The second 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. Both sets of regulations placed more emphasis 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. . . .”
To determine adults’ eligibility for disability benefits, SSA uses a five-step sequential evaluation process. 1.) “an inquiry into the impact of an impairment on the normal daily activities of a child of the claimant’s age—speaking, walking, dressing and feeding oneself, going to school, playing, etc.”
Although the Court required the functional assessment, it did not define the degree of limitation necessary to qualify for benefits, except by analogy to the adult definition of disability. Before the IFA process was introduced in 1991, the national award rate for all types of childhood cases was 38 percent, but the award rate jumped to 56 percent in the first 2 years after the IFA and DBRA regulations were issued. The majority were found eligible based on IFAs. SSA’s efforts and experts’ suggestions are geared toward improving the process rather than addressing the underlying conceptual problems with the IFA. The media have reported allegations that parents coach their children to fake mental impairments by misbehaving or performing poorly in school so that they can qualify for SSI benefits. Unless parents admit to it, coaching is almost impossible to substantiate. We believe that more consistent decisions could be made if adjudicators based functional assessments of children on the functional criteria in SSA’s medical listings.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed the effects of the judicially mandated individualized functional assessment (IFA) process on Supplemental Security Income (SSI) benefits, focusing on: (1) allegations that parents may be coaching their children to fake mental impairments to qualify under the lower eligibility standards created by IFA; and (2) how IFA affects the children's eligibility for benefits.

What GAO Found

GAO found that: (1) the judicial decision that required changes in IFA essentially made the process for determining disability in children analogous to the adult process; (2) the new process assesses how children's impairments limit their ability to act and behave like unimpaired children of similar age; (3) it has become important to obtain evidence of disability from nonmedical sources as part of the children's assessment; (4) although the court required a new type of assessment for disabled children, it did not define the degree of limitation necessary to qualify for SSI benefits; (5) before the IFA process was introduced in 1991, the national award rate for all types of childhood cases was 38 percent, but the award rate jumped to 56 percent in the first 2 years after IFA regulations were issued; (6) the non-medical aspects of the IFA evaluation rely heavily on adjudicator judgment; (7) while the Social Security Administration (SSA) has attempted to improve the process, and thereby reduce fraud and improve accuracy in awards, IFA has an underlying conceptual problem; (8) although the IFA process attempts to improve accuracy, the presence of coaching by parents is almost impossible to detect; and (9) more consistent eligibility decisions could be made if adjudicators based functional assessments of children on the functional criteria in SSA medical listings.