SUPPLEMENTAL 

SECURITY INCOME

Better Management 

Oversight Needed for 

Children’s Benefits

Report to Congressional Requesters

June 2012

GAO-12-497

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-497, a report to 

congressional requesters 

June 2012 

SUPPLEMENTAL SECURITY INCOME

Better Management Oversight Needed for Children’s 

Benefits

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 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. 

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. 

View 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. 
Page i GAO-12-497 Supplemental Security Income 

Letter 1 

Background 3

Number of Children Applying for and Receiving SSI Benefits Due 

to Mental Impairments Has Increased 9

Examiners Rely on a Combination of Key Information Sources to 

Determine Medical Eligibility 19

SSA Has Conducted Few Childhood CDRs in Recent Years 28

Conclusions 39

Recommendations for Executive Action 41

Agency Comments and Our Evaluation 42

Appendix I Scope and Methodology 44

Appendix II Listings for Mental Disorders for Children under Age 18 47

Appendix III Trends on the Three Most Prevalent Primary Impairments among 

Children with Mental Impairments in the Supplemental 

Security Income Program 50

Appendix IV Reported Medication and Psychotropic Drug Use among Children 

Applying for Supplemental Security Income by Select Impairments, 

Fiscal Year 2010 60

Appendix V Comments from the Social Security Administration 62

Appendix VI GAO Contact and Staff Acknowledgments 66

Tables

Table 1: Percentage of Cases by Reported Use of Medication and 

by Select Primary Impairment, Fiscal Year 2010 60

Contents
Page ii GAO-12-497 Supplemental Security Income 

Table 2: Percentage of Medication and Psychotropic Drug Use 

Reported by Select Primary Impairment, Fiscal Year 2010 61

Figures

Figure 1: SSI Benefit Awards to Children with Mental Impairments 

and Key Policy Changes, 1983 to 2011 8

Figure 2: SSI Applications and Initial Level Allowances for Children 

under Age 18, by Physical and Mental Impairment Group, 

Fiscal Years 2000 to 2011 10

Figure 3: Initial Level Allowances for SSI Children with Mental 

Impairments, by Primary Impairment, Fiscal Years 2000 to 

2011 11

Figure 4: Number of Children under Age 18 Receiving Federally 

Administered SSI Payments, by Mental and Physical 

Impairment Group, December 2000 through December 

2011 13

Figure 5: Information Sources Used to Support Determinations for 

Children with Alleged ADHD, Speech and Language 

Delay, and Autism, Fiscal Year 2010 20

Figure 6: Allowances and Denials by Medication Status for 

Children with Alleged ADHD, Speech and Language 

Delay, and Autism, Fiscal Year 2010 24

Figure 7: Number of Childhood CDRs Conducted for SSI Recipients 

under Age 18, by Primary Impairment, Fiscal Years 2000 

through 2011 30

Figure 8: Pending Childhood CDRs and Age 18 Redeterminations 

for Those with Mental Impairments, by Time Lapsed, as of 

August 1, 2011 32

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 33

Figure 10: Applications for Children with ADHD as a Primary 

Impairment, Fiscal Years 2000 to 2011 51

Figure 11: Applications for Children with Speech and Language 

Delays as a Primary Impairment, Fiscal Years 2000 to 2011 53

Figure 12: Applications for Children with Autism as a Primary 

Impairment, Fiscal Years 2000 to 2011 55

Figure 13: Number of Fiscal Year 2010 Initial Determinations for 

Children, by Primary Impairment 56

Figure 14: Number of Fiscal Year 2010 Initial Determinations for 

Children, by Primary Impairment and Age 58
Page iii GAO-12-497 Supplemental Security Income 

Figure 15: Percentage of Fiscal Year 2010 Initial Determinations for 

Children, by Primary Impairment and Gender 59

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

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Page 1 GAO-12-497 Supplemental Security Income 

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.

