United States General Accounting Office

GAO Report to Congressional Requesters

March 1995 SOCIAL SECURITY

New Functional

Assessments for

Children Raise

Eligibility Questions

GAO/HEHS-95-66

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-257473 

March 10, 1995

The Honorable Herb Kohl

The Honorable David Pryor

United States Senate

The Honorable George W. Gekas

The Honorable Gerald D. Kleczka

The Honorable Blanche Lambert Lincoln

The Honorable Nick Smith

House of Representatives

The number of children receiving Supplemental Security Income (SSI)

benefits has nearly tripled over the last 5 years from 300,000 to almost

900,000, and benefit payments now exceed $4 billion annually. The Social

Security Administration (SSA) awards SSI benefits to disabled children who

live in families with low incomes and limited resources. A number of

factors have contributed to the growth in children’s awards, including

outreach efforts by SSA and child advocates, rising numbers of children in

poverty, and major changes in the criteria for determining whether

children are disabled. Growth has been especially rapid in awards to

children with mental impairments.

Particularly troublesome have been allegations that parents coach their

children to fake mental impairments by misbehaving or doing poorly in

school so that they can qualify for cash benefits. These benefits can

amount to almost $5,500 per year for each disabled child.1

 The coaching

allegations, which have been widely reported by the media, have created

the perception among the public that the program is vulnerable to fraud

and abuse. In addition, concerns have been raised that the program could

foster lifelong dependence on government assistance if children come to

view the label “disabled” as a lifetime entitlement to income and medical

benefits. Finally, concerns have been raised about whether the program’s

eligibility criteria for children are too lenient. As a result of these

concerns, reform of the SSI childhood disability program is now the subject

of congressional scrutiny.

In our October 21, 1994, briefing, you asked us to report on SSA’s new way

of assessing children’s impairments using the individualized functional

assessment (IFA) process mandated by the Supreme Court in Sullivan v.

1

Benefits generally are provided without regard to the number of SSI recipients in the household. SSA

estimated in March 1994 that 125,000 children receiving SSI lived in households with at least one other

SSI recipient.

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Zebley. The new IFA process permits the award of benefits to children with

impairments that are less severe than the impairments that previously

could justify an award. We assessed (1) the IFA’s impact on the SSI rolls,

(2) its implementation by SSA, and (3) its vulnerability to coaching.

To develop the information in this report, we (1) reviewed SSA’s childhood

disability program policies, procedures, and records, and discussed the IFA

process with SSA program officials on the national, regional, and local

level; (2) interviewed officials in state disability determination services

(DDSs); (3) reviewed SSA’s study of decisions made on childhood cases

involving behavioral and learning disorders; and (4) attended a June 1994

SSA training course designed to address the problems raised in the study.

We also discussed eligibility issues with officials of the Department of

Health and Human Services’ (HHS) Office of Inspector General (IG), which

recently issued two reports on the SSI childhood disability program. (See

app. I for more details on our scope and methodology.)

Results in Brief Changes in the regulations governing childhood eligibility for SSI have had

a significant impact on the growth and composition of the childhood

disability rolls. In particular, awards have been made to more than 200,000

children who did not meet SSA’s listing of impairments but instead qualified

for benefits based on the less restrictive IFA criteria. These awards account

for about $1 billion a year in benefit payments. About 84 percent of the

children qualifying based on IFAs have mental impairments, and about

one-half of the awards for behavioral disorders, including attention deficit

hyperactivity disorder, are based on the IFA criteria.

In our analysis, we found fundamental flaws in the IFA process.

Specifically, each step of the process relies heavily on adjudicators’

judgments, rather than objective criteria from SSA, to assess the

age-appropriateness of children’s behavior. As a result, the subjectivity of

the process calls into question SSA’s ability to ensure reasonable

consistency in administering the SSI program, particularly for children with

behavioral and learning disorders.

In addition, rapid program growth, particularly in the award of benefits to

less severely impaired children, may also have contributed to the public

concern that parents could be coaching their children to fake mental

impairments in order to qualify for benefits. Studies that we reviewed,

however, have found little evidence that coaching is widespread, but they

relied solely on documentation in case files and, therefore, cannot rule out

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coaching. Although coaching allegations are troublesome, substantiating

them and measuring the extent of coaching is virtually impossible.

Background Since 1974, the SSI program, under title XVI of the Social Security Act, has

provided benefits to low-income blind and disabled persons—adults and

children—who meet financial eligibility requirements and SSA’s definition

of disability. SSA determines applicants’ financial eligibility; state DDSs

determine their medical eligibility. DDSs are state agencies that are funded

and overseen by SSA. To meet the financial test, children must be in

families with limited incomes and assets.

In 1994, children’s federally administered SSI payments totaled

$4.52 billion. Depending on the family’s income, an eligible child can

receive up to $458 per month in federal benefits; 27 states also offer a

supplemental benefit payment. Because SSI is an individual entitlement, no

family cap exists on the amount of benefits received in a household. With

SSI eligibility usually come other in-kind benefits, most notably Medicaid

and Food Stamps.

The Social Security Act defines a disabled child as a person under age 18

who “suffers from any medically determinable physical or mental

impairment of comparable severity” to one that disables an adult. The

statute defines adult disability in terms of an inability to work either in a

former job or in any other job in the national economy. Specifically, adult

disability is defined as the inability

“to engage in any substantial gainful activity by reason of any medically determinable

physical or mental impairment which can be expected to last a continuous period of not

less than twelve months.”

Because children are not expected to work, however, this definition is not

applicable to measure disability in children.

At a DDS, childhood disability determinations are made by an adjudication

team consisting of an examiner and a medical consultant. For mental

impairments, the consultant must be a psychiatrist or child psychologist.

The examiner collects all medical evidence—physical and mental—either

from medical sources who have treated the applicant or from an

independent consultant if more medical information is needed. The

examiner supplements the medical information with accounts of the

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child’s behavior and activities from the child’s teachers, parents, and

others knowledgeable about the child’s day-to-day functioning.

