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Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities

Published:August 28, 2012DOI:https://doi.org/10.1016/j.jand.2012.06.365
      The Behavioral Health Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee and its Scope of Practice Sub-committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) in Intellectual and Developmental Disabilities (IDD). These documents build on the Academy's Revised 2008 SOP for RDs in Nutrition Care and SOPP for RDs.
      American Dietetic Association Quality Management Committee
      American Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.
      The Academy's Code of Ethics
      American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues.
      and the 2008 SOP in Nutrition Care and SOPP for RDs
      American Dietetic Association Quality Management Committee
      American Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.
      are tools within the Scope of Dietetics Practice Framework
      • O'Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      that guide the practice and performance of RDs in all settings. The concept of scope of practice is fluid,
      • Visocan B.
      • Swift J.
      Understanding and using the scope of dietetics practice framework: A step-wise approach.
      changing in response to the expansion of knowledge, the health care environment, and technology. An RD's statutory scope of practice is defined by state legislation (ie, licensure, certification, or title protection laws) and differs from state to state. An RD may determine his or her own individual scope of practice using the Scope of Dietetics Practice Framework,
      • O'Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      which takes into account federal regulations; state laws; institutional policies and procedures; and individual competence, accountability, and responsibility for his or her own actions.
      The Revised 2008 SOP and SOPP
      American Dietetic Association Quality Management Committee
      American Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.
      reflect the minimum competent level of dietetics practice and professional performance for RDs. These standards serve as blueprints for the development of focus area SOP and SOPP for RDs in competent, proficient, and expert levels of practice. The SOP in nutrition care address the four steps of the Nutrition Care Process and activities related to patient/client care.
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      They are designed to promote the provision of safe, effective, and efficient food and nutrition services, facilitate evidence-based practice, and serve as a professional evaluation resource. The SOPP are authoritative statements that describe a competent level of behavior in the professional role. Categorized behaviors that correlate with professional performance are divided into six separate standards.
      Approved April 2012 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) House of Delegates and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: April 2017.
      Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities (IDD) may be addressed to Academy quality management staff: Karen Hui, RD, LDN, manager, Quality Management or Sharon McCauley, MS, MBA, RD, LDN, FADA, director, Quality Management at [email protected].
      These focus area standards for RDs in IDD are a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering IDD nutrition services. They are used by RDs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards may be used to assist RDs in transitioning their knowledge and skills to a new focus area of practice. Like the 2008 “core” SOP in Nutrition Care and SOPP, the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figure 1, Figure 2, Figure 3 available online at www.andjrnl.org) for the SOP and SOPP for RDs in IDD were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDs in IDD were reviewed and approved by the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group, the Academy Quality Management Committee, and its Scope of Practice Subcommittee.

      Three Levels of Practice

      Competent Practitioner

      In dietetics, a competent practitioner is an RD who is starting practice after having obtained RD registration by the Commission on Dietetic Registration or an experienced RD who has recently assumed responsibility to provide nutrition care in a new focus area. A focus area is defined as an area of dietetics practice that requires focused knowledge, skills, and experience. A competent practitioner who has obtained RD status and is starting in professional employment acquires on-the-job skills and engages in tailored continuing education to enhance knowledge and skills. RDs expand their breadth of competence and advance their careers through education and training, knowledge and skill development, professional experience, and interactions with others. The practice of a competent RD can include responsibilities across several areas of practice including, but not limited to, more than one of the following: community, clinical, consultation and business, research, education, and food and nutrition management.

      Proficient Practitioner

      A proficient practitioner is an RD who is generally 3 or more years beyond entry into the profession, who has obtained operational job performance skills, and is successful in his or her chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, and experience in a focus area of dietetics practice. An RD can acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.

      Expert Practitioner

      An expert practitioner is an RD who is recognized within the profession and has mastered the highest degree of skill in or knowledge of a certain focus or generalized area of nutrition and dietetics through additional knowledge, experience, and/or training. An expert practitioner exhibits a set of characteristics that includes leadership and vision and demonstrates effectiveness in planning, achieving, evaluating, and communicating targeted outcomes. An expert practitioner may have an expanded or specialist role, or both, and may possess an advanced credential, if available, in a focus area of practice. Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility.
      Scope of Practice definition of terms Academy of Nutrition and Dietetics website.
      These Standards, along with the Code of Ethics,
      American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues.
      answer the questions: Why is an RD uniquely qualified to provide IDD nutrition services? What knowledge, skills, and competencies does an RD need to demonstrate for the provision of safe, effective, and quality IDD care at the competent, proficient, and expert levels?

