien status, residency, employment, income, and resources. State disability determination services (DDSs) administer the disability eligibility criteria at the initial and reconsideration levels.

  1. Adjudication: For the purposes of this report, adjudication is a decision process by which the SSA first determines whether or not an applicant is eligible for disability benefits after taking into account the citizenship or alien status, residency, income, and resources criteria and then engages in a detailed analysis of specific disability criteria as outlined in the regulations. A final determination or decision can be made at various levels during the adjudication process: at the initial level, reconsideration level, or administrative hearing level. If a claimant is dissatisfied with the outcome of the case, he or she can appeal a hearing-level decision to the SSA Appeals Council, which is the last administrative level of review within the SSA. If a claimant is dissatisfied with the actions taken by the Appeals Council, he or she can appeal to the federal district court.
  2. Allowance: A determination by the disability determination service, an administrative law judge, or the Appeals Council that an applicant meets the medical definition of disability under the law.
  3. Allowance rate: The percentage of allowed disability applications in a given time period calculated as the number of medically allowed applications divided by the total number of applications with a medical decision. (An allowance rate provides a narrower view of the disability program than does an award rate because it excludes nonmedical determinations from its base.)
  4. Applicant: For purposes of this report, an applicant refers to a child under age 18 who has submitted an application to receive benefits through the SSI program.
  5. Award: An administrative determination that an individual is eligible for an SSI benefit; that is, an applicant has met both the disability and the nondisability (citizenship or alien status, residency, work, income, and resource) eligibility criteria and may receive benefits.
  6. Continuing disability review (CDR): An evaluation of an individual’s impairment(s) to determine whether the person is still
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
  1. disabled within the meaning of the law for purposes of eligibility for SSI benefits. (A CDR is a periodic review to determine if an individual who was previously found disabled and eligible for SSI benefits is still disabled. If an individual is determined to be no longer disabled, eligibility for benefits will stop. Individuals who are determined to still be disabled will continue to be eligible to receive disability benefits.)
  2. 7. Deeming: A complex process by which a portion of a child applicant’s parents’ or stepparents’ income and resources is counted as available to the child when determining eligibility for SSI benefits or payment amount.
  3. 8. Denial: For purposes of this report, a denial is a determination by a DDS that an applicant does not meet the SSI disability criteria and is not disabled (i.e., the applicant’s impairment does not meet a listing, medically equal a listing, or functionally equal the listings). (Denials may also occur based on other, nondisability criteria.)
  4. 9. Determination: For purposes of this report, a determination made by the DDS on whether an applicant is disabled. Within a given year, the number of determinations in that year is equal to the sum of all allowances and denials in that year. An individual may have multiple determinations within the same year. For example, an applicant may have two determinations in 1 year if the applicant is denied at the initial level in January, and then allowed at the reconsideration level in September. In this report, we only evaluate determinations made at the initial level to avoid a skewing of the allowance rates caused by multiple denials within one year. Also, for the purposes of this report, the number of determinations can be understood as a proxy for the number of applications among children who are in poverty; specifically, determinations will be the number of children for whom applications for SSI benefits have been submitted and who have already been found to meet the nondisability eligibility criteria.
  5. 10. Disability: According to the Social Security Act, Section 1614(a) (3)(C)(i), “An individual under the age of 18 shall be considered disabled for the purposes of this title if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”
  6. 11. Functional limitation: Functional limitations are the primary criteria on which the SSA based a determination concerning disability. A “medical impairment,” or the existence of a “medically determinable impairment” alone, is not sufficient to make one eligible
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
  1. for SSI; marked and severe functional limitations resulting from the impairments must be established by evidence.
  2. 12. Impairment: An impairment results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by an applicant’s statement of symptoms.
  3. 13. Listing of impairments (listings): The listings are a regulatory list of medical conditions and criteria, produced by the SSA, that serve as a standard for a determination of disability. An in-depth description of the listings can be found in Box 2-1.

BOX 2-1
The Child Mental Disorders Listings

The Listing of Impairments was developed to ease the administrative burden of determining the functional capacity of each claimant and was revised in 1977 to include criteria that would apply to children under age 18 applying for SSI (IOM, 2007). For children, the listings contain specific medical severity criteria describing impairments severe enough to cause marked and severe functional limitations (SSA, 2015b).

SSA uses the listings to identify medically obvious cases of individuals with disabilities, thereby avoiding the time-consuming medical–vocational review (IOM, 2007). The listings allow the SSA to process a high number of cases more quickly. In addition, because SSA uses a specific set of medical criteria to guide each disability determination, the listings help promote equal treatment and adjudicative consistency for applicants (IOM, 2007).

The Listing of Impairments consists of Part A, which is primarily for adults, and Part B, which is for children only. The parts are organized into 14 major body systems for adults and 15 major body systems for children. The listings for each body system begin with an introduction containing definitions of key terms and concepts that describe the diagnosis and severity of impairment. Each major body system and its corresponding diagnostic categories are numbered. The childhood (Part B) body system for mental disorders is identified as 112.00, and its listings are arranged in 11 diagnostic categories, which are

  1. Organic mental disorders (112.02);
  2. Schizophrenic, delusional (paranoid), schizo-affective, and other psychotic disorders (112.03);
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
  1. 14. Medically determinable impairment: A medically determinable impairment is a physical or mental impairment that is established by medical evidence consisting of symptoms, signs, and laboratory findings from acceptable medical sources, not based only on an individual’s statement of his or her symptoms.
  2. 15. Nondisability criteria: Nondisability criteria refer to citizenship or alien status, residency, work, income, and resources criteria that must be met.
  3. 16. “Poor” and “poverty”: For the purposes of this report, poor and poverty refer to a family income less than 200 percent of the federal poverty level (FPL). An in-depth description of poverty can be found in Chapter 5.
  1. 3. Mood disorders (112.04);
  2. 4. Intellectual disability (112.05);
  3. 5. Anxiety disorders (112.06);
  4. 6. Somatoform, eating, and tic disorders (112.07);
  5. 7. Personality disorders (112.08);
  6. 8. Psychoactive substance dependence disorders (112.09);
  7. 9. Autistic disorder and other pervasive developmental disorders (112.10);
  8. 10. Attention deficit hyperactivity disorder (112.11);
  9. 11. Developmental and emotional disorders of newborn and younger infants (112.12).

Each listing, except for listings 112.05 and 112.12, is followed by paragraph A criteria which outline a set of medical findings and paragraph B criteria which outline a set of impairment-related functional limitations (SSA, 2015b). Criteria in both paragraphs must be satisfied in order for an impairment to meet a listing (SSA, 2015b).

It should be noted that there are no listings for learning disorder (LD) and borderline intellectual functioning (BIF). Although there are no listings, there are SSA impairment codes (see Table 2-2). These impairment codes are used when a child’s functioning is found to be of listing-level severity primarily due to LD or BIF. However, since there is no listing, no determination of disability can be made for LD or BIF based on meeting.

