Social Security: Rapid Rise in Children on SSI Disability Rolls Follows
New Regulations (Letter Report, 09/09/94, GAO/HEHS-94-225).

The number of children receiving Supplemental Security Income disability
benefits has more than doubled during the last four years. Although much
of the attention has focused on the Sullivan v. Zebley Supreme Court
decision as the cause of this growth--that decision made the Social
Security Administration's disability criteria for children less
restrictive--GAO found that most of the children who received new awards
would have qualified for them even without the functional assessment
process mandated by the Zebley decision.  Huge increases in the number
of children awarded benefits because of mental impairments account for
more than two-thirds of the growth in awards. Most awards to the
mentally impaired go to mentally retarded children. Although the portion
of mental awards to children with "behavior problems," such as attention
deficit hyperactivity disorder, personality disorders, and autism, is
growing, it is still relatively small. From February 1991 through 1993,
children with "behavior problems" have received 22 percent of awards
made to children with mental impairments.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-225
     TITLE:  Social Security: Rapid Rise in Children on SSI Disability 
             Rolls Follows New Regulations
      DATE:  09/09/94
   SUBJECT:  Social security benefits
             Disability benefits
             Children
             Eligibility criteria
             Eligibility determinations
             Mental illnesses
             Judicial opinions
             Behavioral sciences research
             Handicapped children
IDENTIFIER:  Supplemental Security Income Program
             
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Cover
================================================================ COVER


Report to the Honorable
Gerald D.  Kleczka, House of Representatives

September 1994

SOCIAL SECURITY - RAPID RISE IN
CHILDREN ON SSI DISABILITY
ROLLS FOLLOWS NEW REGULATIONS

GAO/HEHS-94-225

Rapid Rise in Children on SSI


Abbreviations
=============================================================== ABBREV

  DBRA - Disability Benefits Reform Act of 1984
  DDS - disability determination service
  IFA - individualized functional assessment
  HHS - Health and Human Services
  RFC - residual functional capacity
  SSA - Social Security Administration
  SSI - Supplemental Security Income

Letter
=============================================================== LETTER


B-256120

September 9, 1994

The Honorable Gerald D.  Kleczka
House of Representatives

Dear Mr.  Kleczka: 

This report responds to your request for information about the recent
growth in the number of children receiving disability benefits under
the Supplemental Security Income (SSI) program administered by the
Social Security Administration (SSA).  From 1989 to 1993, the number
of children receiving SSI disability benefits has more than doubled,
growing from almost 300,000 to more than 770,000. 

Rising numbers of children in poverty and SSA outreach efforts
explain part of this growth.  This report focuses on two other
significant changes, which in concert had a major impact on SSA's
criteria for determining whether children are eligible for SSI
disability benefits.  First, in February 1990, the U.S.  Supreme
Court mandated in Sullivan v.  Zebley that SSA make its disability
criteria for children less restrictive by adding to its disability
determination process a new basis for awarding benefits to children
who previously would have been denied.  For those children who do not
qualify for benefits on the basis of medical standards alone, the
Court required SSA to add an individualized functional assessment
(IFA) of how each child's impairment limits his or her ability to act
and behave in age-appropriate ways.\1 SSA issued regulations to this
effect in February 1991.  Second, in December 1990, SSA issued
regulations revising and expanding its medical standards for
assessing mental impairments in children by incorporating functional
criteria into the standards and adding such impairments as attention
deficit hyperactivity disorder.  These changes were made to reflect
advances in medicine and science, in accordance with the Disability
Benefits Reform Act of 1984 (DBRA). 

Concern has recently focused on the rapid growth in disability awards
since the Zebley Supreme Court decision, especially for children with
mental impairments.  Of particular concern are children awarded
benefits because of attention deficit hyperactivity disorder and
other disorders that have been broadly characterized as "behavior
problems."