      Overview

      Nutrition services for individuals or people with IDD must balance nutrition needs with the individual's desires, abilities, and supports (necessary services and adaptations) to achieve quality of life. Knowledge and understanding of the unique aspects of providing services to individuals with IDD are essential for the RD to effectively deliver nutrition care.
      Developmental disabilities (DD) are defined as severe chronic disabilities that can be cognitive or physical or both. DD is a broad term that includes intellectual disability (ID) as well as other disabilities that originate before age 22 years.
      American Association on Intellectual and Developmental Disabilities
      Definition of intellectual disabilities.
      ID is diagnosed before age 18 years and is synonymous with the previously used term mental retardation in kind, level, type, and duration of the disability. ID is characterized by significant limitations both in intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills.
      American Association on Intellectual and Developmental Disabilities
      Definition of intellectual disabilities.
      Developmental disabilities are likely to be lifelong and can substantially inhibit a person's capacity to do at least three of the following
      American Association on Intellectual and Developmental Disabilities
      Definition of intellectual disabilities.
      :
      • self-care activities (ie, dress, bathe, eat, and other activities of daily living);
      • speak and be understood;
      • learn;
      • ambulate;
      • make decisions;
      • live on their own; and
      • earn and manage an income.
      DDs can be the result of identified etiologies, such as chromosomal abnormalities, congenital anomalies, inherited metabolic disorders, specific syndromes, neurodevelopment or neuromuscular dysfunction, or may not be associated with any diagnosed condition. Although there are hundreds of specific diagnoses that involve IDD, the most well-known diagnoses that manifest as IDD include Down syndrome, fragile X, autism spectrum disorder, cerebral palsy, and intellectual disability, unspecified.
      The Arc, For People with Intellectual and Developmental Disabilities
      Still in the shadows with their future uncertain: A report on family and individual needs for disability supports (FINDS), 2011.
      The estimated total number of people with ID or DD in the United States from 1994 to 1995 was 4,132,878 (a prevalence of 15.8 people per 1000).
      Prevalence of Mental Retardation and/or Developmental Disabilities: Analysis of the 1994/1995 NHIS-D Institute of Community Integration, University of Minnesota, Minneapolis.
      DDs were reported in 1 in 6 children in the United States from 2006 to 2008.
      • Boyle C.A.
      • Boulet S.
      • Schieve L.A.
      • et al.
      Trends in the prevalence of developmental disabilities in US children, 1997-2008.
      About 13.4 million (4.8%) of the noninstitutionalized child and youth population 5 years and older were estimated to have cognitive difficulty in 2008.
      • Brault M.W.
      Review of changes to the measurement of disability in the 2008 American Community Survey US Census Bureau, September 22, 2009.
      Estimates for adults age 60 years and older with IDD range between 600,000 and 1.6 million. This rapidly growing population is expected to be several million by 2030.
      • Brault M.W.
      Review of changes to the measurement of disability in the 2008 American Community Survey US Census Bureau, September 22, 2009.

