The Statute Already Calls For This

     Senator Ron Wyden, the Chair of the Senate Finance Committee, Senator Robert Casey, the Chair of the Senate Special Committee on Aging and Senator Sherrod Brown have written a joint letter to the Acting Commissioner of Social Security asking that the Social Security Administration incorporate children into its outreach program to those potentially eligible for SSI benefits, As already required by 42 U.S.C. §1383d(a).

NADE Newsletter

      The National Association of Disability Examiners (NADE), an organization of the personnel who make initial and reconsideration determinations on disability claims for the Social Security Administration, has posted its Winter newsletter.

     Here's an excerpt that concerns something I haven't yet seen in my office but probably will, eventually:

For more than a year, analysts across the nation have seen a huge influx in CDB cases [Childhood Disability Benefits, also known as Disabled Adult Child or DAC cases]  cross our desks, with people filing for Childhood Disability Benefits years or even decades after they were approved for SSI. A 38-year-old applying for Childhood benefits? Why now?The OIG’s office conducted an audit last year, summarized in a report submitted in December entitled, “Follow-up on Dis-abled Supplemental Security Income Recipients Potentially Eligible for Childhood Disability Benefits.” ... 

OIG recommended that SSA instruct their staff in the importance of following up on potential leads to other benefits and assessing eligibility for other programs during redetermination and initial claims. They renewed their recommendation that SSA establish an automated solution that identifies SSI recipients who may be entitled to CDB. ...

New Childhood Listings For Depression, Bipolar And Disruptive Mood Dysregulation Disorder

     From Social Security's new mental impairment Listings for children:

112.04 Depressive, bipolar and related disorders (see 112.00B3), for children age 3 to attainment of age 18, satisfied by A and B, or A and C: 

     A. Medical documentation of the requirements of paragraph 1, 2, or 3: 

          1. Depressive disorder, characterized by five or more of the following:

               a. Depressed or irritable mood; 

               b. Diminished interest in almost all activities; 

              c. Appetite disturbance with change in weight (or a failure to achieve an expected weight gain); 

               d. Sleep disturbance; 

               e. Observable psychomotor agitation or retardation; 

               f. Decreased energy; 

               g. Feelings of guilt or worthlessness; 

               h. Difficulty concentrating or thinking; or

              i. Thoughts of death or suicide. 

          2. Bipolar disorder, characterized by three or more of the following: 

               a. Pressured speech; 

               b. Flight of ideas; 

              c. Inflated self-esteem; 

              d. Decreased need for sleep; 

              e. Distractibility; 

            f. Involvement in activities that have a high probability of painful consequences that are not recognized; or

              g. Increase in goal-directed activity or psychomotor agitation. 

         3. Disruptive mood dysregulation disorder, beginning prior to age 10, and all of the following: 

               a. Persistent, significant irritability or anger; 

               b. Frequent, developmentally inconsistent temper outbursts; and 

               c. Frequent aggressive or destructive behavior. 

     AND 

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 112.00F): 

          1. Understand, remember, or apply information (see 112.00E1). 

          2. Interact with others (see 112.00E2). 

          3. Concentrate, persist, or maintain pace (see 112.00E3). 

          4. Adapt or manage oneself (see 112.00E4). 

     OR 

     C. Your mental disorder in this listing category is ‘‘serious and persistent;’’ that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both: 

          1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 112.00G2b); and 

          2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 112.00G2c).

A Three Year Battle Ends With Success

      The parents of four year old Maziah Mills-Sorrells have been trying to get Supplemental Security Income disability benefits for her for three years. A District Court has finally approved her claim. Maziah was born with Klumpke's palsy which causes paralysis of her left arm. He parents both work and are trying to support a family of four on their minimum wage fast food jobs.

OIG Report On Households With Multiple Children Receiving SSI Due To Mental Impairments

     The Social Security Administration's Office of Inspector General (OIG) has recently completed a report on Households with Multiple Children Receiving Supplemental Security Income Payments Because of Mental Impairments. If you're expecting it to be a big expose of rampant fraud or, indeed, of any fraud you're going to be disappointed. It's mostly about efforts the agency has taken and can take to make sure there isn't fraud. 

     Please don't make the assumption that there's fraud just because a family exists which has multiple children with mental impairments. That's not a justified assumption. To give a couple of examples where this might occur, consider a couple who adopts multiple children whom they know have mental impairments or consider a family where one child is born with a congenital mental impairment who then have another child who happens to have the same congenital mental impairment. I've seen these cases.

Many Children Disabled By Mental Disorders Not Drawing The SSI They Deserve

     Dr. James Perrin, professor of pediatrics at Harvard Medical School, was on the Here and Now radio program talking about the Institute of Medicine study on Supplemental Security Income (SSI) benefits for children disabled by mental disorders. Perrin was one of the researchers for the study. The main takeaway from Dr. Perrin: the biggest problem with SSI child benefits for mental disorders is that there are many children who should be on benefits who aren't receiving them.