In your June 20, 1994, request, you asked us to address a number of
issues related to the growing number of children receiving SSI
disability benefits.  This report responds to your request that we
quantify the growth in awards to children with disabilities since the
disability criteria changed, focusing in particular on the growth in
awards for mental impairments and the growth in awards based on the
new functional assessment process.  Subsequent reports will quantify
the variation among states in the rate of growth in awards to
children and address your concerns about whether the program is
adequately meeting the needs of disabled children. 

To quantify the growth in awards to children, we compared the results
of SSA's disability decisions made on children by type of disability
and basis of award 2 years before and 2 years after the criteria
changed.  The early period covers decisions made from January 1,
1988, through February 20, 1990--the date of the Supreme Court
decision.  The latter period covers decisions made from February 11,
1991--the first date both changes were in effect--through December
31, 1992.  (See app.  I for a more detailed discussion of our scope
and methodology.)


--------------------
\1 The medical standards are divided into two sections:  one for
adults and one for children.  The medical standards for childhood
impairments are regulations containing strict medical criteria for
physical and mental impairments that, in and of themselves, are
comparable in severity to impairments that would prevent adults from
engaging in any gainful activity.  Children can also qualify for
benefits under the adult criteria. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The number of children receiving SSI disability benefits has more
than doubled in the last 4 years.  Many Members of Congress have
expressed concern about this growth.  While much of the attention has
focused on the Sullivan v.  Zebley Supreme Court decision as the
cause of this growth, our analysis shows a more complicated picture. 
Although the new functional assessment process established by Zebley
added 87,900 children to the disability rolls through 1992 who
previously would have been denied benefits, this new process only
accounts for about 30 percent of all awards made since it was
implemented.  In contrast, 70 percent of all awards went to children
whose impairments were severe enough to qualify on the basis of SSA's
medical standards alone, without the need for a functional
assessment.  Thus, most of the children who received new awards would
have qualified for them even without the functional assessment
process mandated by the Zebley decision. 

Huge increases in the number of children awarded benefits because of
mental impairments--including children with mental retardation and
other mental disorders, such as attention deficit hyperactivity
disorder--account for more than two-thirds of the growth in awards. 
After the changes revising the medical standards for mental
impairments and adding the functional assessment process, 60 percent
of awards based on the medical standards and 82 percent of awards
based on the functional assessment process went to children with
mental impairments.  Table 1 shows the growth in awards by type of
impairment and basis of award. 



                           Table 1
           
            Growth in Awards by Type of Impairment
                      and Basis of Award



                              Before   After  Before   After
                              regula  regula  regula  regula
                                tory    tory    tory    tory
                              change  change  change  change
Type of impairment                 s       s       s       s
----------------------------  ------  ------  ------  ------
Mental                         1,854   5,501       0   3,192
Physical                       1,691   3,664       0     683
Unknown                            2      18       0       8
Total                          3,547   9,183       0   3,883
------------------------------------------------------------
Source:  Analysis of SSA's 831 file. 

Most awards to the mentally impaired go to children with mental
retardation.  While the portion of mental awards to children with
"behavior problems," such as attention deficit hyperactivity
disorder, personality disorders, and autism and other pervasive
developmental disorders is growing, it is still relatively small. 
From February 11, 1991, through 1993, children with "behavior
problems" have received 22 percent of awards made to children with
mental impairments. 


   SSI PROGRAM FOR CHILDREN HAS
   UNDERGONE MAJOR CHANGES
------------------------------------------------------------ Letter :2

Since 1974, the SSI program has been providing benefits to low-income
blind and disabled persons--children and adults--who meet financial
eligibility requirements and the Social Security Act's definition of
disability.\2

Each eligible child receives a maximum federal benefit of $446 per
month; 27 states also provide a supplemental benefit payment.\3 In
1993, children received a total of $4.35 billion in federally
administered SSI benefits. 


--------------------
\2 SSA determines applicants' financial eligibility; state disability
determination services (DDS) determine their medical eligibility. 
DDSs are state agencies funded and overseen by SSA. 