      Nutrition and Health Concerns in IDD

      Improved care from birth through adulthood has resulted in longer lives for premature babies and a better quality of life and greater longevity in people with IDD. With increasing longevity, the variety of conditions and functional impairments places people with IDD at greater risk for developing chronic diseases.
      • Rosenzweig L.Y.
      Serving the aging developmentally disabled population.
      Compared to the population without disabilities, individuals with IDD are at greater risk for health problems resulting in higher morbidity and earlier mortality.
      • Reichard A.
      • Stolzle H.
      • Fox M.H.
      Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States.
      • Schieve L.A.
      • Gonzalez V.
      • Boulet S.L.
      • et al.
      Concurrent medical conditions and health care use and needs among children with learning and behavioral developmental disabilities, National Health Interview Survey, 2006-2010 National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, United States.
      Such risks can be magnified when a comorbid mental health issue emerges; individuals with coexisting IDD and psychiatric disorders have been identified as a group with particularly complex service needs.
      • Antochi R.
      • Stavrakaki C.
      • Emery P.C.
      Psychopharmacological treatments in persons with dual diagnosis of psychiatric disorders and developmental disabilities.
      There is a strong need for RD involvement to address and manage the multiple special nutritional needs of children and adults with IDD.
      • Buie T.
      • Campbell D.B.
      • Fuchs 3rd, G.J.
      • et al.
      Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: A consensus report.
      American Dietetic Association
      Position of the American Dietetic Association: Providing nutrition services for people with developmental disabilities and special health care needs.
      Health and nutrition issues, often unmet in children with IDD, may include metabolic problems, feeding difficulties, food allergies, and growth and/or developmental problems.
      • Oeseburg B.
      • Dijkstra G.J.
      • Groothoff J.W.
      • Reijneveld S.A.
      • Jansen D.E.
      Prevalence of chronic health conditions in children with intellectual disability: A systematic literature review.
      Early intervention is critical in improving treatment outcomes, preventing secondary disability,
      American Academy of Pediatrics
      Role of the Medical Home in Family-Centered Early Intervention Services.
      and influencing future nutritional health needs. Nutrition problems in the adult are often related to secondary conditions, such as overweight/obesity, gastrointestinal dysfunction, cardiovascular disease (including risk factors), diabetes, osteoporosis, cancer, anemia and food allergies.
      • Seekins T.
      • Trace M.
      • Bainbridge D.
      • et al.
      Promoting health and preventing secondary conditions among adults with developmental disabilities.
      Unlike “typical” aging, some individuals with a disability begin to show higher rates of medical and functional problems at age 50 or younger, including dementia and Alzheimer's disease. Research documents nutritional deficits, inadequate diets, and poor nutritional status among adults with IDD living in the community.
      • Bertoli S.
      Nutritional status and dietary patterns in disabled people.
      • Humphries K.
      • Traci M.A.
      • Seekins T.
      Nutrition education and support program for community-dwelling adults with intellectual disabilities.
      Twenty percent (20%) of children ages 10 through 17 years with IDD are obese vs 15% of children without disabilities.
      Child and Adolescent Health Measurement Initiative
      National Survey of Children's Health, 2007 Data Resource Center on Child and Adolescent Health website.
      Obesity rates for adults with disabilities are 58% higher than for adults without disabilities.
      Behavioral Risk Factor Surveillance System Survey data.
      Factors contributing to a higher incidence of overweight and obesity include consuming fewer healthy food choices, medications that contribute to weight gain, physical limitations, lack of social and financial support, poor eating habits, lack of exercise, and depression.
      American Association on Health and Disability
      Obesity and disability.
      Gastroesophageal reflux disease is believed to occur in almost 50% of individuals with IDD due to premature birth, comorbid complex physical disabilities, and advancing age.
      • Medina W.C.
      Nonverbal individuals with intellectual/developmental disabilities experiencing GERD: From infants to older adults.
      A range of physical and behavioral difficulties often require that the individual receive mealtime assistance, adaptation, and intervention to ensure safety and adequate nutrition.
      • Ball S.L.
      • Panter S.G.
      • Redley M.
      • Proctor C.A.
      • Byrne K.
      • Clare I.C.H.
      The extent and nature of need for mealtime support among adults with intellectual disabilities.
      Problems with oral-motor control and swallowing lead to discomfort, poor nutritional status, dehydration, aspiration, asphyxiation, and can be life threatening.
      • Sullivan P.B.
      • Lamber B.
      • Rose M.
      • Ford-Adams M.
      • Johnson A.
      • Griffiths P.
      Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford Feeding Study.
      Consulting with a speech-language pathologist or occupational therapist is key to addressing many of these concerns in the individual with IDD.

      Provision of Nutrition Services

      Individuals with IDD require varying levels of individualized services and supports determined through person-centered planning, which values the specific needs and desires of the individual. The individual is empowered to achieve personal and/or health-related goals based on strengths and capacity, not disability.
      American Association on Intellectual and Developmental Disabilities
      Definition of intellectual disabilities.
      • Lipscomb R.
      Person-first practice: Treating patients with disabilities.
      The network of people supporting an individual with IDD may be referred to as the circle of support, planning team, support network, or care team. A nutrition plan for a person with IDD often requires adaptation of the typical treatment approach to meet the person's unique needs. An RD with experience in the care of the IDD population is uniquely qualified to provide medical nutrition therapy across the full continuum of care, consistent with the person's medical and behavioral condition(s), prognosis, functional abilities, intellectual and cognitive skills, living environment, self-determination, and choices.
      Provision of nutrition services (eg, consultation, assessment, intervention planning, staff and care provider training, implementation, and monitoring) may occur in the person's home, supported living environment, group home, or intermediate care facility, as well as school, job, and day programs. RDs may also provide nutrition care to children and adults with IDD in acute care settings, outpatient clinics, long-term care settings, skilled nursing, and school settings. Regardless of the setting, it is beneficial when nutrition services are provided within a person-centered medical home model.
      American Academy of Family Physicians
      Definition of patient-centered medical home.
      According to the Family and Individual Needs for Disability Supports survey of 2011, the vast majority of people with IDD (98%) report living in the community, with 78% living with family members, 9% in group homes of six or fewer people and 7% in their own homes or apartments.
      The Arc, For People with Intellectual and Developmental Disabilities
      Still in the shadows with their future uncertain: A report on family and individual needs for disability supports (FINDS), 2011.
      RDs are accountable and responsible for overall provision of nutrition services provided in IDD. In institutional, acute care, and long-term care facilities, dietetic technicians, registered (DTRs) and other support staff may assist in the provision of nutrition care of the individual with IDD. As part of RD/DTR teams, DTRs work under an RD's supervision when providing person-centered nutrition care.

