Developmental approach
1. Sequence of typical development?
2. Principles of developmental science?
3. Relationship based?
4. Child-centered?
5. Play ased?
A. Comprehensive or targeted?
B. Delivered by therapists, parents, or both?
C. Delivered in a naturalistic setting or a clinic-based setting?
Denver Model/Early Start Denver Model (ESDM)
Y
Y
Y
Y
Y
Comprehensive
Both
Both
Developmental Individual-Differences, Relationship-based (DIR/Floortime)
Y
Y
Y
Y
Y
Comprehensive
Both
Both
Hanen’s More than Words
Y
Y
Y
Y
Y
Targeted (communication/language)
Parents
Naturalistic
Joint Attention Mediated Learning (JAML)
Y
Y
Y
Y
Y
Targeted
Parents
Naturalistic
Joint Attention and Symbolic Play Engagement Regulation (JASPER)
Y
Y
Y
Y
Y
Targeted
Both
Clinic based
Relationship Development Intervention (RDI)
Y
Y
Y
Y
Comprehensive
Parents
Naturalistic
Responsive Education and Prelinguistic Milieu Teaching (RPMT)/Milieu Teaching
Y
Y
Y
Y
Targeted (communication/language)
Both
Naturalistic
Responsive Teaching (RT)
Y
Y
Y
Y
Y
Comprehensive
Parents
Naturalistic
Social Communication, Emotional Regulation, and Transactional Support (SCERTS)
Y
Y
Y
Y
Y
Comprehensive
Both (and teachers)
Naturalistic (preschool classroom)
Treatment and Education for Autistic and related Communication Handicapped Children (TEACCH)
Y
Y
Y
Comprehensive
Both
Both
a.
Is the treatment comprehensive or targeted? Comprehensive treatment approaches address multiple domains of development for children with ASD (Eikeseth 2009; Odom et al. 2010; Rogers 1998; Stansberry-Brunsnahan and Collet-Klingenberg 2010; Vismara and Rogers 2010; Wetherby and Woods 2008). In contrast, targeted approaches focus on supporting “pivotal developmental behaviors,” “foundational behaviors” (Mahoney and Perales 2003, 2005), or “developmental precursors” (Schertz and Odom 2007), such as attention, persistence, interest, initiation, cooperation, joint attention, imitation, symbolic play, or affect, which are core deficits that are believed to have cascading effects upon cognitive, language, and social-emotional development (Koegel et al. 1989; Mundy et al. 1990).
b.
Is the treatment delivered by therapists, parents, or both? The inclusion of parents in a developmental treatment approach is a critical part of the relationship-based focus. In addition, training parents to deliver the intervention during daily routines often means that the intervention can be implemented at younger ages and at more intensity (Mahoney and Perales 2003, 2005; McConachie and Diggle 2007; Prizant et al. 2003; Schertz and Odom 2007; Wetherby and Woods 2006).
c.
Is the treatment delivered in the child’s natural setting or is it delivered in a clinic setting? Many developmental treatment approaches focus on implementing the intervention in a child’s natural environment, a requirement of the Individuals with Disabilities Education Improvement Act of 2004, Part C (e.g., home, childcare center, or preschool; Prizant et al. 2003; Wetherby and Woods 2006; IDEA 2004). However, other approaches focus on first teaching skills in a highly structured learning environment and then working with the child to generalize these skills to other more complex, naturalistic settings (Dawson and Osterling 1997). Regardless of the teaching environment, the goal of all early intervention approaches for young children with autism is to increase the child’s ability to actively and meaningfully participate in his/her family and community environments (Sandall et al. 2000).
Review Level 2: Criteria for Establishing Empirical Support for Treatment Efficacy
In addition to considering the developmental components of each treatment approach, we critically analyzed efficacy studies using Nathan and Gorman’s (2002, 2007) criteria for establishing empirical support. Following Rogers and Vismara’s (2008) review on comprehensive ASD treatments, we have added additional criteria to those of Nathan and Gorman. The criteria are as follows:
Type 1 studies
Prospectively designed randomized clinical trials that include blind assessments, inclusion/exclusion criteria, state-of-the-art diagnosis, adequate sample sizes to power the analysis, and clearly described statistical methods. In addition, we expect Type 1 studies to include measures of treatment fidelity to determine the degree to which the treatment delivery adheres to the treatment model (Rogers and Vismara 2008; Stansberry-Brusnahan and Collet-Klingenberg 2010).
