Supplemental Security Income: Preliminary Observations on Children with Mental Impairments
Published: 2011-10-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Social Security Administration's (SSA) Supplemental Security Income (SSI) program provides cash benefits to eligible low-income disabled individuals, including children, as well as certain others. Children may generally qualify for SSI benefits if they meet certain financial requirements and are deemed to have a qualifying medically determinable physical or mental impairment of a specified duration or severity that results in a functional limitation. In 2010, SSA paid more than $9 billion to about 1.2 million disabled children. Over the past decade, the overall number of children receiving SSI benefits has continued to rise. In this statement, GAO discusses initial observations from its ongoing review and examines (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 medical eligibility; and (3) the steps SSA has taken to monitor the continued medical eligibility of these children. To examine these issues, GAO analyzed program data, interviewed SSA officials, conducted site visits to SSA field offices and state disability determination services (DDS) offices, and interviewed external experts. This work is ongoing and GAO has no recommendations at this time. GAO plans to issue its final report in April 2012.
section_title: What GAO Found
paragraphs: The numbers of children applying for and receiving SSI benefits due to a mental impairment has increased over the past decade and now comprise a growing majority of all child beneficiaries. While more than half of child applicants are denied each year, children with mental impairments, such as autism, have represented a growing share of those medically allowed for benefits--increasing from 60 to 67 percent between fiscal years 2000 and 2010. Factors including but not limited to the rising number of children living in poverty and increased diagnosis of certain mental impairments may have contributed to such growth. However, the relative effects of these and other factors on program growth are not fully known at this time. Generally, DDS officials reported that they rely on a combination of key medical and nonmedical information--such as medical records and teacher and parent assessments--in determining a child's medical eligibility and that they consider the totality of information related to the child's impairments, rather than one piece of information in isolation. For example, SSA and DDS officials said that they consider a child's use of prescribed medications in the context of other information including school records and teacher assessments, which are critical in evaluating the child's functioning over time. Yet, despite the importance of such nonmedical evidence, GAO's work shows that examiners sometimes face challenges in obtaining this information partly due to teachers' reluctance to complete the assessments. SSA is required to periodically review the medical eligibility of certain children receiving SSI benefits, but GAO's work shows that SSA has conducted significantly fewer childhood continuing disability reviews (CDR) in recent years. Between fiscal years 2000 and 2010, the number of childhood CDRs and age 18 reviews overall fell from more than 200,000 to about 126,000 (a 38 percent decrease), while childhood CDRs for those with mental impairments dropped from more than 84,000 to about 13,000 (an 84 percent decrease). SSA officials have acknowledged that the agency is not conducting childhood CDRs in a timely manner mostly due to resource constraints. However, SSA recognizes the importance of conducting CDRs and has recently estimated that the CDR process yields a savings-to-cost ratio of $12.50 to $1.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our preliminary observations on  children with mental impairments in the Supplemental Security Income  (SSI) program. Administered by the Social Security Administration (SSA),  SSI is a nationwide federal assistance program that provides cash  benefits to eligible low-income disabled individuals, including children, as  well as certain individuals who are aged or blind. In 2010, SSA paid  almost 8 million recipients about $50 billion in SSI benefits, of which more  than $9 billion was paid to about 1.2 million disabled children. During the  early and mid 1990s, the SSI program experienced a period of  unprecedented growth 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 number of children receiving SSI benefits has  continued to rise, especially for those with mental impairments. Our prior  work has shown that accurately diagnosing some types of mental  impairments is a complex and often subjective process for SSA, which  can sometimes be vulnerable to fraud and abuse.