      Nutrition Assessment

      A comprehensive evaluation is needed when assessing nutritional status in the child or adult with IDD. The assessment should include the impact of disability on nutritional status, current supports, social skills, mealtime supports and dining skills, mobility, sensory processing needs, social and communication skills, level of independence, and cognitive level.
      American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice Group
      The Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals.
      • Ekvall S.
      • Ekvall V.
      Pediatric Nutrition in Chronic Diseases and Developmental Disorders: Prevention, Assessment, and Treatment.
      Another key component is assessing the level of support and assistance the person needs to carry out the nutrition plan. Assessment often requires multiple measures or parameters in addition to using clinical judgment. Anthropometrics in the IDD population can be difficult to obtain because of structural anomalies (eg, kyphosis, scoliosis), as well as neuromuscular, sensory, and compliance issues.
      American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice Group
      The Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals.
      To calculate desired body weight, it may be necessary to use multiple methods and compare results. Methods include World Health Organization or Centers for Disease Control and Prevention growth charts.
      Centers for Disease Control and Prevention website Growth charts.
      Specialty growth curves, while available, are not recommended as a clinical tool.
      • Bull M.J.
      Academy of Pediatrics, Committee on Genetics
      Clinical report: Health supervision for children with Down syndrome.
      Conventional methods to estimate energy requirements are not always accurate in IDD.
      American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice Group
      The Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals.
      • Dickerson R.N.
      • Brown R.O.
      • Hanna D.L.
      • Williams J.E.
      Energy requirements of non-ambulatory, tube-fed adult patients with cerebral palsy and chronic hypothermia.
      Degree of spasticity, severity of the disorder, muscle atrophy, stunted growth, extent of mobility or ambulation, and low muscle tone are factors affecting energy needs. More than one method of determining energy needs may be required, along with assessing weight history/trends, monitoring weights, reviewing laboratory data and food intake records, observing meal times, and obtaining information from the individual and care providers.
      Multiple medications and long-term use of certain medications or treatments and their potential side effects (eg, antiepileptic, psychotropic medications
      • Muench J.
      • Hamer A.M.
      Adverse effects of antipsychotic medications.
      ) are often factors impacting nutrition status and gastrointestinal function. It is common for individuals with IDD to take numerous prescription and nonprescription medications and to use complementary and alternative therapies.
      • Kiefer D.
      • Pitluk J.
      • Klunk K.
      An overview of CAM: Components and clinical uses.
      The RD needs to review all medications and potential food−medication interactions, as well as any alternative or nontraditional therapies (eg, fish oil, gluten-free, casein-free diet
      • Marcason W.
      What is the current status of research concerning use of a gluten-free, casein-free diet for children diagnosed with autism?.
      ) and assist in assessing effective use, risk vs benefit, and any associated safety issues.
      RDs frequently provide services to individuals with IDD who receive or are in need of enteral nutrition support. The RD describes the potential nutritional benefits, risks, and alternatives of enteral nutrition/tube placement for the individual. The RD contributes to decisions regarding formula selection, formula administration (ie, frequency, volume, rate), and proper positioning during and after formula administration. The RD consults with the circle of support when foods are consumed orally in addition to formula by tube, such as the use of intermittent meals that may be incorporated into the individual's daily routine.