 
 

Page 2 GAO-12-497 Supplemental Security Income 

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 cases1 from the 184,150 

initial determinations performed in fiscal year 2010 for children with 

alleged attention deficit hyperactivity disorder (ADHD),2 speech and 

language delay, and autistic disorder and other pervasive development 

disorders (autism).3

 

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.

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, 

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.
 

Page 3 GAO-12-497 Supplemental Security Income 

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.

Since 1974, the SSI program, under Title XVI of the Social Security Act, 

as amended,4 has provided benefits to low-income blind and disabled 

persons—including adults and children,5

 

4

The SSI program was established by Pub. L. No. 92-603, § 301, 86 Stat. 1329, 1465 

(1972), and became effective starting in 1974.

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 

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).

Background

Eligibility Criteria
 

Page 4 GAO-12-497 Supplemental Security Income 

has lasted or can be expected to last for a continuous period of at least 

12 months.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.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.8

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.

As of December 2011, the average 

monthly federal child payment was $592. 

9 The medical evaluation assesses whether the child 

has a physical or mental impairment, or both, that (1) is severe,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.11 The listing of impairments for children describes the impairments 

that cause marked and severe functional limitations.12

 

6

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

If a child has a 

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. 

10To be considered severe, the child’s impairment must cause the child more than minimal 

functional limitations. 20 C.F.R. § 416.924(c). 

1120 C.F.R. § 416.924(a).

12See appendix II for additional information about the listings of mental disorders for 

children. 
 

Page 5 GAO-12-497 Supplemental Security Income 

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.

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.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.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.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.16

If SSA determines that an individual is disabled, the agency is required by 

law to conduct periodic reviews, known as continuing disability reviews 

 

1320 C.F.R. § 416.913.

1420 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.

1520 C.F.R. § 416.903(e).

16For more information about the administrative review process for disability 

determinations, see 20 C.F.R. § 416.1400 et seq.

Initial Determinations and 

Continuing Disability 

Reviews
 

Page 6 GAO-12-497 Supplemental Security Income 

(CDR), to verify the recipient’s continued medical eligibility for receiving 

benefits in certain circumstances.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 

disability18 and (2) at least once every 3 years for all other children under 

age 18 whose conditions are considered likely to improve.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 criteria20 for disability after they reach age 18.21

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.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.23

 

17SSA 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. 

In 1990, the U.S. Supreme Court decided in Sullivan v. 

1842 U.S.C. § 1382c(a)(3)(H)(iv).

1942 U.S.C. § 1382c(a)(3)(H)(ii)(I). 

20Adults 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).

2142 U.S.C. § 1382c(a)(3)(H)(iii). 

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

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

Policy Changes to 

Eligibility Criteria
 

Page 7 GAO-12-497 Supplemental Security Income 

Zebley that SSA’s use of medical listings of impairments for children—

without conducting a functional analysis—was incomplete.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 ageappropriate 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)25

 

24493 U.S. 521, 538-41.

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 fig. 1).

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

Page 8 GAO-12-497 Supplemental Security Income 

Figure 1: SSI Benefit Awards to Children with Mental Impairments and Key Policy 

Changes, 1983 to 2011

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. 
 

Page 9 GAO-12-497 Supplemental Security Income 

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,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).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.

28

 

26A 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. 

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 fig. 2).

27For 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.

28Data on allowances and allowance rates refers to initial level allowances, not final 

allowances, which include appeals decisions. 

Number of Children 

Applying for and 

Receiving SSI 

Benefits Due to 

Mental Impairments 

Has Increased
 

Page 10 GAO-12-497 Supplemental Security Income 

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

Fiscal Years 2000 to 2011 

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. 

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.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 

 

29In accordance with Rosa’s Law, “intellectual disability” has generally replaced the term 

“mental retardation.” Pub. L. No. 111-256, 124 Stat. 2643. 
 

