Multi-Stage Screening Process: A Clinical Psychology Perspective

Background:

Despite knowledge that universal screening can reduce health disparities, screening for ASD is not routine in Early Intervention (EI) settings. The dissemination and implementation of ASD screening in EI may aid in reducing health disparities by (a) increasing rates and reducing ages at ASD diagnosis, and (b) increasing receipt of post-diagnostic intervention. In line with these goals, we have been disseminating a multi-stage, screening and assessment program for 14-36 month-old toddlers, implemented in partnership with EI agencies.

Objectives:

This paper evaluates screening dissemination outcomes using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, specifically regarding the adoption and reach components of our multi-stage screening protocol.

Methods:

Participants were children receiving services from partnering EI agencies, and their parents. Children with previous ASD diagnoses, significant sensory, or medical challenges were ineligible to participate. Our team offered training and support to EIPs to implement a multi-stage ASD screening process as part of their routine clinical practice. Stage 1 screening involved parent report measures, parent concern and provider concern. Stage 2 screening involved an EI administered observational screener. Families who screened positive were offered a free diagnostic evaluation, conducted by clinical psychologists on the research team. Screening and diagnostic assessment were offered in Spanish and English. We collected screening implementation data for each stage, including screening completion rates and referrals following positive screens. Additionally, we gathered administrative data, including demographics of screening eligible participating children and previously diagnosed EI-enrolled children.

Results:

Regarding screening adoption, 2,984 Stage 1 screening packets were distributed to EIPs, of which 473 (16%) were returned, indicating child ineligibility for screening, and 1571 (62.6% of the 2511 eligible) were completed. Of the 1571 Stage 1 questionnaires completed, 39.6% (n=622) scored positive and 64.8% (n=403) of children eligible for Stage 2 (based on Stage 1 positive screening) went on to complete Stage 2. Of those screened at Stage 2, 80.4% (n=324) screened positive due to parent concern, EIP concern, or a positive observational screen score. In turn, 77.2% (n=250) of these children went on to complete a diagnostic evaluation. At the diagnostic evaluation, 80.4% (n=201) received a diagnosis of ASD, 8% of the screen eligible sample, representing a more than three-fold increase over earlier years.

In terms of reach, the demographics (i.e., low-income, linguistic minority, and racial minority statuses) for children who received an ASD diagnosis through our protocol compared to EI-enrolled children already diagnosed with ASD through other routes revealed higher rates of low-income, linguistic minority, and racial minority children among the research project-diagnosed group. Despite early diagnosis, children whose parents were non-US-born, not English proficient, less than high school-educated, or living below the poverty level received roughly half as many hours of EI as their demographically-advantaged counterparts.

Conclusions:

Utilizing the RE-AIM framework, we addressed how early screening and assessment for ASD shows evidence for reach and adoption in improving rates of ASD diagnosis at early ages and in reducing health disparities in early detection. However, greater systemic efforts are needed to address health disparities in service receipt.