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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

June 2012: 

Supplemental Security Income:

Better Management Oversight Needed for Children's Benefits:

GAO-12-497:

GAO Highlights:

Highlights of GAO-12-497, a report to congressional requesters. 

Why GAO Did This Study:

SSA’s SSI program provides cash benefits to eligible low-income 
individuals with disabilities, including children. In 2011, SSA paid 
more than $9 billion to about 1.3 million disabled children, the 
majority of whom received benefits due to a mental impairment. GAO was 
asked to assess (1) trends in the rate of children receiving SSI 
benefits due to mental impairments over the past decade; (2) the role 
that medical and nonmedical information, such as medication and school 
records, play in the initial determination of a child’s eligibility; 
and (3) steps SSA has taken to monitor the continued medical 
eligibility of these children. 

To do this, GAO analyzed program data; interviewed SSA officials; 
conducted site visits to 9 field offices and 11 state DDS offices 
across the nation; reviewed a generalizable sample of 298 claims for 
select impairments from fiscal year 2010; reviewed relevant federal 
laws and regulations; and interviewed external experts, among others. 

What GAO Found:

The number of Supplemental Security Income (SSI) child applicants and 
recipients with mental impairments has increased substantially for 
more than a decade, even though the Social Security Administration 
(SSA) denied, on average, 54 percent of such claims from fiscal years 
2000 to 2011. Factors such as the rising number of children in poverty 
and increasing diagnosis of certain mental impairments have likely 
contributed to this growth. In fiscal year 2011, the most prevalent 
primary mental impairments among children found medically eligible 
were (1) attention deficit hyperactivity disorder, (2) speech and 
language delay, and (3) autism, with autism claims growing most 
rapidly since fiscal year 2000. State disability determination 
services (DDS) examiners also consider the impact of additional, or 
“secondary,” impairments when making a decision, and when present, 
these impairments were used to support 55 percent of those cases GAO 
reviewed that were allowed in fiscal year 2010. However, SSA has not 
consistently collected those impairment data, limiting its 
understanding of how all impairments may affect decisions. 

DDS examiners generally rely on a combination of key medical and 
nonmedical information—-such as medical records and teacher 
assessments-—to determine a child’s medical eligibility for SSI. In 
its case file review, GAO found that examiners usually cited four to 
five information sources as the basis for their decision, and that 
being on medication was never the sole source of support for 
decisions. Moreover, examiners cited medication and treatment 
information, such as reports of improved functioning, as a basis for 
denying benefits in more than half of cases that GAO reviewed, despite 
a perception among some parents that medicating their child would 
result in an award of benefits. Examiners also reported they sometimes 
lacked complete information to inform their decision making. For 
example, several DDS offices reported obstacles to obtaining 
information from schools, which they believe to be critical in 
understanding how a child functions. Examiners also do not routinely 
receive information from SSA field offices on multiple children who 
receive benefits in the same household, which SSA’s fraud 
investigations unit has noted as an indicator of possible fraud or 
abuse. Without such information, examiners may be limited in their 
ability to identify threats to program integrity. 

SSA has conducted fewer continuing disability reviews (CDR) for 
children since 2000, even though it is generally required by law to 
review the medical eligibility of certain children at least every 3 
years. From fiscal year 2000 to 2011, childhood CDRs overall fell from 
more than 150,000 to about 45,000 (a 70 percent decrease), while CDRs 
for children with mental impairments dropped from more than 84,000 to 
about 16,000 (an 80 percent decrease). The most recent data show that 
more than 400,000 CDRs were overdue for children with mental 
impairments, with some pending by as many as 13 years or more. Of the 
more than 24,000 CDRs found to be 6 or more years overdue, 25 percent 
were for children expected to medically improve within 6 to 18 months 
of their initial allowance. SSA acknowledged the importance of 
conducting such reviews, but said that due to resource constraints and 
other workloads, such as initial claims, most childhood CDRs are a 
lower priority. SSA’s process for issuing waivers from the CDR legal 
requirement lacks transparency, and without these reviews, SSA could 
continue to forgo significant program savings.

What GAO Recommends:

GAO recommends that SSA take steps to ensure needed information, such 
as secondary impairment data and school records, is consistently 
collected; make its CDR waiver process more transparent; and conduct 
additional childhood CDRs. SSA agreed with four recommendations and 
disagreed with one that the agency conduct additional childhood CDRs, 
citing resource constraints. The GAO recommendation acknowledges 
resource constraints, as discussed more fully within the report. 

View [hyperlink, http://www.gao.gov/products/GAO-12-497]. To view the 
e-supplement online, click on GAO-12-498SP. For more information, 
contact Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov. 

[End of section] 

Contents:

Letter:

Background:

Number of Children Applying for and Receiving SSI Benefits Due to 
Mental Impairments Has Increased:

Examiners Rely on a Combination of Key Information Sources to 
Determine Medical Eligibility:

SSA Has Conducted Few Childhood CDRs in Recent Years:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Listings for Mental Disorders for Children under Age 18:

Appendix III: Trends on the Three Most Prevalent Primary Impairments 
among Children with Mental Impairments in the Supplemental Security 
Income Program:

Appendix IV: Reported Medication and Psychotropic Drug Use among 
Children Applying for Supplemental Security Income by Select 
Impairments, Fiscal Year 2010:

Appendix V: Comments from the Social Security Administration:

Appendix VI: GAO Contact and Staff Acknowledgments:

Tables:

Table 1: Percentage of Cases by Reported Use of Medication and by 
Select Primary Impairment, Fiscal Year 2010:

Table 2: Percentage of Medication and Psychotropic Drug Use Reported 
by Select Primary Impairment, Fiscal Year 2010:

Figures:

Figure 1: SSI Benefit Awards to Children with Mental Impairments and 
Key Policy Changes, 1983 to 2011:

Figure 2: SSI Applications and Initial Level Allowances for Children 
under Age 18, by Physical and Mental Impairment Group, Fiscal Years 
2000 to 2011:

Figure 3: Initial Level Allowances for SSI Children with Mental 
Impairments, by Primary Impairment, Fiscal Years 2000 to 2011:

Figure 4: Number of Children under Age 18 Receiving Federally 
Administered SSI Payments, by Mental and Physical Impairment Group, 
December 2000 through December 2011:

Figure 5: Information Sources Used to Support Determinations for 
Children with Alleged ADHD, Speech and Language Delay, and Autism, 
Fiscal Year 2010:

Figure 6: Allowances and Denials by Medication Status for Children 
with Alleged ADHD, Speech and Language Delay, and Autism, Fiscal Year 
2010:

Figure 7: Number of Childhood CDRs Conducted for SSI Recipients under 
Age 18, by Primary Impairment, Fiscal Years 2000 through 2011:

Figure 8: Pending Childhood CDRs and Age 18 Redeterminations for Those 
with Mental Impairments, by Time Lapsed, as of August 1, 2011:

Figure 9: Childhood CDRs Pending for at Least 6 Years, by Anticipated 
Medical Improvement Category, for Children with Mental Impairments, as 
of August 1, 2011:

Figure 10: Applications for Children with ADHD as a Primary 
Impairment, Fiscal Years 2000 to 2011:

Figure 11: Applications for Children with Speech and Language Delays 
as a Primary Impairment, Fiscal Years 2000 to 2011:

Figure 12: Applications for Children with Autism as a Primary 
Impairment, Fiscal Years 2000 to 2011:

Figure 13: Number of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment:

Figure 14: Number of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment and Age:

Figure 15: Percentage of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment and Gender:

Abbreviations:

ADHD: attention deficit hyperactivity disorder:

CHIP: Children's Health Insurance Program:

CDR: continuing disability review:

DDS: disability determination services:

IDEA: Individuals with Disabilities Education Act:

PRWORA: Personal Responsibility and Work Opportunity Reconciliation 
Act of 1996:

SSA: Social Security Administration:

SSDI: Social Security Disability Insurance:

SSI: Supplemental Security Income:

View GAO-12-497 Key Component: 
* Supplemental Security Income: State Trends in Applications, 
Allowances, and Benefit Receipts for Children with Mental Impairments 
(GAO-12-498SP, June 2012), and E-supplement to GAO-12-497:

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

June 26, 2012:

The Honorable Susan Collins:
Ranking Member:
Committee on Homeland Security and Government Affairs:
United States Senate:

The Honorable Thomas R. Carper:
Chairman:
The Honorable Scott Brown:
Ranking Member:
Subcommittee on Federal Financial Management, Government Information, 
Federal Services, and International Security:
Committee on Homeland Security and Government Affairs:
United States Senate:

The Honorable Geoff Davis:
Chairman:
Subcommittee on Human Resources:
Committee on Ways and Means:
House of Representatives:

The Honorable Richard E. Neal:
House of Representatives:

The Social Security Administration (SSA) administers the Supplemental 
Security Income (SSI) program, a nationwide federal assistance program 
that provides cash benefits to eligible low-income individuals with 
disabilities, including children, as well as certain individuals who 
are aged or blind. In 2011, SSA paid almost $50 billion in SSI 
benefits to about 8 million recipients, of which about $9.4 billion 
was paid to 1.3 million children. During the early and mid-1990s, the 
SSI program grew at an unprecedented rate for children due, in part, 
to legal developments that expanded program eligibility for children 
with mental impairments. For example, from the end of 1989 through 
1996, the number of children receiving SSI benefits more than tripled 
from 265,000 to about 955,000. Since that time, the overall number of 
children receiving SSI benefits has continued to rise. In addition to 
this growth, the media has suggested that many parents believe it is 
necessary that their child be prescribed psychotropic drugs in order 
to qualify for benefits.

In light of these developments, you asked us to assess, in part, the 
extent to which SSA is monitoring the initial determination and 
continued eligibility of children with mental impairments. 
Specifically, this report addresses (1) the trends in the rate of 
children receiving SSI benefits due to mental impairments over the 
past decade; (2) the role that medical and nonmedical information, 
such as medication and school records, play in the initial 
determination of a child's eligibility; and (3) the steps SSA has 
taken to monitor the continued medical eligibility of these children.

To examine these issues, we analyzed SSA data on trends and 
characteristics of children applying for and receiving SSI benefits. 
We assessed the reliability of the data presented in this report by 
performing data testing, reviewing internal controls and related 
documentation, and interviewing agency officials, and found potential 
limitations with the extent to which primary and secondary impairment 
coding may be present within SSA's 831 Disability file--the computer 
file that contains data on disability determinations. However, because 
SSA uses the 831 Disability file to make (and thus, reflect) the 
decisions regarding medical determinations, we determined that these 
data were sufficiently reliable to describe certain trends among 
children in the SSI program. To corroborate these data and better 
understand what information sources examiners use in determining a 
child's medical eligibility, we reviewed a generalizable probability 
sample of 298 SSI cases[Footnote 1] from the 184,150 initial 
determinations performed in fiscal year 2010 for children with alleged 
attention deficit hyperactivity disorder (ADHD),[Footnote 2] speech 
and language delay, and autistic disorder and other pervasive 
development disorders (autism).[Footnote 3] We also conducted in-depth 
interviews with SSA management and line staff at SSA headquarters and 
within six SSA regions. These regions are Atlanta, Georgia; Dallas, 
Texas; Chicago, Illinois; Philadelphia, Pennsylvania; Boston, 
Massachusetts; and San Francisco, California. Our work included site 
visits to 9 field offices within these regions, as well as 11 state 
disability determination services (DDS) offices (state agencies under 
the direction of SSA that perform medical eligibility determinations 
and continuing disability reviews of SSI applicants). We selected 
these sites on the basis of (1) their geographic location, (2) high 
volume of SSI applications for children with mental impairments, and 
(3) benefit allowance rates for children with mental impairments. In 
addition, we interviewed numerous external experts from the medical 
and disability advocacy communities and reviewed relevant studies, as 
well as relevant federal laws and regulations.

We conducted this performance audit from February 2011 to June 2012 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe the 
evidence obtained provides a reasonable basis for findings and 
conclusions based on our audit objectives. Appendix I discusses our 
scope and methodology in further detail.

Background:

Eligibility Criteria:

Since 1974, the SSI program, under Title XVI of the Social Security 
Act, as amended,[Footnote 4] has provided benefits to low-income blind 
and disabled persons--including adults and children,[Footnote 5] as 
well as certain aged individuals--who meet financial eligibility 
requirements and the definition of disability. For individuals under 
age 18, a disability is a medically determinable physical or mental 
impairment that results in marked and severe functional limitations, 
and is expected to result in death or which has lasted or can be 
expected to last for a continuous period of at least 12 months. 
[Footnote 6] Families of children receiving SSI payments are generally 
required to use the benefit to meet a child's needs, including food, 
clothing, and shelter.[Footnote 7] The maximum federal benefit payment 
for a child receiving SSI benefits in 2012 is $698 per month, 
regardless of the severity of the child's impairment.[Footnote 8] As 
of December 2011, the average monthly federal child payment was $592.

To apply for benefits, the child's parent or guardian usually submits 
an application to SSA either in person at a local SSA office, by 
telephone, or by mail. SSA's field offices are responsible for 
initially processing these applications and for verifying the child's 
and legal guardian's nonmedical eligibility requirements, including 
income, resources, and living arrangement information. After initial 
verification, the field office transmits the case file to their state 
disability determination services office for a medical evaluation. 
[Footnote 9] The medical evaluation assesses whether the child has a 
physical or mental impairment, or both, that (1) is severe,[Footnote 
10] (2) meets or medically or functionally equals impairments that are 
included in SSA's listing of impairments, and (3) meets the duration 
requirement. If these requirements are met, the child is found to be 
disabled for purposes of SSI.[Footnote 11] The listing of impairments 
for children describes the impairments that cause marked and severe 
functional limitations.[Footnote 12] If a child has a severe 
impairment that does not meet or medically equal any listing, the DDS 
will then determine whether the impairment results in limitations that 
functionally equal the listings.

Initial Determinations and Continuing Disability Reviews:

To aid in evaluating whether a child is medically eligible, DDS 
offices review various medical and nonmedical information about the 
child, such as physician notes, psychological tests, school records, 
and teacher assessments.[Footnote 13] In certain situations, such as 
when the evidence is not sufficient to support a decision as to 
whether a child is disabled, the DDS may purchase a consultative 
examination to assist in making the decision.[Footnote 14] If there is 
evidence that indicates the existence of a mental impairment, the DDS 
is supposed to make every reasonable effort to ensure that a qualified 
psychiatrist or psychologist has completed the medical portion of the 
case review.[Footnote 15]

After the initial determination has been made and before returning the 
case file to complete any outstanding nondisability case development, 
SSA selects a sample of initial determinations for a quality assurance 
review. If the case is sampled, the reviewing component sends the case 
to the servicing field office upon completion of its review. If the 
claimant is determined to be disabled, the field office computes the 
benefit amount and initiates benefit payment. If the claim is denied, 
a claimant has 60 days to request that the DDS reconsider its 
decision. If the claimant is dissatisfied with the reconsideration, he 
or she may request a hearing before an administrative law judge, whose 
decision may then be reviewed by SSA's Appeals Council. When these 
administrative review options have been exhausted, the claimant may 
request judicial review by filing an action in a federal district 
court.[Footnote 16]

If SSA determines that an individual is disabled, the agency is 
required by law to conduct periodic reviews, known as continuing 
disability reviews (CDR), to verify the recipient's continued medical 
eligibility for receiving benefits in certain circumstances.[Footnote 
17] More specifically, SSA is generally required to perform CDRs (1) 
during the first year after birth for babies whose low birth weight is 
a contributing factor to the determination of disability[Footnote 18] 
and (2) at least once every 3 years for all other children under age 
18 whose conditions are considered likely to improve.[Footnote 19] DDS 
offices determine when recipients will be due for CDRs on the basis of 
their potential for medical improvement, and select and schedule a 
review date--otherwise known as a "diary date"--for each recipient's 
CDR. At the time of these reviews, the child's representative payee 
generally must present evidence that the child is and has been 
receiving medically necessary and available treatment for his or her 
impairment. SSA is also generally required to redetermine the 
eligibility of children against the adult criteria[Footnote 20] for 
disability after they reach age 18.[Footnote 21]

Policy Changes to Eligibility Criteria:

Since SSI's inception, a number of policy changes have influenced how 
SSA makes disability decisions and the extent children with mental 
impairments are eligible to participate in the program. In 1984, 
Congress mandated the development of new disability standards for 
individuals with mental impairments and the consideration of the 
impact of multiple impairments in determining disability, among other 
things.[Footnote 22] SSA subsequently expanded the list of mental 
impairments it considers disabling in 1985 and again in 1990, when SSA 
added impairments such as ADHD.[Footnote 23] In 1990, the U.S. Supreme 
Court decided in Sullivan v. Zebley that SSA's use of medical listings 
of impairments for children--without conducting a functional analysis--
was incomplete.[Footnote 24] In response, SSA established "functional 
equivalence" as a basis for SSI eligibility for children, whereby a 
child can be found medically eligible for benefits if the child's 
impairment limits his or her functional ability to the same degree as 
described in a listed impairment. In deciding whether an impairment 
functionally equals the listings, SSA examines how the child functions 
compared to children of the same age who do not have impairments-- 
rather than basing the decision on the child's medical diagnosis. The 
Court's decision also resulted in the introduction of the 
individualized functional assessment. This assessment was intended to 
be comparable to SSA's method for evaluating adult impairments and to 
broaden the evaluation of disability in children with physical and 
mental impairments to include the effects of impairments on a child's 
ability to perform age-appropriate activities on a day-to-day basis. 
Awards to children, especially those with mental impairments, 
increased dramatically for several years following the Sullivan v. 
Zebley decision due partly to SSA readjudicating nearly 300,000 
determinations made between January 1980 and February 1991 under the 
revised disability criteria. By 1994, SSA had reprocessed the majority 
of these cases, and subsequently returned to processing their normal 
case loads. The Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA)[Footnote 25] changed the standard 
for children, and the act was expected to reduce the number of awards. 
However, awards to children with mental impairments began to increase 
again shortly after the legislation was enacted (see figure 1).