Working together, the DDS adjudication team determines whether the

applicant’s medical condition matches or is equivalent to an impairment

found in SSA’s listing of medical impairments.2

 If so, benefits are awarded.

If, however, the applicant’s condition is not severe enough to meet or

equal the severity criteria in SSA’s medical listings, the team uses the

evidence to perform an IFA. If the IFA shows the child’s impairment

substantially reduces his or her ability to function age-appropriately,

benefits are awarded. If not, a denial notice is issued, and applicants are

informed of their appeal rights.

SSI Childhood

Eligibility Criteria

Have Undergone

Major Changes

During a 2-month period, SSA issued two sets of new regulations that

significantly changed the criteria for determining children’s eligibility for

SSI disability benefits.3 One set of regulations, issued in accordance with

the Disability Benefits Reform Act of 1984 (DBRA), revised and expanded

SSA’s medical listings for evaluating mental impairments in children to

incorporate recent advances in medicine and science. The second set of

regulations was issued in response to the Sullivan v. Zebley Supreme

Court decision, which required SSA to make its process for determining

disability in children analogous to the adult process. Both sets of

regulations placed more emphasis on assessing how children’s

impairments limit their ability to act and behave like unimpaired children

of similar age. Both also emphasize the importance of obtaining evidence

from nonmedical sources as part of this assessment.

DBRA Regulations

Changed SSA’s Medical

Listings for Assessing

Mental Impairments in

Children

SSA issued new regulations in accordance with DBRA on December 12, 1990.

These new regulations revised and expanded SSA’s medical listings for

childhood mental impairments to reflect up-to-date terminology used by

mental health professionals and recent advances in the knowledge,

treatment, and methods of evaluating mental disorders in children. The

new medical listings for mental impairments provided much more detailed

and specific guidance on how to evaluate mental disorders in children

than the former regulations, which were published in 1977. In particular,

the new medical listings placed much more emphasis on assessing how a

2

SSA’s listing of medical impairments describes impairments—in terms of signs, symptoms, and

laboratory findings—that are presumed to be severe enough to disable an individual.

3

For a complete description of these changes, see Social Security: Rapid Rise in Children on SSI

Disability Rolls Follows New Regulations (GAO/HEHS-94-225, Sept. 9, 1994).

Page 4 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
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child’s mental impairment limits his or her ability to function in

age-appropriate ways. SSA made this change because mental health

professionals consider functional factors particularly important in

evaluating the mental disorders of children.

The former medical listings for mental impairments emphasized the

medical characteristics that must be met to substantiate the existence of

the impairment. Specific areas of functioning sometimes were and

sometimes were not mentioned as a factor in this determination. In

contrast, the new medical listings provide much more detailed guidance

on assessing the functional aspects of each impairment. The standard for

most impairments is divided into two parts: medical and functional

criteria, both of which must be satisfied for the applicant to qualify for a

benefit.

The functional criteria are described in terms of the age of the child and

the specific areas of functioning—such as social, communication/

cognition, or personal/behavioral skills—that must be assessed. The new

medical listings emphasize the importance of parents and others as

sources of nonmedical information about a child’s day-to-day functioning.

In general, the childhood mental listings require children over 2 years old

to have marked limitations in two of the four areas of functioning to

qualify for benefits. Further, when standardized tests are available, the

listing defines the term “marked” as a level of functioning that is two

standard deviations below the mean for children of similar age.

The new medical listings also classified childhood mental disorders into

more distinct categories of mental impairments. Previously, there were 4

impairments listed—mental retardation, chronic brain syndrome,

psychosis of infancy and childhood, and functional nonpsychotic

disorders—now there are 11. Several of the newly listed impairments, such

as autism and other pervasive developmental disorders, mood disorders,

and personality disorders, describe impairments that were previously

evaluated under one or more of the four broader categories of childhood

mental impairments. Several other impairments are mentioned for the first

time, such as attention deficit hyperactivity disorder and psychoactive

substance dependence disorders.

Zebley Regulations Added

Separate Functional

Assessment Process

On February 20, 1990, the Supreme Court ruled that SSA’s process for

determining disability in children under 18 years old violated the Social

Security Act because the process held children to a more restrictive

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disability standard than it did adults. In its opinion, the Court found that

the process for children

“does not account for all impairments ’of comparable severity’ [to adults], and denies

child claimants the individualized functional assessment that the statutory standard

requires . . . .”

To determine adults’ eligibility for disability benefits, SSA uses a five-step

sequential evaluation process. Before Zebley, it used only a two-step

process to determine children’s eligibility for benefits. (See fig. 1.)

Children were awarded benefits only if their impairments met or equaled

the severity criteria in SSA’s medical listings. All other children were denied

benefits. In contrast, adults whose conditions were not severe enough to

qualify under the medical listings could still be found eligible for benefits if

an assessment of their residual functional capacity (RFC) showed that they

could not engage in substantial work. No analogous assessment of

functioning was done for children who did not qualify under the medical

listings.

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Figure 1: Disability Evaluation Process for Adults Versus Children

Step 5:

Considering medical,

vocational, and other

factors, can you

perform generally

available work?

Disabled according

to vocational

factors

Disabled according

to functional

factors

Disabled according

to medical

listings

Disabled according

to medical

listings

Not disabled Not disabled

Not disabled

Disabled according

to medical

listings

Step 4:

Given RFC,

does impairment

allow you

to perform work

done in the past?

Step 3:

Does impairment

meet or equal

severity as defined

in SSA's

medical listings?

Step 2:

Do you

have

a severe

impairment?

Step 1:

Are

you

working?

Step 2:

Do you have an

impairment that meets

or equals severity as

defined in SSA's

medical listings?

Step 1:

Are

you

working?

Step 2:

Do you

have

a severe

impairment?

Step 1:

Are

you

working?

Step 3:

Does impairment

meet or equal

severity as defined

in SSA's

medical listings?

Step 4:

Given IFA, is

impairment

comparably severe to

one that would

disable an adult?

