The U.S. Social Security Administration (SSA) provides disability benefits through the Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI) programs. The SSDI program, established in 1956, provides benefits to eligible adults with disabilities who have paid into the Disability Insurance Trust Fund, as well as to their spouses and adult children who are unable to work because of severe long-term disabilities. Enacted in 1972, SSI is a means-tested program based on income and financial assets that provides income assistance from U.S. Treasury general funds to adults aged 65 and older, individuals who are blind, and adults and children with disabilities. As of December 2017, SSDI had approximately 10.4 million beneficiaries and SSI about 7.1 million recipients who were classified as blind or disabled (SSA, 2018a,b).
To receive SSDI or SSI disability benefits, an individual must meet the statutory definition of disability, which is “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”1 In determining whether the definition of disability is met for an adult, SSA uses a five-step disability evaluation process, described in detail in Chapter 2,2 which includes consideration of the individual’s functional abilities relevant to work.
1 42 U.S.C. 423; see also 20 CFR 404.1505; 20 CFR 416.905.
2 See 20 CFR 404.1520; 20 CFR 416.920.
Seeking to ensure consistency and accuracy in its disability evaluation process, SSA in 2017 asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to convene a committee of relevant experts to provide findings and conclusions regarding the collection of information and assessment of work-related functional abilities (see Box 1-1 for the committee’s Statement of Task). The 15-member committee included experts in the areas of physical medicine and rehabilitation, occupational medicine, internal medicine, mental health, ergonomics, occupational therapy and vocational rehabilitation, social and behavioral science, disability law and policy, measurement and survey methodology, epidemiology, and biostatistics (see Appendix D for biographical sketches of the committee members).
In carrying out this study, the Committee on Functional Assessment for Adults with Disabilities was asked by the sponsor to perform several specific tasks, including identifying and describing evidence-based methods to collect information about an individual’s physical and mental functional abilities relevant to work requirements; discussing the types of information that support findings of limitations in functional abilities relevant to work requirements; and, in the context of disability assessment, describing for functional abilities relevant to work requirements changes related to the progression of common disease processes, including but not limited to back disorders, cardiac impairments, and depression. In addition to these three conditions, the committee chose to address traumatic brain injury because of its prevalence and the associated high rates of cognitive impairment and work disability. As specified in its Statement of Task, the committee was tasked with providing findings and conclusions based on the evidence it gathered. At the committee’s first meeting, SSA confirmed that it wanted the committee to provide only findings and conclusions; recommendations were not to be included in this report.
“Functional abilities relevant to work requirements” are defined by the U.S. Bureau of Labor Statistics’ (BLS’s) Occupational Requirements Survey and the Department of Labor for the Occupational Information System (see Chapter 2). Specific physical and mental functional abilities relevant to work requirements are discussed in Chapters 5 and 6, respectively. The committee also was asked to provide an overview of the functional assessment processes in at least three benefit programs similar to those of SSA that include assessment of disability or vocational capabilities, such as national and state government programs, private-sector programs, and programs based in other countries (see Chapter 8).
The committee conducted an extensive review of the literature pertaining to functional assessment for adults with disabilities, as well as the literature specific to assessment of function and impairment trajectories in individuals with back disorders, cardiac impairments, depression, and traumatic brain injury. This review began with a search in online databases for U.S. and international English-language literature from 1980 through 2018. This search encompassed Medline (Ovid), PubMed, Web of Science, and Scopus, as well as websites including those of SSA, the U.S. Department of Labor, BLS, and the National Academies Press (see Appendix C). A second search of the same databases was conducted for 1998 through 2018 to capture additional peer-reviewed articles and reviews not captured in the initial search (see Appendix C). A third search targeted peer-reviewed articles and review articles pertaining to specific physical assessment instruments from 1980 through 2018 in Medline (Ovid), PubMed, Web of Science, and Scopus (see Appendix C). Committee members and project staff identified additional literature and information using traditional academic research methods and online searches throughout the course of the study.
The committee used a variety of resources to supplement its review of the literature. Meeting in person five times, the committee held three public workshops to hear from invited experts in areas pertinent to its charge (see Appendix A). Speakers at the workshops included experts in functional assessment of physical and mental abilities relevant to work requirements and functional assessment tools and batteries, including the Patient-Reported Outcomes Measurement Information System (PROMIS), the National Institutes of Health (NIH) Toolbox, and the Work Disability-Functional Assessment Battery. The committee also heard from representatives of the Veterans Benefits Administration, workers’ compensation insurance (Chesapeake Employers’ Insurance Company, Maryland), and private disability insurance (Prudential and Sun Life Financial), who addressed the use of functional assessment in different benefit programs that assess disability or vocational capabilities, as well as representatives of several stakeholder organizations, including The Arc, Justice in Aging, Legal Services of New Jersey, and the National Organization of Social Security Claimants’ Representatives. In addition, the committee commissioned three papers: on the assessment of (1) hearing, (2) speech and language, and (3) vision in the context of work requirements.
