Speech and Language Disorders in Children Implications for the Social Security Administration's Supplemental Security Income Program (2016) / Chapter Skim
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4 Supplemental Security Income for Children with Speech and Language Disorders
4 Supplemental Security Income for Children with Speech and Language Disorders
Pages 125-158
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From page 125... ...
The chapter reviews the purpose of the SSI program for children, as well as how this purpose is accomplished through the program's design and operations. It also considers the application of this programmatic design and these operational features to children from low-income, resource-limited households with suspected speech and language disorders potentially severe enough to make them eligible for SSI benefits.
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From page 126... ...
HISTORY OF THE SUPPLEMENTAL SECURITY INCOME PROGRAM FOR CHILDREN1 Created by the Social Security Amendments of 1972 (Public Law 92603) , 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 population.
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SSI Childhood Disability Eligibility Standards from 1974 to 1990 From 1974 to 1990, the Social Security Act set a "comparable severity standard" for determining children's eligibility for benefits. Specifically, the statute allowed eligibility "in the case of a child under the age of 18, if he suffers from any medically determinable physical or mental impairment of comparable severity .
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. In other words, the eligibility determination process for children was an abbreviated7 version of the adult test, lacking the fourth and fifth steps because they addressed employment-related questions that did not apply to most children.
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Alternatively, and consistent with the determination process used for adults, a child's eligibility could rest on a determination that one or more impairments substantially reduced ageappropriate, independent, and effective functioning. In mid- to late 1994, the SSA introduced an impairment code for speech and language disorders, which is discussed in detail in the following subsection.19 The adoption of the functional disability test in Zebley's wake, coupled with new impairment codes and revised Listings for mental disorders that took effect in 1990, had an upward impact on SSI eligibility and enrollment for children and adolescents.
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Of relevance to the present study, the act revised the definition of disability in children by effectively tightening the functional standard. The new statutory standard, which remains in effect today, specified that a child under 18 is considered disabled for SSI benefit purposes if she or he has a "medically determinable physical or mental impairment that results in marked and severe functional limitations"21 and that can be expected to last for a continuous 12-month period or result in death.
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SSI ELIGIBILITY AND THE ELIGIBILITY DETERMINATION PROCESS The purpose of the SSI program is to provide cash assistance to individuals with limited income and resources who are age 65 or older, blind (any age) , or disabled (any age)
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found that approximately 58.0 percent (31.6 percent plus 25.9 percent) of families receiving children's SSI benefits continued to have incomes below 150 percent of the FPL,27 even after accounting for receipt of the benefit.
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As a result, the SSI eligibility determination process evaluates the extent to which physical and mental health conditions are sufficiently severe to impair children's ability to function. A fundamental aspect of functioning ability is communication through speech and language, as described in previous chapters.
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The act explicitly identifies speech and language impairments as a type of disability and defines them as "a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child's educational performance."32 In contrast to the SSI program, IDEA has no financial eligibility tests, nor does it have severity tests with duration requirements. A child will not receive SSI if his or her impairment is expected to improve; however, IDEA provides special education services to children with speech or language impairment regardless of whether the condition is expected to improve.
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SSI FOR CHILDREN WITH SPEECH AND LANGUAGE DISORDERS 135 FIGURE 4-2 For purposes of this report, the SSI eligibility determination process for children. SOURCE: Wixon and Strand, 2013.
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In 2014, three-quarters of children receiving SSI benefits were in households with incomes below 200 percent of the FPL, without taking into account the income from the SSI benefit (Bailey and Hemmeter, 2014)
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. If the Disability Determination Services examiner finds that the claimant has a severe, medically determinable impairment, the claim proceeds to Step 3.
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From a quantitative perspective, the SSA considers an impairment to be "extreme" if a child registers a valid score that is at least three standard deviations from the mean on a comprehensive standardized test designed to measure functioning in any one of the six functional domains (see below) and if the child's day-to-day functioning in domain-related activities is consistent with that score.
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This standard places SSI eligibility criteria on a more limited plane than that used to qualify children for services for children with special health care needs under either IDEA or Title V Six activity domains As noted above, when determining functional equivalence, the SSA considers a child's function in six activity domains.
