Supplemental Security Income: Better Management Oversight Needed for Children's Benefits
Published: 2012-06-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: SSAs SSI program provides cash benefits to eligible low-income individuals with disabilities, including children. In 2011, SSA paid more than $9 billion to about 1.3 million disabled children, the majority of whom received benefits due to a mental impairment. GAO was asked to assess (1) trends in the rate of children receiving SSI benefits due to mental impairments over the past decade; (2) the role that medical and nonmedical information, such as medication and school records, play in the initial determination of a childs eligibility; and (3) steps SSA has taken to monitor the continued medical eligibility of these children.
To do this, GAO analyzed program data; interviewed SSA officials; conducted site visits to 9 field offices and 11 state DDS offices across the nation; reviewed a generalizable sample of 298 claims for select impairments from fiscal year 2010; reviewed relevant federal laws and regulations; and interviewed external experts, among others.
section_title: What GAO Found
paragraphs: The number of Supplemental Security Income (SSI) child applicants and recipients with mental impairments has increased substantially for more than a decade, even though the Social Security Administration (SSA) denied, on average, 54 percent of such claims from fiscal years 2000 to 2011. Factors such as the rising number of children in poverty and increasing diagnosis of certain mental impairments have likely contributed to this growth. In fiscal year 2011, the most prevalent primary mental impairments among children found medically eligible were (1) attention deficit hyperactivity disorder, (2) speech and language delay, and (3) autism, with autism claims growing most rapidly since fiscal year 2000. State disability determination services (DDS) examiners also consider the impact of additional, or secondary, impairments when making a decision, and when present, these impairments were used to support 55 percent of those cases GAO reviewed that were allowed in fiscal year 2010. However, SSA has not consistently collected those impairment data, limiting its understanding of how all impairments may affect decisions.
DDS examiners generally rely on a combination of key medical and nonmedical informationsuch as medical records and teacher assessmentsto determine a childs medical eligibility for SSI. In its case file review, GAO found that examiners usually cited four to five information sources as the basis for their decision, and that being on medication was never the sole source of support for decisions. Moreover, examiners cited medication and treatment information, such as reports of improved functioning, as a basis for denying benefits in more than half of cases that GAO reviewed, despite a perception among some parents that medicating their child would result in an award of benefits. Examiners also reported they sometimes lacked complete information to inform their decision making. For example, several DDS offices reported obstacles to obtaining information from schools, which they believe to be critical in understanding how a child functions. Examiners also do not routinely receive information from SSA field offices on multiple children who receive benefits in the same household, which SSAs fraud investigations unit has noted as an indicator of possible fraud or abuse. Without such information, examiners may be limited in their ability to identify threats to program integrity.
SSA has conducted fewer continuing disability reviews (CDR) for children since 2000, even though it is generally required by law to review the medical eligibility of certain children at least every 3 years. From fiscal year 2000 to 2011, childhood CDRs overall fell from more than 150,000 to about 45,000 (a 70 percent decrease), while CDRs for children with mental impairments dropped from more than 84,000 to about 16,000 (an 80 percent decrease). The most recent data show that more than 400,000 CDRs were overdue for children with mental impairments, with some pending by as many as 13 years or more. Of the more than 24,000 CDRs found to be 6 or more years overdue, 25 percent were for children expected to medically improve within 6 to 18 months of their initial allowance. SSA acknowledged the importance of conducting such reviews, but said that due to resource constraints and other workloads, such as initial claims, most childhood CDRs are a lower priority. SSAs process for issuing waivers from the CDR legal requirement lacks transparency, and without these reviews, SSA could continue to forgo significant program savings.
section_title: What GAO Recommends
paragraphs: GAO recommends that SSA take steps to ensure needed information, such as secondary impairment data and school records, is consistently collected; make its CDR waiver process more transparent; and conduct additional childhood CDRs. SSA agreed with four recommendations and disagreed with one that the agency conduct additional childhood CDRs, citing resource constraints. The GAO recommendation acknowledges resource constraints, as discussed more fully within the report.

section_title: Letter
paragraphs: The Social Security Administration (SSA) administers the Supplemental  Security Income (SSI) program, a nationwide federal assistance program  that provides cash benefits to eligible low-income individuals with  disabilities, including children, as well as certain individuals who are aged  or blind. In 2011, SSA paid almost $50 billion in SSI benefits to about 8  million recipients, of which about $9.4 billion was paid to 1.3 million  children. During the early and mid-1990s, the SSI program grew at an  unprecedented rate for children due, in part, to legal developments that  expanded program eligibility for children with mental impairments. For  example, from the end of 1989 through 1996, the number of children  receiving SSI benefits more than tripled from 265,000 to about 955,000.  Since that time, the overall number of children receiving SSI benefits has  continued to rise. In addition to this growth, the media has suggested that  many parents believe it is necessary that their child be prescribed  psychotropic drugs in order to qualify for benefits.
In light of these developments, you asked us to assess, in part, the extent  to which SSA is monitoring the initial determination and continued  eligibility of children with mental impairments. Specifically, this report  addresses (1) the trends in the rate of children receiving SSI benefits due  to mental impairments over the past decade; (2) the role that medical and  nonmedical information, such as medication and school records, play in  the initial determination of a child’s eligibility; and (3) the steps SSA has  taken to monitor the continued medical eligibility of these children.