Type 2 studies
Clinical trials with a comparison group, and single-subject designs in which there is clear experimental control over the dependent variable. Type 2 studies have some significant flaws, but the overall study design is such that the data can still be used to answer the study question, therefore providing useful information regarding the effectiveness of the intervention.
Type 3 studies
Studies with significant methodological flaws, including studies with pre/post designs without a control group, single-subject studies with designs that do not clearly demonstrate experimental control over the dependent variable, and studies with retrospective designs.
Type 4 and 5 studies
Secondary analysis articles (not included in this review).
Type 6 studies Case reports (not included in this review).
To establish inter-rater reliability on the Nathan and Gorman (2002, 2007) criteria, both the first and second author independently rated 20 % of the studies. Inter-rater reliability for classification of study type was 100 %. Reliability for the seven criteria (randomization, inclusion and exclusion criteria, use of standardized diagnostic batteries, comparison group, blind assessors, treatment of fidelity, and use of a treatment manual) was 82.5 %. All disagreements were a result of the case in which one rater assigned a “+/−” rating and the other either a “+” or a “−” rating only.
Given the large number of studies available for some treatment approaches, we decided to limit the papers to at most three per approach and to prioritize Type 1 and Type 2 studies if they were available. Table 20.2 provides an overview of the main features of each study reviewed, including the sample, outcome measures, treatment procedure, findings, and Nathan and Gorman (2002, 2007) study type representing methodological rigor.
Author(s) and Year | Sample | Outcome measures | Treatment procedures | Findings | |
|---|---|---|---|---|---|
Denver Model/Early Start Denver Model (ESDM) | |||||
Developmental Individual-Differences, Relationship-Based Model (DIR/FLOORTIME) | |||||
Hanen’s More than Words | |||||
Carter et al. 2011 | 62 ss, aged 15–25 mos.; 51 male, 11 female | At 5 mos. post-enrollment: parent–child free play procedure, ESCS, Parent Interview for Autism-Clinical Version; at 9 mos. post-enrollment: parent–child free play procedure, ESCS, Parent Interview for Autism-Clinical Version, MSEL; VABS Second Edition, ADOS, clinical DSM-IV impression | ss randomized to HMTW or “business as usual” control group; HMTW provided over 3.5 mos., consisting of eight group sxs w/ parents only and 3 in-home individualized parent–child sx; focus on: (a) improved 2-way interaction, b) more mature and conventional ways of communicating, (c) better skills in communicating for social purposes, and (d) improved understanding of lang. | No main effects of HMTW on parental responsivity or children’s communication; decent effect sizes for improvements in parental responsivity; treatment effects on child communication gains to 9 mos. post-enrollment that were moderated by enrollment object interest | Type 2 study: + RCT, − Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, − Tx manual |
McConachie et al. 2005 | 51 ss with ASD, 26 parent–child dyads in tx group and 25 parent–child dyads in control group | MCDI; social communication skills from ADOS-G; parent outcome measures on parent tx fidelity, family resources, and stress | 20 weeks of group instruction 1 h/week using the More than Words Program and three home visits | Children in the training group had significantly larger vocabulary size, but no sig. differences in social communication algorithm of the ADOS-G | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Prelock et al. 2011 | 4 ss, aged 37–69 mos. | 3–4 mos. post-tx: CSBS DP (both caregiver questionnaire and examiner’s observations), MCDI: Words and Gestures or Words and Sentences, parent responsiveness and parent satisfaction questionnaire, MSEL | Single-subject design; orientation session and 8 2.5 h sessions; clinic based; included parents in didactic and interactive manner; parents taught strategies to increase communication opportunities and interaction w/ their children, and parents developed own “to-do-at-home” plans | For 3/4 children, improvements on social and symbolic communicative acts and vocabulary, but not on MSEL; 4th child was tested differently due to his more advanced initial profile–he showed notable improvement on Mullen scores, but scored in average range both pre- and post-tx | Type 3 study: − RCT, − Blind assessments, − Incl/excl criteria, + Standardized dx battery, − Comparison group, − Tx fidelity, + Tx manual |
Joint Attention Mediated Learning (Jaml) | |||||
Joint Attention and Symbolic Play Engagement Regulation (JASPER) | |||||
Relationship Development Intervention (RDI) | |||||
