Characterizing Potential Implementation Processes and Influences in a Community Effectiveness Trial of Standardized Pediatric Screening for ASD

Background: Children with autism spectrum disorder (ASD) who start treatment earlier have better outcomes; although universal toddler screening can detect many cases of ASD much younger than the national average (Robins et al., 2014), inconclusive outcome data means standardized screening is not always recommended (Siu et al., 2016). A current randomized trial aims to fill this gap, connecting the dots between the screening and treatment literatures, and demonstrating that standardized, high-fidelity, universal screening lowers the age of diagnosis and treatment onset, leading to improved short- and long-term outcomes. If the study has positive outcomes, a remaining challenge will be the translation of standardized screening into usual pediatric care. Currently, even when physicians report using ASD screening methods, they are not using evidence-based methods to ensure accurate identification of ASD risk.

Objectives: The purpose of this paper is to capitalize on this effectiveness trial to undertake an in-depth examination of implementation factors impacting standardized use of the Modified Checklist for Autism in Toddlers with Follow up (MCHAT-R/F) using the Exploration, Preparation, Implementation and Sustainment (EPIS) framework.

Methods: An implementation researcher is conducting semi-structured interviews with the MCHAT-R/F developers and experts from the three study sites across the recruitment and early implementation phases of the project to gather first-hand accounts potential facilitators and barriers to screening implementation process. An interview guide was developed by independent implementation scientists to gather PI and coordinator perspectives on barriers and facilitators to MCHAT-R/F adoption and early implementation. Transcripts are analyzed in an iterative process using the “coding, consensus, co-occurrence and comparison” methodology rooted in grounded theory (Williams et al., 2009).

Results: Preliminary results suggest that both outer and inner context factors influenced study participation and implementation across study sites and practices. Preliminary analyses indicate the adoption phase was influenced by perceived value of universal screening by physicians and access to timely evaluation and treatment. Implementation barriers included challenges with integrating the screening into workflow and time. Specific influences including leadership, site, provider and patient factors will be described across the preparation and implementation phases.

Conclusions: Standardized ASD screening implementation in community pediatric offices is a complex process involving interactions between intervention developers, and community stakeholders including systems, organizations, and providers. The use of the EPIS framework helps to identify and organize both outer and inner context factors that may impact implementation across the phases of the process. Data gathered during this efficacy trial will provide recommendations for future scale up of universal screening.