My statement today focuses on initial observations from our ongoing  review and examines (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 medical eligibility; and  (3) the steps SSA has taken to monitor the continued medical eligibility of  these children. To examine these issues, we collected agency data on the  overall number of initial disability determinations and allowances, the  number and types of mental impairments, and the number of continuing  disability reviews of children conducted by SSA. We assessed the  reliability of the data presented in this statement and found potential  limitations with the extent to which primary and secondary impairment  codes within SSA’s 831 disability files—the file that contains data on  disability determinations—may be complete. However, because the 831  disability files are used by SSA to 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. In  our ongoing work, we will conduct a case file review of a random,  generalizable sample of select SSI child mental impairments cases  decided in fiscal year 2010, which will potentially assist us in better  understanding the extent of this limitation. We also conducted in-depth  interviews with SSA management and line staff at SSA headquarters and  six SSA regions—Philadelphia, Pennsylvania; Boston, Massachusetts;  Atlanta, Georgia; Dallas, Texas; Chicago, Illinois; 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 their geographic location, as well as  the volume of SSI applications and benefit allowances for children with  mental impairments. In addition, we interviewed numerous external  experts from the medical and disability advocacy communities and  reviewed relevant federal laws and regulations. We plan to issue our final  report in April 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 that the evidence obtained will provide a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Since 1974, the SSI program, under Title XVI of the Social Security Act,  as amended, has provided benefits to low-income blind and disabled  persons, including adults and children as well as certain aged individuals  who meet financial eligibility requirements and SSA’s definition of  disability. For children, a disability is a medically determinable physical or  mental impairment that results in certain functional limitations, and is  expected to result in death or which has lasted or can be expected to last  for a continuous period of at least 12 months. Families of children  receiving SSI payments are generally required to use the benefit to meet  a child’s current and future needs, including food, clothing, and shelter.  The maximum payment for a child receiving SSI benefits is $674 per  month regardless of the severity of the child’s impairment. As of  December 2010, the average monthly child benefit was $597.
To apply for benefits, the child’s parent or guardian usually submits an  application to SSA either in person at a local SSA field office, by  telephone, or by mail. SSA’s field offices are responsible for 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. 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. 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. If there is evidence that indicates the existence of a  mental impairment, DDS makes every reasonable effort to ensure that a  qualified psychiatrist or psychologist has completed the medical portion of  the case review.
After it makes its initial determination, the DDS returns the case file to the  field office, where SSA completes any outstanding non-disability case  development, computes the benefit amount, and begins paying benefits if  the claimant was determined disabled. If the claim is denied, a claimant  has 60 days to request that SSA 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.
After SSA determines that a child is disabled, the agency is required by  law, in certain circumstances, to conduct periodic reviews, known as a  continuing disability review (CDR), to verify a child’s continued medical  eligibility for receiving SSI benefits. SSA is generally required to perform  CDRs (1) during the first year after birth for babies whose low birth weight  is a contributing factor to the determination of disability and (2) at least  once every 3 years for all other children under age 18 whose conditions  are considered likely to improve. DDS offices determine when  beneficiaries 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 beneficiary’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 required to  redetermine the eligibility of children against the adult criteria for  disability after they reach age 18.
section_title: Number of Children Applying for and Receiving SSI Benefits Due to Mental Impairments Has Increased
paragraphs: The numbers of children applying for and receiving SSI benefits due to a  mental impairment has increased over the past decade and now  comprise a growing majority of all child beneficiaries. While not all such  children who are deemed medically eligible ultimately meet SSI’s financial  eligibility requirements, our preliminary analysis of medical allowances  suggests that the growth in the number of child beneficiaries is roughly  proportionate to the growth in the number of applicants. Furthermore,  SSA data showed that the agency has denied a majority of child  applicants each year. Between fiscal years 2000 and 2010, the average  medical allowance rates for children with physical and mental  impairments were about 37 and 46 percent, respectively (see fig.1).
SSA data show the number of child applicants with mental impairments  increased 60 percent between fiscal year 2000 and fiscal year 2010, from  187,052 to 298,264, while the total number of SSI child beneficiaries with  mental impairments on the rolls grew 52 percent from 543,000 to 827,000  (see fig. 2). Our preliminary research suggests that several factors may  have contributed to the increased number of child applicants and  beneficiaries, including but not limited to SSA’s and child advocates’  outreach efforts, improved access to health insurance for children, the  rising number of children living in poverty, and increased diagnosis of  certain mental impairments. However, the relative effects of these and  other factors on program growth are not fully known at this time.
While it is unclear how various factors are contributing to growth at this  time, SSA data show that since fiscal year 2000, children with mental  impairments have represented the majority of all child applications and  medical allowances for SSI benefits. For example, in fiscal year 2010,  about 62 percent of all SSI child applicants had a mental impairment as a  primary diagnosis, and about 67 percent of those applicants were  medically approved for benefits. For those applicant children with mental  impairments, SSA data also suggests that 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  disorders—between fiscal years 2000 and 2010, with the exception of  intellectual disability as most notable (see fig. 3).
