1. Special Dietary Needs Stephanie Alsbrook, RD, LD Arkansas Department of Education Child Nutrition Unit

2. Objectives Identify laws that related to special dietary needs. Identify specific conditions that are considered disabilities. Identify the documentation that is required for students with special dietary needs. Identify the responsibilities of the school food service.

3. Introduction We have seen increasing emphasis on the importance of ensuring that children with disabilities have the same opportunities as other children to receive an education and education-related benefits, such as school meals.

4. Laws The Rehabilitation Act of 1973 Education of the Handicapped Act now the Individuals with Disabilities Education Act Americans with Disabilities Act USDAs nondiscrimination regulation Regulations governing the National School Lunch Program and School Breakfast Program

5. The Rehabilitation Act of 1973 Prohibits discrimination against qualified persons with disabilities in the programs or activities of any agency of the federal governments executive branch or any organization receiving federal financial assistance.

6. Individuals with Disabilities Education Act Previously the Education of the Handicapped Act Requires that a free and appropriate public education be provided for children with disabilities, who are aged 3 through 21.

7. Americans with Disabilities Act A comprehensive law which broadens and extends civil rights protections for Americans with disabilities.

8. Effects of the Laws An increase in the number of children with disabilities who are being educated in regular school programs. In some cases, the disability may prevent the child from eating meals prepared for the general school population. Therefore, we have an increase in the number of students with special dietary needs.

9. Regulations USDAs nondiscrimination regulation Regulations governing the National School Lunch Program and School Breakfast Program Clearly state that substitutions to the regular meal must be made for children who are unable to eat school meals because of their disabilities, when that need is certified by a licensed physician.

10. Rehabilitation Act of 1973 and the Americans with Disabilities Act A person with a disability is defined 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.

11. Physical or Mental Impairment Orthopedic, visual, speech, and hearing impairments Cerebral palsy Epilepsy Muscular dystrophy Multiple sclerosis Cancer Heart disease Metabolic disease (phenylketonuria or PKU and diabetes) Food anaphylaxis (severe food allergy) Mental retardation Emotional illness Drug addiction and alcoholism Specific learning disabilities HIV disease Tuberculosis Others

12. Major Life Activities Caring for ones self Eating Performing manual tasks Walking Seeing Hearing Speaking Breathing Learning Working

13. IDEA Individuals with Disabilities Education Act The term 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.

14. IDEA Disability Categories 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… continued…Hemophilia, leukemia, lead poisoning, tuberculosis. Emotional disturbance Specific learning disabilities Speech or language impairment Traumatic brain injury Visual impairment, including blindness which adversely affects a childs educational performance Multiple disabilities

15. Attention Deficit Disorder ADD or ADHD may fall under one of the thirteen categories Classification depends upon the characteristics associated with the disorder and how they condition presents itself in the particular student.

16. Individualized Education Program IEP – a written statement for a child with a disability that is developed, reviewed, and revised in accordance with the IDEA and its implementing regulations. Is the cornerstone of the students educational program that contains the program of special education and related services to be provided to a child with a disability

17. Health Care Plan Some IEPs are supplemented with a written statement that addresses a students nutritional needs. An individualized Health Care Plan also addresses the nutritional needs of a particular student.

18. Physicians Statement USDA regulations REQUIRE substitutions or modifications in school meals for children whose disabilities restrict their diets. The substitutions or modifications must be supported by a signed statement from a licensed physician. In Arkansas, we use the Special Dietary Needs Form located on our website.

19. Physicians Statement for Children with Disabilities Must include The childs disability An explanation of why the disability restricts the childs diet The major life activity affected by the disability The food or foods to be omitted from the childs diet, and the food or choice of foods that must be substituted.

20. Food Allergies / Intolerance Generally, children with food allergies or intolerances do not have a disability according to the previous definition. The school food service may, but is not required to, make food substitutions for them. However, some food allergies may result in severe, life-threatening (anaphylactic) reactions. In these situations, the childs condition would be considered a disability and should be documented in the licensed physicians assessment. The substitutions prescribed by the physician must be made.

21. Food Intolerances An adverse food-induced reaction that does not involve the bodys immune system. Example: Lactose Intolerance Symptom might include gas, bloating, and abdominal pain – but is not life threatening. Child Nutrition may accommodate these students but are not required to do so. Will still need a Physicians Statement.