      Nutrition Intervention

      RDs in this focus area identify creative approaches to nutrition interventions and determine appropriate nutrition education materials and age-appropriate tools. They discern the level of understanding and support needed by the person, family, and care providers. When developing the nutrition intervention, the RD considers how the person communicates, such as vocalizations, body movements, sign language, and use of augmentative and alternative communication devices.
      National Joint Committee for the Communication Needs of Persons with Severe Disabilities
      Guidelines for meeting the communication needs of persons with severe disabilities [Guidelines].
      The use of person-first language is essential, focusing on the person rather than the disability.
      • Lipscomb R.
      Person-first practice: Treating patients with disabilities.
      Education and adequate training are essential in all steps of implementing the nutrition care plan, not just for the person with IDD, but also for the family, care providers, educators, and other health care professionals. Living environments requiring care provider(s) support can be complicated by high staff turnover and the care provider's lack of food-preparation skills and nutrition knowledge.
      • Humphries K.
      • Traci M.A.
      • Seekins T.
      Nutrition education and support program for community-dwelling adults with intellectual disabilities.
      In addition, a care provider's personal choices and habits may influence the individual's behavior, creating barriers to successful intervention and outcomes. Developing rapport and respectful working relationships with individuals and their circle of support is crucial for desirable outcomes.
      Behavioral responses or actions, both positive and negative, in individuals with IDD communicate wants, needs, or emotions. Determining what the person is trying to communicate helps identify appropriate supports and interventions to achieve the planned outcomes. When behavior negatively impacts success at mealtime and overall success of the nutrition plan, the RD may implement established behavior-change strategies along with positive behavior support strategies, and/or recommend referral for behavioral services.
      • Ball S.L.
      • Panter S.G.
      • Redley M.
      • Proctor C.A.
      • Byrne K.
      • Clare I.C.H.
      The extent and nature of need for mealtime support among adults with intellectual disabilities.
      American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice Group
      The Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals.
      • Rosal M.C.
      • Ebbeling C.B.
      • Lofgren I.
      • Ockene J.K.
      • Ockene I.S.
      • Herbert J.R.
      Facilitating dietary change: The patient-centered counseling model.
      While behavioral supports are often necessary, it is critical to first consider that medical issues may cause undesired behaviors.
      • Buie T.
      • Campbell D.B.
      • Fuchs 3rd, G.J.
      • et al.
      Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: A consensus report.
      Services for individuals with IDD have historically involved federal or state assistance programs, regulations, and funding guidelines that span living, school, work, and health care environments.
      The Arc for People with Intellectual and Developmental Disabilities website Public Policy: Federal Laws.
      Medicaid Program, State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Setting Requirements for Community First Choice Centers for Medicare & Medicaid Services, Department of Health and Human Services.
      RDs practicing in the field of IDD need to be knowledgeable about sources of funding and reimbursement requirements,
      American Academy of Pediatrics
      Role of the Medical Home in Family-Centered Early Intervention Services.
      The Arc for People with Intellectual and Developmental Disabilities website Public Policy: Federal Laws.
      and RDs need to investigate coverage by individual state and private pay programs. Regardless of whether the nutrition interventions that RDs recommend for their clients are consistent with the guidelines for funding, best practices require that RDs pursue nutrition interventions that are consistent with the nutritional needs of the person.
      The IDD practice environment is an area that requires RDs to be proactive team players and identify creative nutrition-intervention approaches. Increasing IDD-related knowledge and skills through education, training, and experience is needed by RDs at all levels of practice. The RD can be influential in educating medical and health professionals on the complex nutritional, health, and behavioral needs of individuals with IDD. RDs can be instrumental in increasing health literacy,
      • Medlen J.
      Health literacy for people with intellectual and developmental disabilities.
      encouraging participation in health-promotion screening and wellness programs, and providing nutrition education.
      • Carmona R.
      Dietetics and disability.
      RDs in IDD need to develop and implement evidence-based medical nutrition therapy protocols, advocate for appropriate support systems, assist individuals in reducing risks of disease, and participate in and publish nutrition research in IDD. The RD can be a formidable advocate for services that address the unique needs of this vulnerable population.

      Academy Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) In Intellectual and Developmental Disabilities

      An RD may use the SOP and SOPP for RDs (competent, proficient, and expert) in IDD (see the website-exclusive Figure 1, Figure 2, Figure 3 at www.andjrnl.org) to:
      • identify the competencies needed to provide IDD nutrition care;
      • self-assess whether he or she has the appropriate knowledge base and skills to provide safe and effective IDD nutrition care for their level of practice;
      • identify the areas in which additional knowledge and skills are needed to practice at the competent, proficient, or expert level of IDD dietetics practice;
      • provide a foundation for public and professional accountability in IDD nutrition care;
      • assist management in the planning of IDD nutrition services and resources;
      • enhance professional identity and communicate the nature of IDD nutrition care;
      • guide the development of IDD nutrition-related education and continuing education programs, job descriptions, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in IDD nutrition care and the understanding of the full scope of this focus area of practice.