\3 Five additional states provide supplemental SSI benefit payments
only to children who are blind and three states provide supplemental
benefits only to children who live in residential care homes. 


      CHANGES TO SSA'S CRITERIA
      FOR DETERMINING DISABILITY
      IN CHILDREN
---------------------------------------------------------- Letter :2.1

During virtually the same period, SSA issued two sets of regulations
that changed the criteria for determining children's eligibility for
SSI disability benefits.  (See fig.  1.) One set of regulations was
issued in response to the Sullivan v.  Zebley Supreme Court decision,
which required SSA to make its process for determining disability in
children analogous to the adult process.  The second set of
regulations, issued in accordance with DBRA, revised and expanded
SSA's medical standards for evaluating mental impairments in children
to incorporate recent advances in medicine and science.  Both sets of
regulations place more emphasis than before on assessing how
children's impairments limit their ability to act and behave like
unimpaired children of similar age.  Both also emphasize the
importance of obtaining evidence from nonmedical sources as part of
this assessment. 

   Figure 1:  Changes to SSA's
   Criteria for Evaluating
   Disability in Children

   (See figure in printed
   edition.)


         ZEBLEY REGULATIONS ADD
         NEW FUNCTIONAL ASSESSMENT
         PROCESS
-------------------------------------------------------- Letter :2.1.1

On February 20, 1990, the Supreme Court ruled that SSA's process for
determining disability in children under 18 violated the Social
Security Act because the process held children to a more restrictive
disability standard than it did adults.  Under the Social Security
Act, a child is entitled to disability benefits if his or her
impairment is "of comparable severity" to that of an adult.\4

To determine adults' eligibility for disability benefits, SSA uses a
five-step sequential evaluation process.  Before Zebley, it used only
a two-step process to determine children's eligibility for benefits. 
(See fig.  2.) Children were awarded benefits only if their
impairments met or equaled the severity criteria in SSA's medical
standards.  All other children were denied benefits.  In contrast,
adults who did not qualify under the standards could still be found
eligible for benefits if an assessment of their "residual functional
capacity" (RFC) showed that they could not engage in substantial
work.  No analogous assessment of functioning was done for children
who did not qualify under the medical standards. 

   Figure 2:  Sequential
   Evaluation Process for Adults
   Versus Children

   (See figure in printed
   edition.)

To eliminate this disparity, the Court mandated that for those
children who do not qualify for benefits under the more restrictive
medical standards, SSA must add a less restrictive individualized
assessment of how the child's impairment affects his or her ability
to function in age-appropriate ways--that is, to act or behave in
ways that children of similar ages normally do--before it can decide
whether the child is eligible for benefits. 

SSA issued regulations implementing the Supreme Court's decision on
February 11, 1991.\5 According to these regulations, for the child to
be eligible for disability benefits, the functional assessment must
show that the child's impairment or combination of impairments limits
his or her ability "to function independently, appropriately, and
effectively in an age-appropriate manner." Specifically, the
impairment must substantially reduce the child's ability to grow,
develop, or mature physically, mentally, or emotionally to the extent
that it limits his or her ability to (1) attain age-appropriate
developmental milestones; or (2) attain age-appropriate daily
activities at home, school, play, or work; or (3) acquire the skills
needed to assume adult roles. 

As a result of these regulations, DDSs now perform an individualized
functional assessment to assess the child's social, communication,
cognitive, personal and behavioral, and motor skills, as well as his
or her responsiveness to stimuli and ability to concentrate, persist
at tasks at hand, and keep pace.\6 In addition to information from
medical sources, DDSs obtain information about the child's behavior
and activities from the child's teachers, parents, and others
knowledgeable about the child's day-to-day functioning, in order to
make these assessments.\7

As part of the settlement of the Zebley case, SSA also agreed to
readjudicate under the new criteria--including the new medical
standards for childhood mental impairments--all decisions made from
January 1, 1980, through February 11, 1991, to deny or terminate
benefits to children.  Of the 287,900 children who have had their
cases readjudicated through March 1, 1994, 129,700 children have been
found eligible under the new criteria--an award rate of 45 percent.\8


--------------------
\4 Disability for adults is defined as the inability to engage in
substantial gainful activity because of a medically determinable
physical or mental impairment that is expected to last at least 12
months or to result in death.  Substantial gainful activity is
defined as earning more than $500 per month. 