Page 11 GAO-12-497 Supplemental Security Income 

and language delay, and (3) autism.30

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

Of these impairments, SSA data 

indicate that applications and allowances for autism saw the largest 

percentage increases from fiscal years 2000 to 2011 (see fig. 3). (See 

app. III for trend information related to these three impairments.)

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

the disability determination. 

 

30These 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. 
 

Page 12 GAO-12-497 Supplemental Security Income 

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. 

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 fig. 4).31

 

31The 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. 

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.
 

Page 13 GAO-12-497 Supplemental Security Income 

Figure 4: Number of Children under Age 18 Receiving Federally Administered SSI 

Payments, by Mental and Physical Impairment Group, December 2000 through 

December 2011 

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). 

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.32

 

32See GAO, Supplemental Security Income: State Trends in Applications, Allowances, 

and Benefit Receipts for Children with Mental Impairments, an E-Supplement to 

GAO-12-497, GAO-12-498SP (Washington, D.C.: June 26, 2012). 
 

Page 14 GAO-12-497 Supplemental Security Income 

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.33

• 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).

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:

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.35

• Increased awareness and improved diagnosis of certain mental 

impairments. The increased awareness and improved diagnosis of 

 

33GAO, Supplemental Security Income: Growth and Changes in Recipient Population Call 

for Reexamining Program, GAO/HEHS-95-137 (Washington, D.C.: July 1995); Social 

Security: Federal Disability Programs Face Major Issues, 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, GAO/HEHS-94-225 (Washington, D.C.: 

September 1994).

34U.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).

35U.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).

Several Factors May 

Contribute to the Growth 

in Numbers of Children 

Applying for and Receiving 

SSI Benefits
 

Page 15 GAO-12-497 Supplemental Security Income 

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 2008.36

• 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.

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.

37

• Focus on identifying children with disabilities through public school 

special education services. The Individuals with Disabilities Education 

 

36Coleen 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).

37Health Coverage of Children: The Role of Medicaid and CHIP, Kaiser Commission on 

Medicaid and the Uninsured, February 2011. 
 

Page 16 GAO-12-497 Supplemental Security Income 

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.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,39

• 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.

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.

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.

 

38Pub. 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.

39According 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).
 

Page 17 GAO-12-497 Supplemental Security Income 

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,40

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.

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.

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.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 

 

4020 C.F.R. § 416.926a(a).

41Estimates 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.

42The 95 percent margins of error for percentages in this paragraph range from plus or 

minus 10 to plus or minus 14 percentage points.

Secondary Impairments 

Were Present for Many of 

Those Found Medically 

Eligible
 

Page 18 GAO-12-497 Supplemental Security Income 

functional equivalence, but only 22 percent of cases allowed on the basis 

of meeting or medically equaling the listings.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, 

 

43The 95 percent margins of error for percentages for these data range from plus or minus 

5 to plus or minus 11 percentage points.
 

Page 19 GAO-12-497 Supplemental Security Income 

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.

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.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.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.46

 

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

While examiners relied on multiple information 

sources, we found that the extent they used these sources varied (see fig. 

5).

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

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

Examiners Rely on a 

Combination of Key 

Information Sources 

to Determine Medical 

Eligibility
 

Page 20 GAO-12-497 Supplemental Security Income 

Figure 5: Information Sources Used to Support 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. 

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.47

 

4720 C.F.R. § 416.912(d).

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, 
 

Page 21 GAO-12-497 Supplemental Security Income 

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.48

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.

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.

49

 

4820 C.F.R. § 416.917.

These sources include parents, day care 

providers, teachers, and others knowledgeable about the child’s day-today 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.)

4920 C.F.R. § 416.924a.
 

Page 22 GAO-12-497 Supplemental Security Income 

Several DDS officials told us school records and teacher assessments 

(standardized questionnaires)50

• 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.” 

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 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 

 

50The 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.
 

Page 23 GAO-12-497 Supplemental Security Income 

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.

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 

fig. 6).

