U.S. guidelines for detecting autism emphasize screening and also incorporate clinical judgment. However, most research focusses on the former. Among 1,654 children participating in a multistage screening protocol for autism, we used mixed methods to evaluate: (1) the effectiveness of a clinical decision rule that encouraged further assessment based not only on positive screening results, but also on parent or provider concern, and (2) the influence of shared decision-making on screening administration. Referrals based on concern alone were cost-effective in the current study, and reported concerns were stronger predictors than positive screens of time-to-complete referrals. Qualitative analyses suggest a dynamic relationship between parents' concerns, providers' concerns, and screening results that is central to facilitating shared decision-making and influencing diagnostic assessment.

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BackgroundPsychotherapy implementation must contend with the task of preparing a mental health workforce to provide the highest quality services to as much of a service population as possible, in high-income as well as low-to-middle income countries.ObjectiveWe outline general challenges and solutions and investigate how well various implementation strategies would fit a clinical population.MethodsUsing a data set from a prior cluster randomised trial with a clinically diverse population and 33 intervention practices, we presented multiple illustrations comparing the ability of different implementation strategies to serve youth and families with procedures in which service providers were trained.FindingsA series of survival functions demonstrated that many common implementation strategies are unlikely to create a prepared workforce, given the large and diverse number of practices needed to be mastered by providers.Clinical implications‘Benchmark’ solutions that afforded superior coverage of the service population could be supported through paced learning approaches (ie, training interventions a little at a time) using extensible, modular intervention designs.

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