22. Food Allergies Hypersensitivity from an abnormal response of the bodys immune system to food or food additives that would otherwise be considered harmless. Many of the true food allergy symptoms often resemble allergic reactions to other substances, such as penicillin, drugs, bee stings, hives, and itching. May cause anaphylactic reactions Childs condition would meet definition of disability. Are required to make accommodations.

23. Other Special Dietary Needs The school food service may make food substitutions, at their discretion, for individual children who do not have a disability, but who are medically certified as having a special medical or dietary need. Such determinations are made on a case-by- case basis. Examples: food intolerances, food allergies (not life-threatening), high blood pressure, high cholesterol, etc. A medical statement (from a recognized medical authority) that includes the requested substitutions or modifications is required.

24. Medical Statement For Children with Special Dietary Needs Must include: An identification of the medical or other special dietary condition which restricts the childs diet. The food or foods to be omitted from the childs diet. The food or choice of foods to be substituted.

25. School Food Service Responsibilities Staff must make food substitutions or modifications for students with disabilities. Substitutions or modifications for children with disabilities must be based on a prescription written by a licensed physician. The school food service is encouraged to provide food substitutions or modifications for children without disabilities with medically certified special dietary needs who are unable to eat regular meals as prepared.

26. Continued… Substitutions for children without disabilities, with medically certified special dietary needs must be based on a statement by a recognized medical authority. Under no circumstances are school food service staff to revise or change a diet prescription or medical order. Recommendations for accommodations or changes to existing diet orders should be documented in writing to protect the school. Schools should retain copies of special, non- meal pattern diets on file for reviews.

27. Review of Diet Orders 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. We recommend verifying the diet orders on a semester basis.

28. Requests for Food Preferences The school food service is not required to accommodate food preferences. Example 1: Mom writes a note that says Susie does not like green beans, so please substitute carrots. Example 2: Family has started a low carb diet to lose weight and requests a similar diet for school meals. Example 3: Religious Preferences. If the school makes accommodations for one student in one of these situations, they must accommodate for all students.

29. Providing Special Meals to Children with Disabilities The school food service is required to offer special meals at no additional cost. School food service managers should be involved in decisions regarding special meals or modifications.

30. Providing Special Meals to Children with Disabilities The school food service is not required to provide meal services to children with disabilities when the meal service is not normally available to the general student body, unless a meal service is required under the childs IEP. Example: If the school breakfast program is not offered, the school food service is not required to provide breakfast to the child with a disability, unless this is specified in the childs IEP.

31. Menu Modifications Children with disabilities who require changes to the basic meal (such as special supplements or substitutions) are required to provide documentation with accompanying instructions from a licensed physician. This is required to ensure that the modified meal is reimbursable, and to ensure that any meal modifications meet nutrition standards which are medically appropriate for the child.

32. Texture Modifications For children with disabilities who only require modifications in texture (chopped, ground, or pureed food), a licensed physicians written instructions indicating the appropriate food texture is highly recommended.

33. Legal Concerns Schools which do not make appropriate program accommodations for children with disabilities could be found in violation of Federal civil rights laws.

34. Liability School administrators and food service staff should be aware of two issues involving liability: The schools responsibility for providing program accommodations for children with disabilities The question of personal responsibility in cases of negligence.

35. Trained Personnel Please note: In order to accommodate a child with a disability, the school must ensure that both facilities and personnel are adequate to provide necessary services. In some cases, it may be advisable for specially trained personnel, such as a RD, to provide guidance on how to modify a childs meals to comply with requirements provided in the licensed physicians statement.

36. Administering Feedings For certain children with disabilities, it may be necessary to have a nurse or trained health aide feed the child or have a specially trained professional, such as a special education teacher, occupational therapist, or speech therapist, assist the child to develop and improve his or her eating skills. The determination of who will feed the child is a local school decision. The school food service is responsible for providing the food – not for physically feeding the child.

37. Negligence If a mishap should occur, personal liability would normally depend on whether or not the person responsible for the feeding has been negligent.

38. The Kids Are Worth The Effort!! We want every child to eat with us! We want to make accommodations! We want healthy children! We will take the extra time because our children are worth it!