      Application to Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuitive Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 1 online at www.andjrnl.org) during the acquisition and development of knowledge and skills. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDs in IDD. In Academy Focus Area SOP and SOPP, the levels are represented as competent, proficient, and expert practice.
      All RDs, even those with considerable experience in other practice areas, must begin at the competent level when practicing in a new setting. At the competent level, an RD starting to work with individuals with IDD is learning the principles that underpin this focus area and is developing skills for safe and effective IDD practice. This RD, who may be an experienced RD or may be new to the profession, has a breadth of knowledge in nutrition overall and may have proficient or expert knowledge/practice in another focus area. However, the RD new to the focus area of IDD may experience a steep learning curve.
      At the proficient level, an RD has developed a deeper understanding of IDD care and is better equipped to apply evidence-based guidelines and best practices than at the competent level. This RD is also able to modify practice according to unique situations (eg, daily energy needs of 600 calories or less, physical abnormalities that interfere with digestion/elimination, multiple medications impacting nutritional intake, digestion, absorption, and elimination). The RD at the proficient level may possess a specialist credential.
      At the expert level, the RD thinks critically about IDD nutrition practice, demonstrates a more intuitive understanding of IDD nutrition care and practice, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of experience and education. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of RDs working in IDD in various disciplines and practice settings. Expert RDs, with their extensive experience and ability to see the significance and meaning of IDD nutrition care within a contextual whole, are fluid and flexible and, to some degree, autonomous in practice. Expert RDs not only implement IDD nutrition practice, they also drive and direct clinical practice, conduct and collaborate in research, contribute to interdisciplinary teams, and lead the advancement of IDD nutrition practice.
      Indicators for the SOP (Figure 2; available online at www.andjrnl.org) and SOPP (Figure 3; available online at www.andjrnl.org) for RDs in IDD are measurable action statements that illustrate how each standard may be applied in practice. Within the SOP and SOPP for RDs in IDD, an “X” in the competent column indicates that an RD who is caring for individuals with IDD is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RD in IDD could be an RD starting practice after registration or an experienced RD who has recently assumed responsibility to provide IDD nutrition care for individuals. An X in the proficient column indicates that an RD who performs at this level has a deeper understanding of IDD nutrition care and has the ability to modify therapy to meet the needs of individuals with IDD in various situations (eg, using augmentative communication tools to incorporate medical nutrition therapy into meal planning, grocery shopping, and food preparation, or devising a meal plan for a person with aspiration risk who refuses enteral tube placement). An X in the expert column indicates that the RD who performs at this level possesses a comprehensive understanding of IDD nutrition care and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RD builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in online Figure 2 and Figure 3 (available at www.andjrnl.org) in boldface type originate from the 2008 SOP in Nutrition Care and SOPP for RDs
      American Dietetic Association Quality Management Committee
      American Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.
      and should apply to RDs in all three practice levels. Several indicators developed for this focus area not in boldface type are identified as applicable to all levels of practice. Where Xs are placed in all three levels of practice, it is understood that all RDs in the field of IDD are accountable for practice within each of these indicators. However, the depth with which an RD performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDs in IDD is warranted. It is the totality of the RD's practice that defines the level of practice and not any one indicator or standard.
      RDs should review the SOP and SOPP in IDD at regular intervals to evaluate their individual focus area nutrition knowledge, skill, and competence. Regular self-evaluation is important because it helps identify opportunities to improve and/or enhance practice and professional performance. This self-appraisal also enables RDs in IDD to better use the Commission on Dietetic Registration's Professional Development Portfolio for self-assessment, planning, improvement, and commitment to lifelong learning.
      • Weddle D.O.
      The professional development portfolio process: Setting goals for credentialing.
      These Standards can be used in each of the five steps of the Professional Developmental Portfolio process (Figure 4). RDs are encouraged to pursue additional training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the statutory scope of practice, as defined by state legislation (ie, licensure, certification, or title protection laws). RDs are expected to practice only at the level at which they are competent, and this will vary depending on education, training and experience.
      • Gates G.
      Ethics opinion: Dietetics professionals are ethically obligated to maintain personal competence in practice.
      RDs are encouraged to pursue additional knowledge and skill training regardless of practice setting to promote consistency in practice and performance and continuous quality improvement. See Figure 5 for case examples of how RDs in different roles, at different levels of practice, may use the SOP and SOPP for RDs in IDD. Figure 6
      American Association on Intellectual and Developmental Disabilities website.
      American Dietetic Association
      Nutrition Care Manual: Developmental Disabilities Section.
      American Dietetic Association
      Pediatric Nutrition Care Manual: Developmental Disabilities Section.
      National Institutes of Health, National Institute of Neurological Disorders and Stroke, National Institute of Neurological Disorders and Stroke, National Institutes of Health website: Health Information A-Z.
      University of Washington Center for Human Development and Disability
      Nutrition Focus Newsletter.
      Nutrition Standards of Care: To Provide Proper Nutrition to Persons with Intellectual Disabilities Research and Training Center (RTC): Rural Practice Guidelines Series (Fall 2005). Montana Disability and Health Program website.
      Behavioral Health Nutrition Dietetic Practice Group and Pediatric Nutrition Practice Group
      Academy of Nutrition and Dietetics Pocket Guide to Children with Special Health Care and Nutritional Needs.
      New York State Office for People with Developmental Disabilities: Putting People First Preventative Health Care Screening Guidelines for People Aging with Intellectual and Other Developmental Disabilities, February 2009.
      Rehabilitation Research and Training Center (RRTC) on Aging with Developmental Disabilities: Lifespan Health and Function Department of Disability and Human Development, University of Illinois at Chicago website.
      American Academy for Cerebral Palsy and Developmental Medicine website.
      • Wittenbrook W.
      Nutritional assessment and intervention in cerebral palsy.
      Down Syndrome Medical Interest Group-USA website.