Adults

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

N

Y

N

N

N

N

N

N

N

N

N

Children: Pre-Zebley Children: Post-Zebley

Page 7 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
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To eliminate this disparity, the Court mandated that for those children

who do not qualify for benefits under the more restrictive medical listings,

SSA must add a less restrictive individualized assessment of how the child’s

impairment affects his or her ability to function in age-appropriate

ways—that is, to act or behave in ways that children of similar ages

normally do—before it could decide whether the child was eligible for

benefits. The Court said that although a vocational analysis does not apply

to children because they are not expected to work, SSA could make

“an inquiry into the impact of an impairment on the normal daily activities of a child of the

claimant’s age—speaking, walking, dressing and feeding oneself, going to school, playing,

etc.”

Although the Court required the functional assessment, it did not define

the degree of limitation necessary to qualify for benefits, except by

analogy to the adult definition of disability.

To implement the Zebley decision, SSA convened a group of experts in

April 1990 to help formulate new regulations using age-appropriate

functional criteria. Included were experts in general and developmental

pediatrics, child psychology, learning disorders, and early and adolescent

childhood education as well as advocates from groups such as Community

Legal Services in Philadelphia (plaintiff’s counsel in the Zebley case), the

Association for Retarded Citizens, and the Mental Health Law Project. SSA

also consulted with its regional offices and the state DDSs.

Building on the functional criteria added to the listings after DBRA, SSA

issued regulations implementing the Supreme Court’s decision on

February 11, 1991.4

 According to these regulations, for the child to be

eligible for disability benefits, the IFA must show that the child’s

impairment or combination of impairments limits his or her ability “to

function independently, appropriately, and effectively in an

age-appropriate manner.” Specifically, the impairment must substantially

reduce the child’s ability to grow, develop, or mature physically, mentally,

or emotionally to the extent that it limits his or her ability to (1) attain

age-appropriate developmental milestones; (2) attain age-appropriate daily

activities at home, school, play, or work; or (3) acquire the skills needed to

assume adult roles. Although SSA officials describe these as state-of-the-art

4

Final regulations incorporating voluminous public comments were issued on September 9, 1993.

These regulations, which were not substantially different from the February 1991 interim final

regulations, have a September 9, 1997, sunset date, after which time they will no longer be effective,

unless the Secretary of HHS extends, revises, or reissues them.

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criteria for assessing children’s functioning, they concede that many of

these concepts are not clear cut.

As a result of these regulations, DDSs now perform IFAs to assess the child’s

social, communication, cognitive, personal and behavioral, and motor

skills, as well as his or her responsiveness to stimuli and ability to

concentrate, persist at tasks at hand, and keep pace.5

 Like the DBRA

regulations, the IFA process requires DDSs to supplement medical

information with information about the child’s behavior and activities

from the child’s teachers, parents, and others knowledgeable about the

child’s day-to-day functioning in order to make these assessments.

Generally, if the IFA shows that a child has a moderate limitation in three

areas of functioning or a marked limitation in one area and a moderate

limitation in another, benefits are awarded. In contrast, the more

restrictive functional criteria under SSA’s mental listings require two

marked limitations.

In addition to measuring functioning as part of the IFA process, the Zebley

regulations added the concept of functional equivalence to SSA’s medical

listings. Before Zebley, a child qualified for benefits only if his or her

impairment met or was medically equivalent to the severity criteria in the

listings. After Zebley, a child could qualify if his or her impairment was

functionally equivalent to an impairment in the medical listings, as long as

there was a direct, medically determinable cause of the functional

limitations. The regulations provide 15 examples of conditions—such as

the need for a major organ transplant—presumed to be functionally

equivalent to the listed impairments.

IFA Process Has Had

a Major Impact on the

Rolls

Of the 646,000 children added to the SSI rolls from February 1991 through

September 1994, about 219,000 (one-third) were awarded benefits based

on the less restrictive IFA process. If all 219,000 children receive the

maximum benefit, their SSI benefits would cost about $1 billion a year.

About 84 percent of these children had a mental impairment as their

primary limitation, and about 16 percent had physical impairments. (Fig. 2

shows a breakdown of the impairments.)

5

Social, communication, cognitive, and motor skills are assessed for children of all ages; personal and

behavioral skills are assessed for children 1 year old and older. The ability to concentrate, persist at

tasks at hand, and keep pace are assessed for children 3 years old and older; responsiveness to stimuli

is assessed in children under 1 year old.

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Figure 2: Most IFA Awards Go to

Children With Mental Impairments

38.8% • Mental Retardation

14.8% • Attention Deficit Hyperactivity

Disorder

•

8.6%

Personality and Other Behavioral

Disorders

22.2%•

Other Mental Illnesses

•15.7%

Physical Impairments

Physical

Mental

Source: Analysis of SSA’s 831 file.

Figure 3 shows the substantial increase in the number of awards. Much of

this increase was due to the implementation of new medical listings for

mental impairments. The IFA process also added to the growth in the rolls

and accounted for a substantial portion of new awards. Figure 3 also

shows that the average monthly number of applications jumped

dramatically after Zebley and has continued to grow. Many observers

attribute this increase in applications to the publicity surrounding Zebley,

as well as to increased outreach by SSA, some of which was

congressionally mandated.

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Also, some of the increase in awards may have been attributable to the

close scrutiny of the IFA process by courts and disabled child advocates,

which some believe may have resulted in some DDSs feeling pressured to

increase their award rates during the 1991-1992 period. (App. II provides a

chronology of their actions.) Before the IFA process was introduced in

1991, the national award rate for all types of childhood cases was

38 percent, but the award rate jumped to 56 percent in the first 2 years

after the IFA and DBRA regulations were issued. More recently, during 1993

and 1994, the award rate has dropped dramatically. The national award

rate for 1994 was 32 percent—lower than it was in the 2 years before

Zebley.

