# Presentation: 240216

## Accommodating Children with Special Dietary Needs

**Notes:**
In August 1991, USDA issued guidance entitled, Accommodating Children with Special Dietary Needs in the School Nutrition Programs.  USDA worked closely with the Department of Education and the Department of Justice in the development of the guidance.

The goal was to provide operational guidance that reflected the requirements of statute and regulations:
The Rehabilitation Act of 1973
The Individuals with Disabilities Education Act
Americans with Disabilities Act
7 CFR Part 15b
7 CFR 210.10(g)
While the statutory and regulatory provisions remain essentially unchanged, over the past 10 years, some of the reference material changed.

This revision of the guidance was intended to offer clarification and update information without making substantive changes.

## Schools must make substitutions in foods in the reimbursable meal for students who are disabled and whose disability restricts their diet.

**Notes:**
The basic intent of statute and regulations is to ensure that children with disabilities have access to program benefits

In the case of the Child Nutrition Programs, this means that substitutions to the reimbursable meal must be made for children who are unable to eat school meals because of their disabilities.

The word “substitution” is used because for the most part, accommodations under the school meal programs will involve replacing one food with another, although this will not always be the case.

## What are Disabilities?

- Disability is defined in:
- Section 504 of the Rehabilitation Act of 1973
- Americans with Disabilities Act of 1990
- Part B of the Individuals with Disabilities Education Act (IDEA)
- IEP

**Notes:**
Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 defines a “person with a disability” as any person who:
has a physical or mental impairment which substantially limits one or more major life activities,
has a record of such an impairment or,
is regarded as having such an impairment.
“Physical or mental impairment” includes many diseases and conditions, a few of which may be: 
orthopedic, visual, speech, and hearing impairments;  cerebral palsy;  epilepsy;  muscular dystrophy;   multiple sclerosis;
cancer;  heart disease;  metabolic diseases, such as diabetes or phenylketonuria (PKU);  food anaphylaxis (severe food allergy);  mental retardation;  emotional illness;  drug addiction and alcoholism;  specific learning disabilities;  HIV disease; and tuberculosis. 
Please reference the Act for a more detailed explanation.
“Major Life Activities” covered by this definition include caring for one’s self, eating, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

Under Part B of the Individuals with Disabilities Education Act (IDEA) a child with a “disability” means a child evaluated in accordance with IDEA as having one or more of the recognized thirteen disability categories and who, by reason thereof, needs special education and related services.  IDEA recognizes 13 disability categories which establish a child’s need for special education and related services.  These disabilities include:  autism;  deaf-blindness;  deafness or other hearing impairments;  mental retardation;  orthopedic impairments;  other health impairments due to chronic or acute health problems, such as asthma, diabetes, nephritis, sickle cell anemia, a heart condition, epilepsy, rheumatic fever, hemophilia, leukemia, lead poisoning, tuberculosis;  emotional disturbance;  specific learning disabilities;  speech or language impairment;  traumatic brain injury; and visual impairment; including blindness which adversely affects a child’s educational performance; and multiple disabilities.  Attention deficit disorder or attention deficit hyperactivity disorder may fall under one the the 13 categories.  Please refer to the Act noted above for more information.

The Individualized Education Program (IEP) means a written statement for a child with a disability that is developed, reviewed and revised in accordance with the IDEA and its implementing regulations.  NOTE:  Some states supplement the IEP with a written statement specially designed to address a student’s nutritional needs.  Other states employ a “Health Care Plan” to address the nutritional needs of their students.  For ease of reference, the term “IEP” is used to reflect the IEP as well as any written statement designating the required nutrition services.

## Disability

- Accommodation **MUST** be made
**No** extra charge
- A disability determination can only be made by a licensed physician

**Notes:**
Regardless of which menu planning approach is used, substitutions must be made for children with disabilities whose disability restricts their diet.  The need for the accommodation must be supported by a statement signed by a licensed physician.

Meals must be served free or at a reduced-price to children who qualify for these benefits regardless of whether they have a disability. These meals must be at no additional cost to these children.

The majority of osteopathic physicians are primary care physicians, licensed by the State to  prescribe medication or to perform surgery.  Osteopathic physicians are equal members with M.D.’s.