As part of our preliminary work, we examined individual mental  impairments to determine which impairments had the highest number of  applications and medical allowances. SSA’s data on disability  determinations is based on the primary impairment as designated by the  DDS. SSA’s policy operations manual directs DDS examiners to code  the primary impairment as the most severe condition that rendered the  child disabled. In instances where multiple impairments are present, the  secondary impairment is generally the next most severe following the  primary. However, SSA officials have acknowledged that primary  impairment codes are sometimes missing or inaccurately coded. In  addition, the primary impairment code listed may be only one of several  impairments that led DDS examiners to find the child medically eligible for  benefits. In our ongoing review, we plan to conduct an in-depth case file  review to determine the extent to which a secondary impairment was  present for the most prevalent impairments and the extent to which the  secondary impairment, or combination of impairments, influenced the  eligibility decision. SSA data show that for fiscal year 2010, the three  most prevalent primary mental impairments among medical allowances  were for (1) attention deficit disorder/attention deficit hyperactivity  disorder (ADD/ADHD), (2) speech and language delay, and (3) autistic  disorder and other pervasive development disorders (autism). The  following information provides a brief summary of each of these three  impairments as they compare to the incidence of all mental impairments,  as well as in terms of the proportion of applications and medical  allowances:  ADD/ADHD. Between fiscal years 2000 to 2010, applications for this  condition as a primary impairment more than doubled, from about 55,000  to 113,000. Also, the number of children found to be medically eligible  increased by more than 100 percent, from 13,857 to 30,108 (see fig. 4).  By December 2010, about 212,000 such children were receiving SSI  benefits, and they comprised 26 percent of child recipients with mental  impairments.
While children with ADD/ADHD represent the single largest primary  diagnostic group, SSA data show that the majority of ADD/ADHD  applications over the years have been medically denied. Some of the  examiners we interviewed said that they rarely find a child medically  eligible for benefits solely on the basis of an ADD/ADHD impairment  alone, but more commonly in combination with another impairment, such  as asthma or oppositional defiant disorder. Nevertheless, SSA officials  suggested that the increase in both applications and medical allowances  for children with ADD/ADHD might be attributable to an increase in  diagnosis over the last decade, and cited a National Institute of Health  survey finding that ADHD diagnoses had increased, on average, by 3  percent from 1996 to 2006 and by 5.5 percent, on average, from 2003 to  2007. SSA officials also noted a 2008 medical study reporting that  ADHD is one of the most commonly diagnosed childhood  neurobehavioral disorders.
Speech and language delay. During the last decade, both applications  and medical allowances for children with speech and language delay  have increased overall, but the proportion of applicants found medically  eligible has remained relatively stable over time. Between fiscal years  2000 to 2010, applications for this impairment more than doubled, from  21,615 to 49,664 while the number of children found to be medically  eligible nearly tripled, from 11,565 to 29,147 (see fig. 5). As of December  2010, about 174,000 (21 percent) children with mental impairments were  receiving benefits due to a speech and language delay. While some DDS  officials expressed the view that increases could be attributed to  increased school testing and screening programs, SSA officials said  further study was needed to better understand these particular increases.
Autism. Between fiscal years 2000 and 2010, autism applications more  than quadrupled from 5,430 to 23,203, and medical allowances increased  similarly from 5,050 to 20,319 (see fig. 6). As of December 2010, about  95,000 (11 percent) children with mental impairments were receiving SSI  benefits due to autism. DDS examiners have generally found the vast  majority of those children applying for SSI on the basis of autism  medically eligible for benefits. SSA officials attributed the increase in the  number of autism applications and medical allowances over the years to  greater incidence of autism among children and explained that some  children who may have previously been diagnosed as intellectually  disabled are instead being diagnosed as autistic. According to one study  SSA cited, the prevalence of autism in children has increased from 0.6  per 1,000 live births in 1994 to 3.1 per 1,000 live births in 2003, while the  prevalence of intellectual disability decreased by 2.8 per 1,000 live births  in 2003.
section_title: Examiners Report Using a Combination of Key Information Sources in Determining Medical Eligibility
paragraphs: In our preliminary work, DDS officials reported that they rely on a  combination of key medical and nonmedical information—such as  medical records, prescribed medications, school records, and teacher  and parent assessments—in determining a child’s medical eligibility.  Several DDS officials 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. With regard to the  medical information used by examiners, 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. According to many of the DDS  officials we interviewed, examiners attempt to obtain medical evidence,  such as psychological tests, physician’s notes, and mental health records,  for children with alleged mental impairments. If such evidence is not  available or existing evidence is inconclusive, some DDS officials we  spoke with said that they will purchase a consultative examination for the  child. This examination is intended to provide the additional medical  evidence, such as results of a physical examination and laboratory  findings, needed for a determination. 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 over time. For this reason,  some DDS officials said that information from a treating source with a  long-standing relationship with the child, such as a physician, is more  useful.