Figure 3: IFA and Changes in Medical

Listings Both Contribute to Growth in

the Rolls

Monthly Average

0

10000

20000

30000

40000

50000

1/1/88-2/20/90 2/11/91-12/31/92 1/1/93-12/31/93 1/1/94-9/30/94

IFA Awards

Listings Awards

Applications

Source: Analysis of SSA’s 831 file.

IFA Process Has Been

Difficult to Implement

Consistently

Our review indicates that the IFA process has been difficult to implement

consistently and reliably, particularly for children with mental

impairments, because the process requires adjudicators to make a series

of judgment calls in a complex matrix of assessments about

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age-appropriateness of behavior. SSA and IG studies of children with mental

impairments have borne out these difficulties. Although SSA has tried to

add rigor to the IFA process through guidance and training, we believe that

problems will likely continue because of the difficulties inherent in using

age-appropriate behavior as an analog for the adult vocational assessment

of residual functional capacity.

IFA—A Complex Process

That Relies Heavily on

Adjudicator Judgment

Determining disability for children with impairments that are not severe

enough to match a listed impairment can be a highly subjective process.

SSA designed the IFA process to provide DDS adjudicators with a structure to

help them make uniform and rational disability determinations for

children with less severe impairments. Even so, the necessity to assess a

child’s ability to function age-appropriately requires DDS adjudicators to

make a series of judgments, which we believe raises questions about the

consistency and reliability of DDS decisions. SSA and IG studies and our

analysis document problems throughout the IFA process, especially for

mental impairments. (See app. III for a more detailed discussion of the

problems that SSA and the IG identified.)

Extensive evidence needed: To make disability determinations, DDSs use

information from both medical and nonmedical sources, including

teachers, day care providers, parents, and others knowledgeable about the

child’s day-to-day behavior and activities. For the functional assessment,

observations are needed about the child’s behavior over a long period of

time, so evidence-gathering can be a considerable task. SSA found in its

1994 study that the lack of sufficient supporting documentation was the

most common problem in its sample of childhood disability decisions.

School officials in particular are an important source of nonmedical data

on children’s behavior over time. Each DDS develops its own

questionnaires for eliciting the data, and inquiries are made on virtually

every applicant because this information is also used to assess functioning

under the medical listings. We estimate that the process now results in

about 500,000 inquiries to schools each year, a substantial reporting

burden. Some parties believe that the open-ended questionnaire design in

many states and the burden on school officials faced with many inquiries

may be contributing to poor quality data from this key source.

Difficulty classifying limitations: If an IFA is needed, a disability adjudicator

must classify the child’s limitations in the appropriate areas of functioning,

as shown in figure 4. This is a complex judgment because some areas are

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closely interrelated and impairments may or may not affect functioning in

more than one area. If, for example, evidence indicates that a child gets in

fights at school, the adjudicator must determine whether the specific

behavior is evidence of a limitation in social skills, personal and

behavioral skills, or some combination of these. SSA found that in cases of

incorrect awards a common mistake that adjudicators made was to count

the effect of an impairment in two areas when only one was appropriate.

This resulted in the impairment seeming more severe than it actually was.

Problems defining degrees of limitation: Once the areas have been

identified, the adjudicator must judge the degree of limitation. Because

only certain conditions—such as low intelligence quotient (IQ)—can be

objectively tested and determined, SSA has defined the severity of

limitations by comparison with expected behavior for the child’s

chronological age. Figure 4 shows the degrees of limitation adjudicators

use to assess children 3 through 15 years old. SSA’s guidance defines a

limitation in the moderate category as more than a mild or minimal

limitation but less than a marked limitation. The terms “mild” and

“minimal” are not defined, but SSA guidance describes an impairment in the

marked category as one that “seriously” interferes with a child’s ability to

function age-appropriately, while a moderate limitation creates

“considerable” interference. Within each category, adjudicators are

expected to be able to differentiate the degree of limitation. For example,

a moderate rating can range from a “weak moderate” (just above a

less-than-moderate) up to a “strong moderate” (just below a marked

limitation).

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Figure 4: Structure of the IFA Process

Area of limitation Moderate Marked Extreme

Less than

No evidence moderate

Degree of limitation

Cognitive ability

Communication ability

Social skills

Personal/behavioral patterns

Concentration, persistence,

and pace in completing tasks

Motor skills

Response to stimuli

Limited guidance for summing the result: Because the IFA process is

inherently subjective, SSA cannot provide an objective procedure for

summarizing the IFA results. Therefore, SSA instructs adjudicators to step

back and assess whether the child meets the overall definition of

disability. As an example to guide adjudicators, SSA has said that an award

may generally be granted if a child has a moderate limitation in three

areas. However, SSA officials stress that this statement assumes “three

good, solid moderates,” and they characterize it as a general guideline, not

a firm rule. Also, they stress that other possible combinations of ratings,

such as two strong moderates, could justify finding a child disabled,

depending on the individual child’s circumstances. In the end, officials

stress that adjudicators are expected to award or deny benefits based on

an overall judgment, not on any specific sum of severity ratings.

SSA and IG Studies

Highlight IFA Difficulties

SSA’s 1994 study of 325 childhood awards highlighted the difficulties in

using the IFA process to reliably identify disabled children, particularly

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children with behavioral and learning disorders.6 In the study, SSA’s Office

of Disability selected cases of 325 children with behavioral and learning

disorders who had been found eligible. The majority were found eligible

based on IFAs. These cases had been decided by DDS adjudicators, based on

their understanding of existing guidance from SSA. Then, SSA’s regional

quality assurance staff had reviewed the decisions and found them

accurate. The study involved a third group of experts in the Office of

Disability who reviewed the same cases and found inaccuracies in the

decisions. Based on their findings, we concluded that about 13 percent of

the awards reviewed by SSA had been made to children who were not

impaired enough to qualify. Also, another 23 percent of the awards had

been made without sufficient supporting documentation.7

A January 1995 IG report focused on IFA-based awards to children with

mental impairments. IG staff, with assistance from the Office of Disability,

reviewed 129 IFA-based awards for mental retardation, attention deficit

hyperactivity disorder, and other behavioral or learning disorders. The IG

found that 17 (13 percent) of the awards should have been denials and

another 38 (29 percent) had been based on insufficient evidence. The IG

attributed this to DDS adjudicators’ difficulty interpreting and complying

with SSA’s IFA guidelines for assessing the severity of children’s mental

impairments. Many adjudicators reported that they found the SSA

guidelines unclear and not sufficiently objective. The IG stated that this

group of children had less severe impairments than those children

determined disabled based on the medical listings, making the assessment

of their impairments’ effect on their ability to function age-appropriately

more difficult.