This does not include Christian Science practitioners, chiropractors or other persons involved in providing care or treatment but who are not licensed as physicians by the state.

## Statement For Children With Disabilities

- What the disability is
- How it restricts diet
- Major life activity affected
- Foods to be omitted
- Foods to be substituted

**Notes:**
A child with a disability must be provided substitutions in foods when that need is supported by a written statement signed by a licensed physician.  

The statement must identify the five points which are shown in this slide.

In regards to the third bullet in the slide, major life activity, generally this separates persons with disabilities from persons with other special needs.  Essentially, a disability is a condition that substantially limits one or more major life activity, such as: caring for one’s self, eating, performing manual tasks, walking, hearing, speaking, breathing, learning, working.

## FOOD RELATED DISABILITIES

- Diabetes
- PKU
- Food Anaphylaxis

**Notes:**

These disabilities are among the most prevalent food related disabilities that will require food substitutions of one kind or another.

## OTHER FOOD ACCOMMODATIONS

- Texture
- IV
- Tube Feeding

**Notes:**
When making texture modifications - and no substitution is being made, a physician’s statement is not absolutely necessary.  However, the State agency or school food authority may apply stricter guidelines.

To minimize the chance of misunderstandings, it is recommended that the school food service, at a minimum, maintain written instructions or guidance from a licensed physician regarding the texture modifications to be made.

School food service must follow instructions that have been prescribed by the licensed physician.

## Children Who Are Not Disabled But Have Other Special Dietary Needs

- Food allergies or intolerances
**NOT** generally disabilities **UNLESS** anaphylactic
- Accommodation **MAY** be made **BUT** is **NOT** Required
- In many cases, allergies can be dealt with through “Offer-Versus-Serve” or by providing additional selections

**Notes:**

Generally, food allergies or intolerances are not a disability as defined under either Section 504 of the Rehabilitation Act or Part B of IDEA.  The school food service may make food substitutions, at their discretion, for these children.  Such determinations are made on a case-by-case basis.  

However, when, in the licensed physician’s assessment, food allergies may result in severe, life-threatening (anaphylactic) reactions, the child’s condition would meet the definition of “disability” and the substitutions prescribed by the licensed physician must be made.  

## Statement For Children Who Are Not Disabled

- The substitutions must be supported by a statement signed by a recognized medical authority (physicians, physician assistants, nurse practitioner, or other professionals) specified by the State agency.

## Statement For Children Who Are Not Disabled(continued)

- The statement must include:
- an identification of the medical or other special dietary condition which restricts the child’s diet,
- the food or foods to be omitted from the child’s diet; and
- the food or choice of foods to be substituted.

## Recognized Medical Authority

- Physician
- Physician Assistant
- Nurse
- Nurse Practitioner
- Other professionals specified by the State agency.

**Notes:**
The documentation does not have to be provided by a licensed physician, though it may be.

“Other” refers to an authority other than the ones listed above that have been designated by the State agency.  If you are uncertain about whether or not to accept documentation, you should check with the State agency.

## NEVER	

- Revise or Change a Prescription or Medical Order

**Notes:**
School food service must never revise or change a prescription or diet order.  This not only protects the child but it also protects the food service personnel.

All changes to the diet order must be made in writing.  The statement does not have to be renewed each year, if there are no changes affecting the child’s dietary needs.

## School Food Service Records

- It is important that all recommendations for accommodations or changes to existing diet orders be documented in writing to protect the school and minimize misunderstandings.  Schools should retain copies of special, non-meal pattern diets on file for reviews.
- The diet orders do not need to be renewed on a yearly basis; however, schools are encouraged to ensure that the diet orders reflect the current dietary needs of the child.

## Commonly Asked Questions

- These questions are grouped under the following topics:
- Meals and/or foods outside of the normal meal service
- Special needs which may or may not involve disabilities
- Responsibilities of food service management companies and other food service operations
- Feeding in separate facilities–generally not acceptable
- Temporary disabilities
- Complicated feedings
- School food service account; and
- Documentation

**Notes:**
These questions are taken from the guidance manual, Accommodating Children with Special Dietary Needs.

## Meals and/or Foods Outside of the Normal Meal Service

**Situation:**
- 	As part of the therapy for a child with a disability, the licensed physician has required the child to consume six cans of cranberry juice a day.  The juice is to be served at regular intervals, and some of these servings would occur outside of the normal school meal periods.  Is the school food service required to provide all of the servings of juice?

