Determining whether a child is disabled under SSI regulations is a collaborative effort among Federal and State officials.SSA relies, to a great extent, upon your professional expertise and judgment to help it evaluate and decide an SSI claim. Your information is not the only information SSA considers when it decides if the child qualifies for benefits, but it is very important information. SSA makes its decision based on all of the medical, school and other information it receives.
Introduction: Under the Supplemental Security Income (SSI) program, Social Security can provide benefits to children with disabilities. A child who is eligible for Federal SSI cash benefits is also eligible, depending on the State, for State supplemental payments, Medicaid, Food Stamps, and other social services. This financial, medical and rehabilitation services support may enable a child to achieve a level of functioning that gives him or her a significant degree of self support. When this support is coupled with various work incentives provided by the disability program, it can ultimately lead a child to independence so that he or she can leave the disability rolls.
To receive SSI payments, a child must meet two sets of eligibility criteria: financial criteria, based on the income and resources of the child and family; and medical criteria about the child's impairment or combination of impairments. The local Social Security office decides if a child's income and resources are within the SSI limits. In making that decision, the Social Security office must consider the income and resources of parents who are living in the same household with the child. The Disability Determination Services (DDS) obtains the necessary information and makes the medical decision in childhood disability claims. The DDS is a State agency that makes disability determinations for SSA, using SSA rules.
Social Security reviews every SSI case from time to time to make sure that people getting benefits are still disabled and are getting the right amount. Also, SSI beneficiaries (or their payees) are required to report any changes in their situations, such as changes in income, resources, household composition, school attendance, marital status, and improvement in medical condition.
Representative Payees: When a child is eligible, benefits are usually paid to a responsible individual or organization, known as a representative payee. Typically, a parent or other relative with whom the child lives serves as payee. In some cases, though, a friend or family member cannot serve as payee, and a qualified organization is appointed payee for the child. No matter who serves as payee, the payments must be spent for the use and benefit of the child. The payee's first priority is to ensure that the child's current needs are met. This includes food, clothing, shelter, medical care and personal comfort items. Once these needs are met, funds can be spent on other items, such as life insurance, burial arrangements, needed renovations to make the child's home safer or more accessible, furnishings for the child's use, medical equipment, dental care, and school expenses.
Funds not used for the child's current needs must be saved. Each year, payees are required to account for how benefits are used.
Definition Of Disability For Children: Under the law, a child is considered disabled for SSI purposes if: he or she has a medically determinable physical or mental impairment (or combination of impairments); and the impairment(s) results in marked and severe functional limitations; and the impairment has lasted (or is expected to last) for at least one year or to result in death.
What is a medically determinable physical or mental impairment?: To meet SSA's definition, a child's impairment must result from anatomical, physiological, or psychological abnormalities that are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. The impairment must be established by medical evidence consisting of signs, symptoms and laboratory findings. To establish or prove disability, there must be evidence from acceptable medical sources to establish whether a child has a medically determinable impairment. Acceptable medical sources are: licensed physicians (medical or osteopathic); licensed or certified psychologists (includes school psychologists, for purposes of establishing mental retardation/learning disorder/borderline intellectual functioning); optometrists (for the measurement of visual fields or acuity); licensed podiatrists (for purposes of establishing impairments of the foot or foot and ankle, depending on the State); and qualified speech-language pathologists (for purposes of establishing speech or language impairments).
Once SSA has established the existence of an impairment, it may also use evidence from other sources to show the severity of the impairment and how it affects the child's functioning. Other sources include medical sources not listed above, schools, public and private social welfare agencies, and parents, guardians and other caregivers.
Your Role As A Treating Physician Or Other Health Professional: By "health professional," SSA means a physician, psychologist, speech-language pathologist, nurse practitioner, physician assistant or other treating professional. As such, you may have had regular contact with a child who has filed for disability benefits.Because of your ongoing treating relationship with this child, you are one of the best providers of medical information about the child's disability or impairment. In addition to the medical information (history, clinical/laboratory findings, and diagnosis), SSA requires information on the impact of any medical treatment/therapy on the child's daily living activities, the side effects of medication, any periods of hospitalization or being homebound, effects on school activities, attendance and performance, and any developmental delays.
SSA evaluates physical and mental impairments in children in terms of several domains of activity that together represent all aspects of a child's functioning. It is therefore important that you provide an opinion about how the child typically functions in these domains compared to children of the same age who do not have impairments. The descriptions of the domains below are drawn directly from SSA's regulations:
Acquiring and Using Information: SSA will consider how well a child learns or acquires information, and uses the information he/she has learned. Learning and thinking begin at birth. A child learns as he/she explores the world through sight, sound, taste, touch, and smell. As a child plays, he/she acquires concepts and learns that people, things, and activities have names. This lets the child understand symbols, which prepares him/her to use language for learning. Using the concepts and symbols acquired through play and learning experiences, a child should be able to learn to read, write, do arithmetic, and understand and use new information.
Thinking is the application or use of information a child has learned. It involves being able to perceive relationships, reason, and make logical choices. People think in different ways. When a child thinks in pictures, he/she may solve a problem by watching and imitating what another person does. When a child thinks in words, he/she may solve a problem by using language to talk his/her way through it. A child must also be able to use language to think about the world and to understand others and express him or herself; e.g., to follow directions, ask for information or explain something.
Attending and Completing Tasks: SSA will consider how well a child is able to focus and maintain attention; and begin, carry through, and finish activities, including the pace at which the child performs activities and the ease with which the child changes them.