Responsive Education And Prelinguistic Milieu Teaching (RPMT)/Milieu Teaching | |||||
Social Communication, Emotional Regulation, and Transactional Support (SCERTS) | |||||
Rogers et al (2006 (Denver Model) | 10 ss, aged 20–65 mos.; all male; all nonverbal | Collected within 3 weeks of last tx session: ADOS, SCQ, MSEL, VABS–Interview Edition, CDI, intervention hx, play-based speech probes; collected during weekly tx sessions: speech samples; collected at 3 mos. | Single-subject design (A-B-A) using randomization to either Denver Model or PROMPT; 12 weekly 1-h sessions; for Denver Model condition, parents were present and active in sessions, and were expected to deliver treatment objectives 45 min/day; for PROMPT condition, parents observed sessions via video, and were expected to work on children’s word development 30 min/day | No differences in acquired lang. skills by group; by end of tx, 8/10 children used 5 + novel, functional words spontaneously and spoke multiple times per hour | Type 2 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Vismara et al. (2009 (ESDM) | 8 ss, aged 10–36 mos., seven had diagnosis of autism; one child diagnosed with autism at 18 mos. at conclusion of tx but showed significant signs consistent with autism at time of enrollment | Coding of parent–child play and therapist-child play for number of spontaneous functional verbal utterances and imitative acts; ADOS and MSEL; CBRS; ESDM Fidelty Scale for parent implementation of model | Nonconcurrent multiple baseline design; parents attended 1-h clinic visit/week for 12 weeks to receive one-on-one parent training in ESDM | Child’s production of spontaneous functional verbal utterances increased w/ parent and therapist once tx began; 7/8 children demonstrated consistent increase in imitative behaviors; number of children’s spontaneous verbal utterances showed largest gain once parents met ESDM fidelity; 7/8 parents acquired mastery of ESDM techniques at fidelity level of 85 % or above by 6th tx session and maintained through follow up | Type 2 study: − RCT, + /-Blind assessments (not blind to tx, but blind to order of session), + Incl/excl criteria, − Standardized dx battery, − Comparison group, + Tx fidelity, − Tx manual |
Dawson et al. 2010 (ESDM) | 48 ss, aged 18–30 mos.; 3.5 males for every 1 female in study; diagnosed with ASD or PDD-NOS; stratified randomization on basis of composite IQ at entry | Collected at study entry and then at the end of 1 year of tx and 2 years of tx: ADI-R, ADOS, MSEL, VABS-Interview Edition, RBS | Randomized to either ESDM group or A/M community tx group; ESDM condition included: 2-h session with trained therapist 2X/day 5 days/week for 2 years (actual mean h = 15.2 h/wk), parent training 2X/mo and were expected to use ESDM strategies during daily activities (actual mean h = 16.3 h/wk), multidisciplinary team, individualized tx objectives; A/M community condition included: comprehensive diagnostic evaluations, referral to community providers for intervention commonly available in the community (actual mean h of individual tx = 9.3 h/wk) (actual mean hrs of group tx = 9.3 h/wk) | At end of 2 yrs. of tx ESDM group showed significantly improved cognitive ability (MSEL) mostly due to receptive and expressive language improvements and significantly improved adaptive behavior (VABS) when compared to A/M group; children in the ESDM group were more likely to experience a change in diagnosis from autism to PDD-NOS than A/M group | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Hilton and Seal 2007 | 2 ss, aged 2 yrs; monozygotic twin brothers | CBCS; coded videos of sx for communication and behavior data; mother’s journal recorded tx sessions and perceptions of child progress | One twin received DIR and one received ABA; each received 2 1-h weekly sessions administered by clinicians; 16/18 sessions each; both also received speech therapy 2X/wk | Slight gain in communication composite score for ABA child and slight loss for DIR child; contrasted gains and losses in 6 of 7 CSBS subscales; coded behavioral data showed increase in number and duration of crying episodes in ABA child, but none in DIR participant | Type 3 Study: + RCT, +/-Blind assessments (-for CSBS, + for video coding); − Inc/excl criteria, − Standardized dx battery, + Comparison group, − Tx fidelity, + Tx manual |