We observed firsthand the difficulty that adjudicators face in making the

judgments required by the IFA process for children who have behavioral

and learning disorders. In June 1994, we attended 1-day training sessions

for DDS adjudicators and SSA’s regional quality assurance staff from across

the nation. The Office of Disability presented the findings from its 1994

study and discussed the policies and procedures that DDS and quality

assurance staff had misapplied. In this training, Office of Disability staff

presented case studies of children included in the 1994 study. After those

in attendance reviewed the evidence for each child’s case, they were asked

to assess the degree to which the child’s impairment limited his or her

functioning. The attendees’ opinions were tallied and in all cases they

were split. During discussions of each case, attendees often voiced

6

The study’s sampling methodology does not permit the results to be projected to the universe of

childhood cases or to any subset of the universe.

7

See appendix III for details on the study and how we calculated these percentages.

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differing views on why they believed, for example, that the child’s

limitation was less than moderate or moderate, or whether a moderate

limitation was a good, solid moderate, or a weak moderate. In some cases,

the opinion of the majority of attendees turned out to be different from the

conclusion of the Office of Disability.

In addition to the national training in June 1994, SSA took other steps to

correct implementation problems, including (1) issuing numerous

instructional clarifications and reminders, (2) requiring DDSs to specially

code certain types of mental impairments and all decisions based on three

moderate limitations (to facilitate selecting samples of cases for further

study), and (3) establishing more rigorous requirements for documenting

awards that are based on three moderate limitations. The Office of

Disability plans to do a follow-up study to assess the effectiveness of its

remedial efforts.

Some experts believe that further steps could be taken to improve the IFA

process. For example, experts we contacted commented on the need for

more complete longitudinal evaluations by professionals. They pointed out

that more complete examinations—sometimes including multiple visits

and observations of both parents and children—would help to address

concerns about the adequacy of information from schools and medical

sources and provide higher assurance of good decisions. They stated that

because professionals are trained to identify malingering in mental

examinations, the expanded examinations might also help relieve

concerns about coaching. They agreed that such examinations would raise

the program’s administrative costs considerably, but because a child can

receive almost $5,500 a year in benefits (which can continue for life) they

believed that the costs would be justified.

SSA’s efforts and experts’ suggestions are geared toward improving the

process rather than addressing the underlying conceptual problems with

the IFA. The difficulties so far in implementing the IFA bring into question

whether these types of incremental actions can ensure consistently

accurate decisions for children with mental impairments, especially

behavioral and learning disorders.

Extent of Coaching

Unknown

The rapid growth in awards to children with mental

impairments—particularly behavioral and learning disorders—has

contributed to the public perception that the SSI program for children is

vulnerable to fraud and abuse. The media have reported allegations that

Page 16 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
B-257473 

parents coach their children to fake mental impairments by misbehaving

or performing poorly in school so that they can qualify for SSI benefits.

Critics believe that cash payments and Medicaid act as incentives for some

parents to coach and, therefore, they are concerned about the extent to

which parents can manipulate the disability determination process.

However, we believe that measuring the extent to which coaching may

actually occur is extremely difficult.

Unless parents admit to it, coaching is almost impossible to substantiate.

The nature of the parent-child relationship makes investigating coaching

allegations difficult. Many communications between parent and child take

place at home, out of the view of outside observers. In addition, the

variability of children’s behavior makes knowing whether a child’s

behavior is the result of coaching difficult. Behavior can vary naturally

among children of the same age—or in the same child over time—as they

go through stages in development or respond to changes in their home or

school environment. If a child started misbehaving in school, investigators

would need baseline evidence to establish that the child had not

misbehaved extensively in the past. Finally, even if investigators could

identify a sudden change in behavior, they would have to rule out other

reasons for the change, such as changes in the child’s household or

neighborhood environment. In short, knowing whether the child is

performing poorly or misbehaving because of coaching or for other

reasons is difficult.

Because coaching is difficult to detect, the extent of coaching cannot be

measured with much confidence. In recent studies, SSA and the HHS IG

reviewed case files and identified scant evidence of coaching or

malingering.8

 In the rare instances where they found evidence of possible

coaching or malingering, most of the claimants had been denied benefits

anyway. (App. III summarizes the results of the SSA and IG studies,

including their scopes and methodologies.)

Actions to Reduce

Program’s Possible

Vulnerability to Coaching

To protect program integrity, SSA has taken several steps to help provide

assurance that the process can detect coaching or malingering and then

make the appropriate eligibility determination. In June 1994, SSA began

requiring DDSs to report to SSA’s regional quality assurance units any case

8

SSA considered possible coaching to be involved in any case in which the child reported or an

information source suspected that the parent or other caregiver had told the child to misbehave or

perform poorly. SSA also looked for evidence that the child had malingered; that is, deliberately

provided wrong information or did not put forth his or her best effort during testing, regardless of

whether coaching was suspected.

Page 17 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
B-257473 

with an allegation or suspicion of coaching. Such cases include those in

which teachers, physicians, or psychologists indicate that (1) the child’s

behavior was atypical of the child’s customary school behavior, (2) the

child was uncooperative during testing, or (3) the child’s behavior

deteriorated without explanation during the 6-month period preceding the

application. According to SSA, its regional quality assurance units review

all alleged cases of coaching. As of mid-January 1995, DDSs nationwide had

reported alleged coaching in 674 childhood cases—or less than one-half of

1 percent of all childhood applications filed during the period—and fewer

than 50 of these children had been awarded benefits.