To examine these issues, we analyzed SSA data on trends and  characteristics of children applying for and receiving SSI benefits. We  assessed the reliability of the data presented in this report by performing  data testing, reviewing internal controls and related documentation, and  interviewing agency officials, and found potential limitations with the  extent to which primary and secondary impairment coding may be  present within SSA’s 831 Disability file—the computer file that contains  data on disability determinations. However, because SSA uses the 831  Disability file to make (and thus, reflect) the decisions regarding medical  determinations, we determined that these data were sufficiently reliable to  describe certain trends among children in the SSI program. To  corroborate these data and better understand what information sources  examiners use in determining a child’s medical eligibility, we reviewed a  generalizable probability sample of 298 SSI cases from the 184,150  initial determinations performed in fiscal year 2010 for children with  alleged attention deficit hyperactivity disorder (ADHD), speech and  language delay, and autistic disorder and other pervasive development  disorders (autism). We also conducted in-depth interviews with SSA  management and line staff at SSA headquarters and within six SSA  regions. These regions are Atlanta, Georgia; Dallas, Texas; Chicago,  Illinois; Philadelphia, Pennsylvania; Boston, Massachusetts; and San  Francisco, California. Our work included site visits to 9 field offices within  these regions, as well as 11 state disability determination services (DDS)  offices (state agencies under the direction of SSA that perform medical  eligibility determinations and continuing disability reviews of SSI  applicants). We selected these sites on the basis of (1) their geographic  location, (2) high volume of SSI applications for children with mental  impairments, and (3) benefit allowance rates for children with mental  impairments. In addition, we interviewed numerous external experts from  the medical and disability advocacy communities and reviewed relevant  studies, as well as relevant federal laws and regulations.
We conducted this performance audit from February 2011 to June 2012  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe the  evidence obtained provides a reasonable basis for findings and  conclusions based on our audit objectives. Appendix I discusses our  scope and methodology in further detail.
subsections: section_title: Background
subsections: section_title: Eligibility Criteria
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,individuals—who meet financial eligibility requirements and the definition  of disability. For individuals under age 18, a disability is a medically  determinable physical or mental impairment that results in marked and  severe functional limitations, and is expected to result in death or which   as well as certain aged  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 needs, including food,  clothing, and shelter. The maximum federal benefit payment for a child  receiving SSI benefits in 2012 is $698 per month, regardless of the  severity of the child’s impairment.monthly federal child payment was $592.
The medical evaluation is conducted under applicable legal requirements and SSA  policy. severe impairment that does not meet or medically equal any listing, the  DDS will then determine whether the impairment results in limitations that  functionally equal the listings.
section_title: Initial Determinations and Continuing Disability Reviews
paragraphs: 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, the DDS is supposed to make every reasonable effort to  ensure that a qualified psychiatrist or psychologist has completed the  medical portion of the case review.
After the initial determination has been made and before returning the  case file to complete any outstanding nondisability case development,  SSA selects a sample of initial determinations for a quality assurance  review. If the case is sampled, the reviewing component sends the case  to the servicing field office upon completion of its review. If the claimant is  determined to be disabled, the field office computes the benefit amount  and initiates benefit payment. If the claim is denied, a claimant has 60  days to request that the DDS reconsider its decision. If the claimant is  dissatisfied with the reconsideration, he or she may request a hearing  before an administrative law judge, whose decision may then be reviewed  by SSA’s Appeals Council. When these administrative review options  have been exhausted, the claimant may request judicial review by filing  an action in a federal district court.
If SSA determines that an individual is disabled, the agency is required by  law to conduct periodic reviews, known as continuing disability reviews  (CDR), to verify the recipient’s continued medical eligibility for receiving  benefits in certain circumstances. More specifically, SSA is generally  required to perform CDRs (1) during the first year after birth for babies  whose low birth weight is a contributing factor to the determination of  disability 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 recipients will be due for CDRs on the basis of their  potential for medical improvement, and select and schedule a review  date—otherwise known as a “diary date”—for each recipient’s CDR. At  the time of these reviews, the child’s representative payee generally must  present evidence that the child is and has been receiving medically  necessary and available treatment for his or her impairment. SSA is also  generally required to redetermine the eligibility of children against the  adult criteria for disability after they reach age 18.
section_title: Policy Changes to Eligibility Criteria
paragraphs: Since SSI’s inception, a number of policy changes have influenced how  SSA makes disability decisions and the extent children with mental  impairments are eligible to participate in the program. In 1984, Congress  mandated the development of new disability standards for individuals with  mental impairments and the consideration of the impact of multiple  impairments in determining disability, among other things. SSA  subsequently expanded the list of mental impairments it considers  disabling in 1985 and again in 1990, when SSA added impairments such  as ADHD.
In 1990, the U.S. Supreme Court decided in Sullivan v.
Zebley that SSA’s use of medical listings of impairments for children— without conducting a functional analysis—was incomplete. In response,  SSA established “functional equivalence” as a basis for SSI eligibility for  children, whereby a child can be found medically eligible for benefits if the  child’s impairment limits his or her functional ability to the same degree as  described in a listed impairment. In deciding whether an impairment  functionally equals the listings, SSA examines how the child functions  compared to children of the same age who do not have impairments— rather than basing the decision on the child’s medical diagnosis. The  Court’s decision also resulted in the introduction of the individualized  functional assessment. This assessment was intended to be comparable  to SSA’s method for evaluating adult impairments and to broaden the  evaluation of disability in children with physical and mental impairments to  include the effects of impairments on a child’s ability to perform age- appropriate activities on a day-to-day basis. Awards to children,  especially those with mental impairments, increased dramatically for  several years following the Sullivan v. Zebley decision due partly to SSA  readjudicating nearly 300,000 determinations made between January  1980 and February 1991 under the revised disability criteria. By 1994,  SSA had reprocessed the majority of these cases, and subsequently  returned to processing their normal case loads. The Personal  Responsibility and Work Opportunity Reconciliation Act of 1996  (PRWORA) changed the standard for children, and the act was  expected to reduce the number of awards. However, awards to children  with mental impairments began to increase again shortly after the  legislation was enacted (see fig. 1).
section_title: Number of Children Applying for and Receiving SSI Benefits Due to Mental Impairments Has Increased
paragraphs: The number of children applying for and receiving SSI benefits due to a  mental impairment has increased for more than a decade, and these  children comprise a growing majority of all child recipients on the SSI  disability rolls. While not all such children who are deemed medically  eligible ultimately meet SSI’s financial eligibility requirements, the  numbers of children applying for SSI benefits due to a mental impairment  increased from 187,052 in fiscal year 2000 to 315,832 in fiscal year 2011  (a 69 percent increase). Despite this increase, SSA data indicated that  the agency has denied a majority of these child applicants each year. In  fact, for initial determinations in fiscal years 2000 to 2011, the average  denial rates for children with physical and mental impairments were about  63 and 54 percent, respectively, and allowance rates have remained  relatively stable over time for both groups of children. SSA data also  showed that since fiscal year 2000, children with mental impairments  represented the majority of all child applications and allowances for SSI  benefits (see fig. 2).
