Five Questions With: Stephen Buka

"RECENT CRITICISMS of SSI benefits to families of children with mental disorders centered around the diagnosis of ADHD." / COURTESY BROWN

A new Institute of Medicine report co-authored by Brown University epidemiologist professor Stephen Buka, examines a Social Security Administration program meant to support children with disabilities and their families. Buka recently elaborated on the findings of the “Disabilities in Low-Income Children with Mental Disorders” study for PBN.

PBN: What impact did the recession have on the program, both in terms of funding and the eligible pool of children and families in need?
BUKA:
The 2008-2009 economic downturn in the U.S. had a dramatic impact on the SSI program, with substantial increases in the number and proportion of children living below the federal poverty level. We estimated that an additional 4 million families met the financial eligibility levels for the program (approximately 200 percent of the Federal Poverty Level). As a result, between 2000 to 2011, the number of children applying for SSI benefits increased from 187,052 to 315,832. During that period the total number of children receiving SSI benefits for mental disorders increased by almost 60 percent, from approximately 543,000 to approximately 861,000.

PBN: Is the lack of general acceptance of ADHD as a mental disorder, as opposed to something kids will simply grow out of, one of the reasons critics have questioned the program’s growth? What more can be done to highlight ADHD as a legitimate disability for children and their families?
BUKA:
Indeed, recent criticisms of SSI benefits to families of children with mental disorders centered around the diagnosis of ADHD. A challenge is that many children have problems with attention and impulsivity which are often temporary and improve with age. However, the committee made careful distinctions between transient childhood attention problems and a formal diagnosis of ADHD. This disorder is serious, typically long-lasting and with serious implications for child functioning. Approximately 70 percent of children with ADHD experience other behavioral and health concerns which further warrant additional supports and assistance. Research programs on the course, treatment, and severity of children with ADHD, including those at Brown University, are helping to highlight the severity and importance of this condition.

PBN: Where does Rhode Island stand compared to other states in terms of benefits and reaching eligible children?

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BUKA: The report noted the striking levels of state-to-state variation in the rates at which children are allowed SSI disability benefits for mental disorders. There is also variation in the rate at which children receive SSI for mental disorders. In some states, the likelihood that an application will be found eligible to receive SSI benefits is approximately 7 times greater than others. Rhode Island fell squarely in the middle of the pack, in terms of the frequency of applications, the acceptance and denial rates.

PBN: Your assessment of the program found that there isn’t enough monitoring of a child’s progress to determine when benefits are no longer needed. Who would be responsible for the costs associated with such monitoring and is it clear it would be less than allowing children to simply “age out” of the program?
BUKA:
The average annual cost of providing benefits to an eligible family was on the order of $5,000-$7,000 annually. Some families may remain on the program for many years after the child has improved to a level where additional financial supplements were no longer appropriate. The cost of more closely monitoring and reviewing a child’s progress is likely to be considerably below that of allowing children to ‘age out’ of the program.

PBN: What do you hope occurs with SSI as a result of the Institute of Medicine report?
BUKA:
I would hope that the main outcome of our work is a growing appreciation for the magnitude and burden of mental disorders among children living in poverty in the U.S. The report was commissioned due to concerns that the over 800,000 children receiving SSI benefits for mental disorders was excessive and possibly unwarranted. We concluded, to the contrary, that the number of poor children with serious mental disorders far exceeds this estimate. For example, we estimate that less than 10 percent of poor children with moderate to severe mood disorders were recipients of SSI benefits in 2012. Are direct cash benefits to families the best public policy to mitigate the occurrence and impact of mental disorders among low income families? Probably not. While supporting the goals of the SSI program, I would hope that this report would help advance a richer discussion of effective solutions, including mental health equity for insurance plans, evidence-based preventive interventions and more.

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