Along with this new requirement, in August 1994, SSA required DDSs to send

applicants’ schools a set of questions specifically designed to elicit the

teacher’s views on whether the child had been coached. Additionally, each

SSA regional office has established toll-free telephone numbers for the

exclusive use of teachers and school officials to notify the regional quality

assurance unit of coaching allegations. In mid-November 1994, SSA

instructed DDSs to begin distributing these toll-free numbers to schools.

Also, SSA has instructed its field offices and telephone service centers to

report to the regional quality assurance units any allegations of coaching

received from the general public. As of mid-January 1995, from all of these

sources, SSA had received a total of 42 telephone calls with allegations of

coaching involving 54 individuals. According to SSA, each allegation from

teachers, school officials, or the general public is reviewed if the child was

awarded benefits.

Conclusion Childhood disability decisions based on the IFA process are among the

toughest that DDSs must make. Particularly in assessing behavioral and

learning disabilities, the level of judgment required makes the IFA process

difficult to administer consistently. Moreover, the high level of subjectivity

leaves the process susceptible to manipulation and the consequent

appearance that children can fake mental impairments to qualify for

benefits. Indeed, the rise in allegations of coaching may reflect public

suspicion of a process that has allowed many children with less severe

impairments to qualify for benefits. Although scant evidence exists to

substantiate that coaching is a problem, coaching cannot be ruled out and

its extent is virtually unmeasurable.

We believe that a more fundamental problem than coaching is determining

which children are eligible for benefits using the new IFA process. Our

analysis documents the many subjective judgments built into each step of

Page 18 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
B-257473 

the IFA process to assess where a child’s behavior falls along the

continuum of age-appropriate functioning. Moreover, studies by SSA and

the IG of children awarded benefits for behavioral and learning disorders

illustrate the difficulties that SSA has experienced over the last 4 years in

making definitive and consistent eligibility decisions for children with

these disorders.

SSA’s efforts have been aimed at process improvements rather than

reexamining the conceptual basis for the IFA. Despite its efforts, too much

adjudicator judgment remains. Although better evidence and more use of

objective tests where possible would improve the process, the likelihood

of significantly reducing judgment involved in deciding whether a child

qualifies for benefits under the IFA is remote. We believe that more

consistent decisions could be made if adjudicators based functional

assessments of children on the functional criteria in SSA’s medical listings.

This change would reduce the growth in awards and target disability

benefits toward children with more severe impairments.

Matter for

Consideration by the

Congress

Given widespread concern about growth in the SSI program for children

and in light of our findings about the subjective nature of the IFA process,

the Congress could take action to improve eligibility determinations for

children with disabilities. One option the Congress could consider is to

eliminate the IFA, which would require amending the statute. The Congress

could then direct SSA to revise its medical listings, including the functional

criteria, so that all children receive functional assessments based on these

revised criteria.

Page 19 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
B-257473 

We did not request official agency comments from SSA on a draft of this

report. However, we discussed the draft with SSA program officials, who

generally agreed that we had accurately characterized the IFA process and

the results of studies. SSA officials had some technical comments, which

we have incorporated where appropriate.

Please contact me on (202) 512-7215 if you have any questions about this

report. Other major contributors are Cynthia Bascetta, Ira Spears, Ken

Daniell, David Fiske, and Ellen Habenicht.

Jane L. Ross

Director, Income Security Issues

Page 20 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Page 21 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Contents

Letter 1

Appendix I 

Scope and

Methodology

24

Appendix II 

Efforts to Affect

Implementation of the

Zebley Decision

26

January 1991 26

February 1991 26

June 1991 27

December 1992 27

Appendix III 

Studies Done by SSA

and the Inspector

General

28

1994 Study by SSA’s Office of Disability 28

Inspector General Study 30

Figures Figure 1: Disability Evaluation Process for Adults Versus

Children

7

Figure 2: Most IFA Awards Go to Children With Mental

Impairments

10

Figure 3: IFA and Changes in Medical Listings Both Contribute to

Growth in the Rolls

11

Figure 4: Structure of the IFA Process 14

Abbreviations

DBRA Disability Benefits Reform Act of 1984

DDS disability determination service

HHS Health and Human Services

IFA individualized functional assessment

IG Inspector General

IQ intelligence quotient

RFC residual functional capacity

SSA Social Security Administration

SSI Supplemental Security Income

Page 22 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Page 23 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix I 

Scope and Methodology

To develop the information in this report, we (1) reviewed SSA’s childhood

disability program policies, procedures, and records, and discussed the IFA

process with SSA program officials on the national, regional, and local

level; (2) interviewed officials in state DDSs; (3) reviewed SSA’s report on its

1994 study of children with behavioral and learning disorders; and

(4) attended a June 1994 SSA training course that was based on findings

from its study. We also discussed eligibility issues with officials of HHS’ IG,

which recently issued two reports on the SSI childhood disability program.9

To develop SSI childhood program award rate data, we obtained SSA’s

computerized records on the results of initial determinations and

reconsideration disability decisions made by DDSs for children under 18

years old from 1988 through September 1994.10 These records exclude the

results of disability decisions made by administrative law judges. From

these records, we determined (1) the overall award rate for children,

(2) the percentage of IFA awards that were based on mental impairments

versus physical impairments, (3) the average monthly number of

childhood applications, and (4) the average monthly number of awards

that were based on IFAs versus medical listings. These data, as applicable,

were determined for the following periods: (1) 2 years before the Supreme

Court’s Sullivan v. Zebley decision (Jan. 1, 1988, through Feb. 20, 1990);

(2) 2 years after the IFA process was implemented (Feb. 11, 1991, through

Dec. 31, 1992); (3) January-December 1993; and (4) JanuarySeptember 1994. Because no IFA process existed before the Zebley

decision, no pre-Zebley awards were decided based on IFAs.