When Used in Eligibility 

Decisions, Medication and 

Treatment Information Is 

Frequently a Basis for 

Denying Benefits
 

Page 24 GAO-12-497 Supplemental Security Income 

Figure 6: Allowances and Denials by Medication Status for Children with Alleged 

ADHD, Speech and Language Delay, and Autism, Fiscal Year 2010

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.51 We found that in cases in 

which psychotropic drug use was reported,52 applicants were also more 

likely to be denied.53

 

51The 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. 

In these cases, 68 percent were denied and 32 

percent were allowed. Nevertheless, our case file review suggests 

52Psychotropic drugs, such as antidepressants and antipsychotics, affect brain activity 

associated with mental processes and behavior.

53For more detailed information on applicants’ reported medication and psychotropic drug 

use, see appendix IV.
 

Page 25 GAO-12-497 Supplemental Security Income 

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 “[t]hese 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 “[n]ot 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.54

 

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

it.

The mother argued the 
 

Page 26 GAO-12-497 Supplemental Security Income 

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.

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, 

Examiners Sometimes 

Lack Complete 

Information to Inform 

Their Decision Making and 

Identify Potential Threats 

to Program Integrity
 

Page 27 GAO-12-497 Supplemental Security Income 

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. 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.56

 

55The 95 percent margin of error for percentages in this paragraph range from plus or 

minus 9 to plus or minus 10 percentage points.

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 

56The 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.
 

Page 28 GAO-12-497 Supplemental Security Income 

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 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).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).58

 

57Under 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.

From fiscal years 2000 to 2011, the number of adult 

58The SSDI program provides benefits to eligible individuals who meet certain minimum 

work requirements. 

SSA Has Conducted 

Few Childhood CDRs 

in Recent Years
 

Page 29 GAO-12-497 Supplemental Security Income 

CDRs fell from 584,000 to 179,000.59

 

59For 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. 

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.
 

Page 30 GAO-12-497 Supplemental Security Income 

Figure 7: Number of Childhood CDRs Conducted for SSI Recipients under Age 18, 

by Primary Impairment, Fiscal Years 2000 through 2011
 

Page 31 GAO-12-497 Supplemental Security Income 

Because SSA has conducted fewer childhood CDRs in recent years, as 

of August 1, 2011,60 the agency had a backlog of about 435,000 child SSI 

recipients with mental impairments whose review had not yet been 

conducted (see fig. 8).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.62

 

60SSA conducts an annual analysis of pending CDRs for children. This is the most recent 

date for which these data are available.

61A total of about 861,000 child recipients with mental impairments were receiving SSI 

benefits as of December 2011.

62SSA 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.

Hundreds of Thousands of 

Childhood CDRs Are 

Overdue by More than 3 

Years, Including Reviews 

for Children Expected to 

Medically Improve
 

Page 32 GAO-12-497 Supplemental Security Income 

Figure 8: Pending Childhood CDRs and Age 18 Redeterminations for Those with 

Mental Impairments, by Time Lapsed, as of August 1, 2011

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 fig. 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 
 

Page 33 GAO-12-497 Supplemental Security Income 

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

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

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 

Due to Competing 

Workloads, SSA Gives 

Lower Priority to Most

Childhood CDRs, Including 

Legally Required Reviews 

for Children Likely to 

Medically Improve
 

Page 34 GAO-12-497 Supplemental Security Income 

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 disorders63 and speech and language 

delay having the highest cessation rates, 39 and 38 percent, 

respectively.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.65

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 

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.

 

63Personality 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, app. 1. 

64The 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.

6542 U.S.C. § 1382c(a)(3)(H)(iii) and (iv), respectively.
 

Page 35 GAO-12-497 Supplemental Security Income 

receiving SSI benefits who are likely to medically improve.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.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.

68

 

6642 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 

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. 

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.

67Social Security Administration Office of the Inspector General, “Follow-Up: Childhood 

Continuing Disability Reviews and Age 18 Redeterminations” (A-01-11-11118), Sept. 23, 

2011.