Figure 1: SSI Benefit Awards to Children with Mental Impairments and 
Key Policy Changes, 1983 to 2011:

[Refer to PDF for image: line graph] 

Year: 1983; 
Number of children awarded benefits: 18,098. 

Year: 1984; 
Number of children awarded benefits: 21,023. 

Year: 1985; 
Number of children awarded benefits: 21,778. 

Year: 1986; 
Number of children awarded benefits: 26,601. 

Year: 1987; 
Number of children awarded benefits: 24,986. 

Year: 1988; 
Number of children awarded benefits: 24,254. 

Year: 1989; 
Number of children awarded benefits: 25,836. 

Year: 1990; 
Number of children awarded benefits: 42,712. 

Year: 1991; 
Number of children awarded benefits: 75,401. 

Year: 1992; 
Number of children awarded benefits: 144,787. 

Year: 1993; 
Number of children awarded benefits: 160,388. 

Year: 1994; 
Number of children awarded benefits: 135,776. 

Year: 1995; 
Number of children awarded benefits: 112,778. 

Year: 1996; 
Number of children awarded benefits: 85,314. 

Year: 1997; 
Number of children awarded benefits: 63,212. 

Year: 1998; 
Number of children awarded benefits: 77,900.

Year: 1999; 
Number of children awarded benefits: 82,239. 

Year: 2000; 
Number of children awarded benefits: 85,959. 

Year: 2001; 
Number of children awarded benefits: 98,405. 

Year: 2002; 
Number of children awarded benefits: 110,707. 

Year: 2003; 
Number of children awarded benefits: 120,580. 

Year: 2004; 
Number of children awarded benefits: 122,125. 

Year: 2005; 
Number of children awarded benefits: 116,862. 

Year: 2006; 
Number of children awarded benefits: 109,773. 

Year: 2007; 
Number of children awarded benefits: 107,652. 

Year: 2008; 
Number of children awarded benefits: 116,531. 

Year: 2009; 
Number of children awarded benefits: 127,277. 

Year: 2010; 
Number of children awarded benefits: 134,915. 

Year: 2011; 
Number of children awarded benefits: 131,630. 

Key policy changes: 

1985: New mental listings; 
1990: Zebley decision; new mental listings; 
1990-1994: SSA reprocesses prior cases; 
1996: PRWORA enacted. 

Source: GAO analysis of SSA data form the Supplemental Security Record. 

Note: Due to limited diagnosis codes available prior to 1983, SSA 
trend data specific to children with mental impairments are only 
available from 1983 to present. This figure is not intended to depict 
all of the possible factors which may have contributed to program 
trends. It is not possible to measure definitively the contribution 
each policy change made to these trends, and correlation does not 
imply causality. 

[End of figure] 

Number of Children Applying for and Receiving SSI Benefits Due to 
Mental Impairments Has Increased:

The number of children applying for and receiving SSI benefits due to 
a mental impairment has increased for more than a decade, and these 
children comprise a growing majority of all child recipients on the 
SSI disability rolls. While not all such children who are deemed 
medically eligible ultimately meet SSI's financial eligibility 
requirements,[Footnote 26] the numbers of children applying for SSI 
benefits due to a mental impairment increased from 187,052 in fiscal 
year 2000 to 315,832 in fiscal year 2011 (a 69 percent increase). 
[Footnote 27] Despite this increase, SSA data indicated that the 
agency has denied a majority of these child applicants each year. In 
fact, for initial determinations in fiscal years 2000 to 2011, the 
average denial rates for children with physical and mental impairments 
were about 63 and 54 percent, respectively, and allowance rates have 
remained relatively stable over time for both groups of children. 
[Footnote 28] SSA data also showed that since fiscal year 2000, 
children with mental impairments represented the majority of all child 
applications and allowances for SSI benefits (see figure 2).

Figure 2: SSI Applications and Initial Level Allowances for Children 
under Age 18, by Physical and Mental Impairment Group, Fiscal Years 
2000 to 2011:

[Refer to PDF for image: 2 line graphs] 

Physical: 

Fiscal year: 2000; 
Applications: 145,350; 
Allowances: 55,270. 

Fiscal year: 2001; 
Applications: 146,010; 
Allowances: 56,720. 

Fiscal year: 2002; 
Applications: 151,540; 
Allowances: 55,680. 

Fiscal year: 2003; 
Applications: 158,440; 
Allowances: 57,960. 

Fiscal year: 2004; 
Applications: 160,540; 
Allowances: 58,650. 

Fiscal year: 2005; 
Applications: 160,040; 
Allowances: 58,430. 

Fiscal year: 2006; 
Applications: 158,730; 
Allowances: 57,710. 

Fiscal year: 2007; 
Applications: 161,960; 
Allowances: 58,600. 

Fiscal year: 2008; 
Applications: 162,690; 
Allowances: 61,240. 

Fiscal year: 2009; 
Applications: 169,040; 
Allowances: 64,200. 

Fiscal year: 2010; 
Applications: 179,350; 
Allowances: 64,820. 

Fiscal year: 2011; 
Applications: 182,180; 
Allowances: 65,290. 

Mental: 

Fiscal year: 2000; 
Applications: 187,050; 
Allowances: 81,330. 

Fiscal year: 2001; 
Applications: 194,610; 
Allowances: 92,540. 

Fiscal year: 2002; 
Applications: 217,390; 
Allowances: 104,470. 

Fiscal year: 2003; 
Applications: 244,790; 
Allowances: 117,700. 

Fiscal year: 2004; 
Applications: 255,350; 
Allowances: 120,600. 

Fiscal year: 2005; 
Applications: 254,920; 
Allowances: 117,540. 

Fiscal year: 2006; 
Applications: 242,410; 
Allowances: 109,810. 

Fiscal year: 2007; 
Applications: 241,200; 
Allowances: 106,350. 

Fiscal year: 2008; 
Applications: 250,080; 
Allowances: 113,400. 

Fiscal year: 2009; 
Applications: 267,600; 
Allowances: 123,670. 

Fiscal year: 2010; 
Applications: 298,260; 
Allowances: 132,030. 

Fiscal year: 2011; 
Applications: 315,830; 
Allowances: 132,190. 

Source: GAO analysis of SSA data from 831 Disability file. 

Note: The information highlighted in this graphic is based on the 
primary impairment code recorded in the disability determination. Data 
represented as "applications" reflect SSI benefit claims where an 
initial disability determination decision was made each year. Some 
applications could have more than one determination if selected for a 
quality review or if the disability claim is updated during the same 
year. Such determinations are reflected in the data presented in the 
figure. 

[End of figure] 

SSA data show that, for those children with mental impairments who 
apply, the number of children found medically eligible for benefits 
has increased for almost every mental impairment category--such as 
speech and language delay and mood disorder--for fiscal years 2000 to 
2010, with the exception of intellectual disability.[Footnote 29] SSA 
data also show that the three most prevalent primary mental 
impairments among those children found medically eligible in fiscal 
year 2011 were for (1) ADHD, (2) speech and language delay, and (3) 
autism.[Footnote 30] Of these impairments, SSA data indicate that 
applications and allowances for autism saw the largest percentage 
increases from fiscal years 2000 to 2011 (see figure 3). (See appendix 
III for trend information related to these three impairments.) 

Figure 3: Initial Level Allowances for SSI Children with Mental 
Impairments, by Primary Impairment, Fiscal Years 2000 to 2011:

[Refer to PDF for image: multiple line graph] 

Allowances: 

Fiscal year: 2000; 
Conduct/Oppositional Defiant/Personality disorders: 3,840; 
Autism: 5,050; 
Mood disorders: 5,090; 
Speech and language delays: 11,570; 
ADHD: 13,860; 
Intellectual disability: 26,370; 
Other[A]: 15,550. 

Fiscal year: 2001; 
Conduct/Oppositional Defiant/Personality disorders: 4,900; 
Autism: 6,220; 
Mood disorders: 6,590; 
Speech and language delays: 13,360; 
ADHD: 18,120; 
Intellectual disability: 26,670; 
Other[A]: 16,680. 

Fiscal year: 2002; 
Conduct/Oppositional Defiant/Personality disorders: 5,730; 
Autism: 7,490; 
Mood disorders: 7,790; 
Speech and language delays: 16,410; 
ADHD: 21,560; 
Intellectual disability: 27,180; 
Other[A]: 18,330. 

Fiscal year: 2003; 
Conduct/Oppositional Defiant/Personality disorders: 6,210; 
Autism: 8,630; 
Mood disorders: 9,010; 
Speech and language delays: 19,810; 
ADHD: 26,160; 
Intellectual disability: 27,560; 
Other[A]: 20,320. 

Fiscal year: 2004; 
Conduct/Oppositional Defiant/Personality disorders: 6,210; 
Autism: 9,680; 
Mood disorders: 9,760; 
Speech and language delays: 21,340; 
ADHD: 28,740; 
Intellectual disability: 24,600; 
Other[A]: 20,270. 

Fiscal year: 2005; 
Conduct/Oppositional Defiant/Personality disorders: 5,800; 
Autism: 10,630; 
Mood disorders: 9,840; 
Speech and language delays: 21,610; 
ADHD: 28,030; 
Intellectual disability: 22,240; 
Other[A]: 19,400. 

Fiscal year: 2006; 
Conduct/Oppositional Defiant/Personality disorders: 5,380; 
Autism: 11,610; 
Mood disorders: 9,080; 
Speech and language delays: 20,910; 
ADHD: 25,960; 
Intellectual disability: 19,160; 
Other[A]: 17,720. 

Fiscal year: 2007; 
Conduct/Oppositional Defiant/Personality disorders: 5,170; 
Autism: 12,930; 
Mood disorders: 8,910; 
Speech and language delays: 21,140; 
ADHD: 24,630; 
Intellectual disability: 17,150; 
Other[A]: 16,430. 

Fiscal year: 2008; 
Conduct/Oppositional Defiant/Personality disorders: 5,250; 
Autism: 15,810; 
Mood disorders: 9,200; 
Speech and language delays: 22,950; 
ADHD: 26,310; 
Intellectual disability: 17,180; 
Other[A]: 16,700. 

Fiscal year: 2009; 
Conduct/Oppositional Defiant/Personality disorders: 5,550; 
Autism: 18,230; 
Mood disorders: 9,870; 
Speech and language delays: 26,840; 
ADHD: 27,670; 
Intellectual disability: 17,830; 
Other[A]: 17,680. 

Fiscal year: 2010; 
Conduct/Oppositional Defiant/Personality disorders: 5,790; 
Autism: 20,320; 
Mood disorders: 10,590; 
Speech and language delays: 29,150; 
ADHD: 30,110; 
Intellectual disability: 17,680; 
Other[A]: 18,390. 

Fiscal year: 2011; 
Conduct/Oppositional Defiant/Personality disorders: 5,742; 
Autism: 22,931; 
Mood disorders: 10,340; 
Speech and language delays: 29,309; 
ADHD: 29,872; 
Intellectual disability: 16,456; 
Other[A]: 17,538.

Source: GAO analysis of SSA data from 831 Disability file. 

Note: The information highlighted in this graphic is based on the 
primary impairment code recorded in the disability determination.

[A] The "other" category includes borderline intellectual functioning; 
learning disorders; developmental and emotional disorders in newborns 
and younger infants; psychoactive substance dependence disorder; 
somatoform disorders/eating and tic disorders; anxiety disorders; 
schizophrenic, delusional, schizoaffective, and other psychotic 
disorders; and organic mental disorders. 

[End of figure] 

SSA data also show that the cumulative numbers of children receiving 
SSI benefit payments due to a mental impairment has steadily 
increased. From December 2000 to December 2011, the total number of 
children with mental impairments on the SSI disability rolls grew 
almost 60 percent, from about 543,000 to almost 861,000 (see figure 
4).[Footnote 31] Even though the cumulative number of children on the 
rolls has reached an all-time high, SSA data indicate that the 
percentage of children awarded SSI benefits each year due to a mental 
impairment has remained relatively stable, averaging about 65 percent 
from 2000 to 2011.

Figure 4: Number of Children under Age 18 Receiving Federally 
Administered SSI Payments, by Mental and Physical Impairment Group, 
December 2000 through December 2011:

[Refer to PDF for image: stacked line graph] 

Fiscal year: 2000; 
Physical: 270,290; 
Mental: 542,780. 

Fiscal year: 2001; 
Physical: 280,970; 
Mental: 569,880. 

Fiscal year: 2002; 
Physical: 297,890; 
Mental: 578,160. 

Fiscal year: 2003; 
Physical: 308,260; 
Mental: 614,420. 

Fiscal year: 2004; 
Physical: 310,580; 
Mental: 648,320. 

Fiscal year: 2005; 
Physical: 316,880; 
Mental: 686,480. 

Fiscal year: 2006; 
Physical: 334,780; 
Mental: 717,340. 

Fiscal year: 2007; 
Physical: 354,230; 
Mental: 739,920. 

Fiscal year: 2008; 
Physical: 368,090; 
Mental: 759,040. 

Fiscal year: 2009; 
Physical: 381,680; 
Mental: 791,360. 

Fiscal year: 2010; 
Physical: 385,720; 
Mental: 827,130. 

Fiscal year: 2011; 
Physical: 391,710; 
Mental: 860,970. 

Source: GAO analysis of SSA data from the Supplemental Security Record. 

Note: This figure does not include those diagnostic groups that SSA 
reported as "unknown." SSA data showed that as of December 2000, 
"unknowns" totaled 33,042 children (4 percent of all children), and as 
of December 2011, 24,443 children (2 percent of all children). 

[End of figure] 

Additional information on trends in the numbers of SSI applications, 
allowances, and benefit receipts for children with mental impairments 
for individual U.S. states can be found in an electronic supplement to 
this report.[Footnote 32]

Several Factors May Contribute to the Growth in Numbers of Children 
Applying for and Receiving SSI Benefits:

We previously reported that various factors--such as expanded 
disability standards and major program outreach--contributed to rapid 
growth in the SSI children caseload during the 1990s.[Footnote 33] At 
that time, we also reported that various factors contributed to growth 
in the total number of SSI recipients, such as fraud and abuse, 
immigration, and the economy. Some research suggests additional 
factors may be currently affecting the growth and composition of 
childhood disability applicants and recipients, especially for those 
children with mental impairments. Some of these factors may include, 
but are not limited to:

* Increased number of children living in poverty in United States. The 
number of children who are financially eligible for SSI benefits may 
have increased because the number of children living in poverty has 
increased significantly over the past decade. From 2000 to 2010, the 
overall poverty rate for children increased from 16 (11.6 million) to 
22 percent (16.4 million).[Footnote 34] In addition, research has 
shown that certain impairments are more prevalent among children in 
low- income households. For example, the prevalence of ADHD among 
children during the period between 2007 and 2009 was 7.9 percent for 
children with a family income of 200 percent or more of the poverty 
level, whereas the incidence of ADHD was 10.3 percent for children 
with a family income of less than 100 percent of the poverty level, 
according to the National Center on Health Statistics.[Footnote 35]

* Increased awareness and improved diagnosis of certain mental 
impairments. The increased awareness and improved diagnosis of certain 
mental impairments in recent years may also be contributing to the 
growth among individual mental impairments, such as ADHD and autism. 
According to the Centers for Disease Controls and Prevention, about 
one in six U.S. children had a reported developmental disability from 
2006 to 2008, which represents an increase of 17 percent from 1997 to 
2008.[Footnote 36] Researchers noted that the number of children with 
select developmental disabilities, such as ADHD and autism, has 
increased. They added that more study was needed to better understand 
the influence of factors, such as early intervention services, on the 
prevalence of developmental disabilities in recent years. Some 
disability advocates have also suggested that the increased prevalence 
of certain mental impairments may be due, in part, to a diagnostic 
shift in the general population, away from the less specific diagnosis 
of intellectual disability and toward more targeted diagnoses, such as 
autism and speech and language delay.

