More than 200,000 children with emotional or developmental disorders could lose Supplemental Security Income benefits as a result of the welfare reform legislation passed by Congress and signed by President Bill Clinton last month.

So say the Judge David Bazelon Center for Mental Health Law_a legal advocacy organization in Washington, D.C., for people with mental illness_and at least one psychiatrist who helped develop criteria by which children with disorders that do not fall easily into a diagnostic category have been able to qualify for Supplemental Security Income (SSI) benefits.

The new welfare reform bill, formally titled the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, eliminates those criteria as a path to receiving benefits.

Under the new rules, children can qualify for benefits under the SSI program only if they have a "medically determinable physical or mental impairment [that] results in marked and severe functional limitations."

The SSI program is a cash benefit program for low-income, aged, blind, and disabled individuals. It currently provides children with disabilities up to $470 a month. Children who qualify for SSI, in most states, also qualify for the Medicaid program. While the new welfare reform bill leaves the Medicaid program itself intact, children who lose their SSI benefits because of changes in the new law could also lose their Medicaid benefits. The Congressional Budget Office has estimated that more than 47,000 children could lose Medicaid benefits because of changes in the SSI provisions of the new welfare bill.

"The implication for patients and families is clearly that [the new legislation] will cut off certain populations from access to appropriate care," said Stanley Greenspan, M.D., a founder of the National Center for Infants, Toddlers, and Families in Rockville, Md.

Individual Functional Assessment

Greenspan was one of several child development experts who in 1990 helped develop criteria_known as Individual Functional Assessments_by which children could qualify for SSI benefits if they have developmental disorders that do not fall into a diagnostic category.

The Bazelon Center for Mental Heath Law reports that 44 percent of all children receiving benefits through the Individual Functional Assessment have a serious emotional or mental disorder. The Bazelon Center report cites an estimate by the Congressional Budget Office that more than 267,000 children could lose SSI benefits because of elimination of the Individual Functional Assessment.

The Individual Functional Assessments grew out of a 1990 U.S. Supreme Court decision in Zebley vs. the Social Security Administration, requiring the use of criteria in the evaluation of children that are comparable to the criteria used for evaluating adults for the SSI program

(Psychiatric News, April 5, 1991).

Since the criteria for adults depends on an assessment of the adult's "functioning" in areas of daily living, the SSA was charged with developing similar criteria that looked at the functioning of children.

These criteria were to supplement the list of medical diagnoses by which a child can qualify for benefits.

"The thinking behind the individual functional assessments is that for many children, a diagnosis is not appropriate," Greenspan told Psychiatric News. "A diagnosis doesn't tell you as much as understanding the child's individual development."

He continued, "We looked at criteria for evaluating the child's ability to function in daily life, very much like the criteria used to evaluate adults_functioning in the family, with peers, with play material, and the ability to learn from the environment. We came up with a series of functional criteria which were added to the diagnostic criteria."

By eliminating those individual functional assessments, Greenspan said, "children with significant functional impairment who need services but don't have a diagnosis will not be eligible."

Greenspan noted, as an example, that many children have "severe uneven maturation of the central nervous system and experience all kinds of behavioral problems, but don't quite fit the diagnosis for autism or mental retardation."

Under the rules of the new welfare reform bill, Greenspan said, the pediatricians, child psychiatrists, and others who are called upon to make assessments of children will face a dilemma:

"Do they try to find the closest diagnosis that works, even though it would not be accurate?" Greenspan wondered. "Or do they try to very accurately describe the child with a functional assessment" and disqualify the child from receiving benefits?

State-by-State Breakdown

The Bazelon Center report includes a state-by-state breakdown of the number of children who currently receive benefits and the number of children who will be reviewed under the new rules.

In California alone, 73,680 children receive benefits under the SSI program; under the new rules, 15,908 of those children will be reviewed according to the new standard.

The Bazelon Center report notes that during the debate in Congress over welfare reform, the individual functional assessment generated heated controversy because critics alleged that parents coach their children to fake mental disorders.

Those allegations prompted several examintions of the program by the Social Security Administration, the Health and Human Services Office of Inspector General, and the General Accounting Office.

While the investigations criticized some aspects of the program, none was able to substantiate allegations of widespread fraud, the Bazelon Center reports.

(The Bazelon Center report on the effect of the new welfare legislation on children can be accessed on the World Wide Web at .)

State and Local Governments

In a September 15 memorandum to district branch and state legislative representatives, APA Director of Government Relations Jay Cutler noted that the responsibility of caring for children who lose their SSI eligibility under the new welfare reform law will ultimately fall on state and local governments.

"As state legislatures address how to utilize their block grants and design their welfare programs, district branches/state associations can offer valuable input," Cutler stated. "For example, psychiatry and local organizations that represent children, disabled persons, patients, and other concerned providers can work together to ensure that disabled children's needs are considered in the new welfare program."

(Psychiatric News, October 18, 1996)