Rajareya and Nopmaneejumruslers 2011 | 32 ss, aged 2–6 yrs of age; all met DSM-IV criteria for autistic disorders; 8:1 male to female ratio | Primary outcome measure: FEAS; CARS; and FEDQ | Added new DIR/Floortime tx to see if there would be additional benefits over routine clinical care; stratified random assignment based on age and symptom severity; control group got typical treatment as usual in Thailand (20–40 h of ABA), experimental group got supplemental DIR Floortime tx administered to parents (no direct contact with children in this condition); 1 day training workshop + 3 h DVD lecture + 1.5 h one-on-one session, families to deliver 20 h/week of tx at home (actual amount = 15.2 h/wk); | Intervention group showed significantly greater decrease in overall autistic severity w/CARS; statistically significant gain in FEDQ filled out by parents; parents who added in home DIR/Floortime for 10 h + /week had better tx delivery fidelity than those who did less, but not sig. difference | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, − Standarized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Solomon et al. 2007 | 68 ss, aged 18 mos to 6 yrs at time of diagnosis with autistic disorder, PDD-NOS, or Asperger’s syndrome | FEAS caregiver and child sections; subjective ratings by home consultants on 6 pt scale of Greenspan’s functional developmental levels (FDL); parent satisfaction of PLAY project on 4-pt Likert scale | PLAY Project Home Consultation Project = 1 day parent training workshop; 3–4 h/monthly home visits by consultants for parent training, videotaping, and child assessment; parent-led tx for min of 15 h/week; tx given for 1 year | No change in parents’ FEAS scores before and after PLAY; increase in child’s total and scaled FEAS scores over 1 year period; 45 % of children made “good” to “very good” functional developmental progress; overall parent-reported satisfaction with PLAY project was 90 % | Type 3 study: − RCT, + Blind assessments, + Inc/excl criteria, − Standardized dx battery, − Comparison group, + Tx fidelity, + Tx manual |
Schertz and Odom 2007 | 3 ss, aged 20–28 mos. diagnosed with early ASD as dx by the M-CHAT, PDD-ST-II, & ISCQ | Coded video tapes of weekly 10-min parent–child interaction for four joint attention behaviors: (1) focusing on faces; (2) turn taking; (3) responding to joint attention; (4) initiating joint attention; qualitative data from weekly sx, parent interviews, and parent notes | Parent training in families’ homes based on JAML manual (4 phases of tx to increase 4 joint attention behaviors); families received between 11 and 16 tx sx over 9–26 weeks | Single-subject, multiple baseline design; changes in child performance were reflected as the number of 10-s intervals during weekly 10-min videos in which the child engaged in four joint attention behaviors; in tx condition, each of 3 toddlers surpassed baseline performance levels for all 4 targeted outcomes; 2 of 3 toddlers demonstrated repeated joint attention by end of tx | Type 2 study: − RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, − Comparison group, + Tx fidelity, + Tx manual |
Kasari et al. 2006 | 56 ss, aged 3–4 yrs. with ASD as dx by the ADOS and ADI-R | MSEL, ESCS, Structured Play Assessment, Reynell Developmental Language Scales, and 15 min. caregiver-child interaction videotaped and coded for child’s play behaviors, types of functional and symbolic play acts, and the joint attention skills of the dyad | Direct therapist-child intervention in the clinic focused on either joint attention skills (JA group) or symbolic play skills (SP group); 30 min per day for 5–6 weeks (on average children in the joint attention group received 28.6 sx and the symbolic play group received 34.7 sx; not a significant difference in # of sx); children in all 3 groups were also enrolled in 30 h. of ABA-based hospital early behavioral intervention | Children randomized to 1 of 3 groups: joint attention (JA), symbolic play (SP), or control group; at time of post-tx children in the JA group initiated significantly more showing and responded more to joint attention in the ESCS and more joint attention in caregiver–child play; children in the SP group showed higher levels of play in the ESCS and caregiver–child interaction and more diverse types of play during the caregiver-child interaction than the other two groups | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Kasari et al. 2008 | 56 ss, aged 3–4 yrs. with ASD as dx by the ADOS & ADI-R in original study; 56 ss at 6 mos. post-tx and 53 ss at 12 mos. post-tx | Assessments of joint attention (JA) skills, symbolic play (SP) skills, mother–child interactions, and language development at pre- and post-tx, and at 6 and 12 months post-tx on the MSEL, the ESCS, the Reynell Developmental Language Scales, Structured Play Assessment, and caregiver–child interaction (see Kasari et al. 2006 above for details) | See Kasari et al. 2006 above | Follow-up to Kasari et al. 2006 study above; both JA and SP groups showed significantly greater growth in expressive language over time when compared to the control group; children who begun tx at the lowest language levels showed significantly more improvement in language development in the JA group than the SP or control groups | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Kasari et al. 2010 | 38 child–parent