diff --git a/SOPs/Lab/SOP-LAB-002-Vineland-3-Assessment.md b/SOPs/Lab/SOP-LAB-002-Vineland-3-Assessment.md new file mode 100644 index 0000000..118d403 --- /dev/null +++ b/SOPs/Lab/SOP-LAB-002-Vineland-3-Assessment.md @@ -0,0 +1,291 @@ +--- +title: "Standard Operating Procedure for Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) Administration" +author: "" +date: 2025-12-29 +version: "1.0" +status: "Draft" +--- + +## 1. Purpose +The purpose of this Standard Operating Procedure (SOP) is to establish standardized procedures for administering the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) to pediatric participants with neurodevelopmental disorders in research settings. This SOP ensures consistency, reliability, validity, data integrity, and regulatory compliance across all study personnel. + +## 2. Scope +This SOP applies to: +- Clinical Research Coordinators (CRCs) +- Licensed psychologists and psychometrists +- Trained research assistants conducting Vineland-3 assessments +- Study personnel involved in neurodevelopmental disorder research + +This SOP covers: +- Pre-assessment preparation and participant screening +- Interview format selection and administration +- Respondent selection and informed consent +- Data collection and scoring procedures +- Quality control and data integrity +- Documentation and deviation handling + +## 3. Regulatory and Quality References +- FDA 21 CFR Part 11 – Electronic Records; Electronic Signatures +- FDA 21 CFR Parts 50, 56, 312 – Human Subjects Protection and Clinical Investigations +- ICH E6(R2) Good Clinical Practice (GCP) +- ISO 9001 – Quality Management Systems +- Vineland-3 Manual and Technical Documentation (Pearson) +- Study Protocol and Statistical Analysis Plan +- Institutional Review Board (IRB) Approval Letter +- HIPAA Privacy Rule (45 CFR Part 164) + +## 4. Definitions +| Term | Definition | +|-----|------------| +| Vineland-3 | Vineland Adaptive Behavior Scales, Third Edition – a standardized assessment measuring adaptive behavior across four domains | +| Adaptive Behavior | Skills needed for everyday living including communication, socialization, daily living, and motor skills | +| Respondent | The person (typically parent/caregiver) who provides information about the participant's adaptive behavior | +| Interview Form | Semi-structured format where the examiner asks questions directly to the respondent | +| Parent/Caregiver Form | Self-administered questionnaire completed by the respondent | +| Domain | Major category of adaptive behavior (Communication, Daily Living Skills, Socialization, Motor Skills) | +| Standard Score | Normalized score with mean of 100 and standard deviation of 15 | +| v-scale score | Domain and subdomain scores with mean of 15 and standard deviation of 3 | +| Neurodevelopmental Disorder | Conditions affecting neurological development (e.g., autism spectrum disorder, ADHD, intellectual disability, genetic syndromes) | + +## 5. Roles and Responsibilities +| Role | Responsibility | +|-----|----------------| +| Principal Investigator (PI) | Overall study oversight, protocol compliance, and data integrity | +| Licensed Psychologist | Clinical supervision, quality assurance of assessments, certification of administrators | +| Clinical Research Coordinator | Scheduling, respondent identification, consent verification, assessment administration (if trained) | +| Trained Research Assistant | Vineland-3 administration, accurate scoring, and documentation | +| Data Manager | Data entry verification, database integrity, and audit compliance | +| Quality Assurance | SOP compliance monitoring and CAPA implementation | + +## 6. Required Training and Competency +All personnel administering the Vineland-3 must complete: +- Current GCP training certification +- Vineland-3 administration training (minimum 4 hours) including: + - Review of Vineland-3 manual and technical documentation + - Understanding of adaptive behavior constructs + - Practice administrations with supervision + - Competency verification (minimum 3 supervised administrations with 95% scoring accuracy) +- Study-specific protocol training +- Training on this SOP with documented acknowledgment +- HIPAA and human subjects protection training + +*Training records and competency documentation must be maintained in the study regulatory binder and personnel files.* + +## 7. Materials and Equipment +- Vineland-3 Interview Form protocol booklets (age-appropriate) +- Vineland-3 Parent/Caregiver Rating Form (if applicable) +- Vineland-3 Scoring and Reporting Software (Q-global or equivalent) +- Secure computer with appropriate licenses and network access +- Participant study folder with protocol-specific forms +- Informed consent and assent documentation +- Private, quiet assessment room +- Age-appropriate comfort items (toys, snacks as permitted by protocol) +- Study-specific case report forms (CRFs) + +## 8. Pre-Assessment Procedures + +### 8.1 Participant Eligibility Verification +- Confirm participant enrollment and eligibility per study protocol +- Verify informed consent and assent (if applicable) is current and complete +- Confirm inclusion/exclusion criteria including neurodevelopmental disorder diagnosis +- Review participant demographics and relevant medical/developmental history + +### 8.2 Respondent Selection +The Vineland-3 respondent must: +- Be the parent, primary caregiver, or individual with extensive knowledge of the participant's daily functioning +- Have regular contact with the participant (minimum 4-6 hours per day or equivalent) +- Be able to provide informed responses in English or approved translated version +- Provide consent for participation in the assessment process + +**Documentation Required**: Record respondent name, relationship to participant, and frequency of contact in study records. + +### 8.3 Scheduling and Environment Preparation +- Schedule assessment at a time convenient for respondent (typically 30-60 minutes) +- Ensure private, quiet room free from distractions +- Prepare all materials and verify software access before respondent arrival +- Review participant's protocol schedule to coordinate with other study visits +- Confirm respondent understanding of assessment purpose and process + +### 8.4 Form Selection +Select appropriate Vineland-3 form based on: +- **Interview Form** (Comprehensive or Brief): Recommended for standardization, rapport building, and when detailed clinical information is needed +- **Parent/Caregiver Rating Form**: Acceptable when interview format is not feasible; requires literate respondent +- **Age Range**: Birth through 90 years (use age-appropriate norms) +- **Protocol Requirements**: Follow study-specific form designation if specified + +## 9. Vineland-3 Administration Procedures + +### 9.1 General Assessment Guidelines +- Create a comfortable, non-judgmental atmosphere +- Explain that assessment measures typical performance, not maximum capability +- Emphasize there are no "right" or "wrong" answers +- Clarify that assessment focuses on what the child **usually does**, not what they **can do** +- Maintain professional boundaries and avoid providing clinical feedback during administration + +### 9.2 Interview Form Administration (Step-by-Step) + +#### Starting the Interview +1. Greet respondent and verify participant identity using two identifiers +2. Review informed consent and confirm respondent's voluntary participation +3. Explain assessment purpose: "This questionnaire helps us understand [participant's name]'s everyday skills in areas like communication, daily living, socializing, and movement." +4. Establish rapport and clarify confidentiality protections +5. Record assessment start time + +#### Conducting the Interview +1. **Follow Standardized Script**: Use questions as written in the Interview Form manual +2. **Score Response in Real-Time**: + - **2 = Yes, usually**: Performs activity habitually without reminders + - **1 = Sometimes or partially**: Emerging skill or requires assistance + - **0 = No, never**: Does not perform activity + - **DK = Don't Know**: Respondent lacks sufficient information + - **N/O = No Opportunity**: Participant has not had chance to perform activity +3. **Probe When Necessary**: If response is unclear, ask neutral follow-up questions (e.g., "Can you give me an example of how [name] does this?") +4. **Maintain Engagement**: Acknowledge respondent input, remain neutral, avoid leading questions +5. **Observe for Respondent Fatigue**: Offer breaks if needed, especially with comprehensive form + +#### Completing the Interview +1. Administer all required items per basal/ceiling rules (see Section 9.4) +2. Review for any skipped or ambiguous items +3. Thank respondent for their time and participation +4. Record assessment completion time +5. Do **not** provide preliminary scores or clinical interpretations to respondent + +### 9.3 Parent/Caregiver Rating Form Administration +If using the self-administered form: +1. Provide respondent with form and clear instructions +2. Remain available to answer procedural questions without influencing responses +3. Ensure private space for completion +4. Review completed form for missing or double-marked items before respondent leaves +5. Collect form and verify all sections are complete + +### 9.4 Basal and Ceiling Rules (Interview Form) +To ensure efficient and valid administration: + +**Basal Rule**: +- Establish a basal by obtaining **7 consecutive scores of 2** +- If basal is not achieved, continue backward until 7 consecutive 2s are obtained +- Items below basal are assumed to be scored as 2 + +**Ceiling Rule**: +- Discontinue subdomain when **7 consecutive scores of 0** are obtained +- Items above ceiling are assumed to be scored as 0 + +**Note**: Some subdomains (e.g., Motor Skills for older children) may have abbreviated ranges. Follow manual guidelines for age-specific starting points. + +### 9.5 Pediatric and Neurodevelopmental Considerations +When assessing children with neurodevelopmental disorders: +- **Use Concrete Examples**: Some respondents may need help understanding items; provide neutral examples without suggesting answers +- **Consider Adaptive Equipment**: Score based on how the child performs the activity, even with assistive devices (e.g., communication device for verbal communication items) +- **Account for Behavioral Variability**: If behavior fluctuates significantly, ask respondent to consider typical frequency over the past month +- **Cultural Sensitivity**: Be aware of cultural differences in expectations for adaptive behavior (e.g., self-care, socialization norms) +- **Document Unique Circumstances**: Note in study records if participant has unusual living situation or support that affects adaptive behavior assessment + +## 10. Scoring and Data Entry + +### 10.1 Scoring Procedures +- Score assessment immediately after administration while details are fresh +- Use Vineland-3 Scoring Software (Q-global or equivalent) per licensing agreement +- Enter all item responses