This is the accessible text file for GAO report number GAO-13-165R entitled 'Department of Defense Policies on Accommodating Children with Special Needs in Child Care Programs' which was released on January 16, 2013. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. GAO-13-165R: United States Government Accountability Office: Washington, DC 20548: January 16, 2013: The Honorable Carl Levin: Chairman: The Honorable James M. Inhofe: Ranking Member: Committee on Armed Services: United States Senate: Subject: Department of Defense Policies on Accommodating Children with Special Needs in Child Care Programs: The Department of Defense (DOD) subsidizes child care programs to assist military families, including many with children with special needs, in balancing the competing demands of family life, accomplishing the DOD mission, and improving their financial health. Although DOD has a number of child care programs on and off installations, most military families who use DOD-provided care use Child Development Centers (CDC) or other forms of on-installation care, such as family homes. DOD child care is not guaranteed to all who need it, and the availability of such care depends on demand and the services' budgetary resources. However, when space is available, DOD officials stated that the military services are required to offer accommodations to children with special needs unless those accommodations fundamentally alter the nature of the program. For example, a child with special needs requiring constant one-on-one care may be denied a slot in a CDC, which is a group setting, because that level of care would result in a fundamental change to the nature of the program.[Footnote 1] Senate Report 111-201 directed DOD to report on a number of issues related to children with special needs in the areas of education and child care, including services and challenges for military dependent children with special needs and their families.[Footnote 2] The Senate Report also directed GAO to review DOD's report. We recently issued a report on DOD schools to fulfill part of this requirement,[Footnote 3] but because child care service delivery structures differ, we examined the child care portion separately. This product describes key DOD policies and procedures for: (1) accommodating children with special needs, (2) monitoring program compliance with accommodation policies, and (3) administering medication to children with special needs to relieve symptoms quickly in emergencies[Footnote 4] and related litigation, if any. To identify policies and procedures related to these topics, we reviewed DOD policy and guidance documentation and accreditation criteria that pertain to accommodating children with special needs. We also interviewed officials at the Office of the Secretary of Defense (OSD) and each military service, national accreditation officials, and the Director of DOD's contractor--Kids Included Together--who works with child care staff to accommodate children with special needs in DOD facilities. In addition, we contacted national representatives of the Epilepsy Foundation, American Diabetes Association, and Autism Speaks to better understand the concerns of military families of children with special needs regarding the barriers families face in accessing DOD child care for their children. We selected these groups based on particular special needs brought to our attention in our discussions with DOD, our review of relevant litigation, and their work with and knowledge of potential child care access issues faced by military families with children with special needs. To identify any litigation regarding DOD's medication policies for child care, we searched legal databases using relevant search terms in order to identify any current cases being litigated in federal court, or any decisions issued by the Defense Office of Hearings and Appeals, involving denial of DOD child care or special education services for military dependents with special needs. Because we searched with specific keywords, it is possible that not all cases were captured. In addition, the databases varied in the types of keywords that could be used in a search, which may have further limited the search results. This report focuses on describing DOD's policies and procedures; we did not conduct analyses to assess whether and how these procedures were implemented. As with any system of internal controls, both the design and the implementation of the system are key to its effectiveness. Specifically we did not independently verify data about the number of CDC's that passed inspection or were accredited, and did not test the application of DOD's policies and procedures related to the inspection process. Also, we did not gather additional data at the installation level, or assess whether DOD's or the services' certification processes, provision of services, or medication policies comply with federal laws regarding persons with disabilities. Enclosure I summarizes challenges we faced in providing a more detailed analysis beyond describing DOD policies and procedures. We conducted our work from March 2012 to January 2013 in accordance with all sections of GAO's Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions. Results in Brief: DOD officials stated that their policy is to accommodate children with special needs unless those accommodations fundamentally alter the nature of the program. However, DOD does not centrally collect or maintain data on accommodation decisions; instead they are kept at the installation level. Two services--Army and Air Force--have begun or plan to collect specific data at the service level to monitor and track services to children with special needs across their installations by 2013. Further, the services have different definitions of special needs, although officials told us DOD is working on a standard definition. According to OSD officials, each service has established an assessment process to determine how to accommodate children with special needs in DOD's child care programs. This assessment process is the primary means through which parents can address concerns related to finding appropriate child care for their children with special needs, as well as to help identify support and outreach programs for the family. The National Defense Authorization Act for Fiscal Year 2010 created the Office of Special Needs, which is responsible for enhancing and