Everyone is at some risk of developing a mental health disorder, regardless of age, sex, income, or ethnicity. In the U.S. and much of the developed world, mental disorders are one of the leading causes of disability.
According to the WHO peak mental health is more than just the absence of mental health problems. It is the ability to manage existing conditions and stressors while maintaining ongoing wellness and happiness.
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Current estimates suggest that between 1 and 3 percent of people living in the United States will receive a diagnosis of mental retardation. This report assesses the process used by the U.S. Social Security Administration (SSA) to identify individuals with cognitive limitations who experience significant problems in their ability to perform work and may therefore be in need of governmental support. It evaluates the existing disability determination process in the context of current scientific knowledge and clinical practice. Mental retardation, a condition characterized by deficits in intellectual capabilities and adaptive behavior, can be particularly difficult to diagnose in the mild range of the disability.
SSA administers two disability programs that provide income and medical benefits to individuals who are either unable to work or to function as expected given their age because of disability. The Disability Insurance (DI) program, which operates under Title II of the Social Security Act, provides monetary payments to formerly employed individuals who have contributed to the Social Security trust fund through Social Security tax on earnings. Certain classes of dependents of insured individuals are also eligible for DI benefits. The Supplemental Security Income (SSI) program, which operates under Title XVI of the Social Security Act, provides payments to individuals (including children younger than 18 years of age) with a disability who have limited income and other resources. Such a person does not have to have been employed or a contributor to Social Security to be eligible for SSI benefits, although a means test is applied to both income and assets.
Satisfaction of any one of these four criteria in an individual who has mental retardation meets the step 3 criterion of SSA's determination process; i.e., that the individual has a prima facie case of disability that results in an inability to work.
Medical criteria for evaluating children with mental retardation are described in Listing 112.05. Like the definition for adults, mental retardation in children for SSA disability purposes is characterized by significantly subaverage general intellectual functioning, with deficits in adaptive functioning. The Listing, again in paraphrase, includes six criteria for assessing severity of the condition:
Subsequent to the adoption of this definition, the field disagreed over whether mental retardation was a constitutional condition or one based on deficits in social competence (Biasini et al., 1999). Edgar Doll, for instance, proposed that mental retardation was a condition of genetic origin that resulted in social incompetence and arrested development (Doll, 1936a). He believed the condition was incurable. In contrast, Kuhlman (1920) proposed that the condition resulted from a subnormal rate of development, suggesting that it was a result of social functioning deficits rather than genetic conditions. Despite these differences in definition, however, they all focused on the inability to perform common behaviors, delays in social development, and low intelligence (Yepsen, 1941).
It is important to note that the differences between the SSA definition of mental retardation and those of the major professional and health-related organizations derive from the purpose for which it is used. The SSA definition is used not for diagnostic purposes, but rather for purposes of program eligibility. The SSA definition fulfills its purpose of identifying individuals with cognitive limitations who experience significant problems in their ability to perform work and may therefore be in need of governmental support.
Among different racial/ethnic groups, the prevalence of mental retardation was higher among black youth (16.2/1,000) than white (9.8/1,000), Hispanic (9.0/1,000) and other (6.4/1,000) youth. Prevalence rates are higher in some racial/ethnic groups partly because the responses to the National Health Interview Survey are provided by parents, who may have cultural reasons for concealing their child's cognitive disability. The correlation of low socioeconomic status and mental retardation is very high (see Chapter 2), and poverty rates are very high among black and Hispanic youth.
Individuals with a diagnosis of mental retardation constitute a significant number of all recipients of SSA disability benefits. Data from SSA's Annual Statistical Supplement (2001a) indicate that as of December 2000, 567,151 persons with a diagnosis of mental retardation were receiving DI benefits, including 257,601 workers, 299,925 children age 18 or older, and 9,625 widows or widowers. Individuals classified as mentally retarded represented 10 percent of all workers with disabilities.
The current study was designed to assess SSA's disability determination process for mental retardation. The committee was asked to examine new scientific opportunities and associated practice techniques to improve the current determination process. In addition, the committee has been asked to suggest new procedures to respond to these developments. Finally, this study will identify promising research opportunities that might help to clarify unaddressed or incompletely answered questions. SSA is most concerned about accurately diagnosing mental retardation among individuals in the mild range of retardation.
The diagnosis of mental retardation, as well as the receipt of benefits, has associated public policy implications. These policy issues relate to the context in which the program operates, as well as the impact of benefit receipt. Recipients get money to help with income maintenance, but they also get health care coverage through Medicaid. This health care coverage allows individuals with chronic medical conditions to receive needed treatment. In response to a number of issues, SSA changed the nature of its definitions of mental retardation and consequently the number of individuals receiving benefits. Any review of current practice has to consider that additional changes, while well meaning, may have negative effects on beneficiaries and the disability program itself. The committee has included an analysis of these issues in its assessment of the current determination system.
It is important to know whether the major instruments in the field, such as the Wechsler scales and Stanford-Binet Test of Intelligence, adequately assess intelligence in a given case. If they do not, clinically acceptable and programmatically workable alternative instruments should be explored. This may entail identifying other instruments (including nonverbal intelligence assessment instruments as well as instruments available in languages other than English) that have sufficient reliability and validity to adequately diagnose mental retardation. Of course, any additional instruments identified should have the potential for wide use in clinical practice settings.
Finally, the process of evaluating scientific evidence generally reviews an area in great detail. The committee summarizes here its finding with respect to additional research that might improve the assessment and diagnosis of mental retardation. It is important to know what research needs to be conducted so that individuals with mental retardation can be better identified and can therefore have access to more appropriate services from education, health, and social service agencies. This question is designed to address the long-term needs of SSA and disability benefit recipients.
Literature searches were conducted in peer-reviewed journals; technical manuals on intelligence and adaptive behavior measures were reviewed; papers were commissioned from experts on a number of topics central to the committee's work; and feedback was solicited from professional practice, advocacy, and other relevant groups. Members also reviewed technical and policy literature from SSA and other government agencies to get a better sense of the disability programs and benefits provided to individuals with mental retardation. To better understand the practical and policy implications of proposed recommendations on benefit receipt, the committee conducted statistical procedures called Monte Carlo simulations to examine the consequences of altering the criteria for scores on intelligence and adaptive behavior measures. In all of its review work, the committee focused in particular on the area of mild mental retardation, which is most problematic.
This report is focused on specifying criteria for the determination of mental retardation for SSI/DI eligibility purposes. It examines the contextual issues affecting SSA disability benefit programs, with Committee members recognizing that any evaluation of the current determination process for mental retardation is likely to have public policy effects. These effects are discussed in Chapter 2. SSA's charge to the committee posed several questions. The first, do current IQ tests adequately reflect widely accepted concepts of intelligence, is discussed in Chapter 3. The second asks how adaptive functioning is best defined and assessed; the committee's detailed response is in Chapter 4. SSA also asked about the relationship between measures of intelligence and adaptive behavior, which is covered in Chapter 5. Chapter 6, on differential diagnosis, explains how the conditions that share signs and symptoms with mental retardation are best distinguished from it. Suggestions for additional research that might shed light on any unaddressed or incompletely resolved issues in the field of mental retardation are mentioned throughout the text and are summarized in Chapter 5. 2ff7e9595c
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