\5 In the wake of the Zebley decision, SSA stopped denying benefits
to children whose impairments did not meet or equal the medical
standards.  It operated under an interim policy for determining
disability in children until the regulations went into effect.  The
interim policy outlined preliminary general criteria for assessing
functioning in children. 

\6 Social skills, communication skills, cognitive skills, and motor
skills are assessed for children of all ages.  Personal and
behavioral skills are assessed for children aged 1 and older.  The
ability to concentrate, persist at tasks at hand, and keep pace are
assessed for children aged 3 and older; responsiveness to stimuli is
assessed in children under age 1. 

\7 The regulations issued in response to Zebley also expanded the
criteria for determining whether a child qualified for benefits under
the medical standards by adding the concept of "functional
equivalence." Before Zebley, a child qualified for benefits under the
medical standards only if his or her impairment met the severity
criteria in the standards or were medically equivalent to the
standards.

After Zebley, a child could also qualify for benefits under the
medical standards if the functional limitations resulting from his or
her impairment were the same as the disabling functional consequences
of an impairment listed in the medical standards, as long as there
was a direct, medically determinable cause for the functional
limitations.  The regulations provide 15 examples of conditions--such
as the need for a major organ transplant--presumed to be functionally
equivalent to the impairments listed in the medical standards. 

\8 As of March 1, 1994, SSA had notified almost 452,500 Zebley class
members that they could have their cases readjudicated, of which over
321,600 responded affirmatively.  Of the 321,600, SSA has
readjudicated about 287,900 cases.  About 33,700 cases remain to be
readjudicated. 


         REGULATIONS SUBSTANTIALLY
         CHANGE CRITERIA FOR
         ASSESSING CHILDREN'S
         MENTAL IMPAIRMENTS
-------------------------------------------------------- Letter :2.1.2

SSA issued new regulations in accordance with DBRA on December 12,
1990, that revised and expanded its medical standards for childhood
mental impairments to reflect up-to-date terminology used by mental
health professionals and recent advances in knowledge, treatment, and
methods of evaluating mental disorders in children.\9

The new medical standards for mental impairments provide much more
detailed and specific guidance on how to evaluate mental disorders in
children than the former regulations, which were published in 1977. 
In particular, the new medical standards place much more emphasis on
the importance of assessing how a child's mental impairment limits
his or her ability to function in age-appropriate ways.  SSA made
this change because mental health professionals consider functional
factors particularly important in evaluating mental disorders of
children. 

The former medical standards for mental impairments emphasized the
medical characteristics that must be met to substantiate the
existence of the impairment.  Specific areas of functioning sometimes
were and sometimes were not mentioned as a factor in this
determination.  In contrast, the new medical standards provide much
more detailed guidance on assessing the functional aspects of each
impairment.  The standard for most impairments is divided into two
parts:  medical and functional criteria, both of which must be
satisfied for the applicant to qualify for a benefit. 

The functional criteria are described in terms of the age of the
child and the specific areas of functioning--such as social,
communication, or cognition skills--that must be assessed.  Like the
Zebley regulations, the new medical standards emphasize the
importance of parents and others as sources of information about a
child's day-to-day functioning. 

The new medical standards also classify childhood mental disorders
into more distinct categories of mental impairments.  Previously,
there were 4 impairments listed--mental retardation, chronic brain
syndrome, psychosis of infancy and childhood, and functional
nonpsychotic disorders--now there are 11.  Several of the newly
listed impairments, such as autism and other pervasive developmental
disorders, mood disorders, and personality disorders, describe
impairments that were previously evaluated under one or more of the
four broader categories of childhood mental impairments.  Several
other impairments are mentioned for the first time, such as attention
deficit hyperactivity disorder and psychoactive substance dependence
disorders. 