* Increased numbers of previously uninsured children obtaining health 
care coverage. Today, more low-income children may have access to 
health care coverage than in years past, potentially providing them 
with greater access to physicians and medical treatments and increased 
opportunities for diagnosis of a mental impairment. Since fiscal year 
2000, Medicaid and the Children's Health Insurance Program (CHIP)--the 
nation's largest health care financing programs that can be accessed 
by low-income children--have insured an increasing number of children. 
In fact, from fiscal year 2000 to 2009, the number of children 
enrolled in Medicaid increased from about 24 million to 34 million, 
while during the same period, the number of children enrolled in CHIP 
increased from about 3.4 million to 7.7 million. According to the 
Kaiser Commission on Medicaid and the Uninsured, about 90 percent of 
all children in the United States had some type of health care 
coverage, with Medicaid and other public programs insuring about 35 
percent of these children.[Footnote 37]

* Focus on identifying children with disabilities through public 
school special education services. The Individuals with Disabilities 
Education Act (IDEA), as reauthorized in 2004, allows school districts 
to use some of their IDEA funding for early intervening services for 
students who have not been identified as needing special education, 
but who need additional academic and behavioral support.[Footnote 38] 
Some special education practitioners we interviewed believe that this 
expansion of services to children not previously identified as having 
a disability might cause parents to mistakenly conclude that their 
children have a disability and are therefore eligible for SSI 
benefits. While many children may be receiving services under IDEA, 
[Footnote 39] children would not necessarily qualify for SSI benefits 
given that "disability" is defined differently under the Social 
Security Act and IDEA and they may not meet the financial eligibility 
criteria for SSI.

* Fewer children leaving the disability program prior to age 18. In 
recent years, SSA has conducted significantly fewer childhood CDRs. As 
a result, the number of children who remain on the SSI benefit rolls 
each year has increased because fewer children are being removed from 
the disability program prior to age 18.

While each of these factors may contribute to the overall program 
growth, the relative effects of these and other factors are not fully 
known, and were beyond the scope of this report. Also, the overall 
child population in the United States has grown since 2000 and the 
demographics of this population may have changed since that time.

Secondary Impairments Were Present for Many of Those Found Medically 
Eligible:

For many children found medically eligible for SSI benefits, examiners 
cited a secondary impairment as evidence when making a determination. 
When evaluating how a child functions, examiners assess the 
interactive and cumulative effects of all of the impairments for which 
they have evidence, including those that are not considered severe, 
[Footnote 40] and subsequently code those primary and secondary 
impairments relevant to the determination in their management system, 
whether the determination is allowed or denied. When we asked SSA to 
provide us with data on secondary impairments, officials said that 
there were significant inconsistencies in how examiners nationwide 
code these impairments, and said that we would need to review 
individual cases in order to reliably obtain information on secondary 
impairments.

To better understand what role secondary impairments play in the 
eligibility process, as well as the extent to which examiners used a 
combination of impairments to support determinations, we conducted a 
case file review of initial determinations when the primary impairment 
was ADHD, speech and language delay, or autism. We estimate that of 
the applicants found medically eligible in fiscal year 2010, 55 
percent had a secondary impairment present, and of these cases, 94 
percent of the secondary impairments were mental.[Footnote 41] More 
specifically, of the ADHD cases DDS examiners allowed, 74 percent had 
a secondary impairment present, while 49 and 39 percent of autism and 
speech and language cases, respectively, had a secondary impairment 
present.[Footnote 42]

We also found that when secondary impairments were present, examiners 
used functional equivalence as the basis for an allowance more often 
than they used meeting or medically equal the listings as the basis. 
Our case file review showed that examiners used a secondary impairment 
to support 49 percent of cases allowed on the basis of functional 
equivalence, but only 22 percent of cases allowed on the basis of 
meeting or medically equaling the listings.[Footnote 43]

The presence of multiple impairments may explain why examiners have 
allowed an increasing number of ADHD, speech and language delay, and 
autism cases using functional equivalence as a basis for the 
determination. Determining disability for children with impairments 
that are not severe enough to match a listed impairment can be 
subjective. In order to make a disability determination on the basis 
of functional equivalence, examiners must gather extensive evidence 
from both medical and nonmedical sources, including teachers, parents, 
and others knowledgeable about the child's day-to-day behavior and 
activities. The examiner is then required to classify the child's 
limitation into certain areas or domains of functioning, such as 
acquiring and using information and interacting with others. This 
process requires DDS examiners to make a series of judgments, because 
these domains of functioning may be closely interrelated and 
impairments may or may not affect functioning in more than one area. 
Nevertheless, examiners' use of functional equivalence as a basis for 
determinations has steadily increased for more than a decade for those 
impairments we reviewed. In fiscal year 2011, 71 percent of recipient 
children with ADHD were allowed on this basis, compared to 23 percent 
in fiscal year 2000. Eighty-one percent of children with speech and 
language delays were allowed on the basis of functional equivalence in 
fiscal year 2011, an increase from 59 percent in fiscal year 2000. 
Compared to ADHD and speech and language delay, the percentage of 
autism recipients allowed on the basis of functional equivalence is 
lower--30 percent in fiscal year 2011--but this still represented an 
increase from the 9 percent allowed on this basis in fiscal year 2000.

While it appears that DDS examiners consider secondary impairments 
when making a determination as evidenced by our case file review, SSA 
officials told us that DDS examiners do not always consistently and 
accurately code secondary impairment data, which they acknowledged 
prevents them from fully understanding trends in the disability 
determination process. We found in our case file review that examiners 
sometimes code a secondary impairment that was alleged by a claimant, 
but not material to the ultimate determination. For example, examiners 
coded a secondary impairment that they did not use as support in 27 of 
80 allowance cases for which a secondary impairment was present. SSA 
officials told us that with better information on secondary 
impairments they could compare trends for decisions with single and 
multiple impairments, and better target CDRs towards those impairments 
most likely to improve over time. Officials attributed the coding 
errors primarily to a lack of understanding among examiners about the 
importance of impairment coding, and said that the agency was taking 
steps, such as issuing revised guidance and developing trainings, to 
clarify the importance of capturing such information. However, 
officials said that improving proper coding holds a lower priority 
among its competing workloads.

Examiners Rely on a Combination of Key Information Sources to 
Determine Medical Eligibility:

DDS examiners rely on a combination of key medical and nonmedical 
information sources--such as medical records, effects of prescribed 
medications, school records, and teacher and parent assessments--in 
determining a child's medical eligibility for benefits.[Footnote 44] 
Several DDS officials we interviewed said that when making a 
determination, they consider the totality of information related to 
the child's impairments, rather than one piece of information in 
isolation.[Footnote 45] Based on our case file review, we estimate 
that examiners generally cited four to five information sources as 
support for their decisions in fiscal year 2010 for the three most 
prevalent mental impairments.[Footnote 46] While examiners relied on 
multiple information sources, we found that the extent they used these 
sources varied (see figure 5).

Figure 5: Information Sources Used to Support Determinations for 
Children with Alleged ADHD, Speech and Language Delay, and Autism, 
Fiscal Year 2010:

[Refer to PDF for image: horizontal bar graph] 

Percent of determinations supported[A]: 

Observations from a treating source (e.g., pediatrician, 
psychologist): 65%. 

Teacher assessment: 63%; 

Testing by a treating source (e.g., pediatrician, psychologist): 61%; 

Consultative exam observations: 50%. 

Consultative exam tests: 45%. 

Parent assessment: 44%. 

School tests: 43%. 

Information on medication or treatment: 38%. 

Assessment by a third party (e.g., grandparent, neighbor): 7%. 

Source. GAO estimates based on case file review of sampled initial 
determinations for children with alleged ADHD, speech and language 
delay, and autism, fiscal year 2010.  

[A] The 95 percent margin of error for these estimates does not exceed 
plus or minus 7 percentage points. 

[End of figure] 

In more than 90 percent of the cases we reviewed, the examiner used 
some form of medical evidence to support the decision, regardless of 
whether the child's impairment met, medically equaled, or functionally 
equaled the listings. SSA generally requires DDS examiners to assist 
children and their parents or guardians in obtaining medical records 
in an effort to develop at least a 1-year-long medical history prior 
to applying for benefits.[Footnote 47] We estimate that examiners used 
observations from a treating source, such as a pediatrician or 
psychologist, about a child's functioning and testing by a treating 
source as support for 65 percent and 61 percent of their 
determinations, respectively, making them among the most commonly 
cited information sources. According to many of the DDS officials we 
interviewed, examiners attempt to obtain medical evidence, such as 
psychological tests, physician's notes, and mental health records, for 
children with alleged mental impairments.

If such evidence is not available or is inconclusive, DDS examiners 
may purchase a consultative exam to provide additional medical 
evidence and help them establish the severity of a child's impairment. 
[Footnote 48] This examination is intended to provide the additional 
medical evidence, such as results of a physical examination and 
laboratory findings, needed for a determination. Based on our case 
file review, we estimate at least one consultative examination was 
present in 52 percent of the cases. In some cases, DDS offices 
requested multiple consultative examinations, such as both a 
psychological and speech and language evaluation to address different 
aspects of the alleged impairment. Consultative examinations also 
provide information on the severity of the child's impairment. For 
example, one examination provider described a case in which a child 
with a speech and language delay had receptive and expressive language 
skills that were nearly 2 years behind his chronological age. We 
estimated that cases were more likely to be allowed if the 
consultative exam provider described the child's impairment as severe. 
However, many DDS officials told us that such examinations are only a 
"snap-shot" in time and do not provide a longitudinal view of the 
child's functioning. For this reason, some DDS officials said that 
information from a treating source with a long- standing relationship 
with the child, such as a physician, is more useful.

In addition to medical evidence, SSA uses nonmedical information to 
evaluate the severity of the child's impairment and functioning as 
part of the eligibility determination.[Footnote 49] These sources 
include parents, day care providers, teachers, and others 
knowledgeable about the child's day-to-day behavior and activities. 
SSA field office staff may also provide observations about the child, 
if the child is present for the disability interview. (We estimate 
about 8 percent of child applicants were present at the field office 
for the disability interview.):

Several DDS officials told us school records and teacher assessments 
(standardized questionnaires)[Footnote 50] are especially critical for 
determining medical eligibility because these assessments provide 
information on a child's functioning over time and are generally more 
objective than parent assessments. According to some DDS examiners, 
parents primarily observe their child in an unstructured home 
environment after the child's medications have worn off, and may not 
know what behaviors are developmentally normal, whereas teachers are 
generally in a position to compare the child to other children and 
provide neutral observations on how the child relates to peers, 
responds to medication, and performs in school. We estimate teacher 
assessments and school testing were used to support 63 and 43 percent 
of determinations, respectively. We also identified several examples 
in the case files we reviewed where the teacher's assessment was used 
to establish the child's level of functioning and response to 
medication. For example:

* To support an allowance in one autism case, the examiner noted "Per 
teacher, he is virtually nonverbal. The teacher confirms he is not 
toilet trained or independent in any area of self care.":

* To support a denial decision in one ADHD case, the examiner noted 
that the teacher's assessment indicated that the child's medication 
"has 'helped tremendously' with [the child's] ability to concentrate." 
Additionally, according to the teacher the child "has many friends and 
is very social. She has no problems interacting with others. Claimant 
has no problems with self care. She participates in the softball and 
dance team." 

* To support a denial decision in one autism case, the examiner 
reported that the "teacher…notes he is more controlled on his meds." 

After the necessary information is collected to make a disability 
determination, several examiners said that they compare all the 
information to identify inconsistencies and assign weight to the 
various sources. For example, some officials told us examiners assess 
the credibility of parents' assessments of children's functioning by 
comparing it to physicians' and teachers' statements. SSA policy notes 
that an inconsistency does not necessarily mean that a determination 
cannot be made because often most of the evidence or the most 
substantial evidence outweighs the inconsistent evidence and 
additional information would not change the determination or decision. 
Among the 298 alleged ADHD, speech and language delay, and autism 
cases we examined, there were 25 in which material inconsistencies 
could not be resolved between sources, requiring the examiner to 
assign more or less weight to certain sources. Examiners assigned more 
weight to teacher assessments or information from school testing in 11 
of the 25 cases. Examiners also generally assigned more weight to 
testing and observations of functioning by a consultative examiner (10 
of the 25 cases) or by a treating source (10 of the 25 cases). In 
contrast, parents' assessments were given less weight in 14 of the 25 
cases, although decisions were made on a case by case basis. In one 
ADHD case, the child's mother alleged a developmental delay, but a 
psychological consultative exam did not find evidence of such a delay. 
The child's teacher also stated that the child performed well 
academically when not under timed conditions. In this case, the 
examiner gave less weight to the parent's assessment and denied the 
claim.

When Used in Eligibility Decisions, Medication and Treatment 
Information Is Frequently a Basis for Denying Benefits:

Despite a media report that prescription medication is considered by 
some parents as key to obtaining SSI benefits, we found that 
medication and treatment information is frequently a basis for denying 
benefits. SSA and DDS officials told us that medication is generally 
given no more weight than any other medical or nonmedical information 
in determining a child's medical eligibility. In addition, several DDS 
officials told us medication is considered in the context of other 
sources of information as "just one piece of the puzzle." Our case 
file review confirmed that information on medication and treatment was 
never the sole source of support for an allowance or denial. In fact, 
we found that applicants were more likely to be denied than allowed 
when medication was reported (see figure 6).

Figure 6: Allowances and Denials by Medication Status for Children 
with Alleged ADHD, Speech and Language Delay, and Autism, Fiscal Year 
2010:

[Refer to PDF for image: horizontal bar graph] 

Reported/used: Medication use; 
Application denied: 65%; 
Application allowed: 35%. 

Reported/used: Psychotropic drug(s) use; 
Application denied: 32%; 
Application allowed: 68%. 

Reported/used: Medication or treatment used to support determination; 
Application denied: 34%; 
Application allowed: 66%. 

Not reported/used: Medication use; 
Application denied: 47%; 
Application allowed: 53%. 
        
Not reported/used: Psychotropic drug(s) use; 
Application denied: 48%; 
Application allowed: 52%. 
        
Not reported/used: Medication or treatment used to support 
determination; 
Application denied: 48%; 
Application allowed: 52%. 

Source: GAO estimates based on case file review of sampled fiscal year 
2010 initial determinations for children with alleged ADHD, speech and 
language delay, and autism.        

[End of figure]

When applying for benefits, parents reported that their children were 
prescribed some form of medication in 58 percent of the cases we 
reviewed. Of cases where medication was reported as present, 65 
percent were denied and 35 percent were allowed. By comparison, 47 
percent of cases were denied and 53 percent were allowed when 
medication was not reported as present.[Footnote 51] We found that in 
cases in which psychotropic drug use was reported,[Footnote 52] 
applicants were also more likely to be denied.[Footnote 53] In these 
cases, 68 percent were denied and 32 percent were allowed. 
Nevertheless, our case file review suggests examiners did not decide 
whether to allow or deny a claim based on the absence or presence of 
medication. Although medication was reported as present in 58 percent 
of cases, it was only cited as support for a determination in 38 
percent of cases.

Beyond examining cases where parents reported that their children were 
prescribed medication, we also specifically looked at cases where 
examiners cited information on medication or treatment as part of the 
rationale for their determinations. We found examiners generally 
considered how the child responded to these interventions when making 
a determination, and in 66 percent of the cases where information on 
medication or treatment was used to support a determination, the 
applicant was denied. When examiners cited medication and treatment as 
a basis for denials, they noted that the child's functioning improved 
due to these interventions. For example, in one denied ADHD case, the 
examiner wrote that the claimant "has responded well to medication and 
while on medication has no problems functioning, completing work on 
time and getting along with others." In one denied speech and language 
delay case, the examiner noted that the claimant "has been through 
multiple therapies" and that "these therapies have been successful." 
To the extent that medication improves functioning, DDS officials told 
us they could potentially find that the child is not disabled under 
program rules. In contrast, in cases where the child's functioning was 
not improved by medication, this information generally helped support 
an allowance. For example, in one allowed ADHD case, the examiner 
noted that the child was "not able to complete work independently 
despite tx [treatment] with psych meds and special supervision in a 
partial [classroom] inclusion setting." In another allowed ADHD case, 
the examiner observed that both the treating source and teacher's 
assessment "indicate marked limitations in attention and concentration 
even with stimulant meds." 