68This was the most recent annual CDR report available at the time of our discussion, in 

February 2012.
 

Page 36 GAO-12-497 Supplemental Security Income 

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.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.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.71

 

6920 C.F.R. § 416.990(g).

In light of the questions we raised, SSA indicated it would 

begin issuing a formal waiver document after undertaking its ongoing 

70The 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. 

71SSA 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.
 

Page 37 GAO-12-497 Supplemental Security Income 

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.72

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.

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.

73

 

72Social Security Administration, Annual Report of Continuing Disability Reviews, Fiscal 

Year 2010 (May 1, 2012). 

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. 

73GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G (Washington, 

D.C.: August 2001).
 

Page 38 GAO-12-497 Supplemental Security Income 

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.74

 

74The 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). 

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 
 

Page 39 GAO-12-497 Supplemental Security Income 

year 2010 would save federal programs the present value of estimated 

lifetime benefits of $3.5 billion.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 Plan76 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.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.

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 

 

75This 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.

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

77Funding 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. 

Conclusions
 

Page 40 GAO-12-497 Supplemental Security Income 

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 
 

Page 41 GAO-12-497 Supplemental Security Income 

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.

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 

Recommendations for

Executive Action
 

Page 42 GAO-12-497 Supplemental Security Income 

process for making information about issued waivers available to the 

public.

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. 

Agency Comments 

and Our Evaluation
 

Page 43 GAO-12-497 Supplemental Security Income 

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 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. 

Daniel Bertoni

Director

Education, Workforce,

and Income Security Issues
Appendix I: Scope and Methodology

Page 44 GAO-12-497 Supplemental Security Income 

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 

Appendix I: Scope and Methodology
Appendix I: Scope and Methodology

Page 45 GAO-12-497 Supplemental Security Income 

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),1 speech and language 

delay, and autistic disorder and other pervasive development disorders 

(autism).2

 

1

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

(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 

2

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.
Appendix I: Scope and Methodology

Page 46 GAO-12-497 Supplemental Security Income 

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.
Appendix II: Listings for Mental Disorders for 

Children under Age 18

Page 47 GAO-12-497 Supplemental Security Income 

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:1

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.2

 

1

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, app. 1. 

2

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.

Appendix II: Listings for Mental Disorders for 

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

Children under Age 18

Page 48 GAO-12-497 Supplemental Security Income 

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 
Appendix II: Listings for Mental Disorders for 

Children under Age 18

Page 49 GAO-12-497 Supplemental Security Income 

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.3

 

3

See 20 C.F.R. §§ 416.926 and 416.926a.

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.
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 50 GAO-12-497 Supplemental Security Income 

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),1 (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.2 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.3

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 fig. 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. 

 

1

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

2

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.

3

According to SSA officials, the error rate for impairment coding is estimated between 5 

and 6 percent. 

Appendix III: Trends on the Three Most Prevalent 

Primary Impairments among Children with Mental 

Impairments in the Supplemental Security Income 

Program
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 51 GAO-12-497 Supplemental Security Income 

Figure 10: Applications for Children with ADHD as a Primary Impairment, Fiscal 

Years 2000 to 2011

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. 

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 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 52 GAO-12-497 Supplemental Security Income 

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,4

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.

and 

oppositional defiant disorder was the secondary impairment cited most 

frequently in the individual cases we reviewed.

5

 SSA officials also noted a 2008 medical study reporting that ADHD 

is one of the most commonly diagnosed childhood neurobehavioral 

disorders.6

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 fig. 11). 

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.

 

4

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.

5

Centers for Disease Control and Prevention/National Survey of Children’s Health, 

National Health Interview Survey, 2004-2006. 

6

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). 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 53 GAO-12-497 Supplemental Security Income 

Figure 11: Applications for Children with Speech and Language Delays as a Primary 

Impairment, Fiscal Years 2000 to 2011

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. 