The complete SSA childhood mental disorders listings are reproduced in Appendix B. Additional information on the origin, design, and structure of the medical listings can be found in Appendix C, which contains Chapter 5 of the Institute of Medicine report Improving the Social Security Disability Decision Process (IOM, 2007).

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
  1. 17. Recipient: An individual who receives SSI benefits. The total number of recipients at a point in time (or within a specified period) is the total number of individuals who are receiving benefits, regardless of the date on which they became eligible to receive benefits.
  2. 18. Substantial gainful activity (SGA): Work activity is “substantial” if it involves doing significant physical or mental activities and is “gainful” if it is usually done for pay or profit.
  3. 19. Suspension: An ineligibility status that causes the nonpayment of benefits for a period of anywhere from 1 to 12 months for any of a number of reasons. (Payments can resume if the recipient reestablishes eligibility during the suspension reinstatement period. If a recipient does not become eligible again within the 12 months, benefits will be terminated.)
  4. 20. Termination: Cessation of benefits, which can occur for a number of reasons, including death, medical improvement, or a period of suspension lasting longer than 12 months. (Once benefits are ceased, an individual cannot receive benefits without filing a new application.)

REQUIREMENTS FOR SSI ELIGIBILITY

For a child to receive SSI benefits, two basic conditions must be met: (1) the child must meet citizenship or alien status, residency, work, income, and resource criteria; and (2) the child must be found to have a severe impairment that meets the statutory and regulatory standards for disability. State agencies, which are fully funded by the federal government, working under the guidance and rules of the Social Security Administration are responsible for making disability determinations (SSA, 2007). The process for becoming eligible for child SSI benefits begins when an individual files an application for benefits with the SSA. The adjudication process proceeds through multiple steps, as illustrated in Figure 2-1. Each step in the process is discussed in detail below.

It should be noted that while this report and the committee describe the adjudication process as proceeding through four steps, the SSA formally describes the process as a three-step process, but with step 3 composed of two parts, step 3a and step 3b. Step 3 in this report is the same as step 3a in the SSA regulations, and step 4 in this report is the same as step 3b in the SSA regulations.

Step 1: Work and Income

Determination of employment status and financial eligibility is the first step in the determination of a child’s eligibility for SSI disability benefits.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

images

FIGURE 2-1 For purposes of this report, the SSI adjudication process.
SOURCE: Wixon and Strand, 2013.

The work, income, and resource eligibility criteria must be met prior to any evaluation of disability.

After an application for child SSI benefits is filed, the SSA field offices

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

will first determine whether the child is engaged in SGA. SGA2 is defined as work that involves doing significant and productive physical or mental duties and that is done (or intended) for pay or profit (SSA, 2014a). If a child engages in SGA, the claim will be denied.

If a child is not employed, FOs will proceed to evaluate financial eligibility based on the child’s income and the parents’ and stepparents’ income and resources (Wixon and Strand, 2013). Until a child attains age 18, a portion of his or her parents’ and stepparents’ income is used to determine financial eligibility through a complex process known as deeming. A certain portion of the parents’ and stepparents’ income and resources is “deemed” to be available to the child as a member of the household and therefore counted toward eligibility. Some types of parental income and resources are deemed, and others are not.

Income that is not deemed includes Temporary Assistance for Needy Families, pensions from the Department of Veterans Affairs, general assistance, foster care payments for an ineligible child, and income used to make court-ordered support payments (SSA, 2014g). Resources that are not deemed may include the primary residence, one vehicle used primarily for transportation, and pension fund money (SSA, 2014g). The SSA’s Deeming Eligibility Chart for Children for 2015 is reproduced in Appendix A.

If the employment, income, and resources criteria are met, the case will proceed to the second step. It should be noted that, because of the deeming process, the SSI income eligibility criteria do not necessarily predict the level of poverty of the household. After deeming exclusions are applied, children eligible for SSI may come from households with income above 100 percent of the FPL. As reported in Chapter 5, three-quarters of children receiving SSI benefits were in households with income less than 200 percent of the FPL, without taking into account the income from the SSI benefit (Bailey and Hemmeter, 2014).

Step 2: Medically Determinable Impairment, Severity, and Duration

In the second step, the DDS evaluates whether an applicant has a “severe medically determinable impairment” as required by the Social Security Act, and the claim will be denied if the child does not have a severe medically determinable impairment as defined by statute and in the Code of Federal Regulations (SSA, 2011a).

The SSA defines a medically determinable physical or mental impairment

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2 The monthly SGA amount for nonblind individuals with disabilities for 2015 is the SGA amount for 2000 multiplied by the ratio of the national average wage index for 2013 to that for 1998, or, if larger such SGA amount for 2014 ($1,070). If the amount so calculated is not a multiple of $10, we round it to the nearest multiple of $10 (SSA, n.d.).

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

as an impairment that results “from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques” (SSA, 2013c). A medically determinable impairment must be established by medical evidence that includes symptoms, signs, and laboratory findings (SSA, 2013c). Furthermore, the medical evidence used to support a medically determinable impairment must come from an SSA-approved list of medical sources, which includes licensed physicians and psychologists (SSA, 2013b). If there is not sufficient medical evidence to support a finding of a medically determinable impairment, the claim will be denied.

Applicants will also be denied if the impairment is not considered severe. The SSA defines a nonsevere impairment as an impairment or combination of impairments that does not “cause more than a minimal limitation in the individual’s ability to function in an age-appropriate manner” (SSA, 2014e).

Applicants will also be denied if their impairment is not expected to cause death or has neither lasted 12 months, nor can be expected to last for a continuous period of 12 months or more (SSA, 2000).

If the DDS finds that the claimant has a severe, medically determinable impairment, the claim will proceed to step 3.

Step 3: The Listings

In the third step, the DDS will perform a medical screen to determine if the child has one or more severe impairments that “meet” or “medically equal” the criteria articulated within the listings, published by the SSA (Wixon and Strand, 2013). The relevant definitions are as follows:

  • Meets a listing: If the evidence in a case establishes the presence of all the criteria required by one of the listings and meets the duration requirement, then the claimant’s impairment meets that specific listing (SSA, 2013d).
  • Medically equals a listing: If a claimant’s impairment is not found to meet the exact requirements of a specific listing, the claimant can still be found disabled if the impairment is at least equal in severity and duration to the criteria of any listed impairment, as established by the relevant evidence in the claimant’s case record (SSA, 2013d).

If a child’s impairment meets or medically equals a listing, benefits will be awarded. Otherwise, the claim will proceed to step 4.

Box 2-1 provides a discussion of the purpose and structure of the Child

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

BOX 2-2
112.11 Attention Deficit Hyperactivity Disorder Criteria

ADHD: Manifested by developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity.

The required level of severity for these disorders is met when the requirements in both A and B are satisfied.