We excluded children who had applied during 1988 through February 10,

1991, from the universe of children on whom decisions were made from

February 11, 1991, through September 30, 1994. We did this to minimize

the extent to which data in these comparison periods reflect the result of

cases readjudicated as part of the settlement in the Zebley class action

lawsuit. We were not able to identify or exclude Zebley classmembers for

whom benefits had been denied or terminated from 1980 through 1987

from any of the comparison periods. According to SSA, Zebley

9

See Concerns About the Participation of Children with Disabilities in the Supplemental Security

Income Program (A-03-94-02602), Department of Health and Human Services, Office of Inspector

General (Oct. 13, 1994); and Supplemental Security Income: Disability Determinations for Children

with Mental Impairments (A-03-94-02603), Department of Health and Human Services, Office of

Inspector General (Jan. 26, 1995).

10The childhood program statistics presented in this report were developed using the same basic

methodology used in Social Security: Rapid Rise in Children on SSI Disability Rolls Follows New

Regulations (GAO/HEHS-94-225, Sept. 9, 1994). This report focused on the growth in awards after SSA

changed the disability criteria for children.

Page 24 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix I 

Scope and Methodology

classmembers are more likely to have physical impairments than the

general population of new SSI child applicants.

We performed our work from May 1994 through February 1995 in

accordance with generally accepted government auditing standards.

Page 25 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix II 

Efforts to Affect Implementation of the

Zebley Decision

January 1991 One month before SSA issued regulations implementing the new IFA

process, the Zebley plaintiff’s counsel submitted interrogatories to SSA

asking, among other things, why nine DDSs with the lowest award rates for

children had such low award rates.11

SSA regional officials were tasked with answering some of the counsel’s

interrogatories and, in some instances, the officials informed the states

that they were the subject of the counsel’s inquiry. Also, from time to time

thereafter, SSA officials shared state-by-state award rate data with state

DDSs. Some SSA regional officials stated that they believed some DDSs could

have felt pressured to increase their award rates.

February 1991 In the month that SSA issued regulations implementing the new IFA process,

a federal district court ordered SSA to perform special quality assurance

reviews of disability applications denied under the new regulations. The

court order required SSA to do quality assurance reviews of denials made

by 10 state DDSs that, according to SSA, Zebley plaintiff’s counsel had

identified as denial prone due to their low award rates.12 Based on its own

studies, SSA had argued before the court that low award rates were not

reliable indicators of whether special corrective action was needed to

avoid incorrect denials, but the court required SSA to implement the special

quality assurance reviews for these 10 states.

Under the court order, during the first month after the new regulations

were in effect, SSA had to review the lesser of 100 or all denials for each

denial-prone state. SSA reviewed only 25 denials for other states. A

subsequent March 1991 court order required SSA, after the first month, to

review at least 1,000 denials per month nationwide. SSA’s sample of 1,000

denials included 15 percent of the denials from each of the 10 denial-prone

states.

By memorandum in February 1991, SSA informed all DDSs of the special

quality assurance requirements and identified the 10 states that had been

classified as denial prone. The court order required that SSA send the

results of the quality assurance reviews monthly to the Zebley plaintiff’s

counsel.

11The nine states were Alabama, Arkansas, Colorado, Louisiana, Mississippi, Nebraska, South Carolina,

West Virginia, and Wisconsin.

12The 10 states were Alabama, Arkansas, Colorado, Louisiana, Mississippi, Nebraska, New Mexico,

South Carolina, West Virginia, and Wisconsin.

Page 26 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix II 

Efforts to Affect Implementation of the

Zebley Decision

June 1991 The Zebley plaintiff’s counsel wrote to the SSA Commissioner citing a

“disturbing pattern” of low allowance rates in eight states and asked the

Commissioner to take remedial steps.13

December 1992 In a newsletter to legal aid societies, the Zebley counsel listed 13 DDSs

whose cumulative allowance rates were at 50 percent or below.14 The

counsel encouraged legal aid society representatives in those states to

contact the DDS directors and “confront them with their sub-par

performance.”

13The eight states were Connecticut, Kentucky, Louisiana, Nebraska, New Mexico, Texas, West

Virginia, and Wisconsin.

14The 13 states were Arkansas, Connecticut, Louisiana, Maine, Mississippi, Missouri, Montana,

Nebraska, New Mexico, South Carolina, Tennessee, Texas, and West Virginia.

Page 27 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix III 

Studies Done by SSA and the Inspector

General

1994 Study by SSA’s

Office of Disability

SSA considers behavioral and learning disorders to be the most susceptible

to coaching and malingering. In 1994, SSA’s Office of Disability in Baltimore

reviewed a national sample of 617 school-age children who had applied

due to behavioral and learning disorders. Because the sample was small,

the findings of the study cannot be projected to the universe of childhood

disability claims or to the subset of specific impairments studied.

Scope and Methodology The 617 children were selected from those who had applied due to such

impairments as attention deficit disorder, attention deficit hyperactivity

disorder, personality disorder, conduct disorder, learning disorder,

oppositional defiant disorder, anxiety disorder, developmental delay,

behavior disorder, speech and language disorders, borderline intellectual

functioning, and adjustment disorder. According to SSA, these types of

disorders constitute about 20 percent of all childhood disability

applications. SSA excluded cases involving extremely severe mental

disorders, such as psychotic disorders and mental retardation.

SSA selected the 617 cases from final DDS decisions that SSA’s regional

quality assurance staff had already reviewed for accuracy. The 617 cases in

the sample consisted of 325 awards and 292 denials that DDSs adjudicated

during October 1992 through July 1993. SSA reviewed case file

documentation for the 617 cases.

Coaching In its review of case file documentation, SSA considered coaching to be

involved in any claim in which the child reported or an information source

suspected that the parent or other caregiver had told the child to act or

respond in a manner that would make the child appear more functionally

limited than he or she actually was. In addition, SSA looked for evidence

indicating that the child had malingered; that is, deliberately provided

wrong information or did not put forth his or her best effort during testing.