improving support for families of children with special needs. Although DOD officials stated that this office does not have an oversight role or enforcement authority over DOD child care, the Office of Special Needs and OSD have coordinated on some activities to better serve the DOD population of children with special needs. Additionally, DOD contracts with Kids Included Together to support the work of its child care staff in accommodating children with special needs and offers other services to help child care staff and parents deal with behavioral problems and other issues. Representatives of national disability organizations said that military parents of children with special needs face challenges accessing DOD child care that go beyond those faced by nonmilitary parents of children with special needs in accessing private child care. For example, in some cases military families never make it to the top of waiting lists for local special needs services due to frequent moves. DOD monitors child care programs' compliance with accommodation policies through its inspection process as well as evaluations of program performance in national accreditation reviews. Inspections include criteria that address inclusion of children with special needs. For example, they may assess whether equipment, material or furnishings are available to provide access for children with disabilities to the program's curriculum and activities. They may also assess whether there is a process in place to develop strategies to support children with special needs. According to DOD officials, all CDCs in the four services had passed or were in the process of passing their inspections for fiscal years 2011 and 2012. Accreditation reviews by national organizations also include criteria related to access and accommodation of children with special needs, and DOD officials told us that almost all CDCs were accredited or were in the process of becoming accredited in fiscal years 2011 and 2012.[Footnote 5] DOD reported that child care programs follow the individual services' policies for administering medications. Those policies vary and in some cases are in flux. The Navy and Marine Corps have policies allowing trained DOD child care staff or nurses to administer medications prescribed to manage severe complications of epilepsy and diabetes, while the Army and Air Force are in the process of updating their policies for administering these medications. Our search of legal databases did not find any ongoing cases against the military regarding the denial of child care due to special needs services. Recently, the Army was named as a defendant in a lawsuit involving the refusal to administer a medication to a child with special needs by CDC staff to stop seizures in an emergency. The suit was settled in August 2011. Background: OSD establishes overarching child care policy for DOD and provides oversight and guidance to the services, which administer their own child care programs.[Footnote 6] In fiscal year 2011 approximately 200,000 children were served, including about 27,000[Footnote 7] children with special needs.[Footnote 8] The services' procedures for accommodating children with special needs are specified in their child care instructions. The National Defense Authorization Act for Fiscal Year 2010 created the Office of Community Support for Military Families with Special Needs, referred to as the Office of Special Needs (OSN).[Footnote 9] The office is responsible for enhancing and improving support for families of children with special needs and monitoring the services' programs that support these families. OSD prescribes policies and procedures and sets standards for child care programs on DOD installations. The various services are responsible for establishing procedures for inspecting child care programs; these procedures are to include inspecting the facility for health and safety conditions as well as determining compliance with other DOD standards, such as having trained staff. In accordance with OSD requirements, each child care program is to be certified by the relevant service to operate as long as agency inspections determine that it is in compliance with DOD standards. If a program is determined to be out of compliance, the installation commander is generally required to remedy any violations within 90 days and to remedy any life-threatening violation, whether discovered at inspection or otherwise, immediately.[Footnote 10] In addition to being certified by the relevant services, the approximately 800 CDCs are required[Footnote 11] to be accredited by a national accreditation organization.[Footnote 12] While a number of national accreditation bodies accredit DOD's CDCs, DOD officials stated that almost all CDCs are accredited by the National Association for the Education of Young Children. School Age Care providers are generally accredited by the Council on Accreditation.[Footnote 13] Each service has an assessment process to determine how best to accommodate children with special needs without fundamentally altering the nature of the child care program.[Footnote 14] This assessment process, which involves parents, is generally intended for children with more than minimal needs and is used on an as-needed basis. Multidisciplinary teams, called Inclusion Action Teams (IAT),[Footnote 15] conduct these assessments by considering the needs of the child, the disability, staffing needs and training requirements, the resources of the program, and the types of child care DOD offers. Accommodating Children with Special Needs: Key aspects of DOD's policies and procedures for accommodating children with special needs are: * Officials told us that DOD's policy is to accommodate children with special needs. According to DOD officials, DOD child care programs may not exclude children with special needs and must offer accommodations, unless those accommodations fundamentally alter the nature of the program. Accommodations can include a variety of actions, such as creating a developmentally appropriate environment, changing staff/ child ratios and/or group sizes, and making necessary program adaptations. The assessment process can also include determining the DOD child care setting that is appropriate to meet the child's needs, such as center-or home-based care. If a child's presence requires fundamentally altering the program, poses a direct threat to the health and safety