A Social Security program that supports low-income children with disabilities is not overserving the estimated need, but may be underserving it. Those are main conclusions from a new Institute of Medicine report <!-- and accompanying editorial in the <em>Journal of the American Medical Association</em> --> co-authored by Brown University epidemiologist Stephen Buka.

PROVIDENCE, R.I. [Brown University] — Poverty and mental disability form a tragic pairing for hundreds of thousands of children in the United States. A new Institute of Medicine report that evaluates a Social Security Administration program meant to support such children and their families finds that the program may not be serving as many families as it could.

“This is not gross overprovision of services, if anything it’s gross underprovision,” said report co-author Stephen Buka, professor of epidemiology in the Brown University School of Public Health. “The reservoir of potentially eligible children who are not receiving benefits is quite substantial.”

In 2013, nearly 1 percent of all U.S. children received support from the Supplemental Security Income program because of low household income and mental disabilities, including attention deficit and hyperactivity disorder, a mood disorder, an autism spectrum disorder, or other condition. The program’s size, recent apparent growth, and news reports about instances of fraud prompted criticism that led the Social Security Administration to ask the Institute of Medicine to assess the program.

Stephen Buka
"Poverty exacerbates the challenges of having a mental disorder."
Image: David O’Connor

Buka and his fellow IOM committee members conducted a comprehensive analysis of SSI program data from 2004 to 2013. They compared factors such as the prevalence of mental disability in the population eligible for SSI benefits with the prevalence in the general population of children and among those receiving Medicaid. This period included such profound economic shifts as the recession that began in 2008. The committee noted that poverty and disability are often mutually reinforcing risk factors.

“It is the case that ADHD is more common among poor families than middle-class families, but what’s more striking is that if you have ADHD and you are in a poor family, the repercussions and the resulting disability are greater,” Buka said. “Poverty exacerbates the challenges of having a mental disorder.”

The committee’s conclusion is that SSI is not overserving the nation’s population of low-income families grappling with childhood mental disability.

“After taking child poverty into account, the increase in the percentage of poor children receiving SSI benefits for mental disorders is consistent with and proportionate to trends in prevalence of mental disorders among children in the general population,” Buka and his colleagues wrote.

Moreover, the committee’s analysis of state-by-state variations in benefits and the nationally high prevalence of some disorders compared to enrollment in the program led them to estimate that SSI doesn’t reach many children who would be eligible.

The program could benefit from potential reforms, Buka and co-authors added. Many children who receive treatment improve markedly. It therefore may be proper to monitor for such progress and to end benefits for children who no longer need them.

“The fact that typically once you are determined to be eligible for benefits you stay on the program until you age out is something we’re critical of,” Buka said. “The program needs to be more vigilant to monitor childrens’ improvements over time.”