dyads; children were aged 21–36 mos. with ASD as dx by an independent clinician; parents’ mean age was 34.5 yrs.; no significant differences found between parents in both groups | MSEL; child-caregiver 15 min. play interaction videotaped and coded for: (a) percentage of time in engagement states (collapsed into unengaged/other; object engagement, and joint engagement); (b) play types (functional, symbolic); and (c) frequencies of initiating and responding to joint attention; MSEL collected pre-tx and at 12-mo. follow up; parent–child play interaction was conducted at pre-tx; after 8 weeks of tx or waitlist and at 12-mo. follow up; caregivers also rated on Caregiver Quality of Involvement Scale and adherence to tx protocol | Immediate treatment (IT) group immediately received 8 weeks of tx; 3 sx/week = 24 caregiver-mediated tx sx total in a laboratory playroom setting; each sx included direct instruction, modeling, guided practice, and feedback from the interventionist; intervention focused on ten modules for teaching children joint attention and symbolic play | Child–parent dyads randomly assigned to immediate treatment (IT) group or wait-list (WL) control group; the IT group made significant improvements in amount of time in joint engagement, responsiveness to joint attention, and in the diversity of play skills when compared to the WL control group at the 8-week point; Caregivers were rated high on tx fidelity at the end of the 8 weeks of tx; tx-related gains in joint engagement, joint attention responding skills, & types of functional skills were maintained or improved for the IT group after 12 mos. | Type 1 study: + RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Hancock and Kaiser 2002 | 4 ss, aged 35–54 mos.; 3 male, 1 female | Collected throughout tx and follow-up: frequency of total child utterances, spontaneous child utterances, total use of targets, frequency of targets used spontaneously, # of different word roots used, and MLU; collected shortly after last tx session & last follow-up session: SICD, PPVT-R, Expressive One-Word Picture Vocabulary Test-Revised, parent satisfaction questionnaire | Therapist-implemented “enhanced milieu teaching”; single-subject, multiple baseline design; part of larger study which randomized children to different txs; children randomly assigned to a specific number of baselines; tx consisted of sessions 2x/wk for 15 min/session; clinic-based; follow-up period of 1x/mos., 15 min sessions for 6 mos.; parents did not observe sessions | All children showed positive increases for specific target language use, maintained across the 6 mos. follow-up; positive lang. effects generalized to interactions w/ mothers at home for 3/4 children; variable results across children for standardized measures | Type 2 study: − RCT, − Blind assessments, + Incl/excl criteria, + Standardized dx battery, − Comparison group, + Tx fidelity, − Tx manual |
Kaiser et al. 2000 | 6 ss, aged 32–54 mos.; all male | Collected throughout tx and follow-up: frequency of total child utterances, spontaneous child utterances, total use of targets, frequency of targets used spontaneously, number of different word roots used, and MLU; collected shortly after last tx session and last follow-up session: SICD, PPVT-R, Expressive One-Word Picture Vocabulary Test-Revised, parent satisfaction questionnaire | Parent-implemented “enhanced milieu teaching”; single-subject, multiple baseline design; part of larger study which randomized children to different txs; children randomly assigned to a specific number of baselines; parent training consisted of sessions 2x/wk for 45 min./session; clinic-based; follow-up period of 1x/mos., 15 min. sessions for 6 mos. | Parents learned to implement procedures and maintained them over follow-up period, but at lower rates than during active tx; positive effects for use of communication targets for all children and on complexity and diversity of productive language for most children; effects generalized to home setting for 4/6 children; improvement on standardized assessments for 5/6 children | Type 2 study: − RCT,-Blind assessments, + Incl/excl criteria, + Standardized dx battery, − Comparison group, + Tx fidelity, − Tx manual |
Yoder and Stone 2006 | 36 ss, aged 21–54 mos.; 31 male, 5 female | After 6 mos. and 12 mos. (6 mos. after tx ended): free-play session w/ examiner (scored for frequency of nonimitative spoken communication acts and number of different non-imitative words spoken) | Compared “responsive education and prelinguistic milieu teaching” to PECS; 3 20-min sessions/wk for 6 mos. (1:1 w/ therapist); parent offered up to 15 h. of training; clinic-based; designed to facilitate intentional communication for the primary pragmatic functions of commenting, requesting, and turn taking | At 6 mos., PECS group more successful in increasing number of nonimitative spoken communication acts and number of different nonimitative words used; at 12 mos., exploratory analysis showed that growth rate of number of different nonimitative words faster in PECS group for children who began tx w/ high object exploration, but opposite for children who began w/ low object exploration | Type 2 study: + RCT, − Blind assessments, + Incl/excl criteria, + Standardized dx battery, + Comparison group, + Tx fidelity, + Tx manual |