  1. Medically documented findings of all three of the following:
    1. Marked inattention; and
    2. Marked impulsiveness; and
    3. Marked hyperactivity; and
  2. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the following:
    1. Gross or fine motor development at a level generally acquired by children no more than one-half the child’s chronological age, documented by:
      1. (1) An appropriate standardized test; or
      2. (2) Other medical findings; or
    2. Cognitive/communicative function at a level generally acquired by children no more than one-half the child’s chronological age, documented by:
      1. (1) An appropriate standardized test; or
      2. (2) Other medical findings of equivalent cognitive/communicative abnormality, such as the inability to use simple verbal or nonverbal behavior to communicate basic needs or concepts; or
    3. Social function at a level generally acquired by children no more than one-half the child’s chronological age, documented by:
      1. (1) An appropriate standardized test; or

Mental Disorders Listings, which serve as a standard for determination of disability.

Box 2-2 contains Listing 112.11 for attention deficit hyperactivity disorder, which describes the set of medical findings and impairment-related functional limitations that are considered when determining disability for a child (SSA, 2015b).

Step 4: Functional Equivalence

In the fourth step, the DDS will evaluate whether the impairment functionally equals the listings (Wixon and Strand, 2013), i.e., whether the child’s impairment is of listing-level severity, which means it must result in

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
      1. (2) Other medical findings of an equivalent abnormality of social functioning, exemplified by serious inability to achieve age-appropriate autonomy as manifested by excessive clinging or extreme separation anxiety; or
    1. Attainment of development or function generally acquired by children no more than two-thirds of the child’s chronological age in two or more areas covered by a., b., or c., as measured by an appropriate standardized test or other appropriate medical findings.
  1. For children (age 3 to attainment of age 18), resulting in at least two of the following:
    1. Marked impairment in age-appropriate cognitive/communicative function, documented by medical findings (including consideration of historical and other information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, the results of appropriate standardized psychological tests or, for children under age 6, by appropriate tests of language and communication; or
    2. Marked impairment in age-appropriate social functioning, documented by history and medical findings (including consideration of information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, the results of appropriate standardized tests; or
    3. Marked impairment in age-appropriate personal functioning, documented by history and medical findings (including consideration of information from parents or other individuals who have knowledge of the child, when such information is needed and available) and including, if necessary, appropriate standardized tests; or
    4. Marked difficulties in maintaining concentration, persistence, or pace.

“marked” limitations in two domains of functioning or “extreme” limitation in one domain (Wixon and Strand, 2013).

Six Activity Domains

When determining functional equivalence, the SSA considers how a child functions in activities in terms of six domains. The domains are broad areas of functioning that depict activities that children can and cannot do at home, at school, and in the community compared to typical children the same age who do not have impairments (IOM, 2010). Information concerning functioning in the six domains is collected from medical sources, parents, teachers, and others who can describe functioning at home, in childcare, at school, and in the community (SSA, 2015a). The SSA may

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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also request a consultative exam if the medical evidence provided is not adequate (SSA, 2015a).

The first domain, “Acquiring and using information,” refers to how well a child can acquire or learn information and use the information that was learned (SSA, 2015a). An example of limited functioning in acquiring and using information is having difficulty remembering things that were learned in school the previous day (SSA, 2015a).

The second domain, “Attending and completing tasks,” involves how well a child can focus and maintain attention throughout activities and finish the activities (SSA, 2015a). A child with limited functioning in this domain is repeatedly distracted from activities (SSA, 2015a).

The third domain, “Interacting and relating with others,” concerns how well a child can “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” (SSA, 2015a). When a child is unable to form close friendships, he or she is limited in interacting and relating with others (SSA, 2015a).

The fourth domain, “Moving about and manipulating objects,” concerns gross and fine motor skills that include a child’s ability to move from one place to another and his or her ability to move and manipulate things (SSA, 2015a). Difficulty climbing up and down stairs shows limitation in this domain (SSA, 2015a).

The fifth domain, “Caring for yourself,” refers to how well a child can maintain a healthy emotional and physical state, including how well a child can get his or her physical and emotional wants and needs met in appropriate ways, how a child copes with stress and changes in his or her environment, and whether a child takes care of his or her own health, possessions, and living area (SSA, 2015a). A child with limitations in this domain may not dress or bathe themselves appropriately when accounting for age (SSA, 2015a).

The sixth domain, “Health and physical well-being,” involves the “cumulative physical effects of physical or mental impairments and their associated treatments and therapies on functioning” (SSA, 2015a). A child who has frequent seizures related to his or her impairment will have a limitation in the domain for health and physical well-being (SSA, 2015a).

Marked and Extreme Limitations

To functionally equal the listings, a child’s impairment must result in “marked” limitation in two domains or “extreme” limitation in one domain (SSA, 2011b). When deciding whether a child has marked or extreme limitation, SSA considers functional limitations of the child’s impairments

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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and their interactive and cumulative effects (SSA, 2014f). Relevant information in the child’s case record, such as signs, symptoms, laboratory findings, and parental and teacher descriptions of function, is used to determine functioning (SSA, 2014f). Medical evidence such as formal testing is also used to provide developmental and functional information, and the standard scores from the formal tests along with standard deviations of scores are used with the information obtained regarding functioning to determine whether a child exhibits marked or extreme limitation in a domain (SSA, 2014f).

Marked Limitation

When a child has marked limitation, his or her impairment interferes seriously with the ability to independently initiate, sustain, or complete activities (SSA, 2014f). Marked limitation can be described as “more than moderate” but “less than extreme” (SSA, 2014f). The impairment can affect day-to-day functioning by seriously limiting only one activity, or the impairment’s interactive and cumulative effects can limit several activities (SSA, 2014f). For children of any age, marked limitation will be decided if a valid score on a comprehensive standardized test designed to measure ability or functioning in a domain is two standard deviations or more below the mean but less than three standard deviations (SSA, 2014f). The test should be designed to measure ability or functioning in that particular domain, and the child’s day-to-day functioning in domain-related activities should be consistent with the score (SSA, 2014f). For children who have not yet reached age 3 and cannot be tested, marked limitation will generally be decided if they are functioning at a level that is more than one-half but not more than two-thirds their chronological age (SSA, 2014f).

Extreme Limitation

A child has extreme limitation when the impairment interferes very seriously with the ability to independently initiate, sustain, or complete activities (SSA, 2014f). Extreme limitation is also described as “more than marked” (SSA, 2014f). The impairment can effect day-to-day functioning by very seriously limiting only one activity, or its interactive and cumulative effects can limit several activities (SSA, 2014f). As mentioned above, comprehensive standardized test scores may be used for determining extreme limitation (SSA, 2014f). A valid score for extreme limitation is three standard deviations or more below the mean (SSA, 2014f). Children who have not yet attained age 3 will generally be considered to have extreme limitation if they are functioning at a level one-half of their chronological age or less (SSA, 2014f).