accurately +- Verify that software calculates: + - Subdomain v-scale scores + - Domain standard scores + - Adaptive Behavior Composite (ABC) score + - Percentile ranks and age equivalents (if required by protocol) +- **Double-Check Entry**: Review for data entry errors before finalizing + +### 10.2 Quality Control +- **Independent Review**: Have a second trained team member verify scoring accuracy for first 10 assessments and randomly thereafter (minimum 10% of all assessments) +- **Reconcile Discrepancies**: Resolve scoring differences through consensus review; escalate to licensed psychologist if needed +- **Flag Unusual Patterns**: + - Excessive "DK" or "N/O" responses (may indicate inadequate respondent) + - Inconsistent item patterns within subdomains + - Scores significantly discrepant from other clinical data +- Document quality control reviews in study files + +### 10.3 Data Entry into Study Database +- Transfer scores to electronic Case Report Form (eCRF) per protocol schedule +- Ensure compliance with FDA 21 CFR Part 11 for electronic data: + - Use unique user credentials (no shared logins) + - Document audit trail for all entries and changes + - Maintain data backup and security protocols +- Enter only de-identified data per HIPAA requirements +- Verify data accuracy before database lock + +## 11. Documentation Requirements +All assessments must include documentation of: +- Date and time of assessment +- Respondent name and relationship to participant +- Form type and version used (Interview or Parent/Caregiver) +- Raw scores, v-scale scores, standard scores, and ABC +- Any deviations from standard administration (see Section 12) +- Administrator name and signature +- Quality control review (if performed) +- Adverse events or participant distress (if applicable) + +**Storage**: Maintain source documentation in participant study binder. Electronic scores in secure database with access controls. + +## 12. Deviations and Noncompliance + +### 12.1 Common Deviations +Examples of protocol deviations include: +- Using unqualified or inadequately trained respondent +- Administering assessment outside protocol-specified visit window +- Incomplete assessment (e.g., respondent unable to complete interview) +- Software malfunction or scoring errors +- Loss of data due to technical issues + +### 12.2 Deviation Management +- **Document Immediately**: Record deviation in study deviation log and source documents +- **Notify PI**: Report deviation per study procedures (typically within 24-48 hours) +- **Assess Impact**: Determine if deviation affects data validity or participant safety +- **Implement Corrective Action**: Retrain personnel, revise procedures, or exclude data as appropriate +- **Submit Reports**: Follow institutional and sponsor requirements for deviation reporting + +### 12.3 Handling Incomplete Assessments +If assessment cannot be completed: +- Document reason (e.g., respondent time constraints, participant distress, technical issue) +- Attempt to reschedule if within protocol visit window +- Consult PI regarding data handling (e.g., partial data use, exclusion from analysis) +- Do not impute or estimate missing responses + +## 13. Adverse Events and Participant Welfare + +### 13.1 Potential Assessment-Related Issues +While rare, be prepared for: +- **Respondent Emotional Distress**: Questions about child's limitations may be upsetting; offer breaks, provide supportive (non-clinical) listening, refer to PI if needed +- **Disclosure of Safety Concerns**: If respondent reveals abuse, neglect, or imminent harm, follow mandatory reporting laws and study safety protocols +- **Participant Behavioral Issues**: If child becomes distressed during assessment, pause or discontinue; notify PI + +### 13.2 Documentation and Reporting +- Document any adverse event or safety concern in study safety database +- Notify PI immediately for any serious concerns +- Maintain participant confidentiality per HIPAA while ensuring safety + +## 14. Data Security and Confidentiality +- Store all paper Vineland-3 forms in locked, limited-access cabinets +- Maintain electronic data on password-protected, encrypted systems +- Use only study-assigned participant IDs (no PHI in assessment records) +- Dispose of outdated or superseded records per institutional data retention policy +- Limit access to assessment data to authorized study personnel only + +## 15. Quality Control and Auditing +- **Inter-Rater Reliability**: Conduct periodic reliability assessments between administrators (target ≥90% agreement) +- **Periodic Record Review**: Quality Assurance team reviews random sample of assessments quarterly +- **Corrective and Preventive Actions (CAPA)**: Implement when systematic issues are identified +- **Audit Readiness**: Maintain organized, complete documentation for regulatory inspections + +## 16. Revision History and Change Management +All changes to this SOP must follow document control procedures per organizational SOP-001 (or equivalent). Superseded versions must be archived with documented rationale for changes. + +## Version Control +| Version | Date | Description of Change | Author | +|--------|------|----------------------|--------| +| 1.0 | 2025-12-29 | Initial Draft | "" | + +## Approval Signatures +| Name | Title | Signature | Date | +|-----|-------|-----------|------| +| "" | Principal Investigator | "" | "" | +| "" | Licensed Psychologist | "" | "" | +| "" | Quality Assurance | "" | "" | +| "" | Study Sponsor Representative | "" | "" |