--------------------
\9 DBRA specifically mandates that the Secretary of Health and Human
Services (HHS) revise the mental disorders criteria in the medical
standards.  The mental disorder standards are divided into two
parts--one for adults and one for children.  The act states that the
revised standards should realistically evaluate the ability of a
mentally impaired individual to work in a competitive environment. 
It does not specify how to apply this criterion to children. 


   RAPID GROWTH IN NUMBER OF
   CHILDREN RECEIVING SSI
------------------------------------------------------------ Letter :3

The number of children receiving SSI disability benefits has grown
rapidly since the regulatory changes went into effect.  The number of
children receiving SSI disability benefits rose from 296,300 at the
end of 1989--2 months before Zebley--to 770,500 at the end of
1993.\10 (See fig.  3.) Over the same time, children also became a
larger portion of the SSI disability rolls--up from 11.5 percent to
19.9 percent.\11

   Figure 3:  An Increasing Number
   of Children Receive SSI

   (See figure in printed
   edition.)

Source:  Annual Statistical Supplements to the Social Security
Bulletin. 


--------------------
\10 Figures include children under 22. 

\11 The SSI program also provides benefits to low-income persons aged
65 and older.  Children represented 6.5 percent of the total SSI
population at the end of 1989 and 12.9 percent of the total SSI
population at the end of 1993. 


   LARGE INCREASES IN APPLICATIONS
   AND AWARDS
------------------------------------------------------------ Letter :4

The growth in the rolls is the result of huge increases in both
applications and awards for children's disability benefits.  (See
fig.  4.) After both regulatory changes went into effect, DDSs acted
on 23,400 applications each month--more than 2-1/2 times the monthly
average before the changes.  Awards grew even more dramatically than
applications.  Average monthly awards almost quadrupled, from 3,500
before the regulatory changes to 13,100 afterwards.  Awards grew more
sharply than applications because the percentage of applications
resulting in awards--the award rate--also rose substantially.  Before
the changes, a little more than a third (38 percent) of the children
who applied for disability benefits received awards.  After the
changes, more than half (56 percent) of the children received awards. 

   Figure 4:  Growth in
   Applications and Awards

   (See figure in printed
   edition.)

Source:  Analysis of SSA's 831 file. 


   MEDICAL STANDARDS ACCOUNT FOR
   MOST OF AWARD GROWTH
------------------------------------------------------------ Letter :5

Even after Zebley added the new functional assessment process, 70
percent of the children awarded benefits--a total of 207,900
children--had physical or mental impairments severe enough to qualify
for disability benefits under SSA's strict medical standards alone,
without the need to perform an IFA.\12 In contrast, 30 percent--a
total of 87,900 children--qualified under the less restrictive
functional assessment criteria. 

Large increases in the number of children qualifying under the
medical standards--including those with physical impairments--also
account for more than half of the growth in awards.  Awards based on
the standards more than doubled--increasing from 3,500 per month
before the regulations changed to 9,200 per month
afterwards--accounting for 59 percent of the growth in awards. 

In comparison, the new functional assessment process, which made it
possible for children who did not qualify on the basis of the medical
standards alone to be eligible for awards, added an average of 3,900
children to the rolls each month, accounting for 41 percent of the
growth in awards. 


--------------------
\12 The 207,900 awards based on the medical standards include 15,000
awards to children who qualified under the medical standards' new
"functional equivalence" criteria added by the Zebley regulations. 
These children would have been denied benefits before Zebley.  The
15,000 awards--700 per month--represent 5 percent of all awards made
after Zebley. 


   GROWTH MOST DRAMATIC FOR
   CHILDREN WITH MENTAL
   IMPAIRMENTS
------------------------------------------------------------ Letter :6

More than half of the growth in applications and more than two-thirds
of the growth in awards is from children with mental impairments,
including mental retardation and other mental disorders. 