Attention involves regulating levels of alertness and initiating and maintaining concentration. It involves the ability to filter out distractions and to remain focused on an activity or task at a consistent level of performance. This means focusing long enough to initiate and complete an activity or task, and changing focus once it is completed. It also means that if a child loses or changes focus in the middle of a task, he/she is able to return to it without other people having to remind him/her frequently to finish it.
Adequate attention is needed to maintain physical and mental effort and concentration on an activity or task. Adequate attention permits a child to think and reflect before starting or deciding to stop an activity. In other words, the child is able to look ahead and predict the outcome of his/her actions before acting. Focusing attention allows a child to attempt tasks at an appropriate pace. It also helps determine the time needed to finish a task within an appropriate timeframe.
Interacting and Relating with Others: SSA will consider how well a child initiates and sustains emotional connections with others;develops and uses the language of his/her community; cooperates with others; complies with rules; responds to criticism; and respects and takes care of the possessions of others.
Interacting means initiating and responding to exchanges with other people, for practical or social purposes. A child interacts with others by using facial expressions, gestures, actions, or words. A child may interact with another person only once, as when asking a stranger for directions, or many times, as when describing his/her day at school to parents. A child may interact with people one-at-a-time, as when listening to another student in the hallway at school, or in groups, as when playing with others.
Relating to other people means forming intimate relationships with family members and with friends the same age, and sustaining them over time. A child may relate to individuals, siblings, parents or a best friend, or to groups, such as other children in childcare, friends in school, teammates in sports activities, or people in the neighborhood.
Interacting and relating requires a child to respond appropriately to a variety of emotional and behavioral cues. A child must be able to speak intelligibly and fluently so that others can understand; participate in verbal turn taking and nonverbal exchanges; consider others' feelings and points of view; follow social rules for interaction and conversation; and respond to others appropriately and meaningfully.
A child's activities at home or school or in the community may involve playing, learning, and working cooperatively with other children, one-at-a-time or in groups; joining voluntarily in activities with the other children in school or community; and responding to persons in authority (e.g., parents, teacher, bus driver, coach, employer).
Moving About and Manipulating Objects: SSA will consider how well a child moves his/her body from one place to another and; moves and manipulates things. These are called gross and fine motor skills.
Moving one's body involves several different kinds of actions: Rolling one's body; rising or pulling oneself from a sitting to a standing position; pushing oneself up; raising one's head, arms, legs, and twisting one's hands and feet; balancing one's weight on one's legs and feet; shifting weight while sitting or standing; transferring from one surface to another; lowering oneself to or toward the floor as when bending, kneeling, stooping, or crouching; moving oneself forward and backward in space as when crawling, walking, running, and negotiating different terrains (e.g., curbs, steps, hills).
Moving and manipulating things involves several different kinds of actions: Engaging one's upper and lower body to push, pull, lift, or carry objects from one place to another; controlling shoulders, arms, and hands to hold or transfer objects; coordinating eyes and hands to manipulate small objects or parts of objects.
These actions require varying degrees of strength, coordination, dexterity, pace, and physical ability to persist at the task. They also require a sense of where one's body is and how it moves in space; the integration of sensory input with motor output; and the capacity to plan, remember, and execute controlled motor movements.
Caring For Yourself: SSA will consider how well a child maintains a healthy emotional and physical state, including how well the child gets his/her physical and emotional wants and needs met in appropriate ways; copes with stress and changes in the environment; and takes care of his/her own health, possessions, and living area.
Caring for and regulating oneself effectively, with the degree of independence appropriate to a child's age, depends upon the ability to respond to changes in emotions and daily demands of the environment. Caring for oneself is characterized by a sense of personal autonomy, or independence, and mastery, or competence. The effort to become independent and competent should be observable at birth and should continue throughout childhood. Emotional well being requires a basic understanding of the body, including its normal functioning, and physical and emotional needs.
To meet these needs successfully, a child must employ effective coping strategies, appropriate to his/her age, to identify and regulate feelings, thoughts, urges, and intentions. Such strategies are based on taking responsibility for getting needs met in an appropriate and satisfactory manner. This includes establishing and maintaining adequate self-control when regulating responses to changes in moods and environment, and developing appropriate means to delay gratification. Caring for and regulating oneself means becoming increasingly independent in making and following one's own decisions. This entails relying on one's abilities and skills, and displaying consistent judgment about the consequences of caring for oneself. As a child matures, using and testing his/her own judgment helps develop confidence in independence and competence.
Health and Physical Well-being: SSA will consider the cumulative physical effects of a child's physical or mental impairments, and the associated treatments or therapies on a child's functioning. A physical or mental disorder may have physical effects that vary in kind and intensity, and may make it difficult for a child to perform activities independently or effectively. A child may experience problems such as generalized weakness, dizziness, shortness of breath, reduced stamina, fatigue, psychomotor retardation, allergic reactions, recurrent infection, poor growth, bladder or bowel incontinence, or local or generalized pain. A child may have difficulty with senses, including reduced hearing or visual acuity.
How This Information Is Used: SSA will consider all of the relevant information in the child's record and will not consider any single piece of evidence in isolation. The information contained in the child's medical records is considered along with the information provided by teachers, counselors, parents, caregivers, etc., to complete the picture of the child's functioning compared to other children of the same age who do not have impairments. A complete picture is necessary in order for the DDS team (which consists of a disability examiner and a medical or psychological consultant) to make the disability decision. You can help your patients receive timely and accurate decisions on their claims by providing not only requested medical records, but also submitting a detailed report citing the impairments or diagnoses the child has, associated symptoms, clinical findings, and how the child's impairments impact or affect his school performace and ability to perform in the five areas noted above.