SSA data show that, for those children with mental impairments who  apply, the number of children found medically eligible for benefits has  increased for almost every mental impairment category—such as speech  and language delay and mood disorder—for fiscal years 2000 to 2010,  with the exception of intellectual disability. SSA data also show that the  three most prevalent primary mental impairments among those children  found medically eligible in fiscal year 2011 were for (1) ADHD, (2) speech  and language delay, and (3) autism.indicate that applications and allowances for autism saw the largest  percentage increases from fiscal years 2000 to 2011 (see fig. 3). (See  app. III for trend information related to these three impairments.)
section_title: Examiners Rely on a Combination of Key Information Sources to Determine Medical Eligibility
paragraphs: DDS examiners rely on a combination of key medical and nonmedical  information sources—such as medical records, effects of prescribed  medications, school records, and teacher and parent assessments—in  determining a child’s medical eligibility for benefits. Several DDS officials  we interviewed said that when making a determination, they consider the  totality of information related to the child’s impairments, rather than one  piece of information in isolation. Based on our case file review, we  estimate that examiners generally cited four to five information sources as  support for their decisions in fiscal year 2010 for the three most prevalent  mental impairments. While examiners relied on multiple information  sources, we found that the extent they used these sources varied (see fig.  5).
In more than 90 percent of the cases we reviewed, the examiner used  some form of medical evidence to support the decision, regardless of  whether the child’s impairment met, medically equaled, or functionally  equaled the listings. SSA generally requires DDS examiners to assist  children and their parents or guardians in obtaining medical records in an  effort to develop at least a 1-year-long medical history prior to applying for  benefits. We estimate that examiners used observations from a treating  source, such as a pediatrician or psychologist, about a child’s functioning  and testing by a treating source as support for 65 percent and 61 percent  of their determinations, respectively, making them among the most  commonly cited information sources. According to many of the DDS  officials we interviewed, examiners attempt to obtain medical evidence,  such as psychological tests, physician’s notes, and mental health records,  for children with alleged mental impairments.
If such evidence is not available or is inconclusive, DDS examiners may  purchase a consultative exam to provide additional medical evidence and  help them establish the severity of a child’s impairment. This  examination is intended to provide the additional medical evidence, such  as results of a physical examination and laboratory findings, needed for a  determination. Based on our case file review, we estimate at least one  consultative examination was present in 52 percent of the cases. In some  cases, DDS offices requested multiple consultative examinations, such as  both a psychological and speech and language evaluation to address  different aspects of the alleged impairment. Consultative examinations  also provide information on the severity of the child’s impairment. For  example, one examination provider described a case in which a child with  a speech and language delay had receptive and expressive language  skills that were nearly 2 years behind his chronological age. We  estimated that cases were more likely to be allowed if the consultative  exam provider described the child’s impairment as severe. However,  many DDS officials told us that such examinations are only a “snap-shot”  in time and do not provide a longitudinal view of the child’s functioning.  For this reason, some DDS officials said that information from a treating  source with a long-standing relationship with the child, such as a  physician, is more useful.
In addition to medical evidence, SSA uses nonmedical information to  evaluate the severity of the child’s impairment and functioning as part of   These sources include parents, day care the eligibility determination. providers, teachers, and others knowledgeable about the child’s day-to- day behavior and activities. SSA field office staff may also provide  observations about the child, if the child is present for the disability  interview. (We estimate about 8 percent of child applicants were present  at the field office for the disability interview.)
Several DDS officials told us school records and teacher assessments  (standardized questionnaires) are especially critical for determining  medical eligibility because these assessments provide information on a  child’s functioning over time and are generally more objective than parent  assessments. According to some DDS examiners, parents primarily  observe their child in an unstructured home environment after the child’s  medications have worn off, and may not know what behaviors are  developmentally normal, whereas teachers are generally in a position to  compare the child to other children and provide neutral observations on  how the child relates to peers, responds to medication, and performs in  school. We estimate teacher assessments and school testing were used  to support 63 and 43 percent of determinations, respectively. We also  identified several examples in the case files we reviewed where the  teacher’s assessment was used to establish the child’s level of  functioning and response to medication. For example:
To support an allowance in one autism case, the examiner noted “Per  teacher, he is virtually nonverbal. The teacher confirms he is not toilet  trained or independent in any area of self care.”
To support a denial decision in one ADHD case, the examiner noted  that the teacher’s assessment indicated that the child’s medication  “has ‘helped tremendously’ with  ability to concentrate.”  Additionally, according to the teacher the child “has many friends and  is very social. She has no problems interacting with others. Claimant  has no problems with self care. She participates in the softball and  dance team.”
To support a denial decision in one autism case, the examiner  reported that the “teacher…notes he is more controlled on his meds.”