In response to concerns among many about the role medication plays in  the determination process, we asked SSA and DDS officials how  information about a child’s use of prescribed medications is used, and  they told us it is generally given no more weight than any other medical or  nonmedical information in determining a child’s medical eligibility.  Several DDS officials told us that when making determinations for  children with mental impairments, medication is considered in the context  of other sources of information as “just one piece of the puzzle.” To the  extent that medication improves functioning, some DDS officials told us  they could potentially find that the child is not disabled under program  rules. Despite this fact, certain field office and DDS officials  acknowledged they believe some parents are under the impression that  medicating their children will improve their likelihood of being found  eligible for benefits. However, other DDS officials said they think a  number of parents may avoid medicating their child prior to a consultative  examination so that the child misbehaves and appears more disabled.
To better understand the role of prescribed medications, in March 2011,  SSA conducted an analysis to determine the effect reported use of  medications has on determinations for children with three different mental  impairments and concluded that no effect existed. To conduct this review,  SSA compiled reports of medication usage for all fiscal year 2010 initial  determinations for children with ADD/ADHD, oppositional/defiant disorder,  or conduct disorder impairments. For each impairment, SSA calculated  the share of allowance and denial decisions for those claims with and  without related medications. SSA subsequently noted that for the children  examined, those with reports of related medication were more likely to be  denied than to be allowed. Although SSA’s analysis indicates that  allowance and denial rates were similar for children with ADD/ADHD who  were and were not taking related medications, children with related  medications were somewhat more likely to be allowed for  oppositional/defiant disorder and conduct disorder than those without  medications. Because only about one-third of those allowed for these  three impairments had reports of related medication, SSA concluded that  medication usage does not affect the allowance of child claims for these  impairments. However, SSA’s analysis did not control for other factors,  such as DDS location or claimant age, which may also affect allowance  rates. Without a more in-depth analysis, the effect of the underlying  causes of such differences is unknown. Although we did not  independently validate SSA’s findings, as part of our ongoing review, we  plan to conduct a case file review of a random, generalizable sample of  initial determinations decided in fiscal year 2010 for the most prevalent  mental impairments—ADD/ADHD, speech and language delay, and  autism. As part of this effort, we will identify what sources DDSs reported  using to determine the child’s medical eligibility and how they reported  weighing various sources if material inconsistencies could not be  resolved. This case file review should allow us to verify testimonial  evidence from interviews with field office and DDS officials.
In addition to medical evidence, SSA policy directs DDS offices to use  available evidence from nonmedical sources to evaluate the severity of  the child’s impairment and functioning as part of the eligibility  determination. These sources include parents, day care providers,  teachers, and others knowledgeable about the child’s day-to-day behavior  and activities. SSA field office staff may also provide observations about  the child, if the child is present when the parent submits the application, in  person, and the field office may notify the DDS if multiple siblings apply  for benefits at the same time. Several DDS officials told us school records  and teacher assessments (standardized questionnaires) are especially  critical, because these assessments provide information on the child’s  functioning over time and are generally more objective than parent  assessments. Because parents may be unable to accurately assess the  extent of their child’s impairment, nearly all the DDS officials we  interviewed said that information from the school, including the teacher  assessment, was critical for making accurate determinations. According  to some DDS officials, parents may primarily observe their child in an  unstructured home environment after the child’s medications have worn  off, and they 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. Several DDS  officials told us that they compare all the information they collect to  identify inconsistencies and decide how much weight to assign 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.
Despite the importance of nonmedical information in determining a child’s  medical eligibility, our preliminary work shows that examiners sometimes  face challenges obtaining complete information. For example, some 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. In addition, DDS examiners told us that they do  not routinely receive information 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 potential fraud or abuse, particularly where certain mental  impairments are involved. For example, SSA recently 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. However,  investigators found that the school guidance counselor had never  observed the children exhibiting symptoms of ADHD despite seeing them  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. 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. Without such information, DDS examiners may be limited in  their abilities to identify potential fraud or abuse in the program.
section_title: SSA Has Conducted Significantly Fewer CDRs for SSI Children with Mental Impairments
paragraphs: SSA is required to periodically review the medical eligibility of certain  individuals, though our preliminary work shows that SSA has conducted  significantly fewer CDRs for children receiving SSI benefits in recent  years, including those with mental impairments. Between fiscal years  2000 and 2010, childhood CDRs for those recipients under age 18 and  age 18 redeterminations overall fell from more than 200,000 to about  126,000 (a 38 percent decrease), and more specifically, childhood CDRs  for those with mental impairments declined from more than 84,000 to  about 13,000 (an 84 percent decrease) (see fig. 7). SSA officials attribute  the decrease in CDRs overall 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 between fiscal years 1996 and 2002, CDRs  decreased once the funding expired.