of the child or others, or imposes an undue burden, DOD officials stated that services may deny child care. DOD officials said that, for the most part, their policy is to offer at least one child care option to parents of children with special needs who request child care, although some parents may consider not getting their preferred setting to be a denial of care. One way that DOD is taking steps to ensure that their programs are well equipped to accommodate children with special needs is through their contract with Kids Included Together. This nonprofit organization provides training and technical assistance to child care staff working with children with special needs and their families. The contract supporting all four services began in fiscal year 2011, and is managed by the Navy, which has contracted with Kids Included Together since 2007. Kids Included Together specializes in providing best practices training for community-based organizations committed to including children with and without disabilities into their recreational, and child and youth development programs. Kids Included Together provides on-site training and follow-up support to help child care staff implement what they learn and provides strategies for addressing individual situations. Officials from all four services said that this assistance was valuable in developing strategies to effectively serve children with special needs, particularly those with behavioral issues. In addition, DOD officials stated that Child and Youth Behavioral Military and Family Life Counselors support child care program staff and families dealing with various issues, such behavior management. Also, Military OneSource, a free service DOD provides to service members and their families, offers consultations to military parents of children with special needs, such as providing information and referral services to help families determine which community resources are appropriate to meet their needs. * DOD does not have a standard definition of "special needs" for child care programs. DOD officials said that the services have discretion to define special needs for child care programs and do so differently. For example, the Army considers a child with special needs to be one who has been identified as having unique requirements by appropriate medical, educational, or social service authorities. In contrast, the Navy defines children with special needs as those who require more than routine and basic care, including children with or at risk of disabilities, chronic illnesses and physical, developmental, behavioral, or emotional conditions that require health and related services of a type or amount beyond those required by children generally. According to OSD officials, DOD is planning to reduce inconsistencies in definitions and reporting in the future. They said that they are working with representatives of the services on updating their child care policies and procedures, which will include a standard definition of special needs, but have not yet settled on the year in which this will become effective. Three of the four services plan to update their service-specific policies and procedures once OSD has issued their revision, while the Navy has already made some updates. * Data on accommodations provided to children with special needs are not kept centrally. DOD officials said that specific decisions on accommodations offered or denials of child care based on disability or other special needs are collected and maintained by individual installations. Two services have begun or plan to collect these data from installations and will have them available in 2013. The Army is beginning to collect aggregated data from installations such as the number of children with special needs receiving an assessment, the number of children who received the type of child care requested (e.g., center-based), and the number parents who did not choose to use the accommodations offered. Army officials stated that these specific data will be used to track services to children with special needs overall and evaluate their child care programs. The Air Force is also planning to collect this type of information from its installations. * Services use a variety of methods to inform parents about the assessment process. Services use various ways to provide parents information on the assessment process used to determine how to accommodate children with special needs. The Navy includes information on the assessment process in its handbook for parents of children in DOD child care programs. According to officials in other services, such handbooks are specific to each installation and the information included can vary. Currently, the Air Force and the Army are developing standard information about the assessment process to be included in installations' future versions of the parent handbooks. DOD officials said that the services also provide information on the assessment process through other methods, including brochures and events. According to OSD officials, the assessment process is the primary means through which parents can address concerns they have related to finding appropriate child care for their children with special needs, and receive help identifying support and outreach programs. The expectation by the services is that parents will follow their services' chain of command if they have questions that are not addressed through the assessment process. * OSN and OSD are working together on some activities. Although OSN is responsible for developing and implementing a comprehensive policy for the support of military families with children with special needs, it does not have an oversight role or enforcement authority over DOD child care, according to DOD officials. However, OSD and OSN are coordinating some activities to better serve the DOD population of children with special needs. For example, officials told us that OSD and OSN plan to hold a joint presentation with their contractor, Kids Included Together, in December 2012 on the mental health and special needs of children under 3 years of age, and are coordinating the development of a virtual lab school to train staff on how to work with children with special needs. Even with DOD accommodation policies and procedures, representatives of national disability organizations that we spoke with stated that military families of children with special needs face challenges