After the necessary information is collected to make a disability  determination, several examiners said that they compare all the  information to identify inconsistencies and assign weight to the various  sources. For example, some officials told us examiners assess the  credibility of parents’ assessments of children’s functioning by comparing  it to physicians’ and teachers’ statements. SSA policy notes that an  inconsistency does not necessarily mean that a determination cannot be  made because often most of the evidence or the most substantial  evidence outweighs the inconsistent evidence and additional information  would not change the determination or decision. Among the 298 alleged  ADHD, speech and language delay, and autism cases we examined,  there were 25 in which material inconsistencies could not be resolved  between sources, requiring the examiner to assign more or less weight to  certain sources. Examiners assigned more weight to teacher  assessments or information from school testing in 11 of the 25 cases.  Examiners also generally assigned more weight to testing and  observations of functioning by a consultative examiner (10 of the 25  cases) or by a treating source (10 of the 25 cases). In contrast, parents’  assessments were given less weight in 14 of the 25 cases, although  decisions were made on a case by case basis. In one ADHD case, the  child’s mother alleged a developmental delay, but a psychological  consultative exam did not find evidence of such a delay. The child’s  teacher also stated that the child performed well academically when not  under timed conditions. In this case, the examiner gave less weight to the  parent’s assessment and denied the claim.
subsections: section_title: When Used in Eligibility Decisions, Medication and Treatment Information Is Frequently a Basis for Denying Benefits
paragraphs: Despite a media report that prescription medication is considered by  some parents as key to obtaining SSI benefits, we found that medication  and treatment information is frequently a basis for denying benefits. SSA  and DDS officials told us that medication is generally given no more  weight than any other medical or nonmedical information in determining a  child’s medical eligibility. In addition, several DDS officials told us  medication is considered in the context of other sources of information as  “just one piece of the puzzle.” Our case file review confirmed that  information on medication and treatment was never the sole source of  support for an allowance or denial. In fact, we found that applicants were  more likely to be denied than allowed when medication was reported (see  fig. 6).
When applying for benefits, parents reported that their children were  prescribed some form of medication in 58 percent of the cases we  reviewed. Of cases where medication was reported as present, 65  percent were denied and 35 percent were allowed. By comparison, 47  percent of cases were denied and 53 percent were allowed when  medication was not reported as present. We found that in cases in  which psychotropic drug use was reported, applicants were also more  likely to be denied. In these cases, 68 percent were denied and 32  percent were allowed. Nevertheless, our case file review suggests  examiners did not decide whether to allow or deny a claim based on the  absence or presence of medication. Although medication was reported as  present in 58 percent of cases, it was only cited as support for a  determination in 38 percent of cases.
Beyond examining cases where parents reported that their children were  prescribed medication, we also specifically looked at cases where  examiners cited information on medication or treatment as part of the  rationale for their determinations. We found examiners generally  considered how the child responded to these interventions when making  a determination, and in 66 percent of the cases where information on  medication or treatment was used to support a determination, the  applicant was denied. When examiners cited medication and treatment as  a basis for denials, they noted that the child’s functioning improved due to  these interventions. For example, in one denied ADHD case, the  examiner wrote that the claimant “has responded well to medication and  while on medication has no problems functioning, completing work on  time and getting along with others.” In one denied speech and language  delay case, the examiner noted that the claimant “has been through  multiple therapies” and that “hese therapies have been successful.” To  the extent that medication improves functioning, DDS officials told us they  could potentially find that the child is not disabled under program rules. In  contrast, in cases where the child’s functioning was not improved by  medication, this information generally helped support an allowance. For  example, in one allowed ADHD case, the examiner noted that the child  was “ot able to complete work independently despite tx  with  psych meds and special supervision in a partial  inclusion  setting.” In another allowed ADHD case, the examiner observed that both  the treating source and teacher’s assessment “indicate marked limitations  in attention and concentration even with stimulant meds.”
Despite the examiners’ focus on how medication affects functioning,  certain field office and DDS officials acknowledged that they believe some  parents are under the impression that medicating their children will  improve their likelihood of being found eligible for benefits. For example,  in one denied ADHD case the child’s mother did not cooperate with the  DDS’s efforts to obtain a consultative exam. The mother argued the  DDS should already have enough evidence to support an allowance  because the child was taking medication. However, other DDS officials  told us some parents may avoid medicating their child prior to a  consultative examination so that the child misbehaves and appears more  disabled—further reinforcing the importance of multiple tests and  observations for determining eligibility.
section_title: Examiners Sometimes Lack Complete Information to Inform Their Decision Making and Identify Potential Threats to Program Integrity
paragraphs: Despite the importance of nonmedical information in determining a child’s  medical eligibility, examiners sometimes face challenges obtaining  complete information. Several DDS offices reported difficulty obtaining  school records or teacher assessments, which they partly attributed to  school and teacher concerns about the time involved to compile this  information, potential liability issues, or confusion about how such  information is used in the disability decision-making process. For  example, some DDS examiners told us that in certain instances teachers  view their completion of the assessment as affirming that a child is  disabled and thus endorsing SSA’s decision to award benefits. They do  not understand that examiners base their determinations on the totality of  evidence or that the assessment could be used to support a denial. In  one of the cases we reviewed, a teacher returned a blank teacher  assessment with a note stating “we are not allowed to fill these out  anymore.”
Our case file review estimated that teacher assessments were absent for  57 percent of cases for children age 7 or younger—which is unsurprising,  given that many of these children may not yet be school age—but such  assessments were also absent for 25 percent of cases for children older  than age 7. To address this challenge, SSA officials told us that some DDS  offices have dedicated staff to conduct outreach to schools in order to  emphasize the importance of information from schools as an evidence  source. However, they added that these staff have competing priorities,  including recruiting consultative exam providers and other medical  professionals, which limit the amount of outreach they can perform. In  addition to strengthening relationships with school personnel, disability  advocates told us that SSA could revise the teacher assessment by using  clearer language to make it more inviting to teachers. They also noted that  SSA could further emphasize that by completing the assessment, teachers  are not endorsing SSA’s ultimate decision as to whether the child is  disabled or qualifies for benefits. Because schools and teachers are not  required to provide records or teacher assessments, some DDS offices pay  a fee for school records, but state laws prevent others from doing so,  according to SSA officials. SSA officials did not know the extent to which  DDS offices have paid for school records or the amount they had paid.
SSA officials informed us they have heard reports of some DDS offices  facing challenges in obtaining information from schools, but they do not  know the degree to which these challenges exist nationwide, nor has SSA  conducted an empirical analysis of challenges related to obtaining  information from schools. SSA did issue guidance on steps DDS offices  can take to mitigate processing delays associated with obtaining school  evidence during extended school breaks, such as summer vacation, but  the agency has not issued guidance regarding year-round challenges  associated with obtaining information from schools. Without further study  to determine how widespread these obstacles are, it will remain unclear  whether additional guidance is warranted.