**Notes:**
Response to Situation:  
No.  The general guideline in making accommodations is that children with disabilities must be able to participate in and receive benefits from programs that are available to children without disabilities.

In this example, the school food service would be required to provide (and pay for) cranberry juice as part of the regular reimbursable breakfast, lunch and/or snack service.  However, the school food service would not be required to pay for other servings throughout the school day unless specified in the Individualized Education Plan (IEP). 

It must be recognized that there will be exceptions to this general rule.  For example, residential child care institutions (RCCI), such as juvenile correction facilities, may be required to provide additional foods or servings since the child would have no other recourse for meals. 

It must be stressed that such accommodation would depend on the specific circumstances of each case and, in any event, would go beyond obligations under the school nutrition programs. 

In general, additional servings beyond what is required under the program meal may, but need not, be charged to the nonprofit food service account.

## Meals and/or Foods Outside of the Normal Meal Service (continued)

**Situation:**
- 	A child with a disability must have a full breakfast each morning.  Is the school food service required to provide a breakfast for this child even though a breakfast program is not available for the general school population?

**Notes:**
Response to Situation:  
The school food service is not required to provide services and meals to children with disabilities that are not otherwise available to children who are not disabled.  If the school does not have a breakfast program already, it does not need to initiate a program exclusively for children with disabilities. 

However, if the IEP requires that a child receive a breakfast at school, the school must provide the service, and may choose to have the school food service handle the responsibility. 

Another exception to the general rule concerns a child with a disability who resides in a RCCI and requires special food service.  In the case of RCCIs, the institution serves as the child's home, and the child would have no other recourse for meals.  The RCCI must provide the child a full breakfast, if this is specified in the licensed physician's statement or in the IEP. 

## Meals and/or Foods Outside of the Normal Meal Service (continued)

**Situation:**
- 	A licensed physician has prescribed portion sizes that exceed the minimum quantity requirements set forth in the regulations.  Is the school required to provide these additional quantities?

**Notes:**
Response to Situation:  
Yes.  The school must provide the child food portions which exceed the minimum quantity requirements, if specifically prescribed in the licensed physician's statement.

## Special Needs Which May or May Not Involve Disabilities

**Situation:**
- 	A child has a life threatening allergy which causes an anaphylactic reaction to peanuts.  The slightest contact with peanuts or peanut derivatives, usually peanut oil, could be fatal.  To what lengths must the food service go to accommodate the child?  Is it sufficient for the school food service to merely avoid obvious foods, such as peanut butter, or must school food service staff research every ingredient and additive in processed foods or regularly post all of the ingredients used in recipes?

**Notes:**
Response to Situation: 
The school has the responsibility to provide a safe, non-allergic meal to the child if it is determined that the condition is disabling.  To do so, school food service staff must make sure that all food items offered to the allergic child meet prescribed guidelines and are free of foods which are suspected of causing the allergic reaction. This means that the food labels or specifications will need to be checked to ensure that they do not contain traces of such substances.  In some cases, the labels will provide enough information to make a reasonable judgment possible.  If they do not provide enough information, it is the responsibility of the school food service to obtain the necessary information to ensure that no allergic substances are present in the foods served. 

In some cases, it may be necessary to contact the supplier or the manufacturer or to check with the State agency.  Private organizations, such as the Food Allergy and Anaphylaxis Network (see Appendix D), may also be consulted for information and advice.  It is also wise to check with parents about certain foods and even provide them with advance copies of menus.  The general rule in these situations is to exercise caution at all times.  Do not serve foods to children at risk for anaphylactic reactions, if you do not know what is in those foods.  It is important to recognize that a child may be provided a meal, which is equivalent to the meal served to other children, but not necessarily the same meal.  Sometimes, it will be advisable to prepare a separate meal "from scratch" using ingredients that are allowed on the special diet rather than serving a meal using processed foods.