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Benefits will be awarded if it is found that a child’s impairment results in limitations that functionally equal the listings; otherwise, the application for benefits will be denied.

THE APPEALS PROCESS, SUSPENSIONS AND TERMINATIONS, AND RECURRING REVIEWS

The Appeals Process

A claimant has the right to appeal a determination, decision, or dismissal after any step of the disability determination process and can present additional evidence to support his or her case or appoint a representative to

images

FIGURE 2-2 The SSI appeals process.
NOTE: Under the disability redesign prototype model, SSA eliminated the reconsideration step of the appeals process in the following states: Alabama, Alaska, California (Los Angeles North and Los Angeles West DDS offices), Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York, and Pennsylvania. ALJ refers to an administrative law judge.
SOURCE: Morton, 2014.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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do so (Morton, 2014). The appeals process has three levels of administrative review with the SSA before it can be appealed to the U.S. court system (Morton, 2014) (see Figure 2-2).

  • Step 1: Reconsideration.3 Claimants who are dissatisfied with the initial determination may request reconsideration in writing within 60 days after receiving the initial determination notice (SSA, 2014b). A different disability examiner will review the evidence from the initial determination and any additional evidence and notify the claimant in writing of the determination (Morton, 2014).
  • Step 2: Administrative hearing. Claimants who are dissatisfied with the reconsideration determination (or initial determination in states using the disability redesign prototype model) may request a hearing before an administrative law judge in writing within 60 days following receipt of the determination notice (SSA, 2013e). The administrative law judge will make a de novo decision based on the evidence, including testimony from the claimant and any witnesses, such as a medical or vocational expert, and will adjudicate the request for hearing (Morton, 2014). Following the hearing, the claimant is notified in writing of the decision.
  • Step 3: Appeals Council. Claimants who are dissatisfied with the administrative law judge decision or dismissal may request an Appeals Council review in writing within 60 days following receipt of the hearing decision or dismissal (SSA, 2014c). The Appeals Council may deny or dismiss the request, or it may grant the request and either issue a decision (favorable or unfavorable) or remand the claim to an administrative law judge (SSA, 2014c). The claimant is notified in writing of the Appeals Council action.
  • Step 4: U.S. District Court. Claimants who are dissatisfied with the Appeals Council decision or its denial of the request for review may file a civil action with the U.S. District Court which may issue a decision, remand the case to the Appeals Council (Morton, 2014), or dismiss the case.

As shown in Table 2-1, from year to year it is consistently the case that the majority—over 90 percent—of allowances for children are made at the initial determination level. On average, only 3.3 percent of allowances are made at reconsideration, and 4.5 percent of allowances are made at the

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3 Under the disability redesign prototype model, SSA eliminated the reconsideration step of the appeals process in the following states: Alabama, Alaska, California (Los Angeles North and Los Angeles West DDS offices), Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York, and Pennsylvania.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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TABLE 2-1 Percentage of Child Applications Allowed at the Various Levels of the Adjudication Process, 2004-2012

Calendar Year of Filing Percent Allowed at Initial Percent Allowed at Recon Percent Allowed Beyond Recon
2004 91.5% 3.3% 5.3%
2005 91.3% 3.4% 5.3%
2006 90.5% 3.5% 6.1%
2007 90.4% 3.4% 6.2%
2008 90.3% 3.6% 6.1%
2009 90.6% 3.6% 5.8%
2010 92.0% 3.7% 4.3%
2011 95.8% 3.3% 0.9%
2012 98.0% 1.9% 0.1%
Average (9-yr) 92.3% 3.3% 4.5%

SOURCE: SSA, 2013a.

administrative hearing level, the Appeals Council level, or at the federal court level.

Suspensions and Terminations

Recipients’ benefit payments may be suspended or terminated when they are no longer eligible for benefits. Suspensions of benefit payments occur when a recipient is found to no longer be eligible for a number of reasons, including having excess income or resources, whereabouts being unknown, residing in a Medicaid facility or public institution, or no longer being disabled. Suspensions can last up to 12 months. Payments can be reinstated if, within 12 months after a recipient’s payments are suspended, the recipient’s circumstances revert to being consistent with the eligibility criteria.

A termination of SSI benefits occurs when a recipient is ineligible for 12 consecutive months; the terminated recipient cannot receive disability benefit payments without submitting a new application. Terminations can occur when a recipient dies, or after 12 consecutive months of suspension.

Recurring Reviews

Continuing Disability Reviews

CDRs are performed at regular intervals to determine whether a child continues to be eligible for SSI benefits (SSA, 1986). The frequency of

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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reviews depends on whether the impairment is expected to improve and whether the disability is permanent (SSA, 2006a). For impairments expected to improve, CDRs are completed in intervals of 6 to 18 months following the most recent determination or decision (SSA, 2006a). When a disability is not considered permanent and medical improvement for an impairment cannot be predicted, a CDR is conducted at least once every 3 years (SSA, 2006a). When a disability is considered permanent, a CDR is conducted no less than once every 7 years and no more than once every 5 years (SSA, 2006a).

Transitioning into the Adult SSI Disability Standard

The standards for SSI disability benefits for children under 18 are different than the standards for adults 18 and older. As a result, when a recipient turns 18 years old, he or she must be reevaluated to determine eligibility for benefits under the adult standard. These evaluations are known as “age-18 redeterminations” (Morton, 2014). Subject to some exceptions, a recipient’s eligibility for child SSI benefits stops at age 18.

As a result, recipients who turn 18 are no longer part of the child SSI program. These children will leave the child SSI recipient pool and transition either into the adult SSI program or else be terminated if they do not meet the adult disability standards. Those who meet adult standards and go on to be recipients of adult SSI benefits are not counted as terminations from the child SSI program, even though they are no longer recipients of child SSI benefits. Those who do not meet the adult standards at redetermination are counted as terminations.

DESCRIPTION OF SSI DATA

This section describes the sources and types of data used in this report. Our report relies primarily on two measures produced by the SSA: allowances and recipients. SSI allowance and recipient data were provided by two different divisions within the SSA, the Office of Disability Policy Management Information (ODPMI) for allowances and the Office of Research, Evaluation, and Statistics for recipients.

Allowances

ODPMI tracks information on the outcomes of the SSI adjudication process. Specifically, SSA records information on whether or not an applicant is eligible according to the nondisability criteria (citizenship or alien status, residency, work, income, and resource; step 1), and the disability criteria (steps 2, 3, and 4). The emphasis of the committee’s task order was

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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the trends in the rates of disability caused by mental disorders; therefore, denials due to nondisability criteria are not included in the analysis in this report; rather, information specifically about determinations of disability, specifically allowances at the initial level, is prioritized. Administrative information regarding the outcome of a determination of disability is recorded on a standard form called the SSA-831 Disability Determination and Transmittal form. Allowance data included in this report are from the SSA-831 file.