Despite the examiners' focus on how medication affects functioning, 
certain field office and DDS officials acknowledged that they believe 
some parents are under the impression that medicating their children 
will improve their likelihood of being found eligible for benefits. 
For example, in one denied ADHD case the child's mother did not 
cooperate with the DDS's efforts to obtain a consultative exam. 
[Footnote 54] The mother argued the DDS should already have enough 
evidence to support an allowance because the child was taking 
medication. However, other DDS officials told us some parents may 
avoid medicating their child prior to a consultative examination so 
that the child misbehaves and appears more disabled--further 
reinforcing the importance of multiple tests and observations for 
determining eligibility.

Examiners Sometimes Lack Complete Information to Inform Their Decision 
Making and Identify Potential Threats to Program Integrity:

Despite the importance of nonmedical information in determining a 
child's medical eligibility, examiners sometimes face challenges 
obtaining complete information. Several DDS offices reported 
difficulty obtaining school records or teacher assessments, which they 
partly attributed to school and teacher concerns about the time 
involved to compile this information, potential liability issues, or 
confusion about how such information is used in the disability 
decision-making process. For example, some DDS examiners told us that 
in certain instances teachers view their completion of the assessment 
as affirming that a child is disabled and thus endorsing SSA's 
decision to award benefits. They do not understand that examiners base 
their determinations on the totality of evidence or that the 
assessment could be used to support a denial. In one of the cases we 
reviewed, a teacher returned a blank teacher assessment with a note 
stating "we are not allowed to fill these out anymore.":

Our case file review estimated that teacher assessments were absent 
for 57 percent of cases for children age 7 or younger--which is 
unsurprising, given that many of these children may not yet be school 
age--but such assessments were also absent for 25 percent of cases for 
children older than age 7. To address this challenge, SSA officials 
told us that some DDS offices have dedicated staff to conduct outreach 
to schools in order to emphasize the importance of information from 
schools as an evidence source. However, they added that these staff 
have competing priorities, including recruiting consultative exam 
providers and other medical professionals, which limit the amount of 
outreach they can perform. In addition to strengthening relationships 
with school personnel, disability advocates told us that SSA could 
revise the teacher assessment by using clearer language to make it 
more inviting to teachers. They also noted that SSA could further 
emphasize that by completing the assessment, teachers are not 
endorsing SSA's ultimate decision as to whether the child is disabled 
or qualifies for benefits. Because schools and teachers are not 
required to provide records or teacher assessments, some DDS offices 
pay a fee for school records, but state laws prevent others from doing 
so, according to SSA officials. SSA officials did not know the extent 
to which DDS offices have paid for school records or the amount they 
had paid.[Footnote 55]

SSA officials informed us they have heard reports of some DDS offices 
facing challenges in obtaining information from schools, but they do 
not know the degree to which these challenges exist nationwide, nor 
has SSA conducted an empirical analysis of challenges related to 
obtaining information from schools. SSA did issue guidance on steps 
DDS offices can take to mitigate processing delays associated with 
obtaining school evidence during extended school breaks, such as 
summer vacation, but the agency has not issued guidance regarding year-
round challenges associated with obtaining information from schools. 
Without further study to determine how widespread these obstacles are, 
it will remain unclear whether additional guidance is warranted.

In addition to the challenges they sometimes face in obtaining 
information from schools, DDS examiners said that they do not 
routinely receive information from SSA field offices on multiple 
siblings receiving SSI benefits within the same household even though 
they are directed to be alert for such cases. SSA's policy operations 
manual states that disabilities may occur in more than one member of a 
family or household, but notes prior case experience has shown this 
type of situation is an indicator of possible fraud or abuse, 
particularly where certain mental impairments are involved. For 
example, one of SSA's Cooperative Disability Investigations Units 
investigated a case in which parents applied for SSI benefits on 
behalf of their four children, alleging that they all suffered from 
ADHD and conduct issues.[Footnote 56] However, investigators found 
that the school guidance counselor had never observed them exhibiting 
symptoms of ADHD despite seeing the four children daily, and that a 
doctor had rescinded an order authorizing the school to administer 
ADHD medication to the children. In this instance, SSA subsequently 
denied the siblings' applications for SSI benefits. SSA's policy 
operations manual directs examiners to refer such cases to SSA's 
Cooperative Disability Investigations Unit or Office of the Inspector 
General for further development, if questionable issues cannot be 
resolved. Based on our interviews, it appears that SSA field offices 
do not consistently notify DDS examiners when an applicant's siblings 
are already receiving SSI benefits, nor are they always made aware of 
concurrent sibling applications. SSA data indicate that as of January 
2012, nearly 64,000 children, or 5 percent of all child recipients, 
resided in a household where more than 1 child received disability 
benefits. Without information on such children, DDS examiners may be 
limited in their ability to identify potential fraud or abuse in the 
program and elevate these cases to the attention of SSA's fraud 
investigations unit.

SSA Has Conducted Few Childhood CDRs in Recent Years:

SSA has conducted significantly fewer CDRs for children receiving SSI 
benefits since 2000, even though SSA is generally required to perform 
CDRs at least every 3 years on child recipients under age 18 whose 
impairments are likely to improve, as well as certain other 
individuals (see fig 7).[Footnote 57] Childhood CDRs overall fell from 
more than 150,000 in fiscal year 2000 to about 45,000 reviews in 
fiscal year 2011 (a 70 percent decrease). More specifically, CDRs for 
children under age 18 with mental impairments declined from more than 
84,000 to about 16,000 (an 80 percent decrease). Similarly, SSA has 
conducted significantly fewer CDRs for adult benefit recipients of 
either SSI or Social Security Disability Insurance (SSDI).[Footnote 
58] From fiscal years 2000 to 2011, the number of adult CDRs fell from 
584,000 to 179,000.[Footnote 59] However, in comparison, the 
proportion of childhood CDRs conducted has remained much lower than 
the proportion of adult CDRs conducted. SSA officials attribute the 
decrease in CDRs overall, including childhood CDRs for those with 
mental impairments, primarily to resource limitations and a greater 
emphasis on processing initial claims and reducing the backlog of 
requests for appeals hearings in recent years. While SSA did increase 
the number of CDRs it performed after receiving additional funding 
specifically targeted for CDRs from fiscal years 1996 to 2002, CDRs 
decreased once the funding expired.

Figure 7: Number of Childhood CDRs Conducted for SSI Recipients under 
Age 18, by Primary Impairment, Fiscal Years 2000 through 2011:

[Refer to PDF for image: stacked vertical bar graph] 

Fiscal year: 2000; 
Mental impairment CDRs: 84,013; 
Physical impairment CDRs: 66,864. 

Fiscal year: 2001; 
Mental impairment CDRs: 67,012; 
Physical impairment CDRs: 37,909. 

Fiscal year: 2002; 
Mental impairment CDRs: 112,533; 
Physical impairment CDRs: 63,967. 

Fiscal year: 2003; 
Mental impairment CDRs: 90,426; 
Physical impairment CDRs: 44,301. 

Fiscal year: 2004; 
Mental impairment CDRs: 68,444; 
Physical impairment CDRs: 47,053. 

Fiscal year: 2005; 
Mental impairment CDRs: 41,280; 
Physical impairment CDRs: 33,817. 

Fiscal year: 2006; 
Mental impairment CDRs: 13,607; 
Physical impairment CDRs: 14,080. 

Fiscal year: 2007; 
Mental impairment CDRs: 2,983; 
Physical impairment CDRs: 4,632. 

Fiscal year: 2008; 
Mental impairment CDRs: 3,308; 
Physical impairment CDRs: 6,671. 

Fiscal year: 2009; 
Mental impairment CDRs: 7,982; 
Physical impairment CDRs: 15,166. 

Fiscal year: 2010; 
Mental impairment CDRs: 13,086; 
Physical impairment CDRs: 25,987. 

Fiscal year: 2011; 
Mental impairment CDRs: 16,405; 
Physical impairment CDRs: 28,120. 

Source: GAO analysis of SSA data from CDR Waterfall Files. 

[End of figure]

Hundreds of Thousands of Childhood CDRs Are Overdue by More than 3 
Years, Including Reviews for Children Expected to Medically Improve:

Because SSA has conducted fewer childhood CDRs in recent years, as of 
August 1, 2011,[Footnote 60] the agency had a backlog of about 435,000 
child SSI recipients with mental impairments whose review had not yet 
been conducted (see figure 8).[Footnote 61] Of these recipients, about 
344,000 (79 percent) had exceeded the scheduled date by at least a 
year, with about 205,000 (47 percent) exceeding their date by 3 years 
and about 24,000 (6 percent) exceeding the scheduled date by 6 years. 
We also identified several cases which exceeded their scheduled date 
by 13 years or more. SSA data also indicate that while age 18 
redeterminations are conducted in a more timely manner, about 8 
percent of these reviews are also overdue by 3 years or more for 
recipients with mental impairments.[Footnote 62]

Figure 8: Pending Childhood CDRs and Age 18 Redeterminations for Those 
with Mental Impairments, by Time Lapsed, as of August 1, 2011:

[Refer to PDF for image: vertical bar graph] 

Years from scheduled date: Less than 1: 
CDR's: 90,090; 
Age 18 redeterminations: 27,680. 

Years from scheduled date: 1 to less than 2; 
CDR's: 72,280; 
Age 18 redeterminations: 5,130. 

Years from scheduled date: 2 to less than 3; 
CDR's: 67,130; 
Age 18 redeterminations: 1,780. 

Years from scheduled date: 3 to less than 4; 
CDR's: 70,730; 
Age 18 redeterminations: 1,110. 

Years from scheduled date: 4 to less than 5; 
CDR's: 62,760; 
Age 18 redeterminations: 650. 

Years from scheduled date: 5 to less than 6; 
CDR's: 46,800; 
Age 18 redeterminations: 510. 

Years from scheduled date: 6 or more; 
CDR's: 24,400; 
Age 18 redeterminations: 830. 

Source: GAO analysis of SSA data from CDR Waterfall Files. 

[End of figure]

Upon further review of the 24,000 childhood CDRs pending 6 years or 
more, we found that about 70 percent were for children deemed "medical 
improvement possible," while 25 percent of these pending CDRs were for 
those children deemed medically expected to improve (see figure 9). As 
we noted, DDS staff generally establish the timeframe for when SSA 
should conduct a CDR on the basis of the expected likelihood of a 
recipient's medical improvement. The improvement categories and 
general time frames used are (1) "medical improvement expected," 6 to 
18 months; (2) "medical improvement possible," 3 years; and (3) 
"medical improvement not expected," 5 to 7 years. Among childhood 
CDRs, reviews of children who are expected to medically improve are 
more productive than reviews of children who are not expected to 
medically improve because they have a greater likelihood of benefit 
cessation and thus yield higher cost savings over time. In total, 
almost all of the more than 24,000 CDRs pending for 6 years or more 
fell within the improvement categories of "medical improvement 
expected" or "medical improvement possible," and, surprisingly, about 
6,200 of these were pending for children who had been expected to 
medically improve. In fact, we identified nine recipients who were 
expected to medically improve, but whose CDR had been pending for 13 
years or more.

Figure 9: Childhood CDRs Pending for at Least 6 Years, by Anticipated 
Medical Improvement Category, for Children with Mental Impairments, as 
of August 1, 2011:

[Refer to PDF for image: pie-chart] 

Medical Improvement Possible: 70% (17,225 cases); 
Medical Improvement Expected: 25% (6,238 cases); 
Medical Improvement Not Expected: 4% (1,019 cases). 

Source: GAO analysis of SSA data from CDR Waterfall Files. 

Note: Percentages do not equal 100 percent due to rounding. 

[End of figure] 

Due to Competing Workloads, SSA Gives Lower Priority to Most Childhood 
CDRs, Including Legally Required Reviews for Children Likely to 
Medically Improve:

According to SSA officials, when CDR funding is less than what is 
needed to conduct all CDRs at the scheduled intervals, the agency has 
historically given priority to (1) maintaining SSDI CDR currency, (2) 
performing statutorily mandated SSI age 18 and low birth weight 
reviews, and (3) performing reviews considered most cost-effective. As 
a result, SSA has not conducted many other types of the statutorily 
mandated SSI reviews and childhood CDRs in recent years. SSA officials 
also told us that it is more cost effective to conduct adult SSDI CDRs 
than childhood SSI CDRs, because ceasing benefits for a young adult 
recipient may potentially represent decades of saved benefits. 
Additionally, because SSDI benefit payments are, on average, almost 
twice as much as SSI childhood payments, CDRs of adult SSDI cases 
generally produce greater lifetime savings, according to SSA 
officials. However, SSA only ceased about 12 percent of all adult 
claims that received a CDR, compared to 32 percent of children, in 
fiscal year 2011. More specifically, of those childhood CDRs conducted 
for children under age 18 with mental impairments, SSA ceased benefits 
for about 28 percent on average in fiscal year 2011, with personality 
disorders[Footnote 63] and speech and language delay having the 
highest cessation rates, 39 and 38 percent, respectively.[Footnote 64] 

SSA places a high priority on conducting certain SSI reviews, such as 
age 18 redeterminations and CDRs of low birth weight babies. SSA is 
generally required by law to conduct age 18 redeterminations within 1 
year after a child turns age 18, and within 12 months after birth for 
recipients whose low birth weight was a contributing factor material 
to the determination of their disability.[Footnote 65] In fiscal year 
2011, CDRs in these two areas represented 82 percent of all childhood 
reviews. SSA officials told us that if resources are subsequently 
available after addressing these priority areas, they will conduct 
other SSI childhood CDRs. SSA uses a profiling model to score and 
prioritize the performance of CDRs for each recipient group by the 
probability of medical improvement for each recipient. The model 
contains 85 independent variables, including age, primary and 
secondary impairment, time on disability rolls, and medical diary 
type. However, SSA has maintained that due to limited CDR funding in 
recent years, it has conducted relatively few childhood CDRs based on 
this model.

The Social Security Act generally requires that SSA conduct CDRs, no 
less frequently than once every 3 years, for children under the age of 
18 receiving SSI benefits who are likely to medically improve. 
[Footnote 66] While SSA has the authority to waive this requirement on 
a state-by-state basis, SSA officials informed us that the agency has 
never formally exercised that authority. Consequently, SSA initially 
appeared to be in violation of the 3-year requirement set forth in the 
Social Security Act with respect to the more than 200,000 children we 
identified, as of August 1, 2011, for whom medical improvement was 
likely, but who had not received a CDR in the prior 3 years. 
Similarly, SSA's Office of the Inspector General recently reported 
that SSA had not complied with the childhood CDR provision in the 
Social Security Act.[Footnote 67]

On February 23, 2012, we discussed with officials from SSA's Office of 
the General Counsel and the Office of Disability Programs whether the 
agency was in possible violation of the 3-year requirement, their 
views on the legal obligations to conduct CDRs, and whether the agency 
had ever exercised the waiver authority. SSA officials told us that 
they did not agree that the agency had failed to comply with this 
requirement. Rather, they explained that when SSA provides a DDS 
office funding that is not sufficient to cover its entire CDR 
caseload, that funding decision may functionally serve as a waiver of 
the 3-year requirement. However, they acknowledged that such funding 
decisions regarding state DDS offices would not in fact serve as a 
formal waiver under the law. We noted that, in fact, SSA's fiscal year 
2009 CDR report indicated that the agency had not exercised its 
authority to waive the 3-year requirement.[Footnote 68] In short, the 
answers provided to us during this discussion did not provide us with 
sufficient support for their position that the agency had exercised 
its waiver authority and, thereby, justified the practice of 
conducting significantly fewer CDRs than would otherwise be required 
by law. Therefore, we formally requested, in a letter dated March 6, 
2012, that SSA's General Counsel provide us with the agency's official 
views on the issues of (1) their compliance with the CDR requirement, 
(2) their justification for not conducting certain childhood CDRs as 
required by law, and (3) whether the agency has exercised its waiver 
authority.