In addition to the challenges they sometimes face in obtaining information  from schools, DDS examiners said that they do not routinely receive  information from SSA field offices on multiple siblings receiving SSI  benefits within the same household even though they are directed to be  alert for such cases. SSA’s policy operations manual states that  disabilities may occur in more than one member of a family or household,  but notes prior case experience has shown this type of situation is an  indicator of possible fraud or abuse, particularly where certain mental  impairments are involved. For example, one of SSA’s Cooperative  Disability Investigations Units investigated a case in which parents  applied for SSI benefits on behalf of their four children, alleging that they  all suffered from ADHD and conduct issues.found that the school guidance counselor had never observed them  exhibiting symptoms of ADHD despite seeing the four children daily, and  that a doctor had rescinded an order authorizing the school to administer  ADHD medication to the children. In this instance, SSA subsequently  denied the siblings’ applications for SSI benefits. SSA’s policy operations  manual directs examiners to refer such cases to SSA’s Cooperative  Disability Investigations Unit or Office of the Inspector General for further   However, investigators  development, if questionable issues cannot be resolved. Based on our  interviews, it appears that SSA field offices do not consistently notify DDS  examiners when an applicant’s siblings are already receiving SSI  benefits, nor are they always made aware of concurrent sibling  applications. SSA data indicate that as of January 2012, nearly 64,000  children, or 5 percent of all child recipients, resided in a household where  more than 1 child received disability benefits. Without information on such  children, DDS examiners may be limited in their ability to identify potential  fraud or abuse in the program and elevate these cases to the attention of  SSA’s fraud investigations unit.
section_title: SSA Has Conducted Few Childhood CDRs in Recent Years
paragraphs: SSA has conducted significantly fewer CDRs for children receiving SSI  benefits since 2000, even though SSA is generally required to perform  CDRs at least every 3 years on child recipients under age 18 whose  impairments are likely to improve, as well as certain other individuals (see  fig 7). Childhood CDRs overall fell from more than 150,000 in fiscal year  2000 to about 45,000 reviews in fiscal year 2011 (a 70 percent decrease).  More specifically, CDRs for children under age 18 with mental  impairments declined from more than 84,000 to about 16,000 (an 80  percent decrease). Similarly, SSA has conducted significantly fewer  CDRs for adult benefit recipients of either SSI or Social Security Disability  Insurance (SSDI).
From fiscal years 2000 to 2011, the number of adult  CDRs fell from 584,000 to 179,000.proportion of childhood CDRs conducted has remained much lower than  the proportion of adult CDRs conducted. SSA officials attribute the  decrease in CDRs overall, including childhood CDRs for those with  mental impairments, primarily to resource limitations and a greater  emphasis on processing initial claims and reducing the backlog of  requests for appeals hearings in recent years. While SSA did increase the  number of CDRs it performed after receiving additional funding  specifically targeted for CDRs from fiscal years 1996 to 2002, CDRs  decreased once the funding expired.
section_title: Conclusions
paragraphs: SSA, Strategic Plan: Security Value for America, Fiscal Years 2013-2016 (Feb. 2012). because DDS offices have not consistently collected secondary  impairment data. Without steps to ensure that this information is more  reliably recorded, SSA management will not have a complete picture of  the characteristics of children with mental impairments receiving benefits  or changes in this population over time.
Because examiners sometimes lack key information for cases they  review, including school records and information on multiple children  receiving benefits in the same household, they may face challenges in  making eligibility decisions and identifying potential fraud or abuse.  Examiners have also increasingly based allowance decisions on a finding  of functional equivalence for children with the most prevalent mental  impairments, requiring more complex decision making. Yet because  some examiners face obstacles in obtaining information from schools— which they consider critical to understanding how a child functions—SSA  cannot ensure that examiners have the necessary information to arrive at  the most accurate determinations. Additionally, as a key program  gatekeeper, DDS examiners are in a unique position to identify program  integrity threats related to multiple children receiving SSI benefits within  the same household. However, without better information on these types  of arrangements they are unable fulfill this role in preventing potential  fraud and abuse.
The fact that more than 430,000 childhood CDRs are overdue raises  concerns about the agency’s ability to manage limited funds in a manner  that adequately balances its public service priorities with its stewardship  responsibility. When reviews are not conducted as scheduled, some child  recipients may receive benefits for which they are no longer eligible,  potentially costing taxpayers billions of dollars in overpayments.  Furthermore, CDRs provide an important check on program growth by  removing ineligible recipients from the rolls, even while new applicants  are added. If these reviews are not conducted in sufficient numbers, the  agency will continue to struggle to contain growth in benefit payments,  placing added burden on already strained federal budgets. Congress  appropriated funding for SSA to conduct more CDRs in recent years, and  SSA is evaluating how to manage its overall CDR workload. However,  because SSA considers SSI childhood CDRs a lower priority than other  CDRs, it is unclear whether the agency will use this funding to review  children most likely to medically improve—reviews that could yield a high  return on investment. If SSA continues to rely heavily on the use of  waivers to conduct fewer CDRs than would otherwise be required by law,  SSA will potentially forgo future program savings. Furthermore, while we  consider SSA’s decision to begin issuing formal waivers in order to clearly  comply with the CDR legal requirement to be a good start, that action  alone is not sufficient to fully alleviate our concerns with the waiver  process. Until the agency formally implements this waiver process, the  extent to which SSA is conducting CDRs consistently with its legal  requirements will continue to be unclear.