As previously discussed in the chapter, an allowance is defined as a determination by a DDS (or a decision by an administrative law judge or the Appeals Council) that an applicant meets the statutory and regulatory criteria for disability. An individual applicant may have multiple determinations due to multiple denials at different levels of adjudication. For example, within the same year an individual applicant may be denied at the initial and reconsideration levels, but is subsequently allowed at the administrative law judge level. As a result, there would be three adjudications on the record for this individual applicant—two denial determinations and one allowance decision. However, once an allowance has been made, there is no subsequent readjudication of the disability criteria, and therefore, generally, there are no multiple allowances for applications. For the purposes of this report, since we only consider determinations made at the initial level, each determination can only have one outcome: either an allowance or a denial. Subsequent denials or allowances at reconsideration or thereafter, a relatively infrequent occurrence, are not analyzed in this review of the SSI program, and as such, adjusting for multiple determinations and denials for individual applicants is not necessary.

Data on determinations collected by the SSA also include information on three important aspects of every determination: (1) a medical diagnosis associated with the determination, (2) the level of adjudication at which the allowance was made, and (3) the regulation basis code (or regulatory basis) for the allowance. These three key data elements are discussed in the following sections.

Diagnostic Categories for Determinations of SSI Benefits

The SSA Program Operations Manual System (POMS), which provides instructions on completing the SSA-831, requires that the diagnosis or medical basis for the applicant’s disability that is most pertinent to the determination be recorded. The SSA collects information on a primary diagnosis and an optional secondary diagnosis for each determination. According to the POMS DI 26510.015, “The primary diagnosis for an allowance refers to the basic condition that rendered the individual disabled, or in (the case of) a denial, the one which the evidence shows to have the

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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most significant effect on the individual’s ability to work” (SSA, 2014d). A secondary diagnosis is defined as the “most significant diagnosis following the primary diagnosis in severity” (SSA, 2014d).

The SSA disability examiners are required to record an “impairment code” for every disability determination. The SSA’s impairment codes are numeric codes loosely informed by the International Classification of Diseases, 9th Revision (ICD-9) which are used to classify medical diagnoses that are the basis for disability claims. Each impairment code is linked to a diagnostic category within the SSA “Listing of Impairments,” based in part on the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III-R) (SSA, 2010). For each allowance that meets or medically equals a listing, the examiner is required to record the correlated impairment code. For every allowance that functionally equals the listings, examiners must record the impairment code that most closely matches the impairment in the applicant’s case file and that serves as the basis of his or her disability. For denials, examiners are instructed to record an impairment code for the diagnosis that has the most effect on the claimant’s function, or a code for “none established” if there is no diagnosis or when the medical evidence in the file is not sufficient to establish a diagnosis. The analysis of the trends in rate of mental disorders in the SSI program in this report is based on impairment codes recorded only for primary diagnoses.

Table 2-2 shows what the SSA uses to link the childhood mental disorders listings to 18 mental disorder impairment codes. Codes included in this review of the SSI program are denoted with an asterisk (*).

SSI Secondary Impairment Data

Data on secondary diagnoses and impairments are excluded from this review. During public information gathering meetings with the SSA, the SSA staff informed the committee that secondary impairment codes are neither consistently nor accurately recorded by examiners, and recommended that the committee avoid use of the secondary impairment data. Additional information on the rates of secondary impairments for mental disorders in children and also on the reliability and consistency of secondary impairment data can be found in the U.S. Government Accountability Office (GAO) report Supplemental Security Income: Better Management Oversight Needed for Children’s Benefits (GAO, 2012). The GAO conducted a case file review of initial determinations where the initial impairment was ADHD, speech and language delay, or autism. Of the determinations that resulted in an allowance, 55 percent had a secondary impairment recorded. Of those secondary impairments, 94 percent were mental impairments. The GAO also found that in 27 of 80 allowances, examiners coded secondary impairments that were alleged by claimants, but were not relevant to the determination.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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TABLE 2-2 Childhood Listing Impairment Codes

Mental Disorder Listing Diagnostic Category Label Impairment Code
112.02 Organic mental disorders 2940*
112.03 Schizophrenic, delusional (paranoid), schizo-affective, and other psychotic disorders 2950
112.04 Mood disorders 2960*
112.05 Intellectual disability 3180*
112.06 Anxiety disorders 3000*
112.07 Somatoform disorders 3060
112.07 Eating and tic disorders 3070
112.08 Personality disorders 3010
112.08 Conduct disorder 3120*
112.08 Oppositional/defiant disorder 3138*
112.09 Psychoactive substance dependence disorders (alcohol) 3030
112.09 Psychoactive substance dependence disorders (drugs) 3040
112.10 Autistic disorder and other pervasive developmental disorders 2990*
112.11 Attention deficit disorder/attention deficit hyperactivity disorder 3140*
     
112.12 Developmental and emotional disorders of newborn and younger infants 3150
  Learning disorder (LD)a 3152*
  Speech and language impairment 3153
  Borderline intellectual functioningb 3195*

NOTE: Childhood listings are based in part on the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (SSA, 2010). Impairment codes are based on the International Classification of Diseases, 9th Revision, Clinical Modification (SSA, 2013f). Codes included in this review of the SSI program are denoted with an asterisk (*).

a The learning disorder impairment code 3152 does not have a corresponding mental disorder listing, so it cannot be used for an allowance based on meeting a listing.

b The borderline intellectual functioning impairment code 3195 does not have a corresponding mental disorder listing, so it cannot be used for an allowance based on meeting a listing.

The lack of reliable secondary impairment data is a significant limitation. Information about the rates and patterns of comorbidity among children who are applying for and being awarded SSI benefits cannot be evaluated, and comorbidity patterns within the SSI program cannot be compared to comorbidity patterns observed in the general population.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Level of Adjudication

The SSA also collects information on the level of adjudication at which a determination is made. In this report only those determinations made at the initial level are reported and analyzed.

Regulation Basis of Determinations

The SSA keeps records on whether allowances are for impairments that meet a listing, that medically equal a listing, or that functionally equal the listings. Chapter 3 includes an analysis of the trends in the number of allowances by regulation basis code (or regulatory basis) from 2004 to 2013.

Race and Ethnicity Data

Race and ethnicity data are not available from the SSI administrative data. The SSA does not collect any information on race or ethnicity at any point during the adjudication process.

Recipients

A recipient is a child who is receiving SSI disability benefit payments. The number of recipients reflects the total number of individuals who have previously been found to be eligible for benefits and who remain eligible for benefits. The SSA collects and maintains data on the number of individuals who receive SSI benefit payments. These data are known as the “Supplemental Security Record” (SSR). The SSR is a record of the number of individuals who apply for SSI disability benefits, the number of applicants who become eligible for benefits under both the nondisability (citizenship or alien status, residency, work, income, and resource) and disability criteria (awards4), and the number of individuals who are currently recipients of SSI disability benefits payments. The recipient data in the SSR refer to the number of recipients within a time period, specifically within the month of December of the year. All recipient data included in this report are from the SSR. There cannot be more than one recipient count per individual.