Responsive Teaching (RT) | |||||
Mahoney and Perales 2003 | 20 ss with autism or PDD-NOS; mean age of 32 mos, with 80 % of ss under 36 mos at time of enrollment; 12 male | videotaped mother-child interactions coded with CBRS and MBRS, social-emotional functioning from ITSEA and TABS | Tx 1X/week of center-based tx and mean hour of 2.5 h/day of in-home parent-delivered tx for 8–14 mos.; tx focused on reciprocity, contingency, shared control, affect, and matching of pace during play and daily routines | Pre-post design; 80 % of mothers demonstrated significant increase in maternal responsiveness and affect. This increased responsiveness was associated with children’s increased social-emotional functioning (engagement, cooperation, joint attention, and affect) | Type 3 Study: − RCT, − Blind assessments, − Incl/excl criteria, − Standardized dx battery, − Comparison group, + Tx fidelity, + Tx manual |
Mahoney and Perales 2005 | 20 ss with PDDNOS; 20 ss with other DD; 12–54 mos with 85 % of children under 36 mos at time of enrollment; 62 % males | Developmental Rainbow, TBPA, videotaped mother–child interactions coded with CBRS and MBRS, social-emotional functioning from ITSEA and TABS | 1 h/week of parent–child sx at home or at center with early intervention specialist for 1 year; approx. 15 h/wk of parent-delivered tx (parent report); tx focused on cognitive, communication, and social-emotional functioning influenced by parental responsiveness | Pre-post design; significant increases in maternal responsiveness; significant increases in children’s communication, cognitive, and social-emotional functioning; PDDNOS group showed greater gains in development; child outcomes were related to maternal responsiveness | Type 3 Study: − RCT, − Blind assessments, − Incl/exl criteria, − Standardized dx battery, − Comparison group; + Tx fidelity, + Tx manual |
Wetherby and Woods 2006 (preliminary study: Early Social Interaction Project) | 35 ss total: 17 ss; 12–24 mos. of age; with significant red flags for ASD and a provisional clinical diagnosis of ASD; 18 ss in contrast group; 25–36 mos. with “suspected” ASD diagnosis | MSEL; VABS; ADOS; video taped behavior sample coded with CSBS DP | Two home visits per week for 1 year by trained interventionists with focus on increasing communication during daily routines & participation in parent-child FIRST WORDS playgroup for 9 weeks during tx year | Quasi-experimental, one-group pretest-posttest design with a no-treatment contrast group at post only; significant increases in 11 of 13 social communication measures of the CSBS DP, including initiating and responding to joint attention; at post tx group and contrast group were comparable on communicative means and play, but contrast group had significantly poorer performance on all other social communication measures | Type 3 Study: − RCT, + Blind assessments, + Incl/excl criteria, + Standardized dx battery, +/-Comparison group (only posttest), + Tx fidelity, − Tx manual |
reatment and Education for Autistic And Related Communication Handicapped Children (TEACCH) | |||||
Short 1984 | 15 ss; 2.3–7.5 yrs (mean 4.7 yrs.); 12 boys and 3 girls; all met Rutter’s 4 criteria (1978) for diagnosis of autism | (1) Behavioral observation coding for parental and child behavior; (2) semi-structured maternal interview on family stress in relation to child w/autism; (3) questionnaire on effects of child problems on family; (4) parental questionnaire on effects of tx | Tx group compared to wait period control; tx = 4 mos. 29 days; wait period = 1 mo 29 days; tx = TEACCH 6-8 sx of 60–90 min/each | Parental guidance and appropriate child behavior were significantly greater during tx period than during wait period; reductions of inappropriate child behavior and family stress were not significantly different in tx period than wait period | Type 2 Study: − RCT, + Blind assessments, + /-Incl/excl criteria, − Standardized dx battery, +/-Comparison group, − Tx fidelity, − Tx manual |
Ozonoff and Cathcart 1998 | 22 ss; 2–6 yrs of age; 18 boys; 4 girls; all diagnosed with autism | PEP-R; CARS | Tx group = therapist & parent designed tx plan; 10 weeks of 1 h/TEACCH-based home program services with trained graduate students + 1 h clinic visit/week at beginning & gradual decrease to 1 sx/2–3weeks toward end; 1/2 h of tx by parents/day; control group = community tx as usual | Tx group improved significantly more than control group on PEP-R subtests of imitation, fine motor, gross motor, and nonverbal conceptual skills, and overall PEP-R scores | Type 2 Study: − RCT, − Blind assessments, − Incl/excl criteria, − Standardized dx battery, + Comparison group, − Tx fidelity, − Tx manual |