In response, SSA's General Counsel acknowledged, in a letter dated 
April 20, 2012, that there are at least 200,000 children in the SSI 
program under the age of 18 for whom medical improvement is likely, 
but who have not had a CDR in the last 3 years. They also noted that 
while the agency has not issued any documents that formally grant a 
"waiver" to a state, the agency believes the consultation process it 
engages in with each state is consistent with Congress' intent in 
enacting the waiver provision and is consistent with the agency's 
regulatory waiver provision.[Footnote 69] Specifically, SSA informed 
us that the agency consults with the state DDS officials on a 
quarterly basis about how best to manage their workloads, including 
CDRs. In making determinations about the appropriate number of CDR 
cases to conduct, SSA noted that it considers the backlog of pending 
reviews, the projected number of new applications, the current and 
projected staffing levels in each state agency, and the available 
medical and other resources.[Footnote 70] SSA maintains that these 
discussions are, in essence, an "informal" waiver process regarding 
the appropriate number of CDR cases that DDS officers should 
conduct.[Footnote 71] In light of the questions we raised, SSA 
indicated it would begin issuing a formal waiver document after 
undertaking its ongoing consultation process with the DDS offices, in 
order to make clear that it is complying with the requirements of the 
law. Specifically, SSA asserted that it would issue a written document 
to states that waives the requirement to perform all required CDRs 
when the appropriate number of cases that SSA expects the states to 
perform in a fiscal year is less than the total number of CDRs that 
will come due in the state during the relevant fiscal year.

In its most recent CDR report, which covers fiscal year 2010 and was 
dated May 1, 2012, SSA does not make a similar statement, as it did in 
the fiscal year 2009 report, that it had issued no waivers from the 
CDR requirements.[Footnote 72] Rather, the agency explained its 
informal waiver process and the proposed issuance of a formal waiver 
document in the future, similar to its April 2012 letter, but with 
additional detail. The report indicated that the explanation is about 
the agency's "long-standing process;" however, SSA noted, that in 
previous annual CDR reports, the agency had not explained how it had 
met the waiver requirements. To make this point clearer, SSA proposed 
to begin issuing a formal waiver document in fiscal year 2012. We 
believe that there is some inconsistency about how SSA has described 
its waiver process, and thus its adherence to the law in the past, and 
the waiver process has not been transparent and open to date.

SSA's response noted that the agency intends to begin issuing a formal 
waiver document, but did not provide us with information on the extent 
to which the agency's waiver process would be open, transparent, and 
public. According to GAO's Internal Control Management and Evaluation 
Tool, agencies should maintain relevant and reliable information 
relating to their activities and should establish open and effective 
communications channels with relevant groups that could have an impact 
on agency activities, as well as establish communications with 
Congress, other federal agencies, the public, and others so that the 
agency's activities and risk are understood.[Footnote 73] Without a 
transparent, open, and public waiver process, the extent to which SSA 
is conducting CDRs consistently with its legal requirements will 
continue to be unclear as it has been in the past. In addition, it 
appears that SSA's Inspector General was not informed that the agency 
was exercising its waiver authority as it conducted its investigation, 
and as a result that office found SSA to be in violation of the 3-year 
requirement. Yet, SSA is now suggesting that its consultation process 
is, and has been, sufficient to satisfy the 3-year requirement. Until 
SSA formally clarifies how it will implement this waiver process, 
questions will remain about the extent to which the proposed waiver 
process is sufficient to ensure compliance with the law.

Regardless of whether the proposed waiver process is sufficient to 
ensure compliance with the law, hundreds of thousands of childhood 
CDRs still remain overdue. When CDRs are not conducted as scheduled, 
some recipients--regardless of age or impairment--may receive benefits 
for which they are no longer eligible. In September 2011, SSA's Office 
of the Inspector General estimated that SSA had paid about $1.4 
billion in SSI benefits to approximately 513,000 recipients under age 
18 who should have not received them--some of whom were pending 
reviews for 5 or more years.[Footnote 74] They estimated that SSA will 
continue to make improper payments of approximately $461.6 million 
annually until these reviews are completed. Furthermore, in its most 
recently issued CDR report, SSA estimated a program savings of $9.30 
for every $1 invested in conducting CDRs and projected that those CDRs 
conducted for adult SSDI and SSI recipients and for child SSI 
recipients combined in fiscal year 2010 would save federal programs 
the present value of estimated lifetime benefits of $3.5 billion. 
[Footnote 75]

SSA and DDS officials have acknowledged that the agency has not 
conducted reviews for child recipients in a timely manner, and in some 
cases, they have not conducted childhood CDRs prior to a child's age 
18 redetermination. One of the major objectives in SSA's newly issued 
Strategic Plan[Footnote 76] is to "increase efforts to accurately pay 
benefits" and the Plan indicates that SSA intends to conduct more 
CDRs, as funding is available. Congressional appropriations for CDRs 
overall increased from $504 million in fiscal year 2009 to $758 
million in fiscal year 2010 and have essentially remained at this 
level since that time, according to agency officials.[Footnote 77] SSA 
continues to evaluate how to use this funding; however, it is not yet 
known to what extent the agency would increase the number of childhood 
CDRs in the future or target such CDRs toward those children with 
mental impairments who are likely to medically improve.

Conclusions:

Children with mental impairments represent a growing number of 
applicants and recipients within the SSI program, which have 
contributed to the program's overall growth in recent years. However, 
a lack of key information about these children may present SSA with 
ongoing management challenges. In particular, the agency has taken 
steps to better understand program trends, but it does not 
comprehensively determine how multiple impairments influence 
eligibility decisions, in part because DDS offices have not 
consistently collected secondary impairment data. Without steps to 
ensure that this information is more reliably recorded, SSA management 
will not have a complete picture of the characteristics of children 
with mental impairments receiving benefits or changes in this 
population over time.

Because examiners sometimes lack key information for cases they 
review, including school records and information on multiple children 
receiving benefits in the same household, they may face challenges in 
making eligibility decisions and identifying potential fraud or abuse. 
Examiners have also increasingly based allowance decisions on a 
finding of functional equivalence for children with the most prevalent 
mental impairments, requiring more complex decision making. Yet 
because some examiners face obstacles in obtaining information from 
schools--which they consider critical to understanding how a child 
functions--SSA cannot ensure that examiners have the necessary 
information to arrive at the most accurate determinations. 
Additionally, as a key program gatekeeper, DDS examiners are in a 
unique position to identify program integrity threats related to 
multiple children receiving SSI benefits within the same household. 
However, without better information on these types of arrangements 
they are unable fulfill this role in preventing potential fraud and 
abuse.

The fact that more than 430,000 childhood CDRs are overdue raises 
concerns about the agency's ability to manage limited funds in a 
manner that adequately balances its public service priorities with its 
stewardship responsibility. When reviews are not conducted as 
scheduled, some child recipients may receive benefits for which they 
are no longer eligible, potentially costing taxpayers billions of 
dollars in overpayments. Furthermore, CDRs provide an important check 
on program growth by removing ineligible recipients from the rolls, 
even while new applicants are added. If these reviews are not 
conducted in sufficient numbers, the agency will continue to struggle 
to contain growth in benefit payments, placing added burden on already 
strained federal budgets. Congress appropriated funding for SSA to 
conduct more CDRs in recent years, and SSA is evaluating how to manage 
its overall CDR workload. However, because SSA considers SSI childhood 
CDRs a lower priority than other CDRs, it is unclear whether the 
agency will use this funding to review children most likely to 
medically improve-- reviews that could yield a high return on 
investment. If SSA continues to rely heavily on the use of waivers to 
conduct fewer CDRs than would otherwise be required by law, SSA will 
potentially forgo future program savings. Furthermore, while we 
consider SSA's decision to begin issuing formal waivers in order to 
clearly comply with the CDR legal requirement to be a good start, that 
action alone is not sufficient to fully alleviate our concerns with 
the waiver process. Until the agency formally implements this waiver 
process, the extent to which SSA is conducting CDRs consistently with 
its legal requirements will continue to be unclear.

Recommendations for Executive Action:

To strengthen eligibility decisions and improve monitoring of children 
with mental impairments within the SSI program, we recommend that the 
Commissioner of Social Security:

1. Direct the Deputy Commissioners of Retirement and Disability Policy 
and Operations to take steps to ensure that DDS examiners accurately 
record information on secondary impairments in order to improve SSA's 
understanding of how multiple impairments may influence decisions.

2. Direct the Deputy Commissioner of Operations to identify the extent 
to which DDS examiners nationwide experience obstacles in obtaining 
teacher assessments and school records. To the extent these are 
identified, SSA should clarify the nature of these obstacles and 
formulate steps to address them. Such steps could include increased 
DDS outreach to primary and secondary schools, increased SSA 
coordination with the Department of Education, or additional guidance 
to DDS offices.

3. Direct the Deputy Commissioner of Operations to ensure that field 
offices notify their respective DDS offices of those claims in which 
multiple children within the same household are applying for or 
receiving SSI benefits so that examiners will be better able to 
identify potential fraud or abuse in the program and elevate these 
cases to the attention of SSA's fraud investigations unit.

4. Direct the Deputy Commissioner of Quality Performance to eliminate 
the existing CDR backlog of cases for children with impairments who 
are likely to improve and, on an ongoing basis, conduct CDRs at least 
every 3 years for all children with impairments who are likely to 
improve, as resources are made available for these purposes.

5. Direct the Deputy Commissioner of Quality Performance and Deputy 
Commissioner of Operations to take actions to ensure that SSA's CDR 
waiver process is open, transparent, and public. This may include 
promulgating formal guidance for issuing waivers, and a process for 
making information about issued waivers available to the public.

Agency Comments and Our Evaluation:

We provided a draft of this report to SSA for review and comment. In 
its written comments, reproduced in appendix V, SSA agreed with 4 of 
our 5 recommendations and stated that our draft report overall 
reflected a good understanding of the disability determination process 
and the SSI childhood disability program. SSA disagreed with our 
recommendation to eliminate the existing CDR backlog of cases for 
children with impairments who are likely to improve and conduct CDRs 
for these children at least every 3 years, as resources are made 
available for these purposes. SSA agreed conceptually that it should 
complete more CDRs for SSI children but emphasized that it is 
constrained by limited funding and staff resources and as a result had 
to waive many required childhood CDRs in recent years. SSA also argued 
that performing additional SSI child CDRs would have negative impacts 
on the SSDI program. We acknowledge the challenge SSA faces as it 
strives to balance competing workloads. In recognition of the agency's 
resource constraints, we noted in our recommendation that additional 
CDRs for children who are likely to medically improve should be 
conducted "as resources are made available for these purposes." We 
also believe that the increased appropriations for CDRs in recent 
years provides SSA with added flexibility for balancing these 
competing workloads. Moreover, it is important to recognize we are not 
recommending that SSA eliminate its ongoing SSDI CDR efforts. Rather, 
we believe that more attention is needed for SSI children's cases to 
address the existing backlog, especially given the relatively few CDRs 
conducted in this area in recent years, and the high average cessation 
rate for these cases. SSA also provided technical comments that we 
have incorporated, as appropriate.

We are sending copies of this report to the Commissioner of Social 
Security, appropriate congressional committees, and other interested 
parties. In addition, the report is available at no charge on the GAO 
website at [hyperlink, http://www.gao.gov].

If you or your staff have any questions about this report, please 
contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix VI. 

Signed by: 

Daniel Bertoni: 
Director Education, Workforce,  and Income Security Issues: 

[End of section] 

Appendix I: Scope and Methodology:

Our review focused on (1) the trends in the rate of children receiving 
Supplemental Security Income (SSI) benefits due to mental impairments; 
(2) the role that medical and nonmedical information, such as 
medication and school records, play in the initial determination of a 
child's medical eligibility; and (3) the steps the Social Security 
Administration (SSA) has taken to monitor the continued medical 
eligibility of these children.

To examine these issues, we analyzed SSA data on (1) the overall 
number of initial disability determinations and allowances, (2) annual 
benefit awards and recipients, (3) the number and types of mental 
impairments, (4) the number of children receiving SSI benefits 
residing in households where other children also receive SSI benefits, 
and (5) the number of continuing disability reviews of children 
conducted by SSA. In reviewing these data, we acknowledge that the 
child population in the United States has also grown since 2000 and 
demographics of this population may have changed since that time. We 
assessed the reliability of the data presented in this report by 
performing data testing, reviewing internal controls and related 
documentation, and interviewing agency officials, and found potential 
limitations with the extent to which primary and secondary impairment 
coding within SSA's 831 Disability file--the file that contains data 
on disability determinations--may be complete. However, because the 
831 Disability file is used by SSA to make, and thus reflect, the 
decisions made regarding medical determinations, we determined that 
these data were sufficiently reliable to describe certain trends among 
children in the SSI program.

We also conducted in-depth interviews with SSA management and line 
staff at SSA headquarters and within six SSA regions--Atlanta, 
Georgia; Dallas, Texas; Chicago, Illinois; Philadelphia, Pennsylvania; 
Boston, Massachusetts; and San Francisco, California. Our work 
included site visits to 9 field offices within these regions, as well 
as 11 state disability determination services (DDS) offices (state 
agencies under the direction of SSA that perform medical eligibility 
determinations and continuing disability reviews of SSI applicants). 
We performed separate interviews with SSA field office district 
managers, supervisors, and claims representatives, and with DDS 
managers, supervisors, examiners, and medical or psychological 
consultants, when they were available. We selected these sites on the 
basis of their geographic location, high volume of SSI applications 
for children with mental impairments, and variety of benefit allowance 
rates for children with mental impairments. In addition, we 
interviewed numerous external experts from the medical and disability 
advocacy communities and reviewed relevant studies to identify factors 
that may be currently affecting the growth and composition of the 
childhood disability applicants and recipients, especially for those 
children with mental impairments. However, the relative effects of any 
potential factors we identified on the SSI program's growth are not 
fully known and were beyond the scope of this report. We also reviewed 
relevant federal laws and regulations.

We conducted a case file review to verify information obtained through 
our interviews with DDS office staff and to better understand the role 
of secondary impairments in determinations as well as what information 
examiners use when determining a child's medical eligibility. We 
reviewed a probability sample of 298 case files selected from the 
184,150 initial determinations decided in fiscal year 2010 for 
children with alleged attention deficit hyperactivity disorder (ADHD), 
[Footnote 78] speech and language delay, and autistic disorder and 
other pervasive development disorders (autism).[Footnote 79] (Through 
the initial determination process, the DDS assesses whether the 
child's impairment can be established through medical evidence--not 
only by the individual's statement of symptoms--as well as the 
severity of the impairment and whether the impairment results in 
marked and severe functional limitations.) We reviewed electronic case 
files for children with mental impairments and SSA forms to develop a 
standardized data collection instrument. We completed a data 
collection instrument for each initial determination in our sample, 
and each record was independently reviewed by another staff person for 
clarity and accuracy. We based our observations of the sources 
examiners used to support their determinations on examiners' remarks 
in the Childhood Disability Evaluation Form (form SSA-538-F6) and the 
Disability Determination Explanation. Because our purpose was not to 
assess the appropriateness of examiners' decisions but to understand 
what information sources examiners used in explaining the rationale 
for their decision-making, we did not attempt to adjudicate these 
cases ourselves. Our observations were limited by the extent to which 
examiners documented their analysis and rationale on these forms. We 
found the examiners' remarks sufficient to characterize which sources 
were used to support decisions, but examiners provided varying levels 
of detail in their remarks and we had no basis for judging whether 
additional sources of information were used to support but were not 
reported.

As with all probability samples, estimates from our case file review 
are subject to sampling errors. Sampling errors occur because we use a 
sample to draw conclusions about a larger population. If a different 
sample had been taken, the results might have been different. To 
recognize the possibility that other samples might have yielded other 
results, we express our confidence in the precision of our particular 
sample's results as a 95 percent confidence interval. The 95 percent 
confidence interval is expected to include the population value for 95 
percent of samples of this type. When we make estimates for this 
population, we are 95 percent confident that the results we obtained 
are within plus or minus 8 percentage points of what we would have 
obtained if we had included the entire population within our review, 
unless otherwise noted. The text of our report provides more specific 
confidence intervals for various estimates.

We selected the sample from within six strata, consisting of allowance 
and denial decisions and the three most prevalent primary impairments 
among medical allowances for children with mental impairments--ADHD, 
speech and language delay, and autism. We sampled approximately the 
same number of cases from each stratum in order to ensure that the 
sample sizes were sufficient to produce precise estimates within each 
combination of impairment and decision. When generalizing to the 
overall population and to various subpopulations, we weighted each 
case according to its probability of selection, which varied across 
strata due to differences in the number of cases in the stratum 
populations.

We conducted this performance audit from February 2011 to June 2012 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe the 
evidence obtained provides a reasonable basis for findings and 
conclusions based on our audit objectives. 