beyond those faced by non-military families. For example, according to an Autism Speaks representative, communication and behavior issues faced by children with autism can make it difficult to obtain child care in both DOD and non-DOD child care settings because child care providers may not have staff with the appropriate training to work with autistic children. However, the representative said military parents face greater challenges because of the mobile nature of military service. At each new location, families have to navigate complex systems of services, and may face waiting lists to access local resources to help pay for a behavioral specialist or other one- on-one assistance necessary for their child to attend DOD child care. According to the representative, many families may never obtain these resources because they are required to move again before ever reaching the top of the waiting list. DOD monitors child care program compliance with accommodation policies through its internal inspection process as well as through evaluations of program performance in national accreditation reviews. Both include criteria that address inclusion of children with special needs. * All services have specific inspection criteria related to accommodating children with special needs. While the specifics of the inspection criteria differed among the services, all four services included criteria related to inclusion and accommodation. For example, the Air Force's current inspection criteria include determining if equipment, materials, and furnishings are available that provide access for children with disabilities to the CDC's curriculum and activities. Other services had criteria related to assessing children for placement in child care programs. For example the Navy's inspection criteria include determining if an installation's IAT is established to organize resources and develop strategies for supporting children with special needs. DOD officials stated that they update the inspection criteria as requirements change and therefore expect to do so once the updated OSD and service-specific policies and procedures are approved. These officials could not say when these revised policies and procedures will be issued. * Officials said all CDCs in the four services were certified or were in the process of meeting their certification in calendar years 2008- 2012. Officials representing all four services said that all CDCs in all four services were certified in calendar years 2008-2010, as they had stated in their March 2011 report. They also told us that these centers were certified for calendar years 2011 and 2012, as well, although some may have been in the process of correcting deficiencies or too new to have completed the certification process.[Footnote 16] Officials told us that deficiencies related to children with special needs included such things as missing paperwork, clearly posting names of children with allergies, and implementing higher staff/child ratios. Generally, deficiencies must be corrected before the CDC is granted a certificate to operate.[Footnote 17] * For the most part, CDCs were accredited or were in the process of becoming accredited in calendar years 2008-2012. Officials representing all four services told us that almost all CDCs were accredited in calendar years 2008-2010. They also told us that almost all of these centers were accredited or in the process of being accredited for calendar years 2011 and 2012, as well. Officials from all four services said that not all CDCs were accredited for various reasons. For example, according to DOD officials, some CDC programs are currently ineligible for accreditation because the centers are either newly-built and must be open for at least a year before going through the accreditation process, or are being renovated. According to interviews with DOD and accreditation officials, including officials with the Council on Accreditation and the National Association for the Education of Young Children, accreditation programs include criteria related to access and accommodation. For example, the Council on Accreditation's criteria include the requirement that reasonable accommodations exist to allow access to indoor and outdoor activities by children with disabilities. In another example, National Association for the Education of Young Children criteria include requirements that child care programs provide developmental screening for all children within the first 3 months of enrollment. Administering Rescue Medications in Emergencies: In its March 2011 report to Congress required by Senate Report 111- 201, DOD stated that child care programs follow the medication policies established by each service. The services' policies reflect their medical and legal positions on reasonable expectations for their child care staff. These policies vary by service and in some cases are changing. For example, the Navy recently updated its policy by adding language that specifically authorizes and, as needed, requires rescue medications to be administered by DOD child care staff members trained to do so. Similarly, DOD officials stated that the Marine Corps' policy requires that all medications, including rescue medications, be administered by authorized trained staff following medical providers' directions. The Army and Air Force are in the process of updating their policies for administering rescue medications. For example, in 2009 the Army issued a memo with a policy similar to the Navy's regarding a specific rescue medication, Diastat, which is prescribed to manage severe complications of epilepsy.