## Special Needs Which May or May Not Involve Disabilities(continued)

**Situation:**
- 	A child has a health condition that does not meet the definition of "disability" set forth in the legislation and regulations.  For example, the child is overweight (but not “morbidly" so), or the child has elevated blood cholesterol.  Is the school obligated to accommodate the special dietary needs of this child?

**Notes:**
Response to Situation: 
The school may make substitutions for children who are not considered to be disabled, but who should avoid certain foods.  However, the school is not required to do so.  When the school does elect to accommodate children without disabilities, it must have a supporting statement, signed by a recognized medical authority on file.

In most cases, the dietary needs of such children can be accommodated at the food service site in schools and institutions where a variety of nutritious foods are available for individual choice.  In addition, the "offer versus serve" provision which allows students the option to decline one or two foods in the normal (reimbursable) school meal may be of assistance in accommodating an individual's particular diet.

## Special Needs Which May or May Not Involve Disabilities (continued)

**Situation:**
- 	A child's parents have requested that the school prepare a strict vegetarian diet for their child based on a statement from a health food store "nutrition advisor" who is not a licensed physician.  Must the school comply with this request?

**Notes:**

Response to Situation:  
No.  The school is responsible only for accommodating those conditions meeting the definition of disability as described in 7 CFR Part 15b.  Schools are not required to make food substitutions based on food choices of a family or child regarding a healthful diet.

## Responsibilities of Food Service Management Companies (FSMC) And Other Food Service Operations

**Situation:**
- 	A school district has contracted with a FSMC to operate the school's food service.  Is the FSMC obligated to accommodate children with disabilities?

**Notes:**
Response to Situation:  
Yes.  The school is always required to ensure that any benefits available for the general school population are equally available to children with disabilities.  Consequently, accommodations for these children must be made regardless of whether the school district operates the food service itself or contracts with an FSMC to do so. 

However, as a procurement issue, accommodations for children with disabilities must be included in the contract.  School food authorities that do not have any need for special dietary accommodations at the time a FSMC bid is prepared should still include sufficient information in the bid to ensure that the FSMC is aware that dietary accommodations may be required during the term of the contract.

## Responsibilities of Food Service Management Companies (FSMC) And Other Food Service Operations (continued)

**Situation:**
- 	Some schools purchase items from nationally recognized fast-food chains and sell these items on an "a la carte" basis.  These items are frequently sold in a setting such as a kiosk which uses the chain's logo or otherwise advertises the product.  What obligation, if any, does the fast-food chain have to provide alternative meals?

**Notes:**
Response to Situation:  
When the school purchases and sells the product itself, the fast-food chain incurs no more obligations than any other wholesaler or retailer of food products.  Consequently, it is important that parents, school food service staff, and other involved school personnel identify and discuss the particular needs of children with special needs and take steps to ensure such children, especially very young children, do not purchase "a la carte" items which can be harmful to them.
Technically, food items sold strictly on an "a la carte" basis are not part of a reimbursable meal.  The food items are not subject to program regulations as long as they do not belong to any of the categories of foods of minimal nutritional value.  The fast-food chain may not be under the obligation to provide alternate food items, unless this is explicitly stated in its contract to vend food items to the school. 

However, schools would be well advised to obtain from the food chain or vendor(s) specific information on the ingredients in the food products purchased, particularly, if there are children diagnosed at risk of severe food allergies who are participating in the food service.  Furthermore, the school may want to consider including such product information as a specification in its contract with the chain or vendor

## Feeding In Separate Facilities –Generally Not Acceptable

**Situation:**
- 	A school wishes to serve meals to children with disabilities in an area separate from the cafeteria where the majority of school children eat.  May the school establish a separate facility for these children?

**Notes:**
Response to Situation:
Federal civil rights legislation, including Section 504 of the Rehabilitation Act of 1973, IDEA, and Title II of the ADA, requires that in providing for or arranging for the provision of nonacademic services and extracurricular activities, including meals, school districts must ensure that students with disabilities participate along with children without disabilities to the maximum extent appropriate to the needs of students with disabilities.