SSA has conducted fewer childhood CDRs in recent years. As of August  1, 2011, SSA had not yet conducted CDRs for about 434,000 SSI  recipients under age 18 with mental impairments who had reached their  scheduled CDR date (see fig. 8). Of these recipients, about 343,000 (79  percent) had exceeded the scheduled date by at least a year, with about  205,000 (47percent) exceeding their date by 3 years and 24,400 (6  percent) exceeding by 6 years. 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. In September  2011, SSA’s Office of the Inspector General also reported that SSA had  not completed all childhood CDRs and age 18 redeterminations in a  timely manner. When reviews of benefits are delayed or not conducted,  some beneficiaries may receive benefits for which they are no longer  eligible. 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 not have received them. SSA has recently estimated that  that the CDR process yielded a savings-to-cost ratio of roughly $12.50 to  $1 in fiscal year 2009, and that those CDRs conducted for adults and  children combined in fiscal year 2009 will save federal programs an  estimated $4.6 billion.
Of those reviews conducted for child recipients in recent years, the vast  majority were for age 18 redeterminations and low-birth weight babies.  SSA is generally required by law to conduct age 18 redeterminations,  within 1 year after a child turns 18, and within 12 months after the birth of  a child who was allowed benefits because of low birth weight. In fiscal  year 2010, 87 percent of CDRs conducted for child recipients were done  in these two areas, and SSA subsequently terminated benefits for about  52 percent of age 18 recipients and 60 percent of low birth weight  recipients. The remaining 13 percent of CDRs conducted were mostly  reviews of children with mental impairments. Of those CDRs conducted  for children under age 18 with mental impairments, SSA terminated  benefits for about 24 percent of recipients in fiscal year 2010, and  personality disorders and speech and language delay had the highest  cessation rates (34 and 33 percent, respectively).
SSA and DDS officials have acknowledged that the agency is not  conducting reviews for child recipients in a timely manner, and in some  cases, they have not conducted required childhood CDRs prior to a  child’s age 18 redeterminations. SSA officials said that they would like to  conduct additional childhood CDRs, but added that due mostly to funding  constraints they are not able to do so. From 1996 to 2002, Congress  provided funding to SSA to conduct additional CDRs for both Social  Security disability and SSI beneficiaries. Since this funding expired, the  number of CDRs SSA has conducted overall has dramatically declined.  The recently enacted Budget Control Act of 2011 authorized an  increase in funding for CDRs and redeterminations under both the SSI  and the Social Security Disability Insurance programs, starting with an  additional $623 million in fiscal year 2012 and reaching an additional $1.3  billion in each of fiscal years 2017 to 2021. At the time of this statement,  SSA was evaluating how to use this funding for CDRs, should it be  appropriated, and it is not yet known to what extent the agency would (a)  increase the number of childhood CDRs in the future or (b) target such  CDRs toward those mental impairments with the highest cessation rates.
Mr. Chairman and Members of the Subcommittee, this concludes my  prepared statement. I will be happy to respond to any questions.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information related to this statement, please contact me at  (202) 512-7215. Individuals who may key contributions to this statement  include Jeremy Cox, Assistant Director, James Bennett, Edward Bodine,  Sue Bernstein, David Chrisinger, Alex Galuten, Monika Gomez, Jason  Holsclaw, Kristen Jones, Sheila McCoy, Luann Moy, and Paul Wright.
section_title: Appendix I: Listings for Mental Disorders for Children under Age 18
paragraphs: 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, SSA is required to examine whether  the child’s impairment meets, medically equals, or functionally equals any  of the impairments contained in the listings. The actual listings go into  further detail about the level of severity necessary for this step of the  determination, but the general listings for mental disorders in children are  arranged in 11 diagnostic categories. These categories include:  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.
Anxiety disorders: In these disorders, anxiety is either the predominant  disturbance or is experienced if the individual attempts to master  symptoms; e.g., 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 find a child disabled. When a child  has a medically determinable impairment that is not listed, an impairment  that does not meet the requirements of a listing, or a combination of  impairments none of which meets the requirements of a listing, SSA will  make a determination whether the child’s impairment(s) medically or  functionally equals the listings. This determination 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 or medically equals a  listing.
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