      APPLICATIONS TRIPLED FOR
      CHILDREN WITH MENTAL
      IMPAIRMENTS
---------------------------------------------------------- Letter :6.1

Applications for children with mental impairments rose faster than
applications for children with physical impairments.  Applications
for children with mental impairments more than tripled, from 3,700
per month before the changes to 12,000 per month afterwards, while
applications for children with physical impairments more than
doubled, from 5,200 to 10,900 per month.  (See fig.  5.) After the
changes, 51 percent of the applicants had mental impairments,
compared with 40 percent before. 

   Figure 5:  Larger Increase in
   Applications for Children With
   Mental Impairments

   (See figure in printed
   edition.)

Source:  Analysis of SSA's 831 file. 


      AWARDS QUADRUPLED TO
      CHILDREN WITH MENTAL
      IMPAIRMENTS
---------------------------------------------------------- Letter :6.2

Even more pronounced than the growth in applications for children
with mental impairments is the growth in awards.  Both awards based
on the medical standards and awards based on the new functional
assessment process grew more for those with mental impairments than
for those with physical impairments. 

Total awards to children with mental impairments more than quadrupled
after the changes, rising from 1,900 per month to 8,700 per month; at
the same time, awards to children with physical impairments rose from
1,700 per month to 4,300 per month.  (See fig.  6.) After the
changes, children with mental impairments received two-thirds (67
percent) of all awards, compared with about half (52 percent) before. 

   Figure 6:  Larger Increase in
   Awards to Children With Mental
   Impairments

   (See figure in printed
   edition.)

Source:  Analysis of SSA's 831 file. 

The effect of the revised and expanded medical standards for
childhood mental impairments can be seen in the rapid growth in the
number of children with mental impairments awarded disability
benefits based on the new medical standards.  Awards based on the
standards to children with mental impairments almost tripled, from
1,900 per month before the standards changed to 5,500 per month
afterwards.  Over the same time, awards to children with physical
impairments based on the standards more than doubled, from 1,700 per
month to 3,700 per month.  (See fig.  7.) Before the changes, 52
percent of awards based on the standards went to children with mental
impairments; after the changes, 60 percent did.  This growth in
mental impairment awards based on the medical standards accounts for
53 percent of the total growth in awards to children with mental
impairments. 

   Figure 7:  Medical Standards
   Awards Increased More for
   Children With Mental
   Impairments

   (See figure in printed
   edition.)

Source:  Analysis of SSA's 831 file. 

Children with mental impairments received most of the awards based on
the new functional assessment process mandated by Zebley as well. 
More than four-fifths (82 percent) of all awards based on the new
functional assessment process went to children with mental
impairments; an average of 3,200 children with mental impairments and
700 children with physical impairments received awards based on
functional assessments each month.  This new process accounts for 47
percent of the total growth in awards to children with mental
impairments. 


      AWARD RATE HIGHER FOR
      CHILDREN WITH MENTAL
      IMPAIRMENTS
---------------------------------------------------------- Letter :6.3

Awards to children with mental impairments grew at a faster rate than
awards to children with physical impairments.  The award rate for
children with mental impairments rose 23 percentage points (from 50
percent before the changes to 73 percent after), while the award rate
for children with physical impairments rose 8 percentage points (from
32 percent to 40 percent).  Even more significantly, more than half
of the children with mental impairments on whom functional
assessments were done (53 percent) received awards compared with less
than one-sixth (14 percent) of children with physical impairments. 