[End of section] 

Appendix II: Listings for Mental Disorders for Children under Age 18:

The structure of the mental disorders listings for children under age 
18 parallels the structure for the mental disorders listings for 
adults but is modified to reflect the presentation of mental disorders 
in children. Under federal regulations, when a child is not performing 
substantial gainful activity and the impairment is severe, the Social 
Security Administration (SSA) will examine whether the child's 
impairment meets, medically equals, or functionally equals any of the 
impairments contained in the listings. The listings further describe 
the level of severity necessary to meet these requirements. The 
listings for mental disorders in children are grouped into 11 
diagnostic categories:[Footnote 80]

Organic mental disorders. Abnormalities in perception, cognition, 
affect, or behavior associated with dysfunction of the brain. The 
history and physical examination or laboratory tests, including 
psychological or neuropsychological tests, demonstrate or support the 
presence of an organic factor judged to be etiologically related to 
the abnormal mental state and associated deficit or loss of specific 
cognitive abilities, or affective changes, or loss of previously 
acquired functional abilities.

Schizophrenic, delusional (paranoid), schizoaffective, and other 
psychotic disorders. Onset of psychotic features, characterized by a 
marked disturbance of thinking, feeling, and behavior, with 
deterioration from a previous level of functioning or failure to 
achieve the expected level of social functioning.

Mood disorders. Characterized by a disturbance of mood (referring to a 
prolonged emotion that colors the whole psychic life, generally 
involving either depression or elation), accompanied by a full or 
partial manic or depressive syndrome.

Mental retardation. Characterized by significantly sub-average general 
intellectual functioning with deficits in adaptive functioning. 
[Footnote 81] 

Anxiety disorders. In these disorders, anxiety is either the 
predominant disturbance or is experienced if the individual attempts 
to master symptoms; for example, confronting the dreaded object or 
situation in a phobic disorder, attempting to go to school in a 
separation anxiety disorder, resisting the obsessions or compulsions 
in an obsessive compulsive disorder, or confronting strangers or peers 
in avoidant disorders.

Somatoform, eating, and tic disorders. Manifested by physical symptoms 
for which there are no demonstrable organic findings or known 
physiologic mechanisms; or eating or tic disorders with physical 
manifestations.

Personality disorders. Manifested by pervasive, inflexible, and 
maladaptive personality traits, which are typical of the child's long- 
term functioning and not limited to discrete episodes of illness.

Psychoactive substance dependence disorders. Manifested by a cluster 
of cognitive, behavioral, and physiologic symptoms that indicate 
impaired control of psychoactive substance use with continued use of 
the substance despite adverse consequences.

Autistic disorder and other pervasive developmental disorders. 
Characterized by qualitative deficits in the development of reciprocal 
social interaction, in the development of verbal and nonverbal 
communication skills, and in imaginative activity. Often, there is a 
markedly restricted repertoire of activities and interests, which 
frequently are stereotyped and repetitive.

Attention deficit hyperactivity disorder. Manifested by 
developmentally inappropriate degrees of inattention, impulsiveness, 
and hyperactivity.

Developmental and emotional disorders of newborn and younger infants 
(birth to attainment of age 1): Developmental or emotional disorders 
of infancy are evidenced by a deficit or lag in the areas of motor, 
cognitive/communicative, or social functioning. These disorders may be 
related either to organic or to functional factors or to a combination 
of these factors.

According to SSA, these listings are examples of common mental 
disorders that are severe enough to result in a child being disabled. 
When a child has a medically determinable impairment that is not 
listed, an impairment that does not meet the requirements of a 
listing, or a combination of impairments in which none meets the 
requirements of a listing, SSA will make a determination whether the 
child's impairment or impairments medically or functionally equal the 
listings.[Footnote 82] This can be especially important in older 
infants and toddlers (age 1 to attainment of age 3), who may be too 
young for identification of a specific diagnosis, yet demonstrate 
serious functional limitations. Therefore, the determination of 
equivalency is necessary to the evaluation of any child's case when 
the child does not have an impairment that meets a listing. 

[End of section] 

Appendix III: Trends on the Three Most Prevalent Primary Impairments 
among Children with Mental Impairments in the Supplemental Security 
Income Program:

Social Security Administration (SSA) data show that the three most 
prevalent primary mental impairments among those children allowed for 
Supplemental Security Income (SSI) benefits in fiscal year 2011 were 
for (1) attention deficit disorder or attention deficit hyperactivity 
disorder (ADHD),[Footnote 83] (2) speech and language delay, and (3) 
autistic disorder and other pervasive development disorders (autism). 
These data are based on the primary impairment as designated by the 
disability determination services (DDS) examiner.[Footnote 84] SSA's 
policy operations manual directs DDS examiners to code the primary 
impairment as the most severe condition that rendered the child 
disabled. However, SSA officials have acknowledged that primary 
impairment codes are sometimes missing or inaccurately coded.[Footnote 
85]

The following information provides a brief summary of each of these 
three primary impairments as they compare to the incidence of all 
mental impairments, as well as in terms of the proportion of 
applications, allowances, and receipts. Data represented as 
"applications" reflect SSI benefit claims where a DDS examiner made an 
initial disability determination decision. Some applications may have 
been submitted prior to the year when a determination was made. In 
addition, some applications could have more than one determination if 
the claim is selected for a quality review or if the disability claim 
is updated during the same year.

ADHD. From fiscal years 2000 to 2011, applications for this condition 
as a primary impairment more than doubled, from about 55,204 to 
124,217, while allowances have also doubled from 13,857 to 29,872 (see 
figure 10). By December 2011, almost 221,000 such children were 
receiving SSI benefits, and they comprised 26 percent of child 
recipients with mental impairments on the rolls.

Figure 10: Applications for Children with ADHD as a Primary 
Impairment, Fiscal Years 2000 to 2011:

[Refer to PDF for image: stacked vertical bar graph] 

Number of children: 

Fiscal year: 2000; 
Allowances: 13,857; (25%); 
Denials: 41,347; (75%). 

Fiscal year: 2001; 
Allowances: 18,124; (32%); 
Denials: 39,267; (68%). 

Fiscal year: 2002; 
Allowances: 21,558; (33%); 
Denials: 44,509; (67%). 

Fiscal year: 2003; 
Allowances: 26,162; (33%); 
Denials: 53,268; (67%). 

Fiscal year: 2004; 
Allowances: 28,739; (32%); 
Denials: 60,176; (68%). 

Fiscal year: 2005; 
Allowances: 28,026; (31%); 
Denials: 62,865; (69%). 

Fiscal year: 2006; 
Allowances: 25,959; (30%); 
Denials: 61,808; (70%). 

Fiscal year: 2007; 
Allowances: 24,632; (28%); 
Denials: 63,607; (26%). 

Fiscal year: 2008; 
Allowances: 26,305; (28%); 
Denials: 66,568; (72%). 

Fiscal year: 2009; 
Allowances: 27,669; (28%); 
Denials: 71,824; (72%). 

Fiscal year: 2010; 
Allowances: 30,108; (27%); 
Denials: 83,338; (73%). 

Fiscal year: 2011; 
Allowances: 29,872; (24%); 
Denials: 94,345; (76%). 

Source: GAO analysis of SSA data from the 831 Disability file. 

Note: The information highlighted in this graphic is based on the 
primary impairment code recorded in the disability determination. Data 
represented as "applications" reflect SSI benefit claims where an 
initial disability determination decision was made. Some applications 
may have been submitted prior to the year when a determination was 
made. In addition, some applications could have more than one 
determination decision if selected for a quality review or if the 
disability claim is updated during the same year. Such determinations 
are reflected in the data presented in the figure. 

[End of figure] 

While children with ADHD represent the single largest primary 
diagnostic group, SSA has denied the majority of ADHD child applicants 
since fiscal year 2000, because they were not medically eligible. Some 
DDS examiners we interviewed said that they rarely find a child 
medically eligible for benefits solely on the basis of a ADHD 
impairment alone, but more commonly in combination with another 
impairment, such as oppositional defiant disorder. In our case file 
review, we found 37 of 50 ADHD allowances had a secondary impairment 
present,[Footnote 86] and oppositional defiant disorder was the 
secondary impairment cited most frequently in the individual cases we 
reviewed.

SSA officials suggested that the increase in both applications and 
allowances for children with ADHD might be attributable to an increase 
in diagnoses over the last decade, and cited a National Institute of 
Health survey finding that ADHD diagnoses had increased by 3 percent, 
on average, from 1996 to 2006 and by 5.5 percent, on average, from 
2003 to 2007.[Footnote 87] SSA officials also noted a 2008 medical 
study reporting that ADHD is one of the most commonly diagnosed 
childhood neurobehavioral disorders.[Footnote 88] In addition, the 
National Institute of Mental Health has stated that attention deficit 
disorder and ADHD are among the most common childhood disorders in the 
United States.

Speech and language delays. Since fiscal year 2000, both applications 
and allowances for children with speech and language delays have 
increased overall, but the proportion of applicants found medically 
eligible has ranged from 54 to 61 percent during this period. From 
fiscal year 2000 to 2011, applications for this impairment more than 
doubled, from 21,615 to 51,740 while the number of children allowed 
increased from 11,565 to 29,309 (see figure 11).

Figure 11: Applications for Children with Speech and Language Delays 
as a Primary Impairment, Fiscal Years 2000 to 2011: 

[Refer to PDF for image: stacked vertical bar graph] 

Number of children: 

Fiscal year: 2000; 
Allowances: 11,565; (54%); 
Denials: 10,050; (46%). 

Fiscal year: 2001; 
Allowances: 13,358; (56%); 
Denials: 10,386; (44%). 

Fiscal year: 2002; 
Allowances: 16,407; (58%); 
Denials: 11,753; (42%). 

Fiscal year: 2003; 
Allowances: 19,812; (60%); 
Denials: 13,279; (40%). 

Fiscal year: 2004; 
Allowances: 21,342; (60%); 
Denials: 14,251; (40%). 

Fiscal year: 2005; 
Allowances: 21,613; (59%); 
Denials: 14,900; (41%). 

Fiscal year: 2006; 
Allowances: 20,905; (59%); 
Denials: 14,709; (41%). 

Fiscal year: 2007; 
Allowances: 21,137; (58%); 
Denials: 15,018; (42%). 

Fiscal year: 2008; 
Allowances: 22,946; (59%); 
Denials: 15,914; (41%). 

Fiscal year: 2009; 
Allowances: 26,841; (61%); 
Denials: 17,050; (39%). 

Fiscal year: 2010; 
Allowances: 29,147; (59%); 
Denials: 20,517; (41%). 

Fiscal year: 2011; 
Allowances: 29,309; (57%); 
Denials: 22,431; (43%). 

Source: GAO analysis of SSA data from the 831 Disability file. 

Note: The information highlighted in this graphic is based on the 
primary impairment code recorded in the disability determination. Data 
represented as "applications" reflect SSI benefit claims where an 
initial disability determination decision was made. Some applications 
may have been submitted prior to the year when a determination was 
made. In addition, some applications may have been submitted could 
have more than one determination decision if selected for a quality 
review or if the disability claim is updated during the same year. 
Such determinations are reflected in the data in the figure. 

[End of figure] 

Some DDS officials we interviewed attributed the increased number of 
children applying for and receiving SSI benefits to speech and 
language delay to increased school testing and screening program 
services offered under the Individuals with Disabilities Education Act 
(IDEA). The U.S. Department of Education noted in their latest annual 
report that teachers indicated that 89 percent of the children aged 3 
through 5 years served under IDEA received speech or language therapy 
in the 2003 to 2004 school year, and 86 percent received it in the 
2004 to 2005 school year, making it the most common service in both 
years.[Footnote 89] In addition, they noted that speech and language 
impairments were one of the most common disability categories among 
students aged 6 through 21 years served under IDEA, Part B, in the 
fall of 2006. Of these more than 6 million students aged 6 through 21 
years, about 1.2 million, or 19.1 percent, received services due to a 
speech and language impairment.

Some speech and language experts from across the United States told us 
that they were surprised by the increased number of children receiving 
SSI benefits, but acknowledged that the definitions of disability for 
IDEA and the SSI program are different. They added that in some 
instances speech and language disorder may be a provisional diagnosis 
for very young children when it may be difficult to pinpoint a 
specific impairment or impairments, which they believed could be 
contributing to program growth. SSA officials told us that further 
study was needed to better understand increases of this impairment. As 
of February 2012, SSA was considering whether to propose new rules for 
evaluating language and speech and disorders.[Footnote 90]

Autism. From fiscal year 2000 to 2011, autism applications increased 
by almost 400 percent from 5,430 to 26,739, and allowances increased 
similarly from 5,050 to 22,931 (see figure12). As of December 2011, 
about 107,000 (12 percent) children with mental impairments were 
receiving SSI benefits due to autistic disorders. From fiscal year 
2000 to 2011, DDS examiners found from 86 to 94 percent of those 
children applying for SSI on the basis of autism medically eligible 
for benefits.

Figure 12: Applications for Children with Autism as a Primary 
Impairment, Fiscal Years 2000 to 2011:

[Refer to PDF for image: stacked vertical bar graph] 

Fiscal year: 2000; 
Denials: 5,050; (7%); 
Allowances: 380; (93%). 

Fiscal year: 2001; 
Denials: 6,215; (6%); 
Allowances: 365; (94%). 

Fiscal year: 2002; 
Denials: 7,485; (6%); 
Allowances: 489; (94%). 

Fiscal year: 2003; 
Denials: 8,634; (7%); 
Allowances: 643; (93%). 

Fiscal year: 2004; 
Denials: 9,678; (8%); 
Allowances: 810; (92%). 

Fiscal year: 2005; 
Denials: 10,626; (8%); 
Allowances: 891; (92%). 

Fiscal year: 2006; 
Denials: 11,614; (8%); 
Allowances: 1,072; (92%). 

Fiscal year: 2007; 
Denials: 12,926; (10%); 
Allowances: 1,419; (90%). 

Fiscal year: 2008; 
Denials: 15,812; (10%); 
Allowances: 1,666; (90%). 

Fiscal year: 2009; 
Denials: 18,232; (10%); 
Allowances: 2,126; (90%). 

Fiscal year: 2010; 
Denials: 20,319; (12%); 
Allowances: 2,884; (88%). 

Fiscal year: 2011; 
Denials: 22,931; (14%); 
Allowances: 3,808; (86%). 

Source: GAO analysis of SSA data from the 831 Disability file. 

Note: The information highlighted in this graphic is based on the 
primary impairment code recorded in the disability determination. Data 
represented as "applications" reflect SSI benefit claims where an 
initial disability determination decision was made. Some applications 
may have been submitted prior to the year when a determination was 
made. In addition, some applications could have more than one 
determination decision if selected for a quality review or if the 
disability claim is updated during the same year. Such determinations 
are reflected in the data presented in the figure. 

[End of figure] 

SSA officials primarily attribute the increase in the number of autism 
applications and allowances over the years to greater incidences of 
autism among children and explained that some children who may have 
previously been diagnosed as intellectually disabled are instead being 
diagnosed as autistic. In fact, the number of children applying for 
and receiving SSI benefits due to "intellectual disability" or "mental 
retardation" has significantly declined since fiscal year 2000. 
Children receiving benefits due to an intellectual disability 
comprised 51 percent of all mental claims in fiscal year 2000 and 15 
percent in fiscal year 2011. According to one study SSA cited, the 
prevalence of autism in children has increased by 2.5 percent, from 
0.6 per 1,000 live births in 1994 to 3.1 per 1,000 live births in 
2003, while during the same period, the prevalence of mental 
retardation and learning disabilities declined by 2.8 and 8.3 per 
1,000, respectively.[Footnote 91] In addition, the Centers for Disease 
Controls and Prevention estimated in March 2012 that on average 1 in 
88 children in the United States has an autism spectrum disorder, but 
the extent to which this reflects increases in awareness and access to 
services or actual increases in the prevalence of autism symptoms is 
not known.

On the basis of our case file review, we also identified some 
characteristics of children for whom SSA made an initial determination 
in fiscal year 2010 for ADHD, speech and language delay, and autism. 
For example, as shown in figure 13, more than 60 percent of these 
children had ADHD.

Figure 13: Number of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment:

[Refer to PDF for image: pie-chart] 

ADHD: 61.1% (112,527 children); 
Speech and language delay: 26.8% (49,428); 
Autism: 12.1% (22,195). 

Source: GAO analysis of SSA 831 Disability file data on all fiscal 
year 2010 initial determinations for children with alleged ADHD, 
speech and language delay, and autism. 

[End of figure]

The age at which SSA determined whether a child was medically eligible 
for benefits varied by impairment (see figure 14). Children with ADHD 
who applied for benefits were older, on average, than applicants with 
autism or speech and language delay.

Figure 14: Number of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment and Age:

[Refer to PDF for image: 3 vertical bar graphs] 

ADHD: 112,527 cases: 

Age of child: less than 1; 
Initial determinations: 20. 

Age of child: 1; 
Initial determinations: 130. 

Age of child: 2; 
Initial determinations: 840. 

Age of child: 3; 
Initial determinations: 2,680. 

Age of child: 4; 
Initial determinations: 5,430. 