SSA found only 13 cases that showed any evidence of possible coaching or

malingering, and only 3 of these cases were awards. In all cases, the

evidence indicating possible coaching was provided by medical

professionals or psychologists who performed consultative examinations

for SSA. None of the evidence indicating possible coaching or malingering

was provided by schools. The three questioned awards involved children

who may have malingered during IQ testing. In these cases, however, the

awards were based on factors other than the results of the testing. For

example, one child with an oppositional defiant disorder appeared to

Page 28 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix III 

Studies Done by SSA and the Inspector

General

malinger during IQ testing administered by a consultative examiner, but the

award was based on other problems stemming from the disorder, not the

results of the testing.

Incorrect Awards Of the 325 awards reviewed by SSA, SSA found that 8.6 percent (28) should

have been denials and another 27.7 percent (90) should not have been

made without obtaining more supporting documentation. We asked SSA,

based on experience in its quality assurance program, to estimate how

many of the 90 cases with insufficient documentation would have been

denials if all documentation had been obtained, and SSA estimated that 13

(or 4 percent of the 325 awards) would have been denials. Thus, we

concluded that a total of 41 awards (12.6 percent of the 325 awards)

should have been denials. By contrast, of 292 denials reviewed in the

study, SSA found that only 1.4 percent (4) should have been awards, and

another 1.4 percent (4) should not have been made without obtaining

more supporting documentation.

Combining all decisional and documentational errors for the 617 denials

and awards in SSA’s study, the overall error rate for this group of cases was

20.4 percent.15 This is about twice the maximum acceptable error rate of

9.4 percent that SSA allows for decisional and documentational errors

combined for all initial disability decisions made by an individual DDS.

According to SSA’s Office of Disability, a primary reason that DDSs made

awards that should have been denials was that DDSs had frequently

overrated—but rarely underrated—the severity of children’s functional

limitations. Such overrating occurred primarily because DDSs had

(1) compared the child with the perfect child rather than the average child,

(2) based the limitation on a single incident rather than behavior over

time, (3) not considered the child’s ability to function while on an effective

medication regimen, and (4) based the limitation on the child’s life

circumstances rather than the effects of a medically determinable

impairment.

DDSs also had mechanically applied SSA’s guidelines on how to make

awards using the results of the IFA process. SSA’s guidelines instruct DDSs

that they generally should award benefits to children who have moderate

limitations in any three of the areas of ability assessed in the IFA process.

SSA found, however, that DDSs had used this instruction as a rule rather

15The overall error rate for the 617 cases was computed as follows: (28 award decisional errors + 90

award documentational errors + 4 denial decisional errors + 4 denial documentational errors)/ 617 =

0.204.

Page 29 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix III 

Studies Done by SSA and the Inspector

General

than a guideline. DDSs had automatically made awards to any child with

three moderate limitations, regardless of how strong or weak the

moderate limitations were. SSA stated that its guideline assumed “three

good, solid moderates.” SSA found that, when DDSs had identified two

moderate limitations, they sometimes made special attempts to find a third

moderate limitation even though the evidence did not support it.

DDSs had also “double-weighed” the effects of impairments in more than

one of the areas of ability assessed in the IFA process, making the

impairment seem more severe and pervasive than it actually was. For

example, in some cases children displayed a lack of self-control by

exhibiting more than one inappropriate behavior, such as fighting,

aggressive behavior, disrespectful behavior, lying, oppositional behavior,

and stealing. Although all these behaviors should have been rated only in

the personal/behavioral area, DDSs had rated some behaviors in the

personal/behavioral area and others in the social abilities area, giving the

child moderate limitations in two areas rather than only one. This meant

that the child needed only one more moderate limitation to have the three

moderate limitations needed for approval.

SSA also found that DDSs had sometimes based decisions on old evidence

when current evidence indicated children had improved and that DDSs had

sometimes assessed limitations that could not be attributed to medical

impairments.

Inspector General

Study

As the IG reported in January 1995, IG staff reviewed the case files for a

sample of 553 children whose applications were adjudicated by DDSs in

1992. Of the 553 children, 298 had been awarded benefits by 10

DDSs—Connecticut, Illinois, Kentucky, New York, North Carolina, North

Dakota, Pennsylvania, South Dakota, Vermont, and Wisconsin. The

remainder of the 553 cases consisted of a nationwide sample of 255

denials. Of the 298 awards, 129 (43 percent) had been decided based on an

IFA, and 195 of the 255 denials (76 percent) had been decided based on an

IFA. The IG targeted its study at cases involving mental retardation,

attention deficit hyperactivity disorder, and other learning and behavioral

disorders. Based on its review of these cases, IG officials told us that they

had found no evidence of coaching.

As the IG reported, when the IG staff had questions about the accuracy of a

DDS disability determination or about the sufficiency of the evidence

supporting a determination, the IG provided the case file to SSA’s Office of

Page 30 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
Appendix III 

Studies Done by SSA and the Inspector

General

Disability in Baltimore—the same staff responsible for conducting SSA’s

study of 617 childhood disability claims. The Office of Disability reviewed

the accuracy of each of the questioned cases. The IG staff also visited the

10 DDSs to obtain their opinions on the adequacy of the SSA guidelines used

to make disability determinations.

Of the 129 awards reviewed that were based on IFAs, the IG reported that

17 (13 percent) should have been denials and another 38 (29 percent) were

based on insufficient evidence. The IG attributed this problem to DDSs

having difficulty in interpreting and complying with SSA guidelines for

obtaining and evaluating evidence concerning the severity of the mental

impairments of children on whom IFAs are conducted. The IG stated that

these children have less severe impairments than those children

determined to be disabled based on the impairment listing, making the

assessment of the effects of their impairments on their ability to function

age-appropriately more difficult. In discussions with employees of the 10

DDSs, the IG reported that many expressed concern that the SSA guidelines

for determining disability for children with mental impairments were not

sufficiently clear or objective.

(105589) Page 31 GAO/HEHS-95-66 SSI: Childhood Eligibility Decisions
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