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, 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 54 GAO-12-497 Supplemental Security Income 

making it the most common service in both years.7

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.

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.

8

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 fig.12). 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. 

 

7

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). 

8

The new rules would apply to disability claims involving language and speech disorders 

in adults and children under tiltes 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. 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 55 GAO-12-497 Supplemental Security Income 

Figure 12: Applications for Children with Autism as a Primary Impairment, Fiscal 

Years 2000 to 2011

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. 

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 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 56 GAO-12-497 Supplemental Security Income 

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.9

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.

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.

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

Primary Impairment

 

9

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. 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 57 GAO-12-497 Supplemental Security Income 

The age at which SSA determined whether a child was medically eligible 

for benefits varied by impairment (see fig. 14). Children with ADHD who 

applied for benefits were older, on average, than applicants with autism or 

speech and language delay.
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program

Page 58 GAO-12-497 Supplemental Security Income 

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

Note: Age is calculated as of the beginning of fiscal year 2010. 
Appendix III: Trends on the Three Most 

Prevalent Primary Impairments among 

Children with Mental Impairments in the 

Supplemental Security Income Program 

Page 59 GAO-12-497 Supplemental Security Income 

Based on our case file review, we estimate that 72 percent of these 

children were male, although gender composition also varied by 

impairment (see fig. 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 

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

points. 
Appendix IV: Reported Medication and 

Psychotropic Drug Use among Children 

Applying for Supplemental Security Income by 

Select Impairments, Fiscal Year 2010 

Page 60 GAO-12-497 Supplemental Security Income 

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),1

Table 1: Percentage of Cases by Reported Use of Medication and by Select Primary 

Impairment, Fiscal Year 2010

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.

Primary impairment

ADHD Autism

Speech and 

language delay Total

Medication reported 45.9%

(5.9)

3.5%

(1.3)

8.5%

(2.5)

58.0%

(6.5)

Medication not reported 15.2

(5.9)

8.6

(1.3)

18.3

(2.5)

42.0%

(6.5)

Psychotropic drugs reported 42.3

(6.3)

2.2

(1.1)

2.4

(1.5)

46.9%

(6.5)

Psychotropic drugs not 

reported

18.8

(6.3)

9.9

(1.1)

24.4

(1.5)

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. 

 

1

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

Appendix IV: Reported Medication and 

Psychotropic Drug Use among Children Applying 

for Supplemental Security Income by Select 

Impairments, Fiscal Year 2010 
Appendix IV: Reported Medication and 

Psychotropic Drug Use among Children 

Applying for Supplemental Security Income by 

Select Impairments, Fiscal Year 2010 

Page 61 GAO-12-497 Supplemental Security Income 

Table 2: Percentage of Medication and Psychotropic Drug Use Reported by Select 

Primary Impairment, Fiscal Year 2010

Primary 

impairment

Medication 

reported

Medication not 

reported

Psychotropic 

drugs reported

Psychotropic 

drugs not 

reported

ADHD 79.3%

(4.4)

36.1%

(9.3)

90.2%

(3.8)

35.4%

(7.7)

Autism 6.0

(2.3)

20.4

(4.0)

4.6

(2.4)

18.6

(2.8)

Speech and 

language delay

14.7 

(3.9)

43.6

(7.1)

5.2

(3.0)

46.0

(5.7)

Total 100.0% 100.1% 100.0% 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. 
Appendix V: Comments from the Social 

Security Administration

Page 62 GAO-12-497 Supplemental Security Income 

Appendix V: Comments from the Social 

Security Administration
Appendix V: Comments from the Social 

Security Administration

Page 63 GAO-12-497 Supplemental Security Income 
Appendix V: Comments from the Social 

Security Administration

Page 64 GAO-12-497 Supplemental Security Income 
Appendix V: Comments from the Social 

Security Administration

Page 65 GAO-12-497 Supplemental Security Income 
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 66 GAO-12-497 Supplemental Security Income 

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

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.

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments

(131060)
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