In general, children with disabilities must be allowed to participate with other children to the maximum extent appropriate.  In this way, the child has the opportunity to interact with and learn from children without disabilities.  The school must not segregate children with disabilities on the basis of convenience to the school or to other children.

In rare instances, however, it may be to a child's benefit to be served separately.  For instance, a child with severe motor disabilities may be able to receive individualized attention in handling eating utensils if a special education specialist is able to work with them outside the cafeteria.  Nevertheless, it must be emphasized that in all cases, the decision to feed children with disabilities separately must always be based on what is appropriate to meet the needs of the children.  Schools cannot segregate children with disabilities based on the convenience of the school or other children.

## Temporary Disabilities

**Situation:**
- 	A child was involved in an accident and underwent major oral surgery.  As a result, the child will be unable to consume food for a period of time unless the texture is modified.  Is the school obligated to make this accommodation even though the child will not be permanently disabled?

**Notes:**
Response to Situation: 
A child’s whose disability restricts their diet must be provided substitutions or modifications to foods regardless of the duration of the disability.

## Complicated Feedings

**Situation**:
- 	A child enrolled in the school will require tube feedings.  Is the food service only required to pay for and provide the food, or are the costs for the school nurse, an aide or a specially trained professional to administer the feeding also assigned to the food service?

**Notes:**
Response to Situation:  
It must be emphasized that the overall responsibility for accommodating children with disabilities rests with the school district.  The school district administration is responsible for allocating the district’s costs of accommodating children with disabilities and for deciding which personnel will work with individual children. In most instances involving food substitutions, the school food service account will be used to pay the cost of special food and food preparation equipment and food service personnel will generally be responsible for providing the alternate meal.  For example, if a child must have a pureed meal, it is reasonable to expect the school food service to purchase a blender or food processor, and to have the meal prepared by the food service staff. 

In the case of more delicate operations, such as tube feeding, it is advisable that commercial nutritive formulas, prescribed by a licensed physician, and specially designed for tube feedings, be used rather than a school blenderized formula, which may be subject to spoilage and may not always have the correct consistency or nutritive content.  Proper administration of this type of feeding generally requires the skills of specially trained personnel, such as nurses or the special trained aides who regularly work with the child.  Special labor costs may be covered through special education funds, if the child has an IEP.  If the child does not have an IEP, these costs may, as appropriate, be charged in part to the food service account, or may be assigned to the school district’s general fund or to other funding sources.

## Complicated Feedings(continued)

**Situation:**
- 	A child with a disability is on a number of medications.  The physician’s statement is well defined and includes menus with specific foods.  If a situation arises where specific foods are out of stock, should school food service make substitutions on an "as necessary" basis?

**Notes:**
Response to Situation: 
No.  School food service staff cannot decide what substitutions are appropriate for a given child.  Food service staff should not choose the substitutions themselves because a child may be on a specific medication, which could interact in a negative way with a particular food item.

Ideally, a list of appropriate substitutions should accompany the menus and the foods should be on hand on a regular basis.  If such a list is not available, school food service staff must ask parents to obtain from the child’s physician (or the individual who planned the child's menus) a list of those foods that may be substituted.

## School Food Service Account

**Situation:**
- 	A child with a disability needs to consume six cans of a nutritional supplement during the school day: two cans at breakfast, one can as a mid-morning snack, two cans at lunch, and one can as a mid-afternoon snack.  The cost of the breakfast and lunch supplements is allowable food service expenses.  If the school chooses to offer the additional supplement at the mid-morning and mid-afternoon snack period, are these allowable costs to the food service account?

**Notes:**
Response to Situation:
Yes.  While it is not required that these costs be charged to the nonprofit school food service account, these supplements are a legitimate charge to the food service account.

## School Food Service Account (continued)

**Situation: **
- 	A child with a disability requires the services of the school nurse for assistance in feeding at lunch.  Can the food service account be billed for the services of non-food service personnel such as the school nurse or special aide who may be assisting in the feeding of the child or other nutrition related activity?

