Early Start Denver Model
The Early Start Denver Model is an intensive therapeutic intervention. It is a targeted-indicated intervention for autistic children between the ages of 1 and 5 years. It is delivered at home or in a community or clinical setting, and aims to improve children’s cognitive, communicative and social-emotional skills through one-to-one therapy which is centred around play-based affective interactions and real-life activities, and based on principles of applied behavioural analysis.
ESDM is a naturalistic, play-based intervention, centred on teaching learning through social interaction. It is based on developmental psychological theories about how children typically learn and develop, especially how learning occurs within the context of social relationships by engaging in joint interactions in a shared activity, and learning to attend to important aspects of the environment needed for learning (e.g. in a routine such as playing 'peekaboo'). The programme integrates several approaches within therapy for autistic children, most significantly teaching techniques from Applied Behavioural Analysis: for instance, ‘shaping’ uses small steps to teach a bigger skill, ’prompting’ provides cues to help a child learn a skill, and ‘fading’ reduces the number of cues over time. Its overall goal is “to decrease the symptoms of autism that impair children’s ability to learn from everyday experiences and interactions”.
The manualised programme is administered one-to-one by a certified therapist, ideally working in an interdisciplinary team, in ten sessions 1.5–2 hours long for 20 hours a week. This continues for around two years, or until the ESDM Curriculum is completed. Every 12 weeks, the child's progress is reviewed using the programme checklist across a number of communicative, social and cognitive domains and new individualised learning objectives are set. They set discrete, quantifiable goals, e.g. "When the child is hungry, he will approach an adult and say, “I’m hungry,” spontaneously, with eye contact, several times per week, at home and at preschool" (Rogers, 2016:52). The therapist works with the child and parents to identify their priorities, and incorporates the child's own interests and preferences into the therapy. The sessions ideally take place in a familiar environment for the child, such as at home. Parent involvement is important in the programme, and parents are taught skills to embed ESDM techniques in everyday life. At preschool age, playdates with peers are incorporated.
The most rigorous evaluations of ESDM did not measure outcomes for children and young people’s wellbeing, or long-term effects. Additional research in this area would be valuable, particularly as some members of the autistic community advocate for shifting from ‘intervention’ (focus on changing autistic behaviour) to ‘support’ (focus on accommodation) (Davis et al., 2022) and parents of autistic children as well as autistic adults call for a focus on 'real world' outcomes, especially mental health and wellbeing (Autistica, 2016). For more on different approaches to autism interventions and support, the voice of the autistic community, and consideration of individuals' needs, see Davis et al., 2022.
References
Autistica. (2016). Your questions: Shaping future autism research. Available at https://www.autistica.org.uk/downloads/files/Autism-Top-10-Your-Priorities-for-Autism-Research.pdf
Davis, R., Nordahl-Hansen, A., den Houting, J., & Fletcher-Watson, S. (2022). Chapter 39: Helping autistic children. In P. K. Smith & C. H. Hart (Eds.), The Wiley-Blackwell Handbook of Childhood Social Development, 3rd Edition (pp.729–746). Available at https://osf.io/preprints/osf/zrfyp.
Rogers, S. (2016). Early Start Denver Model. In R. G. Romanczyk & J. McEachin (Eds.), Comprehensive Models of Autism Spectrum Disorder Treatment (pp. 45–62). Springer International Publishing. Available at https://link.springer.com/chapter/10.1007/978-3-319-40904-7_3
EIF Programme Assessment
Child outcomes
This programme can affect outcomes for children in Active and healthy, physical and mental wellbeing.
According to the best available evidence for this programme's impact, it can achieve the following positive outcomes for children:
Enhancing school achievement & employment
Improved receptive and expressive language
based on study 1
This programme also has evidence of supporting positive outcomes for couples, parents or families that may be relevant to a commissioning decision. Please see About the evidence for more detail.
Who is it for?
The best available evidence for this programme relates to the following age-groups:
Toddlers Preschool
How is it delivered?
The best available evidence for this programme relates to implementation through these delivery models:
- Individual
Where is it delivered?
The best available evidence for this programme relates to its implementation in these settings:
How is it targeted?
The best available evidence for this programme relates to its implementation as:
- Targeted indicated
Where has it been implemented?
- Argentina
- Australia
- Austria
- Belgium
- Brazil
- Canada
- Chile
- China
- Denmark
- Ecuador
- France
- Germany
- Ireland
- Israel
- Italy
- Japan
- Kuwait
- Mexico
- New Zealand
- Nicaragua
- Peru
- Poland
- Portugal
- Romania
- Russia
- Singapore
- Slovakia
- South Africa
- South Korea
- Spain
- Sweden
- Switzerland
- Taiwan
- Turkey
- Ukraine
- United Kingdom
- United States
Ireland provision
Ireland evaluation
About the programme
What happens during the delivery?
How is it delivered?
The Early Start Denver Model is delivered in ten sessions of 2 hours’ duration each per week for around two years by a practitioner, to individual families.
What happens during the intervention?
