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Systems-Level Analysis of Implementing a Two Stage Screening Protocol for Autism Spectrum Disorders in a Community-Based Setting
Disparities in delay to diagnosis of Autism Spectrum Disorders may be effectively addressed by implementing evidence-based screening protocols in community based settings, such as Early Intervention (EI). Optimizing the efficiency of screening protocols among underserved populations can benefit by engaging implementation and systems sciences to examine factors influencing administration of ASD screening tools.
Objectives:
We present the development, validation and evaluation of a process map—a systems-level visualization of the process logic and flow for screening implementation. We use process maps as the basis for analyses of organizational, administrator, and client characteristics that influence administration of the two-stage ASD screening process at an EI site. This case study emphasizes the value of process evaluation when assessing implementation of complex interventions.
Methods:
To examine process efficiency of a two-stage screening for ASD, we employ multiple qualitative methods to examine administration, scoring, and informing families of findings for each of the instruments used in the two stage screening process. To improve the validity of process maps, we utilized respondent triangulation through inclusion of multiple samples. To date, these include: (1) trainers who provided support for implementation (n=10) and (2) EI service providers who administered the two stage screening (n=15). All participants were asked to develop a process map of the screening process from point of initiation until time of completion. For trainers, we conducted two concurrent focus groups to develop independent process maps and a subsequent member-checking focus to reconcile differences and validate findings. For EI providers, process maps were created during semi-structured interviews. Once collected, we individually analyzed EI provider and trainer process maps, coded associated discussions, and examined findings in regard to process efficiency.
Results:
We highlight three notable findings. First, clinical judgment played a significant role in process efficiency. For example, EI service providers described time delays to screen families that were driven by their ascertainment of families’ ‘readiness to screen’ for ASD. Second, departures from protocol resulted in both negative “drift” from fidelity of administration, but also positive “adaptation” that supported provider’s ability to follow protocols. For example, respondents articulated unique challenges in administering screening given the educational, linguistic and cultural diversity of clients served. Respondents identified both positive adaptations, such as hiring additional staff to support screening, but also possible “drift,” such as adaptation of screening protocols in an attempt to facilitate understanding. Third, the unique roles of the trainers and EI providers led to work flows that are ‘invisible’ to other stakeholders unless careful efforts are undertaken to assess and monitor process.
Conclusions:
Our findings suggest that implementation of ASD screening in community-based settings to reach racial and ethnic minorities requires careful documentation of the variation that may emerge to accommodate the organizational setting, administrator priorities, and the unique characteristics of the populations being served. Moreover, these points of variation may remain ‘invisible’ to the trainers and implementation team if efforts are not taken to engage other stakeholders in assessment of implementation.