**Notes:**
Response to Situation:
Yes.  The services of any personnel necessary to the food service can be paid by the food service account on a pro rata basis.  It must be emphasized, however, that the food service account may only pay for the amount of time that the person actually spends on activities related to the school food service.  If a school nurse spends one hour per day feeding a child with a special need, then only that portion of his/her salary can be charged to the food service account, not the entire salary.  If the child is receiving special education and the child's IEP includes a nutrition or feeding component, special education funds may be available to the school to provide required services for the child.

## Documentation

**Situation:**
- 	The physician's statement only specifies the medical disability, not the required food substitutions.  What should the food service director do?

**Notes:**
Response to Situation:
An appropriate school official (such as the food service director, food service manager or school nurse) must ask parents to obtain more written information from the physician concerning the substitutions or modifications the child requires.  If difficulties arise in obtaining the needed information, the parent(s) should be advised of the problem and asked to work with the school to obtain a complete medical statement for the child.  It is important that the family understand that the school is unable to provide food substitutions or modifications without an adequate diet order or diet prescription.

In some cases, it may be appropriate and helpful for the physician to provide a written referral to a registered dietitian or other qualified professional for diet substitutions.  For further guidance or referral to a registered dietitian, school food service directors may contact the State agency.

## FUNDING INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)

- Services which may be funded through IDEA:
- Special Foods, Supplements, Equipment
- Consultation Services
- Assistance

**Notes:**
In the majority of situations, accommodations can usually be made without substantial expense.  However, there may be times when the nature of a disability can result in significant cost.  For example, IV or tube feedings may require the services of a health care professional as well as equipment. Examples of potential funding sources include:

Individuals with Disabilities Act (IDEA).  Under this law, originally enacted in 1975, Federal funds are provided to assist states and local school districts in making a “ free appropriate education“ available to eligible students with specific disabilities.  In some situations, nutrition services may be specified as: Special Education or Related Services (support service to assist a child with disabilities to benefit from special education.)  This slide shows the kinds of services that can be assisted by these funds.

Consultation services include those of registered dietitian or nutrition professional. Assistance can be from a special education teacher, occupational therapist or other health professional in feeding the child or developing feeding skills.

## FUNDING MEDICAID

**	**
- Varies from state to state
- Paid Directly to Provider

**Notes:**
Medicaid will also sometimes provide funding for accommodations for certain low-income children who are eligible for Medicaid.  Services which may be paid for are medical and remedial in nature and may include; dietary supplements, eating devices, nutritional consultation as medically necessary.

Medicaid is a joint Federal/State Program.  Each state establishes its own standards, so coverage may vary from state to state.

Medicare may provide funding for durable medical equipment needed to accommodate children with end-stage renal disease.

## FUNDINGLOCAL

- PTA
- Voluntary Health Associations

**Notes:**
Funds are sometimes available through local organizations.

## RESOURCES

- State agency
- ADA coordinator
- Health Dept/Hospital

**Notes:**
There also are several sources of technical assistance that may be consulted.

First, check with the State agency.  They have staff that are well versed in nutrition and dietary matters, and, if necessary, they can consult the regional or the National office of the Food and Nutrition Service. 

The Americans with Disabilities Act Coordinator is located in the school district and is usually attached to local disabilities service or human rights office.

Local Health Departments or Hospitals may also be able to provide advice and assistance in understanding diet orders, developing or modifying menus or special purchases.

## RESOURCES

- State Title V Directors
- American Dietetic Assoc.
- University Affiliated Program for Developmentally Disabled (UAP)

**Notes:**
Title V Directors
This refers to Directors of the Maternal and Child Health (MCH and Children with Special Health Care Needs (CSHCN)) programs.  Each state has a director who is responsible for overseeing state programs for children with special health care needs.  Most states also have public health nutritionists who are responsible for nutritional services for these children.

American Dietetic Association  
The ADA’s Technical Information Service may be of assistance by providing a referral to a qualified registered dietitian in your area.  These dietitians can answer questions about special diets, menu planning and can work with school staff to ensure that menus are in compliance with a physician’s diet order.  These services would be an allowable program cost.

University Affiliated Program for Developmentally Disabled (UAP) 
Within their respective states, UAPs serve as links between the academic world and the delivery of services to persons with developmental disabilities.  They may be able to help school nutrition staff in designing appropriate meals or by identifying specialist in these areas.