Age of child: 5; 
Initial determinations: 10,560. 

Age of child: 6; 
Initial determinations: 13,800. 

Age of child: 7; 
Initial determinations: 14,420. 

Age of child: 8; 
Initial determinations: 13,570. 

Age of child: 9; 
Initial determinations: 12,100. 

Age of child: 10; 
Initial determinations: 9,660. 

Age of child: 11; 
Initial determinations: 8,040. 

Age of child: 12; 
Initial determinations: 6,490. 

Age of child: 13; 
Initial determinations: 5,140. 

Age of child: 14; 
Initial determinations: 3,810. 

Age of child: 15; 
Initial determinations: 3,010. 

Age of child: 16; 
Initial determinations: 2,130. 

Age of child: 17; 
Initial determinations: 690. 

Age of child: 18; 
Initial determinations: 0. 

Speech and language delay (49,428 total cases): 

Age of child: less than 1; 
Initial determinations: 730. 

Age of child: 1; 
Initial determinations: 5,120. 

Age of child: 2; 
Initial determinations: 9,340. 

Age of child: 3; 
Initial determinations: 8,740. 

Age of child: 4; 
Initial determinations: 6,640. 

Age of child: 5; 
Initial determinations: 4,880. 

Age of child: 6; 
Initial determinations: 3,490. 

Age of child: 7; 
Initial determinations: 2,630. 

Age of child: 8; 
Initial determinations: 2,090. 

Age of child: 9; 
Initial determinations: 1,560. 

Age of child: 10; 
Initial determinations: 1,290. 

Age of child: 11; 
Initial determinations: 940. 

Age of child: 12; 
Initial determinations: 630. 

Age of child: 13; 
Initial determinations: 480. 

Age of child: 14; 
Initial determinations: 310. 

Age of child: 15; 
Initial determinations: 280. 

Age of child: 16; 
Initial determinations: 200. 

Age of child: 17; 
Initial determinations: 80. 

Age of child: 18; 
Initial determinations: 0. 

Autism (22,195 total cases): 

Age of child: less than 1; 
Initial determinations: 0,160. 

Age of child: 1; 
Initial determinations: 1,400. 

Age of child: 2; 
Initial determinations: 3,340. 

Age of child: 3; 
Initial determinations: 3,050. 

Age of child: 4; 
Initial determinations: 2,480. 

Age of child: 5; 
Initial determinations: 2,010. 

Age of child: 6; 
Initial determinations: 1,700. 

Age of child: 7; 
Initial determinations: 1,330. 

Age of child: 8; 
Initial determinations: 1,230. 

Age of child: 9; 
Initial determinations: 1,010. 

Age of child: 10; 
Initial determinations: 910. 

Age of child: 11; 
Initial determinations: 820. 

Age of child: 12; 
Initial determinations: 690. 

Age of child: 13; 
Initial determinations: 550. 

Age of child: 14; 
Initial determinations: 460. 

Age of child: 15; 
Initial determinations: 460. 

Age of child: 16; 
Initial determinations: 450. 

Age of child: 17; 
Initial determinations: 150. 

Age of child: 18; 
Initial determinations: 0.  

Source: GAO analysis of SSA 831 Disability file data on all fiscal 
year 2010 initial determinations for children with alleged ADHD, 
speech and language delays, and autism. 

Note: Age is calculated as of the beginning of fiscal year 2010. 

[End of figure] 

Based on our case file review, we estimate that 72 percent of these 
children were male, although gender composition also varied by 
impairment (see figure 15). As discussed in appendix I of this report, 
we reviewed case files from a stratified probability sample of 
determinations made in fiscal year 2010.

Figure 15: Percentage of Fiscal Year 2010 Initial Determinations for 
Children, by Primary Impairment and Gender:

[Refer to PDF for image: horizontal bar graph] 

ADHD: 
Girls: 32.7%; 
Boys: 67.3%. 

Speech and language delays: 
Girls: 14.8%; 
Boys: 85.2%. 

Autism: 
Girls: 24.2%; 
Boys: 75.8%. 

Source: GAO estimates based on case file review of sampled fiscal year 
2010 initial determinations for children with alleged ADHD, speech and 
language delays, and autism. 

Note: The 95 percent margin of error for each estimate does not exceed 
plus or minus 10 percentage points. 

[End of figure] 

[End of section] 

Appendix IV: Reported Medication and Psychotropic Drug Use among 
Children Applying for Supplemental Security Income by Select 
Impairments, Fiscal Year 2010:

In our review of a generalizable probability sample of 298 initial 
determinations performed in fiscal year 2010 for children with alleged 
attention deficit hyperactivity disorder (ADHD),[Footnote 92] speech 
and language delay, and autistic disorder and other pervasive 
development disorders (autism), we found parents reported that their 
children were prescribed some form of medication in 58 percent of 
these cases. More specifically, parents reported that their children 
were prescribed psychotropic drugs in 47 percent of these cases (see 
table 1). Children with ADHD accounted for the vast majority of those 
reportedly using medication or psychotropic drugs--79 percent and 90 
percent, respectively (see table 2). The most commonly reported 
psychotropic drugs were Concerta, Ritalin, and Adderall, which are 
prescribed to treat ADHD, as well as Risperdal, which is an 
antipsychotic. Of children reportedly prescribed psychotropic drugs, 
the majority reported using one psychotropic drug.

Table 1: Percentage of Cases by Reported Use of Medication and by 
Select Primary Impairment, Fiscal Year 2010:

Medication reported; 
Primary impairment: 
ADHD: 45.9%; (5.9); 
Autism: 3.5%; (1.3); 
Speech and language delay: 8.5%; (2.5); 
Total: 58.0%; (6.5).

Medication not reported; 
Primary impairment: 
ADHD: 15.2%; (5.9); 
Autism: 8.6%; (1.3); 
Speech and language delay: 18.3; (2.5); 
Total: 42.0%; (6.5).

Psychotropic drugs reported; 
Primary impairment: 
ADHD: 42.3%; (6.3); 
Autism: 2.2%; (1.1); 
Speech and language delay: 2.4; (1.5); 
Total: 46.9%; (6.5).

Psychotropic drugs not reported; 
Primary impairment: 
ADHD: 18.8%; (6.3); 
Autism: 9.9%; (1.1); 
Speech and language delay: 24.4; (1.5); 
Total: 53.1%; (6.5).

Source: GAO analysis of Social Security Administration 831 Disability 
file data on all fiscal year 2010 initial determinations for children 
with ADHD, speech and language delay, and autism.

Note: Entries in parentheses are 95 percent margins of error. 

[End of table] 

Table 2: Percentage of Medication and Psychotropic Drug Use Reported 
by Select Primary Impairment, Fiscal Year 2010:

Primary impairment: ADHD; 
Medication reported: 79.3%; (4.4); 
Medication not reported: 36.1%; (9.3); 
Psychotropic drugs reported: 90.2%; (3.8); 
Psychotropic drugs not reported: 35.4%; (7.7).

Primary impairment: Autism; 
Medication reported: 6.0%; (2.3); 
Medication not reported: 20.4%; (4.0); 
Psychotropic drugs reported: 4.6%; (2.4); 
Psychotropic drugs not reported: 18.6%; (2.8).

Primary impairment: Speech and language delay; 
Medication reported: 14.7%; (3.9); 
Medication not reported: 43.6%; (7.1); 
Psychotropic drugs reported: 5.2%; (3.0); 
Psychotropic drugs not reported: 46.0%; (5.7).

Primary impairment: Total; 
Medication reported: 100.0%; 
Medication not reported: 100.1%; 
Psychotropic drugs reported: 100.0%; 
Psychotropic drugs not reported: 100.0%.

Source: GAO analysis of SSA 831 Disability file data on all fiscal 
year 2010 initial determinations for children with ADHD, speech and 
language delay, and autism.

Note: Some totals may not add to 100 percent due to rounding. Entries 
in parentheses are 95 percent margins of error. 

[End of table] 

[End of section] 

Appendix V: Comments from the Social Security Administration: 

Social Security: 
Office of the Commissioner: 
Social Security Administration: 
Baltimore, MD 21235-0001: 

June 11, 2012: 

Mr. Daniel Bertoni, Director: 
Education, Workforce, and Income Security Issues: 
United States Government Accountability Office: 
441 G. Street, NW: 
Washington, D.C. 20548: 

Dear Mr. Bertoni, 

Thank you for the opportunity to review the draft report, Supplemental 
Security Income: Better Management Oversight Needed for Children's 
Benefits" (GAO-12-497). Our response is enclosed. 

If you have any questions, please contact me at (410) 965-0520. Your 
staff may contact Amy Thompson, Senior Advisor for Records Management 
and Audit Liaison Staff, at (410) 966-0569. 

Sincerely, 

Signed by: 

Dean S. Landis: 
Deputy Chief of Staff: 

Enclosure: 

[End of letter] 

Comments On The Government Accountability Office (GAO) Draft Report, 
"Supplemental Security Income: Better Management Oversight Needed For 
Children's Benefits" (GAO-12-497): 

General Comments: 

It appears the auditors examined Supplemental Security Income (SSI) 
childhood disability payments as an independently funded workload, 
which it is not. Our other important and mandatory program integrity 
work competes for the same scarce resources as SSI childhood payments. 
While we agree conceptually that we should complete more continuing 
disability reviews (CDR) on SSI childhood payments, our ability to do 
so is limited by the funding we receive from Congress. Based on 
Congress' decision to commit insufficient resources for the goals it 
authorizes and requires, we prioritize the program integrity work that 
produces the best return on investment. 

We consider several factors when prioritizing CDRs. GAO's findings 
seem to focus on cessation rates as the primary factor in determining 
our return for completing CDRs. In fiscal year (FY) 2011, over 10 
million Social Security Disability Insurance (SSDI) beneficiaries 
received $128 billion in benefits. Therefore, we conduct more SSDI 
CDRs because SSDI beneficiaries have benefit rates that are, on 
average, almost twice as much as SSI childhood payment rates and 
usually have longer payback periods in the savings calculations. 
Although we agree that the review of childhood cases would produce a 
higher percentage of cessations, the review of SSDI adult cases 
generally produces greater lifetime savings. If GAO disagrees with our 
approach, GAO should be transparent with Congress about the loss to 
the trust funds entailed by its approach. 

Our overall program savings to administrative cost ratios support the 
fact that we responsibly use our limited resources in the most cost-
effective manner. We began calculating savings ratios for the CDR 
Report to Congress in the late 1990s, and since FY 2006 the ratios 
have been about $10 to $1. 

Overall, this draft report reflects a good understanding of our 
disability determination process and the SSI childhood disability 
program, but it does not acknowledge our repeated, but only partially 
successful, requests for additional funding to support completing 
additional CDRs. Despite operating for each of the last two years with 
less funding than we had in FY 2010, we have steadily increased the 
number of medical CDRs we complete. We have also increased the number 
of SSI childhood CDRs we complete each year. It is also important to 
understand that it is not just funding that affects our ability to 
complete this work. We must also have enough trained employees because 
the same people who handle our medical CDR work also make initial 
disability determinations, which have increased by about 30 percent 
since FY 2007. 

Responses To The Recommendations: 

Recommendation 1: 

Direct the Deputy Commissioners of Retirement and Disability Policy 
and Operations to take steps to ensure that DDS examiners accurately 
record information on secondary impairments in order to improve SSA's 
understanding of how multiple impairments may influence decisions. 

Response: 

We agree. 

Recommendation 2: 

Direct the Deputy Commissioner of Operations to identify the extent to 
which DDS examiners nationwide experience obstacles in obtaining 
teacher assessments and school records. To the extent these are 
identified, SSA should clarify the nature of these obstacles and 
formulate steps to address them. Such steps could include increased 
DDS outreach to primary and secondary schools, increased SSA 
coordination with the Department of Education, or additional guidance to
DDS offices. 

Response: 

We agree. 

Recommendation 3: 

Direct the Deputy Commissioner of Operations to ensure that field 
offices notify their respective DDS offices of those claims in which 
multiple children within the same household are applying for or 
receiving SSI benefits so that examiners will be better able to 
identify potential fraud or abuse in the program and elevate these 
cases to the attention of SSA's fraud investigations unit. 

Response: 

We agree. As resources allow, we will explore ways to modify our 
policy and systems to provide this notification. 

Recommendation 4: 

Direct the Deputy Commissioner of Quality Performance to eliminate the 
existing CDR backlog of cases for children with impairments who are 
likely to improve and, on an ongoing basis, conduct CDRs at least 
every 3 years for all children with impairments who are likely to 
improve, as resources are made available for these purposes.

Response: 

We disagree. While we would like to conduct more program integrity 
reviews and meet the CDR goals established by Congress, budget 
restrictions have forced us to waive many childhood SSI CDRs in recent 
years. Given adequate funding, we would increase these reviews and 
target cases that are most likely to show medical improvement, but it 
would mislead Congress to suggest that this problem can be resolved by 
administrative fiat. 

Recommendation 5: 

Direct the Deputy Commissioner of Quality Performance and Deputy 
Commissioner of Operations to take actions to ensure that SSA's CDR 
waiver process is open, transparent, and public. This may include 
promulgating formal guidance for issuing waivers, and a process for 
making information about waivers available to the public. 

Response: 

We agree. As stated in the April 20, 2012 letter to GAO from our 
Office of the General Counsel, we are currently developing a more 
formal waiver process. However, we believe GAO should make it clear to 
Congress that the statutory waiver scheme relies on assumptions about 
predictable and adequate funding that have not been true for almost a 
decade, and that it would be timely for Congress to revisit this 
statutory scheme. 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments:

GAO Contact:

Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov:

Staff Acknowledgments:

In addition to the contact named above, Jeremy Cox (Assistant 
Director), James Bennett, Alexander Galuten, Jason Holsclaw, Kristen 
Jones, Sheila McCoy, Luann Moy, Ernest Powell, Jeff Tessin, and Paul 
Wright made key contributions to this report and the related e- 
supplement.

[End of section] 

Footnotes: 

[1] We originally sampled 300 cases for review but encountered 2 cases 
that were either mis-coded or that lacked an electronic case file. We 
excluded these 2 cases from our analysis, which produced an effective 
sample size of 298.

[2] Children with attention deficit disorder are also included in this 
category.

[3] These were the most prevalent primary mental impairments among 
those children found medically eligible in fiscal year 2011. 
Percentage estimates for initial determinations of children with 
alleged ADHD, speech and language delay, and autism are based on the 
sample and are subject to sampling error. Unless otherwise noted, we 
are 95 percent confident that our estimates are within plus or minus 8 
percentage points of what we would have obtained if we had reviewed 
cases for the entire population. Appendix I provides more information 
about the design of our sample.

[4] The SSI program was established by Pub. L. No. 92-603, § 301, 86 
Stat. 1329, 1465 (1972), and became effective starting in 1974.

[5] For purposes of the SSI program, the term "child" means an 
individual who is neither married nor (as determined by the 
Commissioner of Social Security) the head of a household, and who is 
(1) under the age of 18, or (2) under the age of 22 and (as determined 
by the Commissioner of Social Security) a student regularly attending 
a school, college, or university, or a course of vocational or 
technical training designed to prepare him or her for gainful 
employment. 42 U.S.C. § 1382c(c).

[6] 42 U.S.C. § 1382c(a)(3)(C)(i) and 20 C.F.R. § 416.906.

[7] Typically, a disabled child's SSI benefit is paid on behalf of the 
child to a "representative payee," such as a parent or guardian. The 
"representative payee" is responsible for using benefits received only 
for the child's use and benefit in a manner and for the purposes he or 
she determines, consistent with SSA guidelines, to be in the child's 
best interests. 20 C.F.R. § 416.635(a).

[8] All but five states and the Commonwealth of the Northern Mariana 
Islands supplement federal SSI benefits with additional payments. 
Fourteen states and the District of Columbia have state supplements 
that are either partially or wholly administered by SSA, and 31 states 
self administer their supplements. 

[9] The medical evaluation is conducted under applicable legal 
requirements and SSA policy. 

[10] To be considered severe, the child's impairment must cause the 
child more than minimal functional limitations. 20 C.F.R. § 416.924(c). 


[11] 20 C.F.R. § 416.924(a).

[12] See appendix II for additional information about the listings of 
mental disorders for children. 

[13] 20 C.F.R. § 416.913.

[14] 20 C.F.R. § 416.919a(b). A consultative examination is a physical 
or mental examination or test purchased from a treating source or 
another medical source, including a pediatrician, for an individual at 
SSA's request and expense. 20 C.F.R. § 416.919.

[15] 20 C.F.R. § 416.903(e).

[16] For more information about the administrative review process for 
disability determinations, see 20 C.F.R. § 416.1400 et seq.