      MOST AWARDS FOR MENTAL
      IMPAIRMENTS GO TO CHILDREN
      WITH MENTAL RETARDATION
---------------------------------------------------------- Letter :6.4

After the regulatory changes went into effect, a total of 196,800
children--or 8,700 children per month--received awards because of
mental impairments.  Almost two-thirds of these children--120,300
total, or 5,300 per month--received awards because of mental
retardation.  This represents 41 percent of all awards.  In contrast,
one-fifth of these children--39,400 total, or 1,700 per
month--received awards because they had diagnoses of attention
deficit hyperactivity disorder, personality disorders, or autism and
other pervasive developmental disorders--mental disorders that have
been broadly characterized as "behavior problems." Children with
these diagnoses represented 13.3 percent of all awards.\13

Because SSA revised its medical standards for childhood mental
impairments in December 1990, it is not possible to compare the
number and percentage of children receiving benefits because of
specific types of mental impairments before and after the standards
changed.  The new medical standards recategorized the groupings of
mental impairments, adding some new categories--such as autism and
other pervasive developmental disorders and attention deficit
hyperactivity disorder--that were not specifically identified in the
former medical standards for childhood mental impairments. 


--------------------
\13 SSA and the HHS Office of the Inspector General have noted
problems with the way SSA's computerized record of disability
decisions codes mental impairment cases.  Some behavioral disorders
have been coded as "other" or as "mental retardation" cases.  The
exact extent of these coding anomalies is unknown. 


         TREND CONTINUING FOR 1993
-------------------------------------------------------- Letter :6.4.1

Our data for the period after the regulatory changes cover the
results of disability decisions SSA made on children from February
11, 1991, through the end of 1992.  Data from SSA for 1993 show that
awards to children with mental impairments continued to rise
sharply.\14 (See table 2.)



                           Table 2
           
                Awards to Children With Mental
           Impairments, February 11, 1991, Through
                      December 31, 1993


                                      Percen          Percen
                                        t of            t of
                              Monthl  mental  Monthl  mental
                                   y  impair       y  impair
                              averag    ment  averag    ment
Mental impairment                  e  awards       e  awards
----------------------------  ------  ------  ------  ------
Mental retardation             5,315    61.1   7,081    56.9
Attention deficit                878    10.1   1,690    13.6
 hyperactivity disorder
Personality disorders            614     7.1     936     7.5
Autism/other developmental       249     2.9     364     2.9
 disorders
Organic mental disorders         264     3.0     378     3.0
Schizophrenic/other               84     1.0     131     1.0
 psychotic disorders
Mood disorders                   352     4.1     582     4.7
Anxiety disorders                282     3.2     338     2.7
Alcohol dependence disorders       8     0.1      11     0.1
Drug dependence disorders          5     0.1      13     0.1
Somatoform disorders               5     0.1       9     0.1
Eating and tic disorders          21     0.2      23     0.2
Developmental/emotional          211     2.4     381     3.1
 disorders of infants
Other                            404     4.7     504     4.1
============================================================
Total                          8,693   100.0  12,441   100.0
------------------------------------------------------------
Source:  Analysis of SSA's 831 file and information from SSA. 

About 149,300 children--12,400 per month--received awards in 1993
because of mental impairments.  Children with mental retardation
received 57 percent of these awards and 39 percent of total awards. 
This represents a slightly smaller portion of both mental impairment
and total awards than through 1992, even though the actual number of
such awards grew to 85,000, or 7,100 per month--up from 5,300 awards
per month through 1992. 

Children with attention deficit hyperactivity disorder, personality
disorders, and autism and other pervasive developmental disorders
received a larger portion of awards due to mental impairments and
total awards in 1993.  Such children received a total of 35,900
awards--3,000 per month--or almost one-quarter (24 percent) of all
awards to children with mental impairments and almost one-sixth (16
percent) of total awards in 1993.  This represents a 72-percent
increase in the actual number of awards from 1,700 per month through
1992. 