section_title: Recommendations for Executive Action
paragraphs: To strengthen eligibility decisions and improve monitoring of children with  mental impairments within the SSI program, we recommend that the  Commissioner of Social Security:  1.  Direct the Deputy Commissioners of Retirement and Disability Policy  and Operations to take steps to ensure that DDS examiners  accurately record information on secondary impairments in order to  improve SSA’s understanding of how multiple impairments may  influence decisions.  2.  Direct the Deputy Commissioner of Operations to identify the extent to  which DDS examiners nationwide experience obstacles in obtaining  teacher assessments and school records. To the extent these are  identified, SSA should clarify the nature of these obstacles and  formulate steps to address them. Such steps could include increased  DDS outreach to primary and secondary schools, increased SSA  coordination with the Department of Education, or additional guidance  to DDS offices.  3.  Direct the Deputy Commissioner of Operations to ensure that field  offices notify their respective DDS offices of those claims in which  multiple children within the same household are applying for or  receiving SSI benefits so that examiners will be better able to identify  potential fraud or abuse in the program and elevate these cases to the  attention of SSA’s fraud investigations unit.  4.  Direct the Deputy Commissioner of Quality Performance to eliminate  the existing CDR backlog of cases for children with impairments who  are likely to improve and, on an ongoing basis, conduct CDRs at least  every 3 years for all children with impairments who are likely to  improve, as resources are made available for these purposes.  5.  Direct the Deputy Commissioner of Quality Performance and Deputy  Commissioner of Operations to take actions to ensure that SSA’s  CDR waiver process is open, transparent, and public. This may  include promulgating formal guidance for issuing waivers, and a  process for making information about issued waivers available to the  public.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to SSA for review and comment. In its  written comments, reproduced in appendix V, SSA agreed with 4 of our 5  recommendations and stated that our draft report overall reflected a good  understanding of the disability determination process and the SSI  childhood disability program. SSA disagreed with our recommendation to  eliminate the existing CDR backlog of cases for children with impairments  who are likely to improve and conduct CDRs for these children at least  every 3 years, as resources are made available for these purposes. SSA  agreed conceptually that it should complete more CDRs for SSI children  but emphasized that it is constrained by limited funding and staff  resources and as a result had to waive many required childhood CDRs in  recent years. SSA also argued that performing additional SSI child CDRs  would have negative impacts on the SSDI program. We acknowledge the  challenge SSA faces as it strives to balance competing workloads. In  recognition of the agency’s resource constraints, we noted in our  recommendation that additional CDRs for children who are likely to  medically improve should be conducted “as resources are made available  for these purposes.” We also believe that the increased appropriations for  CDRs in recent years provides SSA with added flexibility for balancing  these competing workloads. Moreover, it is important to recognize we are  not recommending that SSA eliminate its ongoing SSDI CDR efforts.  Rather, we believe that more attention is needed for SSI children’s cases  to address the existing backlog, especially given the relatively few CDRs  conducted in this area in recent years, and the high average cessation  rate for these cases. SSA also provided technical comments that we have  incorporated, as appropriate.
We are sending copies of this report to the Commissioner of Social  Security, appropriate congressional committees, and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or bertonid@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: Our review focused on (1) the trends in the rate of children receiving  Supplemental Security Income (SSI) benefits due to mental impairments;  (2) the role that medical and nonmedical information, such as medication  and school records, play in the initial determination of a child’s medical  eligibility; and (3) the steps the Social Security Administration (SSA) has  taken to monitor the continued medical eligibility of these children.
To examine these issues, we analyzed SSA data on (1) the overall  number of initial disability determinations and allowances, (2) annual  benefit awards and recipients, (3) the number and types of mental  impairments, (4) the number of children receiving SSI benefits residing in  households where other children also receive SSI benefits, and (5) the  number of continuing disability reviews of children conducted by SSA. In  reviewing these data, we acknowledge that the child population in the  United States has also grown since 2000 and demographics of this  population may have changed since that time. We assessed the reliability  of the data presented in this report by performing data testing, reviewing  internal controls and related documentation, and interviewing agency  officials, and found potential limitations with the extent to which primary  and secondary impairment coding within SSA’s 831 Disability file—the file  that contains data on disability determinations—may be complete.  However, because the 831 Disability file is used by SSA to make, and  thus reflect, the decisions made regarding medical determinations, we  determined that these data were sufficiently reliable to describe certain  trends among children in the SSI program.
We also conducted in-depth interviews with SSA management and line  staff at SSA headquarters and within six SSA regions—Atlanta, Georgia;  Dallas, Texas; Chicago, Illinois; Philadelphia, Pennsylvania; Boston,  Massachusetts; and San Francisco, California. Our work included site  visits to 9 field offices within these regions, as well as 11 state disability  determination services (DDS) offices (state agencies under the direction  of SSA that perform medical eligibility determinations and continuing  disability reviews of SSI applicants). We performed separate interviews  with SSA field office district managers, supervisors, and claims  representatives, and with DDS managers, supervisors, examiners, and  medical or psychological consultants, when they were available. We  selected these sites on the basis of their geographic location, high volume  of SSI applications for children with mental impairments, and variety of  benefit allowance rates for children with mental impairments. In addition,  we interviewed numerous external experts from the medical and disability  advocacy communities and reviewed relevant studies to identify factors  that may be currently affecting the growth and composition of the  childhood disability applicants and recipients, especially for those children  with mental impairments. However, the relative effects of any potential  factors we identified on the SSI program’s growth are not fully known and  were beyond the scope of this report. We also reviewed relevant federal  laws and regulations.
We conducted a case file review to verify information obtained through  our interviews with DDS office staff and to better understand the role of  secondary impairments in determinations as well as what information  examiners use when determining a child’s medical eligibility. We reviewed  a probability sample of 298 case files selected from the 184,150 initial  determinations decided in fiscal year 2010 for children with alleged  attention deficit hyperactivity disorder (ADHD), speech and language  delay, and autistic disorder and other pervasive development disorders  (autism). (Through the initial determination process, the DDS assesses  whether the child’s impairment can be established through medical  evidence—not only by the individual’s statement of symptoms—as well as  the severity of the impairment and whether the impairment results in  marked and severe functional limitations.) We reviewed electronic case  files for children with mental impairments and SSA forms to develop a  standardized data collection instrument. We completed a data collection  instrument for each initial determination in our sample, and each record  was independently reviewed by another staff person for clarity and  accuracy. We based our observations of the sources examiners used to  support their determinations on examiners’ remarks in the Childhood  Disability Evaluation Form (form SSA-538-F6) and the Disability  Determination Explanation. Because our purpose was not to assess the  appropriateness of examiners’ decisions but to understand what  information sources examiners used in explaining the rationale for their  decision-making, we did not attempt to adjudicate these cases ourselves.  Our observations were limited by the extent to which examiners  documented their analysis and rationale on these forms. We found the  examiners’ remarks sufficient to characterize which sources were used to  support decisions, but examiners provided varying levels of detail in their  remarks and we had no basis for judging whether additional sources of  information were used to support but were not reported.