[17] SSA conducts two types of reviews to ensure that participants are 
eligible for benefits--CDRs and redeterminations. CDRs verify 
claimants' medical eligibility, while SSI redeterminations generally 
verify their financial eligibility and ensure that the recipient is 
receiving the right amount of SSI benefits. 20 C.F.R. §§ 416.989 and 
416.204. However, age 18 redeterminations also verify claimants' 
medical eligibility under the adult disability criteria.

[18] 42 U.S.C. § 1382c(a)(3)(H)(iv).

[19] 42 U.S.C. § 1382c(a)(3)(H)(ii)(I). 

[20] Adults are considered disabled if they are unable to engage in 
substantial gainful activity by reason of a medically determinable 
physical or mental impairment expected to result in death or last at 
least 12 months. 42 U.S.C. § 1382c(a)(3)(A).

[21] 42 U.S.C. § 1382c(a)(3)(H)(iii). 

[22] Pub. L. No. 98-460, §§ 4 and 5, 98 Stat. 1794, 1800, 1801.

[23] SSA maintains a list of impairments that are severe enough to be 
considered disabling. 

[24] 493 U.S. 521, 538-41.

[25] Pub. L. No. 104-193, 110 Stat. 2105. 

[26] A child may be found medically eligible for benefits due to a 
physical or mental impairment, but SSA must verify the child's 
financial and other nonmedical eligibility. If these other criteria 
are not met, the child will not receive SSI benefits. Although the 
field office performs an initial verification of the child's financial 
eligibility prior to sending a case to the DDS office, the field 
office may identify additional income or assets after the DDS office 
completes its determination of medical eligibility. 

[27] For purposes of this report, data represented as "applying" or 
"applications" reflect SSI benefit claims where a DDS examiner made an 
initial disability determination decision. Some benefit claim 
applications could have more than one determination if the claim is 
selected for a quality review or if the disability claim is updated 
during the same year.

[28] Data on allowances and allowance rates refers to initial level 
allowances, not final allowances, which include appeals decisions. 

[29] In accordance with Rosa's Law, "intellectual disability" has 
generally replaced the term "mental retardation." Pub. L. No. 111-256, 
124 Stat. 2643. 

[30] These data are based on the primary impairment as designated by 
the DDS examiner. The recorded primary impairment code identifies the 
primary impairment used in the medical determination for an 
individual's eligibility for SSI disability benefits. These data 
appear in SSA's 831 and 832/833 Disability files. However, SSA 
officials have acknowledged that the primary codes are sometimes 
missing or inaccurately coded, with an estimated error rate of 5 to 6 
percent. 

[31] The number of adults receiving SSI benefits has also steadily 
increased over the past decade. As of December 2011, 6.8 million 
adults were receiving SSI disability benefits, up from 5.8 million as 
of December 2000. 

[32] See GAO, Supplemental Security Income: State Trends in 
Applications, Allowances, and Benefit Receipts for Children with 
Mental Impairments, an E-Supplement to [hyperlink, 
http://www.gao.gov/products/GAO-12-497], [hyperlink, 
http://www.gao.gov/products/GAO-12-498SP] (Washington, D.C.: June 26, 
2012).

[33] GAO, Supplemental Security Income: Growth and Changes in 
Recipient Population Call for Reexamining Program, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-95-137] (Washington, D.C.: July 
1995); Social Security: Federal Disability Programs Face Major Issues, 
[hyperlink, http://www.gao.gov/products/GAO/T-HEHS-95-97] (Washington, 
D.C.: Mar. 2, 1995); and Social Security: Rapid Rise in Children on 
SSI Disability Rolls Follows New Regulations, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-94-225] (Washington, D.C.: 
September 1994).

[34] U.S. Department of Commerce, Economics and Statistics 
Administration, U.S. Census Bureau, Income, Poverty, and Health 
Insurance Coverage in the United States: 2010 (September 2011), and 
Poverty in the United States: 2000 (September 2001).

[35] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, National Center for Health Statistics, 
Attention Deficit Hyperactivity Disorder Among Children Age 5-17 in 
the United States, 1998-2009, NCHS Data Brief, No. 70, (August 2011), 
and Summary of Health Statistics for U.S. Children: National Health 
Interview Survey, 2010, Vital and Health Statistics, Series 10, Number 
250 (December 2011).

[36] Coleen A. Boyle, Sheree Boulet, Laura A. Schieve, Robin A. Cohen, 
Stephen J. Blumberg, Marshalyn Yeargin-Allsopp, Susanna Visser, and 
Michael D. Kogan. "Trends in the Prevalence of Developmental 
Disabilities in U.S. Children, 1997-2008," Pediatrics, vol.127, no. 6 
(May 23, 2011).

[37] Health Coverage of Children: The Role of Medicaid and CHIP, 
Kaiser Commission on Medicaid and the Uninsured, February 2011. 

[38] Pub. L. No. 108-446, 118 Stat. 2647 and 20 U.S.C. § 1413(f). IDEA 
authorizes federal funding to states for special education and related 
services, and for the states that accept these funds, sets out 
principles under which special education and related services are to 
be provided. See 20 U.S.C. § 1400 et seq. IDEA requires that each 
child with a disability have an individualized education program, and 
children with disabilities may also receive related services, 
including speech-language pathology and audiology services, physical 
therapy, and nursing.

[39] According to the U.S. Department of Education, more than 6 
million children aged 6 to 21 received special education services 
under IDEA, Part B, in the fall of 2006. U.S. Department of Education, 
Office of Special Education and Rehabilitative Services, 30th Annual 
Report to Congress on the Implementation of the Individuals with 
Disabilities Education Act, 2008 (Washington, D.C.: December 2011).

[40] 20 C.F.R. § 416.926a(a).

[41] Estimates based on our case file review are generalizeable only 
to initial determinations made in fiscal year 2010 for the three 
primary mental impairments most frequently allowed for benefits--ADHD, 
speech and language delay, and autism. Unless otherwise noted, the 95 
percent margins of error for these estimates are plus or minus 8 
percentage points.

[42] The 95 percent margins of error for percentages in this paragraph 
range from plus or minus 10 to plus or minus 14 percentage points.

[43] The 95 percent margins of error for percentages for these data 
range from plus or minus 5 to plus or minus 11 percentage points.

[44] For more information, see 20 C.F.R. § 416.913.

[45] For more information, see 20 C.F.R. § 416.924(a).

[46] Specifically, the mean number of sources was 4.6 (plus or minus 
0.2).

[47] 20 C.F.R. § 416.912(d).

[48] 20 C.F.R. § 416.917.

[49] 20 C.F.R. § 416.924a.

[50] The standardized SSA teacher questionnaire includes checkboxes 
and multiple choice questions and is organized into sections that 
cover broad domains of functioning, such as acquiring and using 
information and attending and completing tasks.

[51] The difference in the proportion allowed between cases with and 
without medication was statistically distinguishable at the 0.05 
level. The 95 percent margins of error for percentages in this 
paragraph range from plus or minus 5 to plus or minus 8 percentage 
points. 

[52] Psychotropic drugs, such as antidepressants and antipsychotics, 
affect brain activity associated with mental processes and behavior.

[53] For more detailed information on applicants' reported medication 
and psychotropic drug use, see appendix IV.

[54] This case was not part of our case file review, but SSA provided 
us with information on it.

[55] The 95 percent margin of error for percentages in this paragraph 
range from plus or minus 9 to plus or minus 10 percentage points.

[56] The Cooperative Disability Investigations Program, which is 
managed by SSA's Office of Operations and Office of Inspector General, 
is responsible for investigating questions of fraud in SSA's 
disability programs.

[57] Under Title XVI of the Social Security Act, SSA is generally 
required to (1) conduct a CDR at least every 3 years on all child 
recipients under age 18 whose impairments are likely to improve (or, 
at the Commissioner's option, recipients whose impairments are 
unlikely to improve) (42 U.S.C. § 1382c(a)(3)(H)(ii)(I)); (2) conduct 
a CDR within 12 months after the birth of a child who was granted 
benefits in part because of low birth weight (42 U.S.C. § 
1382c(a)(3)(H)(iv)); and (3) redetermine, within 1 year of the 
individual's 18th birthday (or whenever the Commissioner determines 
the individual is subject to a redetermination), the eligibility of 
any individual who was eligible for SSI childhood payments in the 
month before attaining age 18, by applying the criteria used in 
determining initial eligibility for adults (42 U.S.C. § 
1382c(a)(3)(H)(iii)). For children under the age of 18--except for the 
initial CDR for low birth weight babies--DDS offices are directed by 
SSA policy to determine when recipients will be due for CDRs on the 
basis of their potential for medical improvement, and select and 
schedule a review date--otherwise known as a "diary date"-- for each 
recipient's CDR.

[58] The SSDI program provides benefits to eligible individuals who 
meet certain minimum work requirements. 

[59] For adults receiving SSI, SSA conducts CDRs using two methods: 
(1) SSA headquarters sends some cases to the DDS for a full medical 
review, and (2) SSA mails a questionnaire to other recipients and 
reviews their responses to determine continued eligibility. At this 
time, SSA does not use the mailer process for SSI child recipients. 
For comparability in the number of CDRs for adults and children, the 
CDR data in this section apply to full medical reviews only. 

[60] SSA conducts an annual analysis of pending CDRs for children. 
This is the most recent date for which these data are available.

[61] A total of about 861,000 child recipients with mental impairments 
were receiving SSI benefits as of December 2011.

[62] SSA informed us that 95.6 percent of the age 18 redeterminations 
are released to the field offices for processing by SSA headquarters 
within two months of the recipients' 18TH birthday, and most all of 
them were released by no later than their 19th birthday.

[63] Personality disorders are manifested by pervasive, inflexible, 
and maladaptive personality traits, which are typical of the child's 
long- term functioning and not limited to discrete episodes of 
illness. 20 C.F.R. pt. 404, subpt. P, appendix 1. 

[64] The 32 and 28 percent, respectively, of recipients reflect 
"initial cessations," meaning that the agency concluded at the end of 
the CDR that the claimant involved no longer met the eligibility 
standards to continue receiving benefits, and therefore started the 
process to cease benefits. Claimants may subsequently avail themselves 
of an appeals process, which can result in a reversal of the initial 
cessation. 

[65] 42 U.S.C. § 1382c(a)(3)(H)(iii) and (iv), respectively.

[66] 42 U.S.C. § 1382c(a)(3)(H)(ii)(l). The relevant provision states 
the following: "Not less frequently than once every 3 years, the 
Commissioner shall review […] the continued eligibility for benefits 
under this title of each individual who has not attained 18 years of 
age and is eligible for such benefits by reason of an impairment (or 
combination of impairments) which is likely to improve (or, at the 
option of the Commissioner, which is unlikely to improve)." According 
to its policy guidance, SSA defines both medical improvement expected 
and medical improvement possible cases as being cases likely to improve.

[67] Social Security Administration Office of the Inspector General, 
"Follow-Up: Childhood Continuing Disability Reviews and Age 18 
Redeterminations" (A-01-11-11118), Sept. 23, 2011.

[68] This was the most recent annual CDR report available at the time 
of our discussion, in February 2012.

[69] 20 C.F.R. § 416.990(g).

[70] The relevant provision of the law states that the 3-year 
requirement does not apply to the extent that the Commissioner of 
Social Security determines, on a state-by-state basis, that the 
requirement should be waived to ensure that only the appropriate 
number of such cases are reviewed, and states further that the 
Commissioner shall determine the appropriate number of cases to be 
reviewed based on many of these factors. 42 U.S.C. § 421(i)(2). The 
provision goes on to state that the Commissioner shall only provide 
for such a waiver if the state makes a good faith effort to meet 
proper staffing requirements for the state agency and to process case 
reviews in a timely fashion. The provision also requires the 
Commissioner to report annually to certain congressional committees 
about the waiver determinations SSA has made. Given the delays in 
SSA's response to our formal request for information, we were unable 
to solicit the information necessary to determine whether SSA is 
ensuring such good faith effort on the part of the states and whether 
SSA has been consistently reporting to Congress about its waiving of 
the 3 year requirement. 

[71] SSA makes a distinction between a "formal" waiver that would be 
documented in writing and an "informal" waiver process based on its 
discussions with state officials regarding the appropriate number of 
CDR cases to review. 

[72] Social Security Administration, Annual Report of Continuing 
Disability Reviews, Fiscal Year 2010 (May 1, 2012). 

[73] GAO, Internal Control Management and Evaluation Tool, [hyperlink, 
http://www.gao.gov/products/GAO-01-1008G] (Washington, D.C.: August 
2001).

[74] The SSA Inspector General estimated that SSA did not complete 79 
percent of childhood CDRs and 10 percent of age 18 redeterminations on 
the basis of the results of 275 cases of physical and mental 
impairments they reviewed. To estimate the amount of SSI payments made 
because SSA had not completed a timely childhood CDR, the Inspector 
General calculated the amount of SSI payments made between the 1-year 
anniversary of the scheduled CDR date and the earlier of the month of 
cessation or April 2011 (the date the Inspector General reviewed the 
cases). 

[75] This represents the combined savings to the SSI, SSDI, Medicare, 
and Medicaid programs from CDRs conducted for the SSI and Disability 
Insurance programs, from cessations and terminations due to failure to 
cooperate with a CDR in fiscal year 2010. The estimate includes 
savings to Medicare and Medicaid, as in some cases eligibility for SSI 
and SSDI confers eligibility for certain Medicare or Medicaid 
benefits, as well. SSA noted that the savings-to-cost ratio for fiscal 
year 2010 represents a significant drop from the average ratio for 
fiscal years 1996 through 2009 of $10.60 to $1, attributing the drop 
largely to the Medicaid estimates, which now reflect the effects of a 
Patient Protection and Affordable Care Act provision that allows most 
disabled SSI recipients terminated due to a CDR to retain their 
Medicaid coverage beginning January 1, 2014. Annual Report of 
Continuing Disability Reviews, Fiscal Year 2010, pp. 5, B-1, B-2.

[76] SSA, Strategic Plan: Security Value for America, Fiscal Years 
2013-2016 (Feb. 2012).

[77] Funding for CDRs in both fiscal years 2011 and 2012 was $756 
million. The administration's fiscal year 2013 budget proposal 
includes a supplemental request of $140 million for CDRs and other 
program integrity activities for fiscal year 2012. 

[78] Children with attention deficit disorder are also included in 
this category.

[79] We originally sampled 300 cases for review but encountered 2 
cases that were either mis-coded or that lacked an electronic case 
file. We excluded these 2 cases from our analysis, which produced an 
effective sample size of 298.

[80] For purposes of this appendix, we have provided basic information 
about the 11 mental disorders for children included in SSA's listings. 
For additional information about these listings, refer to 20 C.F.R. 
pt. 404, subpt. P, appendix 1. 

[81] Although for most purposes SSA refers to intellectual 
disabilities rather than mental retardation, consistent with Rosa's 
Law, its medical listings have not been updated to reflect this change.

[82] See 20 C.F.R. §§ 416.926 and 416.926a.

[83] Children with attention deficit disorder are included in the ADHD 
category.

[84] The recorded primary impairment code identifies the primary 
impairment used in the medical determination for an individual's 
eligibility for SSI disability benefits. It appears in the SSA's 831 
and 832/833 Disability files.

[85] According to SSA officials, the error rate for impairment coding 
is estimated between 5 and 6 percent. 

[86] We reviewed a probability sample of 298 case files selected from 
the 184,150 initial determinations decided in fiscal year 2010 for 
children with alleged ADHD, speech and language delay, and autism.

[87] Centers for Disease Control and Prevention/National Survey of 
Children's Health, National Health Interview Survey, 2004-2006. 

[88] P.N. Pastor and C.A. Reuben, Diagnosed attention deficit 
hyperactivity disorder and learning disability: United States, 2004- 
2006. Vital Health Stat 2008; 10 (237). 

[89] U.S. Department of Education, Office of Special Education and 
Rehabilitative Services. Office of Special Education Programs, 30th 
Annual Report to Congress on the Implementation of the Individuals 
with Disabilities Education Act, 2008 (Washington, D.C.: December 
2011). 

[90] The new rules would apply to disability claims involving language 
and speech disorders in adults and children under titles II and XVI of 
the Social Security Act. Specifically, SSA was considering whether to 
add a new body system in the Listing of Impairments in appendix 1 to 
subpart P of part 404 of its regulations (listings) for these 
disorders. 

[91] P.T. Shattuck, "The Contribution of Diagnostic Substitution to 
the Growing Administrative Prevalence of Autism in the U.S. Special 
Education Data." Pediatrics, vol. 117, no. 4 (Apr. 1, 2006) 1028-1037. 

[92] Children with attention deficit disorder are also included in 
this category.

[End of section] 

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