Following Table 20.2 is a brief description of the main tenants of each treatment approach, including a summary of the developmental components of each approach. A review of the selected efficacy studies that met the search criteria for each approach follows. Next is an overall summary of the empirical evidence for developmental treatment approaches for young children with autism, including a discussion of study limitations. The chapter concludes with recommendations for the future, both in terms of additional efficacy and effectiveness studies, as well as the development or modification of treatment approaches to meet the developmental needs of younger children with autism.
Developmental Approaches
Denver Model and Early Start Denver Model (ESDM)
The Denver Model, created in the 1980s at the University of Colorado Health Sciences Center, is a developmental approach for preschool education for children from 2 to 5 years of age with autism (Rogers et al. 1986; Rogers 2005). The Denver Model is administered to small groups of young children with autism in a classroom setting for 4–5 h per day, 12 months a year. The core features of the Denver Model include: (a) an interdisciplinary team that implements a developmental curriculum addressing all domains for each child’s individual needs; (b) a focus on interpersonal interactions and engagement; (c) a focus on reciprocal, functional and spontaneous use of imitation, facial expressions, and objects; (d) an emphasis on verbal and nonverbal communication; (e) a focus on the cognitive aspects of play; and (f) the importance of developing partnership with parents (Dawson and Rogers 2010, p. 15). The Denver Model strongly emphasizes social relationships by using positive affect in social interactions as a motivator for children to pay attention to others and engage in social interactions, by assigning each child to a primary teacher, by fostering peer relationships, and by modeling and prompting social behaviors (Rogers et al. 2001). Families are integral to the Denver Model programs . Parents of children attending the Denver Model programs are encouraged to observe and participate in their children’s classroom. In addition, parents are given a chance to discuss their child’s development or other issues related to parenting a child with ASD during their weekly one-on-one consultation with a child psychologist or psychiatrist or during monthly parent support group meetings with other families in the program.
The Early Start Denver Model (ESDM) is a comprehensive early developmental intervention for children as young as 12 months of age with ASD. ESDM was designed by Rogers and Dawson (2010), and is based upon the Denver Model. At the heart of ESDM are the empirical knowledge base of infant-toddler learning and development and the effects of early autism. ESDM is typically provided in the home by trained therapists and parents during natural play and daily routines. However, current studies are examining group delivery in preschools and childcare centers. The aim of ESDM is to increase the rate of development in all domains for children with ASD and to simultaneously decrease the symptoms of autism. In particular, this intervention focuses on boosting children’s social-emotional, cognitive, and language skills, as development in these domains is particularly affected by autism. ESDM also uses a data-based approach and empirically supported teaching practices that have been found to be effective from research in ABA . ESDM fuses behavioral, relationship-based, developmental, and play-based approaches into an integrated whole that is individualized and standardized. Teaching objectives are based on the Early Start Denver Model Curriculum Checklist, a play-based assessment tool that lists behaviors in each developmental domain in the order in which they occur in typical development. In ESDM, a primary therapist, supported by an interdisciplinary team comprised of occupational therapists, speech pathologists, child psychologists, behavior analysts, physicians, and special educators, assesses the child and identifies developmental objectives to target during intervention. Parents learn to deliver ESDM by using the play-based interactive approach to embed learning opportunities into their daily routines with their children. In intensive delivery of ESDM, each child receives direct intervention one-on-one from members of a team of trained ESDM interventionists, as well as from his or her parents.
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