- During a session, the therapist and child engage in a series of short joint activities, which may include playing alongside each other, interacting with the same object, playing together with the same object or playing a game such as 'peekaboo'. These create a social-emotional context for learning. In these interactions, the therapist seeks to help the child attend to key information in their environment which is needed for language and social development (e.g. faces, action, emotions).
- At preschool age, child-child play dates are also incorporated into the intervention.
- Parents are also given training to use techniques from the Early Start Denver Model and encouraged to implement them at home throughout the day. For example, they are taught to follow the child's lead and talk about what the child is already engaging in (rather than directing the child's attention elsewhere).
- The programme has a manual, and a Curriculum Checklist which enables individualised objectives to be set for each child across a number of domains (receptive and expressive communication, joint attention, imitation, social skills, play skills, cognitive skills, fine and gross motor skills, and self-care skills). These are assessed every 12 weeks.
- It is intended that the therapist is supported by a multi-disciplinary team including child psychologists, speech and language therapists and occupational therapists.
What are the implementation requirements?
Who can deliver it?
Certified
therapists have at least a BSc or BA in a relevant degree (e.g. Early Years
Education, Psychology, etc.) and a MSc or MA and have successfully completed the
ESDM training and certification process.
What are the training requirements?
The training includes:
- reading of the ESDM published manual (Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement, by Rogers & Dawson, 2010),
- introduction workshop online,
- advanced workshop
- at least 2 cases of practice,
- supervision hours
- certification process
Booster training is recommended.
How are the practitioners supervised?
Practitioners are supervised by their ESDM trainer.
What are the systems for maintaining fidelity?
Interaction videos are assessed for fidelity. Supervision is available.
Is there a licensing requirement?
There is no licence required to run this programme.
How does it work? (Theory of Change)
How does it work?
- Positive relationships provide a rich learning context in which children develop communicative skills, including language and social interaction.
- Therapists and parents develop positive relationships with the child. In addition, therapists use a range of Applied Behavioural Analysis techniques in a developmentally appropriate, play-based way to teach a range of skills, including communication skills.
- Parent training helps parents to implement ESDM techniques in everyday life.
- In the short-term, it is intended that children develop their communication, which may involve verbal or non-verbal communication, social-emotional, cognitive, play and self-care skills; parents also learn ESDM techniques.
- In the long-term, it is intended that children’s communication, social-emotional, cognitive, play and self-care skills improve.
Intended outcomes
- Achieving in all areas of learning and development
Contact details
Ifigeneia Mourelatou
Recognition Health
imourelatou@re-cognitionhealth.com
About the evidence
The Early Start Denver Model’s most rigorous evidence comes from an RCT which was conducted in the US.
This study identified statistically significant positive impact on one child outcomes.
A programme receives the same rating as its most robust study, which in this case is the Sulllivan (2013) study, and so the programme receives a Level 3 rating overall.
Study 1
| Citation: | Sullivan (2013) |
| Design: | RCT |
| Country: | United States |
| Sample: | 48 children aged between 18 and 30 months old (range in treatment group 18-30 months, mean 23.9 months, standard deviation 4 months) diagnosed with autism (meeting criteria for autistic spectrum disorder or Pervasive Developmental Disorder – Not Otherwise Specified based on the DSM-IV). |
| Timing: | Post-test |
| Child outcomes: |
|
| Other outcomes: | |
| Study rating: | 3 |
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2010). Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. https://doi.org/10.1542/peds.2009-0958
Sullivan, K. A. (2013). The Early Start Denver Model: Outcomes and Moderators of an Intervention for Toddlers with Autism. [Doctoral Dissertation, University of Washington ]. https://digital.lib.washington.edu:443/researchworks/handle/1773/24294
Dawson et al., (2010) is excluded from contributing to the programme rating due to methodological limitations.
Study design and sample
The first study is a rigorously conducted RCT. This study involved random assignment of children to an ESDM treatment group and a business as usual control group . This study was conducted in the US , with a sample of children aged between 18 and 30 months at the start of the study, with a diagnosis of autism. Most children were White (72.9%), with Asian (12.5%), Latino (12.5%) and multiracial (14.6%). The male-to-female ratio of 3.5:1 reflects the diagnosis rates of autism at the time.
Measures
Expressive and receptive language was measured using the Mullen Scales of Early Learning (Expressive Language and Receptive Language subscales ) (direct assessment).
Gesture and positive affect was measured using the Communication and Symbolic Behaviour Scales – Developmental Profile (subscales) (direct assessment).
Findings
This study identified statistically significant positive impact on a child outcome. This includes receptive and expressive language.
Dawson et al (2010) describes additional outcomes from study 1 described above . The conclusions that can be drawn from this study are limited by methodological issues pertaining to a lack of intention-to-treat analysis, so it received a Level 2+ and does not contribute to the overall programme rating. In this case:
- At post-test, social, communication, motor and daily living skills were measured by the Vineland Adaptive Behaviour Scales] (parent report) )
- This study identified statistically significant positive impact on a number of child outcomes. This includes Mullen Scales of Early Learning and Vineland Adaptive Behaviour Scales.