[Footnote 18] However, at the time of our work, Army officials said that the issue of administering this and one other rescue medication --Glucagon, which is used to treat very low blood sugar[Footnote 19]--had been under further review and a new policy allowing the administration of these rescue medications in child care programs is expected to be released by January 2013. Army officials said that in the meantime each installation's assessment process team determines how the medications can be administered based on the installation's capability, such as the availability of nurses to administer the medication at the CDCs. Air Force officials said that currently the Air Force permits administration of emergency medication, such as Diastat, by its child care staff. However, this policy has not been formally issued. Air Force officials said that they plan to include this new medication policy as part of their inclusion manual, which they anticipate issuing in June 2013. DOD's March 2011 report also stated that there were no current cases being litigated in federal court or before the Defense Office of Hearings and Appeals involving denial of DOD child care or special education services for military dependents with special needs. As of October 2012, DOD officials told us they were not aware of any ongoing litigation on access to child care for children with special needs since the 2011 report. Our search of legal databases did not find any ongoing cases against the military. While there is no ongoing litigation, the Army has previously faced litigation involving the administration of a rescue medication. Specifically, the Army reached a settlement in August 2011 in a case filed in 2007 challenging a CDC's refusal to administer Diastat to a child for whom it was prescribed, an accommodation requested by parents who sought to enroll their child in Army child care.[Footnote 20] Agency Comments: We are not making recommendations in this report. We provided a draft of this report to DOD for its review and comment. DOD stated that it agreed with the report and did not provide written comments. We are sending copies of this report to the Secretary of Defense, appropriate congressional committees, and other interested parties. The report also is available at no charge on the GAO website at [hyperlink, http://www.gao.gov]. If you or your staff members have any questions about this report, please contact me at (202) 512-7215 or brownke@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made key contributions to this report are listed in enclosure II. Signed by: Kay E. Brown: Director, Education, Workforce, and Income Security Issues: Enclosures - 2: [End of section] Enclosure I: Challenges in Obtaining Key Data: In June 2012 we briefed congressional committee staff on information gathered and challenges faced in obtaining key data relevant to the Department of Defense (DOD) child care topics contained in Senate Report 111-201. We faced challenges obtaining information or data because: (1) DOD services were in the process of changing their child care policies for children with special needs, (2) the Office of the Secretary of Defense (OSD) and the services maintained limited aggregated data on assessments and other information related to these children, and (3) parents of children with special needs were difficult to identify and reach for the purposes of learning about their challenges accessing child care. As agreed, we have provided this written product on the three areas for which we were able to obtain sufficient information to describe DOD policies and procedures for providing child care to children with special needs: (1) accommodating children with special needs, (2) monitoring program compliance with accommodation policies, and (3) administering medication to children with special needs to relieve symptoms quickly in emergencies and related litigation, if any. This enclosure includes a more thorough discussion of why we recommended curtailing more in- depth work on these issues until a later time. It also outlines the difficulties in pursuing information directly from parents of children with special needs on the challenges they faced accessing DOD child care. As discussed at the time of our briefing and in this report, some DOD policies on children with special needs were evolving. For example, services did not have a consistent definition of "special needs", but DOD was working on ways to standardize definitions and data collection on children with special needs across the services. In the medication area, two of the four services--Army and Air Force--were in the midst of reevaluating their requirements regarding child care staff administration of rescue medications--a key area of interest for the committee and other groups, especially given recent litigation involving the Army. Hence, we recommended to the committee staff that no further work be done beyond what is reported here until these policies were finalized and implemented, providing us a better opportunity to assess the results of these changes. Limited aggregated data at OSD about assessment results of children with special needs whose families requested accommodations in DOD child care facilities also made it difficult to conduct further work in the area of child care services offered by DOD to these children. For example, without such information, it would be difficult to determine if children had been denied child care and why; how many had been offered child care accommodations different than what was preferred by their parents, and how many parents did not choose to use these accommodations. Without aggregated data in a central location, obtaining this information would likely require an analysis of paper assessment files from Inclusion Action Teams that reside at individual installations. Such an analysis would be resource intensive because the services' assessment processes and how they collect and maintain these data vary. The Army and Air Force aggregated data may provide useful information in the future once reliability is established. Regarding difficulties reaching parents of children with special needs, we were not able to collect sufficient information directly from parents to include in this report. We concluded that further work to learn about the challenges these parents face in accessing and using DOD child care would be problematic. We determined this through: (1) discussions with DOD officials about data availability issues that would limit their ability to provide contact information needed to locate parents of children with special needs who do and do not use DOD child care, and (2) our previous attempts to conduct focus groups for this subset of parents, which resulted in very low attendance rates. These constraints limited our ability to ensure an effective method of inviting parents to focus groups and interviews or in administering a survey. This, in turn, limited the usability of any data we could collect. Addressing issues of access to care would have required comparable groups of parents of children with special needs who did not use DOD child care in addition to groups of parents who did. However, DOD officials told us that generally they did not keep