Study On Child SSI For Mental Illness

     The Institute of Medicine (IOM) has released a 394 page report on Supplemental Security Income (SSI) for children with mental disorders. The study was commissioned by the Social Security Administration. Here are some findings from the report that stuck out to me:

• The percentage of poor children drawing SSI decreased from 2004 to 2013. 
• The total number of children drawing SSI increased from 2004 to 2013. The increase in the number of children receiving SSI due to mental illness closely matched the increase in the number of children receiving SSI due to physical conditions.
• Roughly 60% of children who are likely eligible for SSI due to intellectual disability receive SSI. The percentage is decreasing. At the same time there has been a significant increase in the number of children qualifying for benefits due to autism spectrum disorder. These two trends may be related. Children who once would have been diagnosed with intellectual disability are now diagnosed with autism spectrum disorder.
• Only about 3% of children who are potentially eligible for SSI benefits due to a mood disorder (usually bipolar disorder) are receiving SSI benefits.
• Approximately half of all children receiving SSI were found disabled due to a mental disorder.
• There is considerable variation from state to state in the rate at which SSI claims are filed for children based up on mental illness and the rate at which these claims are approved. The number of claims approved per 100,000 poor children ranges from 107 in Nevada to 744 in Pennsylvania. There's a pronounced geographic tilt. A far greater number of children apply for and qualify for benefits in the Eastern half of the United States than the West. I really wish that I could display the chart and map here but the report in a format that makes this impossible, at least for me. They're on pages 76 and 77 of the report. If you go to the report, do not miss these pages!
• Between 2004 and 2013 the average rate of child SSI determinations decreased by 2%. However, the rate increased by 48% in Rhode Island but decreased by one-third or more in Minnesota, North Dakota, Kansas and Nevada. 
• Diagnosis of mental illness was significantly more common in white children than in African American or Hispanic children. The rate was lowest for Asian-American children.

     Update: A reader was kind enough to help in getting pages 76 and 77 into a format I can post here. Click on each to view full size.

It's Only Fiction

     A recent Orange Is The New Black episode featured a misleading segment touching on Supplemental Security Income for children. I've been around long enough to know that it was never easy to get a child on benefits due to Attention Deficit Disorder-Hyperactivity (ADHD). It's now impossible. Sure, there are children with ADHD who get on benefits now but they're not getting on due to ADHD. They're getting on due to other problems.

New Listings For Children

     Social Security is adopting revised Listings used in determining disability in children for growth disorders and weight loss. This includes one of the more interesting names for a medical condition, "failure to thrive." Children are expected to thrive, that is to rapidly gain weight and height. "Failure to thrive" is an ominous condition and a challenge for a pediatrician's diagnostic skills. When they can't figure out what the specific problem is or how to cure it, disability can result.

Institute Of Medicine Reports Forthcoming

     The newsletter of the National Organization of Social Security Claimants Representatives (NOSSCR), which is not available online, reports that the Institute of Medicine (IOM), a division of the National Academies of Sciences, is working on three "consensus reports" for Social Security which may be coming out later this year. These will deal with:

• Psychological testing, including symptom validity testing;
• Mental impairments in children, especially autism spectrum disorder and attention deficit hyperactivity disorder; and
• Speech and language disorders in children.

     Whatever else it may be, the IOM in this instance is basically a beltway bandit, receiving large sums of money for reports that are always so tentative and hedged that they're useless. I wonder what they'll tell Social Security about symptom validity testing. Social Security has been resistant to using it because of questions about its validity. My understanding is that this sort of testing would only apply to claimants with brain damage or intellectual deficiency. Since the agency is approving so few with either of these problems, I doubt that using symptom validity testing would matter much anyway.

More From Patricia Wen On Child SSI

     Patricia Wen at the Boston Globe has written a new piece on children's disability benefits under Supplemental Security Income. The piece contains words and phrases such as "controversial", "dramatic growth" and "replaced welfare." The piece seems to have little if any new information.

    The hard numbers show that 1,083,874 children received SSI in July 2013 and 1,074,908 received the benefits in July 2014. That's not dramatic growth. That's a modest decline. Ms. Wen doesn't report this.

     Ms. Wen got a lot of attention for her original series of articles on SSI child's disability. She doesn't seem to have anything new to report on the subject but she keeps repeating what she originally wrote.

Glad To Have One Champion In The Media

     Michael Hiltzik takes on a conservative who tries to prove that paying Supplemental Security Income (SSI) disability benefits to children displays "contempt for the underprivileged" and that cutting these children off disability benefits is the "compassionate" thing to do.

Dealing With An SSI Overpayment

     A mother writes about the difficulty she's had dealing with a Supplemental Security Income (SSI) overpayment to her son.