      National Down Syndrome Society website.
      • Chicoine B.
      • McGuire D.
      The Guide to Good Health for Teens and Adults with Down Syndrome.
      National Fragile X Foundation website.
      National Organization for Rare Disorders (NORD) website.
      National Newborn Screening and Genetics Resource Center (NNSGRC), University of Texas Health Sciences Center-San Antonio website.
      Prader-Willi Syndrome Association (USA) website.
      International Rett Syndrome Foundation website.
      UAB Civitan-Sparks Clinics, University of Alabama at Birmingham website.
      • Wittenbrook W.
      Best practices in nutrition for children with myelomeningocele.
      Spina Bifida Association website.
      provides a listing of IDD resources mentioned in the overview and SOP (Figure 2, available online at www.andjrnl.org) and SOPP (Figure 3, available online at www.andjrnl.org) for RDs in IDD.
      Figure thumbnail gr4
      Figure 4Application of the Commission on Dietetic Registration Professional Development Portfolio Process.
      Figure thumbnail gr5
      Figure 5Case examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities (IDD). aRDs in all settings will support the medical home model and be an active collaborator with the individual's psychosocial, medical, and/or educational team.
      Figure thumbnail gr6
      Figure 6Intellectual and Developmental Disabilities (IDD) resources.
      In some instances, components of the SOP and SOPP for RDs in IDD do not specifically differentiate between proficient and expert level practice. In these areas, it was the consensus of the content experts that the distinctions are subtle, captured in the knowledge, experience, and intuition demonstrated within the context of practice at the expert level, which combines dimensions of understanding, performance, and value as an integrated whole.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert level RD practitioners. The knowledge and skills acquired through practice will continually expand and mature. The indicators will be refined as expert level RDs systematically record and document their experience using the concept of clinical exemplars. Clinical exemplars include a brief description of the need for action and the process used to change the outcome. The experienced practitioner observes clinical events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. Clinical exemplars provide outstanding models of the actions of individual RDs in IDD in clinical settings and the professional activities that have enhanced person-centered care.
      Adaptive equipment: Equipment to assist with activities of daily living, such as trunk support for positioning at meal time, customized wheelchairs, supports for feet, or specialized feeding equipment.
      Augmentative and alternative communication (AAC): Incorporates the individual's full communication abilities and may include any existing speech or vocalizations, gestures, manual signs, and aided communication; permits individuals to use every mode possible to communicate.
      American Speech-Language-Hearing Association
      Communication Services and Supports for Individuals with Severe Disabilities: FAQs.
      Circle of support: Network of support for the individual with IDD that may include parents/family members, conservators, paid care providers (direct support staff), health professionals (ie, primary care physician, registered dietitian, therapists, specialty physicians, psychologist), and vocational and educational teachers.
      Functional status: The ability to carry out activities of daily living and participate in life situations and society; is affected by physical, developmental, behavioral, emotional, social, and environmental conditions.
      National Committee on Vital and Health Statistics, Health and Human Services
      Classifying and Reporting Functional Status.
      Individualized education plan (IEP): A written document outlining educational services a child with IDD will receive in the school setting.
      National Dissemination Center for Children with Disabilities
      All About the IEP (Individualized Education Plan).
      Individualized family service plan (IFSP): A written plan developed for eligible infants and toddlers with disabilities through Early Intervention Programs.
      Centers for Disease Control and PreventionNational Center on Birth Defects and Developmental Disabilities
      Cerebral Palsy website.
      Individual support plan or individualized service plan (ISP)/individual plan (IP): The written plan that details the supports, therapies, activities, and resources required for the individual to achieve personal goals.
      The Arc Brokerage Services
      Customers: ISP (Individual Support Plan).
      Medicaid Program
      State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Setting Requirements for Community First Choice. Section 7. Person-Centered Services. Centers for Medicare & Medicaid Services, Department of Health and Human Services.
      Person centered: Working in partnership with individuals with IDD, their families, and their friends to organize and guide change in an individual and their community.
      American Association on Intellectual and Developmental Disabilities
      Person centered planning.
      Person-first language: Language that places the focus on the individual and not the disability; “person ” or “people” should precede the disability for language that does not devalue the person or encourage stereotypic images.
      • Lipscomb R.
      Person-first practice: Treating patients with disabilities.
      The Arc, For People with Intellectual and Developmental Disabilities
      What is person first language?.
      Picture exchange communication system (PECS): A unique augmentative/alternative training package that allows children and adults with autism and other communication deficits to initiate communication.
      Pyramid Educational Consultants, Inc.
      Picture Exchange Communication System (PECS).
      Positive behavioral support strategies: Methods used to help people with IDD manage behavioral issues with positive, life-affirming strategies.
      American Association on Intellectual and Developmental Disabilities
      Positive Behavioral Support.
      Self-determination: The ability to exert control in one's own life and to advocate on one's own behalf; to manage and self-direct one's own support system with choices in caregivers, goods, and services as much as is possible.
      American Association on Intellectual and Developmental Disabilities
      Self determination.
      Sensory processing disorder (formerly known as sensory integration dysfunction): A condition that exists when sensory signals are disorganized causing difficulties with taking in, processing, and responding to sensory information about the environment and from within the body.
      Supports: Supports are resources and strategies that enable people with intellectual and related developmental disabilities to live a more successful life, including people, agencies, money or tangible assets, assistive devices, and environments.
      American Association on Intellectual and Developmental Disabilities
      Supports.
      These standards have been formulated to be used for individual self-evaluation and the development of practice guidelines, but not for institutional credentialing or for adverse or exclusionary decisions regarding privileging, employment opportunities or benefits, disciplinary actions, or determinations of negligence or misconduct. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in these standards is not a substitute for the exercise of professional judgment by the health care professional. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