_________________

4 An award is an administrative status that indicates that an applicant has met both disability and nondisability (work, income, and resource) eligibility criteria. Because awards include nondisability criteria, they are not used in this report. Generally, the numbers of allowances and awards are very similar.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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INTERPRETATION AND USE OF SSI DATA FOR PREVALENCE TRENDS

Restatement of the Task Order Requirements

The task order stipulates that the committee must compare estimates of trends in the prevalence of mental disorders generated by surveys of the general population with trends observed in the SSI program for children with mental disorders. The following sections discuss the committee’s approach to completing this aspect of the task order. Specifically, the following three sections explain first, what is meant by a prevalence trend; second, what “prevalence” in the SSI program is for the purposes of this task order; and third, the challenges of comparing general population estimates of prevalence trends with SSI “prevalence” trends.

What Is a Prevalence Trend?

When we talk about how many people in the population have an illness, we often use the term “prevalence.” By “prevalence” we usually mean point prevalence: the proportion of a population that has a given illness or condition at a certain point in time. Other measures of prevalence are period prevalence, the proportion of the population who have been cases within a given period of time, such as the past year, and, in particular, lifetime prevalence, the proportion of the population who have been cases over their lifetime. As described below, data from the SSI program mainly allow statements about point prevalence—the proportion of children who are SSI recipients in December of each calendar year.

As a proportion, prevalence estimates are based on two values: (1) the number of cases identified (numerator) and (2) the population in which these cases occur (denominator). Again, for the SSI program, our estimated number of “cases” is based on national and state counts of SSI recipients, and the eligible population includes those who are eligible for SSI benefits, such as families who qualify based on lower incomes. Comparing prevalence trends from the SSI program to those in the general population requires that we take into consideration several key factors, including (1) the basis or criteria by which cases are identified (numerator), (2) the definition and enumeration of the relevant population (denominator), (3) the type of prevalence reported (point prevalence or period prevalence), (4) information quality, and more. As detailed below, the sources of data regarding the prevalence of mental disorders in the general population and in the SSI population can differ on all of these factors, adding considerable challenges to their comparisons.

In order to look at trends in prevalence as required by the task order,

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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it is necessary to have multiple estimates of prevalence over a period of time. If these estimates are arranged in order of date, they produce a trend line. Changes in prevalence over time (or the prevalence trend line) can be influenced by many factors, some substantive and some methodological. “Substantive” changes in prevalence trends may result from increases in the risk for a disease (such as increases in lung cancer due to smoking during the late 20th century) or decreases following the introduction of a vaccine or environmental improvements. Methodological factors can include a variety of topics, such as differences in methods of case identification, differences in diagnostic criteria, or changes in the makeup of the population being studied. For example, some wonder whether reported increases in prevalence trends for autism and autism spectrum disorder (ASD) may result from new, broader, and more inclusive diagnostic criteria. Differences in prevalence trends resulting from altered case identification are of concern when studying psychiatric illness because definitions have changed over time; there are no routine, standardized tests for the disease; and many individuals with the disorder may never see an expert diagnostician. Furthermore, methodological difficulties are compounded when information about cases of mental disorders are not routinely monitored or collected by state or national agencies. We know how many cases of measles or rabies occur because reporting is required; however, no official, nationwide record is kept of the number of cases of ADHD or ASD. In comparing SSI prevalence trends to comparable information from the general population we draw on multiple sources of prevalence data, which are discussed below.

Administrative Data

Examples Individuals with Disabilities Education Act (IDEA) data on learning disabilities

IDEA mandates that schools should identify, serve, and report children with specific learning disabilities. The number of children served varies widely between states, depending upon the stringency of the methods used to determine eligibility. Individual state data are reported to the federal government who then track the estimated prevalence of learning disabilities based upon this information.

Advantages

  • Inexpensive means of monitoring number of children served in educational settings over time.
  • Available information on entire population of school-aged children permitting prevalence estimates.
  • Permits annual comparisons over time.
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Disadvantages

  • Inconsistent criteria for identifying students with learning disabilities.
  • Criteria for service eligibility may not be consistent with diagnostic criteria. Children who receive services may not have symptoms that meet diagnostic criteria.

Surveillance Systems

Examples Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP), Autism and Developmental Disabilities Monitoring (ADDM) Network

These two programs are funded by the Centers for Disease Control and Prevention to estimate the number of children with selected developmental disabilities in Atlanta (MADDSP) and the number of children with ASD and other developmental disabilities in a range of communities throughout the United States (ADDM). They are examples of programs using reviews of administrative records. The process is labor intensive. MADDSP identifies children through a process known as active record review (CDC, 2015). Records are reviewed for all children in metropolitan Atlanta who are in contact with multiple health and educational settings, such as clinics and schools that evaluate and provide services to children with developmental disabilities (CDC, 2015). The reviews occur every other year for children who are or will turn 8 years of age within the year of interest and who live with a parent or guardian who is a resident of one of the five counties in which data are tracked (CDC, 2015). Trained abstractors review records and abstract detailed information (CDC, 2015). The abstracted information from all sources for a given child is then reviewed by a trained clinician (CDC, 2015). The ADDM Network consists of between 11 and 14 sites (depending on the survey year) around the United States. All collect data using the same methods, which are modeled after those of MADDSP. Additional information on surveillance systems that collect data on mental disorders is included in Appendix D.

Advantages

  • All potential cases identified have been brought to the attention of health or education service providers as being in need of help; this indicates a level of severity.
  • All cases are evaluated using the same criteria by trained study personnel.
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Disadvantages

  • There may well be cases that are not brought to the attention of service providers.
  • Data collection is erratic when communities opt into or out of the program, for example, in the ADDM Network.
  • If membership in the network is voluntary, there may be bias in the types of communities that opt in or out, so the sampling does not represent the whole country.
  • Variability may be caused by changes in official criteria for use of a service setting or access to benefits such as Medicaid, rather than by changes in the rates of a disorder in the population.

National Surveys Involving Direct Assessment or Parent Report

Examples National Survey of Children’s Health (NSCH), National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS)

Some sources of data on prevalence trends for psychiatric disorders are based on surveys that involve house-to-house sampling or sampling from existing databases, such as school or telephone listings for a given geographic area. These databases are used to recruit individuals into a random sample who are interviewed in person or by telephone. The NHANES is an example of a national survey that then conducts direct interviews with and assessments of children; the NHIS is a national survey in which information on child mental disorders is obtained through parent reports to an interviewer. Additional information on surveys that collect data on mental disorders is included in Appendix D.

Advantages

  • Can be used to generate representative random samples.
  • Can be used to oversample subgroups of interest.