House Budget Committee Attacks Child SSI

    The Republican-controlled House Budget Committee has issued The War on Poverty: 50 Years Later, which is, of course, critical of federal anti-poverty efforts. The major part of discussion in the report of programs run by the Social Security Administration has to do with children's disability benefits under the Supplemental Security Income (SSI) program. The report tells us that "SSI has become a more general welfare program that in large part targets able-bodied single mothers ..." No, actually it targets sick children. With or without SSI, the mothers of seriously ill children usually aren't working anyway. The question is whether we assist them and their children. The report goes on to note that most child SSI recipients don't go on to work and many don't get a high school diploma. What do you expect? If they're seriously ill as children, shouldn't we expect them to have trouble getting a high school diploma and working as adults? If the evidence were the exact opposite, that child SSI recipients were getting high school diplomas and going to work as adults, wouldn't this report say that this shows that the child SSI recipients weren't that sick?

Disruptive Mood Dysregulation Disorder

     Last June, the American Psychiatric Association issued the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This included the new diagnostic category of Disruptive Mood Dysregulation Disorder. This was primarily aimed at children and adolescents. It is a type of mood disorder. It fits poorly into Social Security's childhood listing for mood disorders.

     I'm guessing that Social Security must have given some guidance to the Disability Determination Services (DDS) on how to handle diagnoses of Disruptive Mood Dysregulation Disorder but I haven't seen any. Does anyone have a copy they can shoot my way? You can send feedback to Social Security News, anonymously if you wish. You have to enter valid domain name but the rest can be bogus if you wish. However, you can't send attachments.

It's Tough To Get On SSI Child's Benefits

     The Philadelphia Inquirer has an article on the Supplemental Security Income (SSI) child's benefit program. Despite what you've heard, it's tough to get on benefits. How tough? So tough that most Social Security attorneys refuse to take on any SSI child case.

The Need For Children's SSI Benefits

     Three professors have produced a paper for the Heller School for Social Policy and Management of Brandeis University documenting the hardships faced by families receiving children's Supplemental Security Income (SSI). Even with the children's SSI benefits 45% of the families are unable to meet all their essential expenses, 21% are unable to pay rent, 42% are unable to pay all their utility bills and 24% are unable to receive needed medical care.

Disruptive Mood Dysregulation Disorder

     The new 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the "Bible" of psychiatry, is out. One of the biggest changes in DSM-5 is the addition of the diagnostic category of Disruptive Mood Dysregulation Disorder. This diagnostic category is primarily designed for children and adolescents but I see nothing in DSM-5 that would limit this diagnosis to children and adolescents. 

     This new diagnostic category is important for Social Security since the agency is involved in determining disability in children and adolescents. Many of the children and adolescents filing disability claims will be diagnosed with this disorder.      

     This diagnosis is considered a type of depressive disorder but disruptive mood dysregulation disorder does not fit in Social Security's Listing 112.04 too well. A persistently irritable mood is mentioned in teh Listing but at least four additional criteria must be met to satisfy Part A of the Listing and those other criteria are not part of this diagnosis. My expectation is that Social Security is going to deny virtually all of these cases, at least until the agency updates the Listing.

     I fully expect that Social Security's critics will dismiss disruptive mood dysregulation disorder as merely temper tantrums. That's ridiculous but it won't stop those critics. The critics usually put the term mental illness in quotation marks to begin with since they believe that mental illness isn't, you know, like, really real. I've never quite understood the right's antipathy for psychiatry. I don't think that anyone can get through life without either experiencing mental illness or observing it up close, either in a family member or friend or someone known through work.

     Below are the DSM-5 criteria for the diagnosis of disruptive mood dysregulation disorder. Note how stringent the criteria are and think about how difficult it would be for a child or adolescent with this diagnosis to develop normally.

Disruptive Mood Dysregulation Disorder

Diagnostic Criteria 296.99 (F34.8)

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).

E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D.

F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.

H. By history or observation, the age at onset of Criteria A-E is before 10 years.

I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).

Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to an other medical or neurological condition.

Kira's Story

A Public Debate

     Nicholas Kristof of the New York Times wrote a column in December attacking Supplemental Security Income (SSI) benefits for children. Jonathan Stein and Rebecca Vallas of Community Legal Services in Philadelphia sent a memo to the Public Editor of the Times complaining that Kristof's column was inaccurate and unprofessional. Kristof has responded, publishing the Stein and Vallas memo. I find that memo devastating. You can judge for yourself how well Kristof responds but I think one point needs to be made. Kristof asserts that he talked with proponents of SSI benefits for children. However, if you talk with those proponents, you're almost certain to be referred to Jonathan Stein. He's the one person you need to talk with if you want to talk with a proponent of SSI child's benefits. That's just a fact. Stein has done other things but SSI childs' benefits has been his beat for decades.  Clearly, Kristof never talked with Stein before publishing his column. For that reason alone, I have to call Kristof's research shallow.