--------------------
\14 Our data include the results of initial determinations and
reconsideration decisions made by DDSs.  They include Zebley
classmembers whose cases were readjudicated since February 11, 1991,
for whom benefits had been denied or terminated from 1980 to 1987. 
SSA's data include initial determination decisions made by DDSs on
persons applying for the first time. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

While it is commonly thought that the number of children receiving
SSI disability benefits has grown dramatically because of the Zebley
decision, our analysis presents a more complicated picture.  Clearly,
many of the children now on the rolls are receiving benefits because
they qualified under the new functional assessment process mandated
by Zebley.  But the Congress had already mandated that SSA change its
criteria for assessing mental impairments, and children qualifying
under the resulting regulations constitute a significant portion of
new awards.  Recent congressional debate and legislative proposals
highlight national interest in the SSI program for children.  This
report analyzes the nature of the newly emerging caseload to aid the
Congress in its deliberations on whether the program is meeting its
expectations or whether legislative changes are needed. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

We did not request written comments from HHS on a draft of this
report.  However, we discussed the draft with SSA staff and have
incorporated their comments where appropriate. 

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
from the date of this letter.  At that time, we will send copies to
interested parties and make copies available to others upon request. 

Please contact me on (202) 512-7215 if you have any questions about
this report.  Other major contributors are Cynthia Bascetta, Barry
Tice, Ellen Habenicht, Linda Baker, and Mary Ellen Fleischman. 

Sincerely yours,

Jane L.  Ross
Associate Director,
 Income Security Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To analyze the growth in Supplemental Security Income disability
awards to children since the Social Security Administration changed
its criteria for determining children's eligibility for disability
benefits, we obtained SSA's computerized records on the results of
initial determination and reconsideration disability decisions made
by disability determination services on children under age 18 from
1988 through 1992.  These records exclude the results of disability
decisions made by administrative law judges.  We compared the results
of disability decisions made 2 years before and 2 years after the
criteria changed.  The first period covers decisions made from
January 1, 1988, through February 20, 1990--the date of the Sullivan
v.  Zebley Supreme Court decision.  The latter period covers
decisions made from February 11, 1991--the first date both regulatory
changes were in effect--through December 31, 1992. 

We determined what portion of new awards was due to children
qualifying under the new functional assessment process and what
portion was due to children qualifying under SSA's medical standards. 
We also classified children according to their primary diagnosis to
determine what portion of the new awards was attributable to children
qualifying on the basis of mental versus physical impairments.  Among
children with mental impairments, we identified the portion of those
who qualified on the basis of mental retardation and on the basis of
other mental disorders, focusing in particular on awards to children
with attention deficit hyperactivity disorder, personality disorders,
and autism and other pervasive developmental disorders--mental
disorders broadly characterized as "behavior problems." To determine
whether awards to children with "behavior problems" are growing, we
supplemented our data for the period after the regulatory changes
with data for 1993 from SSA.  Before the medical standards for
childhood mental impairments changed, SSA's computerized records did
not separately identify awards made because of the three "behavior
problem" categories of mental disorders. 

We excluded 139,400 children who had applied during 1988 through
February 10, 1991, from our universe of 652,100 children on whom
decisions were made from February 11, 1991, through the end of 1992. 
We did this to minimize the extent to which data from our comparison
periods reflect the result of cases readjudicated as part of the
settlement in the Zebley class action lawsuit.  About 287,900 Zebley
classmembers for whom benefits were denied or terminated from January
1, 1980, through February 11, 1991, have had their cases
readjudicated as of March 1, 1994.  We were not able to identify or
exclude Zebley classmembers for whom benefits had been denied or
terminated from 1980 through 1987 from either comparison period. 
According to SSA, Zebley classmembers are more likely to have
physical impairments than the general population of new SSI child
applicants.  Thus, our data on applications and awards for both
periods may include an unusually high number of children with
physical impairments.  We did, however, obtain information on the
results of these cases and report them separately from the results of
our comparison. 

We supplemented our analysis of SSA's computerized records on awards
to children with data from SSA on the total number of children and
adults receiving SSI disability benefits.  We used these data to
determine whether children constitute a growing portion of the SSI
rolls. 

We did our work at SSA headquarters in Baltimore, Maryland, from
August 1993 through April 1994 in accordance with generally accepted
government auditing standards. 