As with all probability samples, estimates from our case file review are  subject to sampling errors. Sampling errors occur because we use a  sample to draw conclusions about a larger population. If a different  sample had been taken, the results might have been different. To  recognize the possibility that other samples might have yielded other  results, we express our confidence in the precision of our particular  sample’s results as a 95 percent confidence interval. The 95 percent  confidence interval is expected to include the population value for 95  percent of samples of this type. When we make estimates for this  population, we are 95 percent confident that the results we obtained are  within plus or minus 8 percentage points of what we would have obtained  if we had included the entire population within our review, unless  otherwise noted. The text of our report provides more specific confidence  intervals for various estimates.
We selected the sample from within six strata, consisting of allowance  and denial decisions and the three most prevalent primary impairments  among medical allowances for children with mental impairments—ADHD,  speech and language delay, and autism. We sampled approximately the  same number of cases from each stratum in order to ensure that the  sample sizes were sufficient to produce precise estimates within each  combination of impairment and decision. When generalizing to the overall  population and to various subpopulations, we weighted each case  according to its probability of selection, which varied across strata due to  differences in the number of cases in the stratum populations.
We conducted this performance audit from February 2011 to June 2012  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe the  evidence obtained provides a reasonable basis for findings and  conclusions based on our audit objectives.
section_title: Appendix II: 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, the Social Security Administration  (SSA) will examine whether the child’s impairment meets, medically  equals, or functionally equals any of the impairments contained in the  listings. The listings further describe the level of severity necessary to  meet these requirements. The listings for mental disorders in children are  grouped into 11 diagnostic categories:  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; for example, confronting the dreaded object or situation in a  phobic disorder, attempting to go to school in a separation anxiety  disorder, resisting the obsessions or compulsions in an obsessive  compulsive disorder, or confronting strangers or peers in avoidant  disorders.
Somatoform, eating, and tic disorders. Manifested by physical  symptoms for which there are no demonstrable organic findings or known  physiologic mechanisms; or eating or tic disorders with physical  manifestations.
Personality disorders. Manifested by pervasive, inflexible, and  maladaptive personality traits, which are typical of the child’s long-term  functioning and not limited to discrete episodes of illness.
Psychoactive substance dependence disorders. Manifested by a  cluster of cognitive, behavioral, and physiologic symptoms that indicate  impaired control of psychoactive substance use with continued use of the  substance despite adverse consequences.
Autistic disorder and other pervasive developmental disorders.  Characterized by qualitative deficits in the development of reciprocal  social interaction, in the development of verbal and nonverbal  communication skills, and in imaginative activity. Often, there is a  markedly restricted repertoire of activities and interests, which frequently  are stereotyped and repetitive.
Attention deficit hyperactivity disorder. Manifested by developmentally  inappropriate degrees of inattention, impulsiveness, and hyperactivity.
Developmental and emotional disorders of newborn and younger  infants (birth to attainment of age 1): Developmental or emotional  disorders of infancy are evidenced by a deficit or lag in the areas of  motor, cognitive/communicative, or social functioning. These disorders  may be related either to organic or to functional factors or to a  combination of these factors.
According to SSA, these listings are examples of common mental  disorders that are severe enough to result in a child being disabled. When  a child has a medically determinable impairment that is not listed, an  impairment that does not meet the requirements of a listing, or a  combination of impairments in which none meets the requirements of a  listing, SSA will make a determination whether the child’s impairment or  impairments medically or functionally equal the listings. This can be  especially important in older infants and toddlers (age 1 to attainment of  age 3), who may be too young for identification of a specific diagnosis, yet  demonstrate serious functional limitations. Therefore, the determination of  equivalency is necessary to the evaluation of any child’s case when the  child does not have an impairment that meets a listing.
section_title: Appendix III: Trends on the Three Most Prevalent Primary Impairments among Children with Mental Impairments in the Supplemental Security Income Program
paragraphs: Social Security Administration (SSA) data show that the three most prevalent  primary mental impairments among those children allowed for Supplemental  Security Income (SSI) benefits in fiscal year 2011 were for (1) attention  deficit disorder or attention deficit hyperactivity disorder (ADHD), (2) speech  and language delay, and (3) autistic disorder and other pervasive  development disorders (autism). These data are based on the primary  impairment as designated by the disability determination services (DDS)  examiner. SSA’s policy operations manual directs DDS examiners to code  the primary impairment as the most severe condition that rendered the child  disabled. However, SSA officials have acknowledged that primary  impairment codes are sometimes missing or inaccurately coded.
The following information provides a brief summary of each of these three  primary impairments as they compare to the incidence of all mental  impairments, as well as in terms of the proportion of applications,  allowances, and receipts. Data represented as “applications” reflect SSI  benefit claims where a DDS examiner made an initial disability  determination decision. Some applications may have been submitted prior  to the year when a determination was made. In addition, some applications  could have more than one determination if the claim is selected for a quality  review or if the disability claim is updated during the same year.
ADHD. From fiscal years 2000 to 2011, applications for this condition as a  primary impairment more than doubled, from about 55,204 to 124,217,  while allowances have also doubled from 13,857 to 29,872 (see fig. 10). By  December 2011, almost 221,000 such children were receiving SSI benefits,  and they comprised 26 percent of child recipients with mental impairments  on the rolls.
