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Childhood Disability:
Supplemental Security Income Program

A Guide for Physicians and Other Health Care Professionals

This booklet is for physicians and other health care professionals who treat children with disabilities. It outlines the kinds of medical evidence that the Social Security Administration (SSA) needs to determine disability for a child under the Supplemental Security Income (SSI) program. The SSI program can provide valuable monthly cash payments to children who are disabled under SSA rules and whose families have little income or resources.

Determining whether a child is disabled under SSI regulations is a collaborative effort among Federal and State officials.

We rely upon your professional expertise and judgment to help us. Your information is not the only information we consider when we determine if the child qualifies for SSI, but it is very important to us. We make our determination based on all of the medical, school, and other information that we get.

We appreciate your assistance and support.

Introduction

Under the SSI program, Social Security can provide cash payments to children with disabilities. A child who is eligible for Federal SSI cash payments is also eligible, depending on the State, for State supplemental payments, Medicaid, Food Stamps, and other social services. This financial, medical and rehabilitation support may enable a child to improve his or her level of functioning. When coupled with various work incentives provided by the disability program, this support can ultimately lead an older child to independence so that he or she can leave the disability rolls.

There are two sets of eligibility criteria for receiving SSI:  (1) financial criteria, based on the income and resources of the child and family; and (2) 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), a State agency, obtains the necessary information and makes the medical determination in childhood disability claims for SSA, using SSA rules. A DDS team, consisting of a disability examiner and a medical or psychological consultant, makes the disability determination.

Income includes earnings, Social Security checks, pensions, and non-cash items such as food, clothing, or shelter. The amount of income a person has each month affects the amount of the SSI payment he or she can receive.

Resources include things like bank accounts, stocks, bonds, and property.  Certain things usually do not count as resources, such as personal belongings, the family home, and family car.

Social Security reviews every SSI case from time to time to make sure that people receiving cash payments are still disabled, and are receiving the correct amount.  SSI recipients (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 for SSI, SSA usually makes the cash payments to a responsible person 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 family member or other person cannot serve as payee, and SSA appoints a qualified organization to be payee for the child.  Whether a person or an organization, the payee must use the SSI payment for the benefit of the child and ensure that his or her current needs are met.

The payee's first priority, then, is to provide food, clothing, shelter, medical care, and personal comfort items for the child. Once these needs are met, the payee may spend funds on other items, such as life insurance, burial arrangements, renovations needed to make the child's home safer or more accessible, furnishings for the child's use, medical equipment, dental care, and school expenses.

The payee must save any funds not used for the child's current needs, and must account annually for how he or she used the SSI payments for the child.

If you believe a representative payee is misusing a child's SSI payments, you should call the local Social Security Office.

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(s) 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 the statutory definition of disability, a child’s impairment(s) must result from anatomical, physiological, or psychological abnormalities that are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. We require objective medical evidence (signs, laboratory findings, or both).
We need evidence from acceptable medical sources to establish whether a child has a medically determinable impairment(s). Acceptable medical sources are a:

• Licensed physician (medical or osteopathic doctor).
• Licensed psychologist, which includes:
• A licensed or certified psychologist at the independent practice level; and
• A licensed or certified school psychologist, or other licensed or certified individual with another title who performs the same function as a school psychologist in a school setting, for impairments of intellectual disability, learning disabilities, and borderline intellectual functioning only.
• Licensed optometrist for impairments of visual disorders, or measurement of visual acuity and visual fields only, depending on the scope of practice in the State in which the optometrist practices.
• Licensed podiatrist for impairments of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle.
• Qualified speech-language pathologist for speech or language impairments only. For this source, qualified means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language-Hearing Association.
• Licensed audiologist for impairments of hearing loss, auditory processing disorders, and balance disorders within the licensed scope of practice only. NOTE: Audiologists’ scope of practice generally includes evaluation, examination, and treatment of certain balance impairments that result from the audio-vestibular system. However, some impairments involving balance involve several body systems that are outside the scope of practice for audiologists, such as those involving muscles, bones, joints, vision, nerves, heart, and blood vessels.
• Licensed advanced practice registered nurse (APRN), also known in some States as advanced practice nurse (APN), and advanced registered nurse practitioner (ARNP) for impairments within his or her licensed scope of practice. There are four types of APRNs with a handful of State variations:
• Certified nurse midwife (CNM);
• Nurse practitioner (NP);
• Certified registered nurse anesthetist (CRNA); and
• Clinical nurse specialist (CNS).
• Licensed physician assistant for impairments within his or her licensed scope of practice only.

Once we have established the existence of a medically determinable impairment(s), we may also use evidence from other medical and non-medical sources to assess the severity of the impairment(s) and how it affects the child’s functioning.  Other medical sources not listed above include, for example, naturopaths, chiropractors, and therapists.  Non-medical sources include, for example, school teachers, counselors, daycare center workers, public and private social welfare agency personnel, relatives, and caregivers.

Your Role as a Physician or Other Health Care Professional

As a child’s physician or health care provider, you may have had regular contact with a child who has applied for SSI based on disability.

Because of your ongoing treating relationship with this child, you are one of the best providers of medical information to the DDS.  In addition to the medical information (history, clinical/laboratory findings, and diagnosis), we need information on the effects of any medical treatment/therapy on the child's daily activities, the side effects of medication, any periods of hospitalization or being homebound, effects on school activities, attendance and performance, and any developmental delays.

Description of Information We Need from Physicians and Other Health Care Professionals

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. We need your 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 our regulations and operating instructions.

Acquiring and Using Information

We 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

We consider how well a child:

• is able to focus and maintain attention; and

• begins, carries through, and finishes 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.

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Interacting and Relating with Others

We 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

We 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

We 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

We consider the cumulative physical effects of-

• physical or mental impairments, and

• their 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.

In addition, the medications a child takes (e.g., for asthma, depression) or the treatment a child receives (e.g., chemotherapy, multiple surgeries) may have physical effects that also limit performance of activities.

A child's illness may be chronic with stable symptoms, or episodic with periods of worsening and improvement. We will consider how a child functions during periods of worsening and how often and for how long these periods occur. A child may be medically fragile and need intensive medical care to maintain his/her level of health and physical well being. In any case, as a result of the illness itself, the medications or treatment a child receives, or both, he/she may experience physical effects that interfere with functioning in any or all activities.

All requests for this information will be accompanied by a release-of-information form signed by a parent or guardian (and/or by the child, if appropriate).

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How We Use This Information

We consider all of the relevant information in the child's case record and will not consider any single piece of evidence in isolation. We consider the information contained in your medical records along with the information provided by teachers, counselors, parents, caregivers, and others to complete the picture of the child's functioning compared to that other children of the same age who do not have impairments.  To make a timely and accurate disability determination in the case of each child who applies for SSI based on disability, we depend upon all of the information you provide us and are grateful for your cooperation.

Need More Information?

You can find additional information about the Social Security disability process and the medical criteria that we use to determine disability in children by reviewing General Information and the Medical Listings (Childhood Listings, Part B) on-line.

A complete list of available publications are also on SSA's website.

You may contact the Professional Relations Branch at the Social Security Administration's Headquarters. The address is:

Social Security Administration
Office of Disability Programs
Professional Relations Branch
4670 Annex Building
6401 Security Boulevard
Baltimore, Maryland 21235

Publication No. 64-048
ICN 436930
December 2001

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