      Future Directions

      The SOP and SOPP for RDs in IDD are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, dietetics education programs, and outcomes of practice audits. The authors acknowledge that the three practice levels require more clarity and differentiation in content and role delineation and that competency statements that better characterize differences among the practice levels are needed. Creation of this clarity, differentiation, and definition are the challenges of today's RDs in IDD to better serve tomorrow's practitioners and their clients and customers.

      Conclusions

      The SOP and SOPP for RDs in IDD are complementary documents and are key resources for RDs at all knowledge and performance levels. These standards can and should be used by RDs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective care for individuals with IDD. These standards also serve as a professional resource for self-evaluation and professional development for RDs specializing in IDD practice. Just as a professional's self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 5 years. Current and future initiatives of the Academy, as well as advances in the treatment of individuals with IDD, will provide information to use in these updates and in further clarifying and documenting the specific roles and responsibilities of RDs at each level of practice. As a quality initiative of the Academy and the Behavioral Health Nutrition Dietetic Practice Group, these standards are an application of quality assurance and performance improvement and represent an important collaborative endeavor.

      Acknowledgements

      The authors thank Cecily Byrne, MS, RD, LDN; Carol Gilmore, MS, RD, LD, FADA; and Marsha Stieber, MSA, RD, CNSC, for their assistance with manuscript preparation.

      Appendix

      Figure thumbnail gr1
      Figure 1Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
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      Figure 2Standards of Practice for Registered Dietitians in Intellectual and Development Disabilities.
      Figure thumbnail gr3a
      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
      Figure thumbnail gr3k
      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
      Figure thumbnail gr3l
      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
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      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
      Figure thumbnail gr3q
      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.
      Figure thumbnail gr3r
      Figure 3Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities.

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        Self determination.
        (Accessed February 9, 2012)
        • Sensory Processing Disorder Foundation
        About SPD.
        (Accessed February 24, 2012)
        • American Association on Intellectual and Developmental Disabilities
        Supports.
        (Accessed March 19, 2012)

      Biography

      P. Cushing is a regional dietitian, Tennessee Department of Intellectual and Developmental Disabilities, Nashville.
      D. Spear is coordinator of nutrition services, Oklahoma Developmental Disabilities Services Division, Tulsa.
      P. Novak is a dietitian, Pasadena Child Development Associates, Pasadena, CA.
      L. Rosenzweig is a senior dietitian, Schenectady ARC, Schenectady, NY.
      L. S. Wallace is chief of Nutrition, Boling Center for Developmental Disabilities, University of Tennessee Health Science Center, Memphis.
      C. Conway is chief of Nutritional Services and chief of Diabetes Program, YAI/National Institute for People with Disabilities, New York, NY.
      W. Wittenbrook is a clinical dietitian, Texas Scottish Rite Hospital for Children, Dallas.
      S. Lemons is a pediatric dietitian, ECI of North Central Texas, Fort Worth.
      J. Guthrie Medlen is a dietitian and CEO, JEM Communications/Phronesis Publishing, Portland, OR.