Disadvantages

  • Can be expensive to generate a sample.
  • Can be difficult to get access to the information (e.g., the name, address, age, and sex of each member of the whole population) needed to recruit a truly representative sample, either because there are no records or because permission to use such records is denied (e.g., school registers).
  • In the case of the NSCH, data reflect parents’ understanding rather than documented diagnoses or direct assessment of a child’s symptoms; e.g., such questions from the NSCH as “Please tell me if a
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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  • doctor or other health care provider ever told you” the [child’s name] had [the disorder].
  • If done repeatedly in the same area to measure trends, changes in the local population rather than changes in the rate of disorder may result in changes in prevalence rates.

Meta-Analyses: Synthesis of Published Research Studies

If studies have been published over a period of time it may be possible to identify a trend in the observed prevalence rates. For child and adolescent psychiatric disorders we are limited by the fact that reliable, standardized measures of childhood mental illnesses were first developed in the 1970s. By the end of the 20th century, however, population surveys using either interviews or questionnaires were much more common.

In order to calculate estimates of “true” prevalence, meta-analytic reviews can control for the methodological variability. For example, Polanczyk and colleagues conducted a meta-analysis of ADHD that found no increase in the population prevalence of the disorder over three decades (Polanczyk et al., 2014). Similarly, a survey of studies of depression showed no increase in rates of depression since the 1970s (Costello et al., 2006). As SSI benefits rely on diagnosed cases, the prevalence of benefits in the SSA database can increase even though “true” prevalence is static. It is not possible to use this method to estimate trends in ASD because the diagnosis has changed, and it was rarely included in population surveys until very recently.

Advantages

  • Will include large numbers of subjects.
  • Can sometimes be used to look at age, sex, or race/ethnic differences or family income level.
  • Can be used to study prevalence rates over a considerable period of time.
  • Can deal statistically with methodological issues such as the different time frames of the interviews.

Disadvantages

  • Is dependent on information from published studies, which may lack certain necessary data (e.g., may not specify the age or sex of the participants).
  • Studies tend to vary in how they group diagnoses; e.g., ASD may be included with developmental disabilities.
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

Medicaid Data

The Medicaid Analytic eXtract (MAX) is a set of data files organized at the person level on Medicaid eligibility, service utilization, and payments. The MAX data are pulled from the Medicaid Statistical Information System and are generated by data submitted from state Medicaid files. These data sets are the largest repository of Medicaid claims, but not all states submit data, and in many states the data for children enrolled in Medicaid managed care are not included or not accurate. Still, MAX data provide a strong source of trend data across years on cases that are diagnosed or treated because Medicaid accounts for a large portion of all child health care. MAX data are particularly useful for analyzing trends for children who qualify for Medicaid because of poverty since there is no impairment or condition requirements for eligibility. MAX data are organized into annual calendar year files. For this report, we analyzed trends in annual diagnosis of specific mental disorders and in the provision of specific mental health treatments.

Advantages

  • Closest estimate for national trends in diagnosis and treatment of mental disorders for children and adolescents.
  • Eligibility for poor children similar to SSI eligibility.
  • Clear delineation of psychiatric drug use and diagnosis.

Disadvantages

  • Clinician diagnosis may reflect best reimbursement rather than the most accurate medical condition. Clinician diagnosis is also subject to error; there is evidence that children who receive treatment may not meet diagnostic criteria.
  • Psychotherapy treatments may be omitted in claims systems.
  • Data are often delayed by 2 to 3 years and so may not reflect recent shifts.

What Is a Prevalence Trend in the SSI Program?

The trends observed in the SSI program are a product of variation in the cases of disability that lead to an application for benefits and subsequent selection by the disability adjudication process. Only children whose families have applied for benefits on their behalf and who sequentially meet all of the eligibility criteria can become recipients of SSI benefits.

As shown in Figure 2-1, an allowance is a finding that a child who applied for disability benefits is eligible based on the disability criteria, after having previously met the income and resource criteria. Therefore, the total number of allowances (the dark gray box in Figure 2-1 within a time period

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

images

FIGURE 2-3 SSI relationship of allowances, recipients, terminations, and suspensions.

can be understood as the total number of new cases of disability among children in low-income households whose families applied for benefits within that time period.

Nearly all applications that result in allowance will also result in the applicant becoming a recipient of SSI benefits (dark gray allowance boxes in Figures 2-1 and 2-3). Within the SSI program, the term “recipients” can be understood as the current number of cases receiving benefits (recipient box in Figure 2-3). Once a child becomes a recipient of SSI benefits, he or she will continue to receive benefits until suspended or terminated or until he or she turns 18. As previously explained, a termination or suspension occurs when a recipient is found to no longer be eligible. Loss of eligibility can occur when a child no longer meets the income and resource criteria or

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

images

FIGURE 2-4 Subpopulations of children eligible for SSI.

is no longer disabled. Suspended individuals can reenter the recipient pool if their status changes before they are terminated.

The number of child SSI recipients at any given point in time will be a function of the number of allowances, terminations, age-18 transitions out of the child SSI program, suspensions, and reentries of suspended individuals, indicated by the yellow box in Figure 2-4. Generally, the number of recipients of the SSI benefits can be understood as the number of poor children who are identified as currently disabled by the SSI system. There will be a certain number of recipients who are, in fact, no longer disabled but have not been reevaluated and identified as such. The total number of recipients will fluctuate from year to year, depending on the number of allowances, terminations, age-18 transitions out of the child SSI program, suspensions, and reentries from suspension for that year. If the number of allowances exceeds the number of terminations and suspensions from year to year, the total number of recipients will increase. Because the adjudication process only evaluates children for disability after they meet the income and resource criteria, the identified cases of disability are only among poor children.

As illustrated by the yellow box in Figure 2-4, SSI recipients are a small subset of children in the United States who are simultaneously in low-income households and meet the requirements of having a “severe, medically determinable impairment.” (Medically determinable impairment

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

BOX 2-3
Prevalence in the SSI Program

For the purposes of this report, SSI prevalence is the proportion of children in low-income households in the United States who are recipients of SSI benefits for the selected mental disorders, individually and in aggregate. The yearly estimated prevalence of children in low-income households who are recipients is based on counts of the number of children who are SSI recipients in December of each year.

generally can be understood to mean children with access to health care services who have evidence to support a diagnosis for their condition.) Within the group of children who are potentially eligible (orange box in Figure 2-4), only those children whose families apply for benefits on their behalf (green box in Figure 2-4), and only those who are adjudicated as disabled become recipients, the group of children represented by the yellow box in Figure 2-4. SSI prevalence can be understood as the ratio of the number of children in the yellow box to the number of children in the blue “children in low-income households” box. The amount of time that a child receives benefits can be understood as the duration of time, or persistence of disability. See Box 2-3 for the definition of prevalence in the SSI program for children.

Challenges for Comparing SSI “Prevalence Trends” to Other Prevalence Trends in the General Population

To accomplish the goals of the task order, the committee compared trends in the prevalence, as illustrated by Figure 2-5. Here we briefly

images

FIGURE 2-5 Comparison of “prevalence” estimate for SSI population to “prevalence” estimate for general population.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

describe significant issues for interpreting the trends observed for the SSI program.