While children with ADHD represent the single largest primary diagnostic  group, SSA has denied the majority of ADHD child applicants since fiscal  year 2000, because they were not medically eligible. Some DDS  examiners we interviewed said that they rarely find a child medically  eligible for benefits solely on the basis of a ADHD impairment alone, but  more commonly in combination with another impairment, such as  oppositional defiant disorder. In our case file review, we found 37 of 50  ADHD allowances had a secondary impairment present, and  oppositional defiant disorder was the secondary impairment cited most  frequently in the individual cases we reviewed.
SSA officials suggested that the increase in both applications and  allowances for children with ADHD might be attributable to an increase in  diagnoses over the last decade, and cited a National Institute of Health  survey finding that ADHD diagnoses had increased by 3 percent, on  average, from 1996 to 2006 and by 5.5 percent, on average, from 2003 to   SSA officials also noted a 2008 medical study reporting that ADHD  2007. is one of the most commonly diagnosed childhood neurobehavioral  disorders.that attention deficit disorder and ADHD are among the most common  childhood disorders in the United States.
In addition, the National Institute of Mental Health has stated  Speech and language delays. Since fiscal year 2000, both applications  and allowances for children with speech and language delays have  increased overall, but the proportion of applicants found medically eligible  has ranged from 54 to 61 percent during this period. From fiscal year  2000 to 2011, applications for this impairment more than doubled, from  21,615 to 51,740 while the number of children allowed increased from  11,565 to 29,309 (see fig. 11).
Some DDS officials we interviewed attributed the increased number of  children applying for and receiving SSI benefits to speech and language  delay to increased school testing and screening program services offered  under the Individuals with Disabilities Education Act (IDEA). The U.S.  Department of Education noted in their latest annual report that teachers  indicated that 89 percent of the children aged 3 through 5 years served  under IDEA received speech or language therapy in the 2003 to 2004  school year, and 86 percent received it in the 2004 to 2005 school year,  making it the most common service in both years.that speech and language impairments were one of the most common  disability categories among students aged 6 through 21 years served  under IDEA, Part B, in the fall of 2006. Of these more than 6 million  students aged 6 through 21 years, about 1.2 million, or 19.1 percent,  received services due to a speech and language impairment.
In addition, they noted  Some speech and language experts from across the United States told us  that they were surprised by the increased number of children receiving  SSI benefits, but acknowledged that the definitions of disability for IDEA  and the SSI program are different. They added that in some instances  speech and language disorder may be a provisional diagnosis for very  young children when it may be difficult to pinpoint a specific impairment or  impairments, which they believed could be contributing to program  growth. SSA officials told us that further study was needed to better  understand increases of this impairment. As of February 2012, SSA was  considering whether to propose new rules for evaluating language and  speech and disorders.
Autism. From fiscal year 2000 to 2011, autism applications increased by  almost 400 percent from 5,430 to 26,739, and allowances increased  similarly from 5,050 to 22,931 (see fig.12). As of December 2011, about  107,000 (12 percent) children with mental impairments were receiving  SSI benefits due to autistic disorders. From fiscal year 2000 to 2011, DDS  examiners found from 86 to 94 percent of those children applying for SSI  on the basis of autism medically eligible for benefits.
SSA officials primarily attribute the increase in the number of autism  applications and allowances over the years to greater incidences of  autism among children and explained that some children who may have  previously been diagnosed as intellectually disabled are instead being  diagnosed as autistic. In fact, the number of children applying for and  receiving SSI benefits due to “intellectual disability” or “mental retardation”  has significantly declined since fiscal year 2000. Children receiving  benefits due to an intellectual disability comprised 51 percent of all mental  claims in fiscal year 2000 and 15 percent in fiscal year 2011. According to  one study SSA cited, the prevalence of autism in children has increased  by 2.5 percent, from 0.6 per 1,000 live births in 1994 to 3.1 per 1,000 live  births in 2003, while during the same period, the prevalence of mental  retardation and learning disabilities declined by 2.8 and 8.3 per 1,000,  respectively. In addition, the Centers for Disease Controls and  Prevention estimated in March 2012 that on average 1 in 88 children in  the United States has an autism spectrum disorder, but the extent to  which this reflects increases in awareness and access to services or  actual increases in the prevalence of autism symptoms is not known.
On the basis of our case file review, we also identified some  characteristics of children for whom SSA made an initial determination in  fiscal year 2010 for ADHD, speech and language delay, and autism. For  example, as shown in figure 13, more than 60 percent of these children  had ADHD.
The age at which SSA determined whether a child was medically eligible  for benefits varied by impairment (see fig. 14). Children with ADHD who  applied for benefits were older, on average, than applicants with autism or  speech and language delay.
Based on our case file review, we estimate that 72 percent of these  children were male, although gender composition also varied by  impairment (see fig. 15). As discussed in appendix I of this report, we  reviewed case files from a stratified probability sample of determinations  made in fiscal year 2010.
section_title: Appendix IV: Reported Medication and Psychotropic Drug Use among Children Applying for Supplemental Security Income by Select Impairments, Fiscal Year 2010
paragraphs: In our review of a generalizable probability sample of 298 initial  determinations performed in fiscal year 2010 for children with alleged  attention deficit hyperactivity disorder (ADHD), speech and language  delay, and autistic disorder and other pervasive development disorders  (autism), we found parents reported that their children were prescribed  some form of medication in 58 percent of these cases. More specifically,  parents reported that their children were prescribed psychotropic drugs in  47 percent of these cases (see table 1). Children with ADHD accounted  for the vast majority of those reportedly using medication or psychotropic  drugs—79 percent and 90 percent, respectively (see table 2). The most  commonly reported psychotropic drugs were Concerta, Ritalin, and  Adderall, which are prescribed to treat ADHD, as well as Risperdal, which  is an antipsychotic. Of children reportedly prescribed psychotropic drugs,  the majority reported using one psychotropic drug.
section_title: Appendix V: Comments from the Social Security Administration
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Jeremy Cox (Assistant Director),  James Bennett, Alexander Galuten, Jason Holsclaw, Kristen Jones,  Sheila McCoy, Luann Moy, Ernest Powell, Jeff Tessin, and Paul Wright  made key contributions to this report and the related e-supplement.