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. Medical evidence such as formal testing also is used to provide developmental and functional information, and the standard scores from the formal tests along with the standard deviations of scores are used together with the information obtained regarding functioning to determine whether a child exhibits marked or extreme limitation in a domain (SSA, 2014c)
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. For children of any age, marked limitation is determined if a valid score on a comprehensive standardized test designed to measure ability or functioning in a domain is two standard deviations or more but less than three standard deviations below the mean (SSA, 2014c)
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has reported that, because of resource constraints and competing workload priorities, SSA has not performed continuing disability reviews at these prescribed intervals. The GAO found that the number of reviews had decreased by 70 percent between 2000 and 2011 and that as of August 1, 2011, the SSA was experiencing a backlog of about 435,000 child SSI recipients with mental disorders who had not yet received a prescribed continuing disability review.
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From this point forward, when the committee refers to children with speech and language disorders within the SSI program, it is referring to children with one of these two primary impairments. Evaluating Speech and Language Disorders in Children The process for identifying children with speech and language disorders who are eligible for SSI benefits is consistent with the multidimensional, 37 SSI impairment codes are based on the International Classification of Diseases, Ninth Revision, Clinical Modification (SSA, 2013c)
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Case Examples of Speech and Language Impairments Although a number of medical Listings and impairment codes concern conditions that are strongly associated with speech and/or language impairments (such as autism and attention deficit hyperactivity disorder) , speech and language delays often occur in the absence of known medical or other causes (see Chapter 2)
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; he was given a primary diagnosis of speech and language TABLE 4-2 Allowed Case: Functional Domain Summary Domain Rating Acquiring and using information Less than marked limitation Attending and completing tasks Less than marked limitation Interacting and relating with others Extreme limitation Moving and manipulating objects No limitation Caring for self Less than marked limitation Health and physical well-being No limitation SOURCE: Unpublished dataset provided by the Social Security Administration.
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TABLE 4-3 Denied Case: Functional Domain Summary Domain Rating Acquiring and using information No limitation Attending and completing tasks No limitation Interacting and relating with others Less than marked limitation Moving and manipulating objects No limitation Caring for self No limitation Health and physical well-being No limitation SOURCE: Unpublished dataset provided by the Social Security Administration.
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Because the review involved children determined to be entitled to SSI benefits, all of the cases met the SSI financial eligibility criteria, described earlier in this chapter. According to the SSA, 20 percent of children with speech and language disorders who receive SSI benefits are initially allowed because their condition "meets or medically equals" a Listing, while 80 percent are allowed because their condition "functionally equals" the Listings.
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. Figure 4-3 thus shows that the most common secondary impairment codes recorded in the sample of case files are for those conditions that, as noted in Chapter 2, 30 25 20 Case Files 15 10 5 0 Secondary Impairments FIGURE 4-3 Secondary impairments for children with the primary impairment code for speech and language disorders within the random sample of cases reviewed.
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As discussed earlier in this chapter, age-appropriate functioning across six domains is central to an SSI child eligibility determination based on functional status. All but two of the case files in the random sample re Figure 4-4 viewed included a function report form completed by a parent or guardian.
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Furthermore, as Table 4-4 shows, the majority of the children in TABLE 4-4 Relationship Between Receipt of Speech-Language Therapy and IDEA Services Documented in the Case Files Reviewed Individualized Education Plan or Individual Family Service Plan in File Speech-Language Therapy Documented in File Yes No Yes 68 33 Uncertain 14 13 No 12 12 NOTE: The sample size is 152 case files. SOURCE: Unpublished dataset provided by the Social Security Administration.
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Finally, evidence of evaluation and treatment documented or reported to have been received in the case files is consistent with professional standards. While this information cannot be considered representative of, or generalized to, the entire SSI child disability population with primary speech and language disorders, it does provide additional insight into children who receive SSI benefits for these disorders.
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been terminated because they have not been reevaluated. The total number of child SSI recipients fluctuates depending on the number of allowances, terminations, suspensions, and suspension reentries over time.
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population. NOTES: FPL = federal poverty level; SSI = Supplemental Security Income.
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FINDINGS AND CONCLUSIONS This chapter has reviewed the SSI program for children, how it has changed over time, and how those changes have shaped the population of children receiving SSI benefits for speech and language disorders. The committee's review of the relevant statutes and regulations was supplemented by individual case examples, as well as a review of a random sample of SSI case files.
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4-3. An analysis of the impact of SSI revealed that children's SSI benefits raised family income above the FPL by 26.4 percent for families with child SSI beneficiaries.
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4-4. SSI benefits have the effect of lifting some children and their fami lies out of poverty.
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2015. National trends in the child SSI program.
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2013. Identifying SSA's sequential disability determination steps using administrative data.
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