records of children with special needs whose parents applied for DOD child care but did not accept the accommodation offered them. Although the Exceptional Family Member Program in each service may have been able to supply a list of children with special needs, DOD may not have been able to determine which children were using DOD child care. Also, such a list would include only a subset of all military families of children with special needs because, according to DOD officials, not all such families enroll in the Exceptional Family Member Program, although it is mandatory that they do so. In addition, we had concerns about the attendance of an adequate number of parents of children with special needs at focus groups. In conducting early planning for related work, we found that few parents-- and on two occasions, none--attended focus groups to discuss their experiences accessing DOD child care for their children with special needs. When talking to officials about why this was the case, we were told that there could be a number of reasons for a low turnout among parents with children with special needs. In particular, military parents, especially parents of children with special needs, may have faced time pressures that limited their ability to participate in activities beyond their primary military duties, such as a focus group. Further, DOD officials told us that some military parents may have been sensitive about having a child with special needs and may not have wanted to call attention to this fact by participating in a focus group. Instead of conducting focus groups to learn about the challenges DOD families of children with special needs face in accessing DOD child care, we contacted national representatives of the Epilepsy Foundation, American Diabetes Association, and Autism Speaks who were in direct contact with military and nonmilitary families. This information is contained in the body of this report. [End of section] Enclosure II: GAO Contact and Staff Acknowledgments: GAO Contact: Kay E. Brown, (202) 512-7215 or brownke@gao.gov: Contributors to this report include Janet Mascia, Assistant Director; Julianne Hartman Cutts, Holly Dye, Kirsten Lauber, Jim Rebbe, and Kate van Gelder. [End of section] Footnotes: [1] DOD officials said that children who need occasional one-on-one care, such as for toileting, or who have a caregiver that the family has arranged for may be admitted to a CDC. [2] S. Rep. No. 111-201, at 138 (2010). [3] See GAO, Military Dependent Students: Better Oversight Needed to Improve Services for Children with Special Needs, [hyperlink, http://www.gao.gov/products/GAO-12-680] (Washington, D.C.: Sept. 12, 2012) [4] In this report we refer to medications needed in emergencies to relieve symptoms quickly as rescue medications. [5] Because the focus of our objectives was to describe DoD's policies and procedures, we did not independently verify data about the number of CDCs that passed inspection or were accredited. Also, we did not test the application of DOD's policies and procedures related to the inspection process. [6] As defined in Department of Defense Instruction 6060.2, child care programs (referred to by DOD as child development programs) may consist of CDCs, family child care homes, and alternative locations. [7] According to DOD's annual report for 2011, about 27,000 children with special needs were enrolled in DOD child care programs as of the specific date, or "date of record", for which each service collected these data. [8] According to DOD, the services have discretion in defining "special needs" for purposes of their child care programs. [9] Pub. L. No. 111-84, § 563(a), 123 Stat. 2190, 2304 (codified as amended at 10 U.S.C. § 1781c). [10] The installation commander may waive the 90-day requirement and authorize the program to remain open in a case in which the violation cannot reasonably be remedied within the 90-day period or in which major facility reconstruction is required. [11] 10 U.S.C. § 1797. [12] Accreditation is the formal evaluation of an organization against accepted criteria or standards. A professional society, non- governmental organization, or a governmental agency may conduct accreditation activities. For example, accredited organizations may be required to undergo a period of rigorous self-study and be capable of providing programs and services that meet or exceed the accrediting body's standards. [13] The National Association for the Education of Young Children sets and monitors standards for high-quality early childhood education programs and accredits programs that meet these standards. The Council on Accreditation is a national body that accredits after-school programs in the United States and on U.S. military installations worldwide. [14] The Air Force does not currently have centralized assessment guidance; however, officials said that they are developing guidance for a standardized process. [15] Each service currently refers to the assessment process by a different name. For example, the Army currently calls the process Special Needs Assessment Process. The Marine Corps process uses Special Needs Evaluation Review Teams, and the Navy uses Inclusion Action Teams, or IATs. Army and Marine Corps officials said that they are revising their policies to use the term IAT. We use the term IAT throughout this report to refer to the assessment process for all services. [16] After we obtained this information from DOD, we are aware that one facility was closed in December 2012 for reasons unrelated to serving special needs children. [17] We did not independently verify these data nor test the application of DOD's policies and procedures related to the inspection process. [18] Diastat (also known generically as Diazepam) is used in emergency situations to stop cluster seizures (episodes of increased seizure activity) in people who are taking other medications to treat epilepsy. [19] Glucagon is a hormone produced in the pancreas and is used to raise very low blood sugar. [20] The Army's plan for treatment in the event of an emergency seizure situation was to call 911, but the parents were concerned that this would delay treatment. [End of section] GAO’s Mission: The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO’s commitment to good government is reflected in its core values of accountability, integrity, and reliability. 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