The committee’s work was further informed by previous reports of the National Academies. These included Measuring Functional Capacity and Work Requirements: Summary of a Workshop (IOM and NRC, 1999), Survey Measurement of Work Disability: Summary of a Workshop (IOM and NRC, 2000), The Dynamics of Disability: Measuring and Monitoring
Disability for Social Security Programs (IOM and NRC, 2002), Visual Impairments: Determining Eligibility for Social Security Benefits (NRC, 2002), Improving the Social Security Disability Decision Process (IOM, 2007a), The Future of Disability in America (IOM, 2007b), Cardiovascular Disability: Updating the Social Security Listings (IOM, 2010a), HIV and Disability: Updating the Social Security Listings (IOM, 2010b), A Database for a Changing Economy: Review of the Occupational Information Network (O*NET) (NRC, 2010), Psychological Testing in the Service of Disability Determination (IOM, 2015), Informing Social Security’s Process for Financial Capability Determination (NASEM, 2016), and The Promise of Assistive Technology to Enhance Activity and Work Participation (NASEM, 2017).
Chapter 2 focuses on disability and function, providing further context for this report and introducing the committee’s conceptual framework as well as a description of SSA’s collection of the information on function and disability used in determining an individual’s eligibility for benefits. Chapter 3 describes the types, sources, and quality of functional information; the properties of assessment measures; and potential sources of bias in assessments. Topics covered in Chapter 4 include integrated assessments of work-related function, the relationship between activities of daily living and the physical and mental demands of work, and instruments designed to assess limitations in work activity due to health conditions. Chapters 5 and 6, respectively, review functional assessments of physical and mental abilities relevant to work requirements. Chapter 7 addresses selected impairments and associated limitations in functional abilities relevant to work. Chapter 8 provides a review of functional assessment processes in selected benefit programs that assess disability or vocational capabilities. Finally, Chapter 9 presents the committee’s overall conclusions. The report also includes four appendixes: Appendix A provides the agendas for the three public sessions held for this study; Appendix B is a glossary of terms used in the report; Appendix C gives further detail on the committee’s literature searches; and Appendix D contains biographical sketches of the committee members.
IOM (Institute of Medicine). 2007a. Improving the Social Security disability decision process. Washington, DC: The National Academies Press.
IOM. 2007b. The future of disability in America. Washington, DC: The National Academies Press.
IOM. 2010a. Cardiovascular disability: Updating the Social Security listings. Washington, DC: The National Academies Press.
IOM. 2010b. HIV and disability: Updating the Social Security listings. Washington, DC: The National Academies Press.
IOM. 2015. Psychological testing in the service of disability determination. Washington, DC: The National Academies Press.
IOM and NRC (National Research Council). 1999. Measuring functional capacity and work requirements: Summary of a workshop. Washington, DC: National Academy Press.
IOM and NRC. 2000. Survey measurement of work disability: Summary of a workshop. Washington, DC: National Academy Press.
IOM and NRC. 2002. The dynamics of disability: Measuring and monitoring disability for Social Security programs. Washington, DC: National Academy Press.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. Informing Social Security’s process for financial capability determination. Washington, DC: The National Academies Press.
NASEM. 2017. The promise of assistive technology to enhance activity and work participation. Washington, DC: The National Academies Press.
NRC (National Research Council). 2002. Visual impairments: Determining eligibility for Social Security benefits. Washington, DC: National Academy Press.
NRC. 2010. A database for a changing economy: Review of the Occupational Information Network (O*NET). Washington, DC: The National Academies Press.
SSA (U.S. Social Security Administration). 2018a. Annual statistical supplement, 2018—OASDI current-pay benefits: Summary (5.A). https://www.ssa.gov/policy/docs/statcomps/supplement/2018/5a.pdf (accessed April 3, 2019).
SSA. 2018b. Annual statistical supplement, 2018—SSI summary (7.A). https://www.ssa.gov/policy/docs/statcomps/supplement/2018/7a.pdf (accessed April 3, 2019).