Differences Between the General Population and the SSI Population

An important difference between estimates of prevalence produced by the national surveys and prevalence of mental disorders ascertained by the SSI program is in the composition of the populations surveyed. National surveys are designed to estimate the prevalence of mental disorders among all children, regardless of their income, and regardless of the severity of their disease. In contrast, the SSI adjudication process restricts eligibility for the SSI benefits to those children who meet the income and resource criteria and also meet the requirements of having a severe, medically determinable impairment.

To reduce the effect of real differences on comparisons between the SSI and general populations, the committee compared SSI prevalence data with the U.S. data for children in families meeting poverty criteria (discussed further in Chapter 5). Furthermore, the committee also commissioned a study of Medicaid data, which allowed an analysis of trends in the diagnosis of mental disorders within the population of children who have met criteria for having low income. The Medicaid study also allows a comparison of trends in the rates of mental disorder among all children enrolled in Medicaid with children who are enrolled in Medicaid on the basis of receiving SSI disability benefits.

Other Potential Methodological Concerns

There are various other methodological concerns. First, the SSI taxonomies and categories for disorders are different. The SSI listings criteria are not the same as the diagnostic criteria articulated in the DSM or the ICD. The SSI listings only roughly approximate diagnostic criteria.

Second, the way in which the diagnostic categories in the SSI program are assigned to a determination of disability has significant implications. For every determination that meets or equals a listing, the examiner must record the correlated impairment code. The first listing that can be supported by the evidence in an applicant’s file will be selected by the examiner as the basis for the allowance. For example, an applicant may submit an application alleging disability due to asthma; however, if the examiner finds more evidence supporting an allowance on the basis of ADHD, the applicant’s SSI diagnosis would be ADHD.

For every determination that functionally equals the listings, an examiner is required to record an impairment code. Allowances that functionally equal the listings, by definition, do not meet criteria for a condition

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

TABLE 2-3 Challenges in Comparing SSI Prevalence Trends with Prevalence Trends in the General Population

SSI Recipients Population
General Under-18
Medicaid Population
Key differences in the composition of populations surveyed
(The “denominator” in prevalence)
Only poor children. Children of all income levels. Primarily children in poverty or in other disadvantaged populations.
Only children with “severe, medically determinable impairments.” All children, regardless of the presence of any impairment. Children enrolled in Medicaid who have either two outpatient visits or one inpatient visit.
Key differences between the cases identified
(The “numerator” in prevalence)
SSI data rely on SSI listings and impairment codes. The SSI listings and impairment codes are not currently consistent with the DSM and ICD or any other current taxonomy for mental disorders in children. General population surveys rely on a wide range of methodologies and taxonomies for identifying and classifying cases. These vary depending on the survey/study. Diagnoses are based on physician assignment of a diagnosis, based on the ICD, for billing and reimbursement purposes.
     
SSI classification is based on a review of a range of materials provided by parents, clinicians, and schools to the DDS. Diagnoses can be based on parent report (e.g., NSCH or NHIS), direct assessment (e.g., NHANES), review of medical records (e.g., ADDM), or assessment for service eligibility (e.g., IDEA). Diagnoses are based assessment of a patient by a clinician in a clinical setting.

in the listings; however, examiners must still record an impairment code that closely matches a diagnosis in the applicants file. Allowances that functionally equal the listings may be caused by a condition or a combination of conditions that are not in the SSA’s listings or impairment codes. An impairment code would still be assigned with that allowance, regardless of whether the impairment code fully reflects the underlying causes of the child’s disability. Because of these administrative requirements, the impairment codes associated with an allowance may not accurately reflect the child’s mental disorder. Table 2-3 recaps the challenges encountered in comparing prevalence estimates in the SSI and general populations.

Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

SUMMARY

With these caveats in mind, the committee set out to compare prevalence rate and prevalence rate trends in the SSI and general (total and impoverished) populations of children. Recognizing the limitations of these comparisons, the committee is of the opinion that helpful inferences can be drawn from analyzing data presented in this report. Furthermore, comparing SSI with Medicaid prevalence and trends provides an opportunity to test whether SSI prevalence and trends data deviate substantially from a second comparison population.

FINDINGS

  • For a child (0–17 years of age) to be eligible to receive the SSI disability benefits, the child must meet statutory requirements for having a severe medically determinable impairment, must not be employed, and must come from a household that does not exceed a certain level of income and resources.
  • The majority of children who are recipients of SSI benefits come from households at or below 200 percent of the FPL.

CONCLUSIONS

  • Childhood SSI recipients represent a population of children whose families have applied for benefits and who also have had the resources to supply the necessary evidence to support a successful application for SSI benefits. Many severely impaired or disabled children in the United States are recipients of SSI benefits. Most children who are recipients of the SSI benefits will have severe impairments and will come from an impoverished household.
  • Comparisons between trends in the prevalence of mental disorders in the general population and trends in the SSI population are complicated because of differences in the composition of the populations surveyed (the denominator in the prevalence) and differences in the cases identified (the numerator in the prevalence). Differences in the populations surveyed include income and the severity of impairments. Differences in cases identified also include differences in how disorders are classified for the SSI program versus in national surveys or clinical settings.
  • For the purposes of this report, SSI prevalence is either the proportion of children in low-income households, or the proportion of all children in the United States who are recipients of SSI benefits for the selected mental disorders.
Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Suggested Citation:"2 The SSI Program for Children." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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Next: 3 National-Level Trends in the SSI Program for Children with Mental Disorders, 20042013 »
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Children living in poverty are more likely to have mental health problems, and their conditions are more likely to be severe. Of the approximately 1.3 million children who were recipients of Supplemental Security Income (SSI) disability benefits in 2013, about 50% were disabled primarily due to a mental disorder. An increase in the number of children who are recipients of SSI benefits due to mental disorders has been observed through several decades of the program beginning in 1985 and continuing through 2010. Nevertheless, less than 1% of children in the United States are recipients of SSI disability benefits for a mental disorder.

At the request of the Social Security Administration, Mental Disorders and Disability Among Low-Income Children compares national trends in the number of children with mental disorders with the trends in the number of children receiving benefits from the SSI program, and describes the possible factors that may contribute to any differences between the two groups. This report provides an overview of the current status of the diagnosis and treatment of mental disorders, and the levels of impairment in the U.S. population under age 18. The report focuses on 6 mental disorders, chosen due to their prevalence and the severity of disability attributed to those disorders within the SSI disability program: attention-deficit/hyperactivity disorder, oppositional defiant disorder/conduct disorder, autism spectrum disorder, intellectual disability, learning disabilities, and mood disorders. While this report is not a comprehensive discussion of these disorders, Mental Disorders and Disability Among Low-Income Children provides the best currently available information regarding demographics, diagnosis, treatment, and expectations for the disorder time course - both the natural course and under treatment.

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