Sam Goldstein and Jack A Naglieri (eds.)Interventions for Autism Spectrum Disorders2013Translating Science into Practice10.1007/978-1-4614-5301-7_4© Springer Science+Business Media New York 2013
4. Early Start Denver Model
An Intervention for Young Children with Autism Spectrum Disorders
(1)
Neurology, Learning and Behavior Center, School of Medicine, University of Utah, 230 South 500 East, Suite 100, 84102 Salt Lake City, UT, USA
Abstract
While an increasing number of children with Autism Spectrum Disorder (ASD) are being identified at younger ages, most early interventions are targeted at older preschoolers. The necessity for early interventions for toddlers has increased as the gap widens between age of identification and age of available intervention. Further, few studies or sources have compared the effectiveness of present interventions. Interventions including Applied Behavioral Analysis (ABA); the Lovaas Model; the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH); and Social Communication, Emotional Regulation, and Transactional Support (SCERTS®) have received support in the treatment of ASD. A promising intervention developed by Sally Rogers and Geraldine Dawson (The Early Start Denver Model: promoting language, learning, and engagement. NY, Guilford) comprises elements of ABA and relationship-based approaches to target the younger children now being identified as having ASD as infants and toddlers. With origins from the Denver Model of 1981, the Early Start Denver Model (ESDM) is the only early intervention model validated in a randomized clinical trial for children as young as 18 months, as reported by Dawson et al. [Pediatrics, 125(1), e17–e23, 2010]. A manualized treatment, ESDM has gained acceptance as an efficacious program [as reported by Rogers and Dawson (The Early Start Denver Model: promoting language, learning, and engagement. NY, Guilford, 2010)]. Published in 2010, the ESDM will require further longer term follow-up studies and replications to demonstrate consistency of results over time.
Introduction and Overview of Chapter
While an increasing number of children with Autism Spectrum Disorder (ASD) are being identified at younger ages, most early interventions are targeted at older preschoolers. The necessity for early interventions for toddlers has increased as the gap widens between age of identification and age of available intervention. Further, few studies or sources have compared the effectiveness of present interventions. Interventions including Applied Behavioral Analysis (ABA); the Lovaas Model; the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH); and Social Communication, Emotional Regulation, and Transactional Support (SCERTS®) have received support in the treatment of ASD. A promising intervention developed by Sally Rogers and Geraldine Dawson comprises elements of ABA and relationship-based approaches to target the younger children now being identified as having ASD as infants and toddlers (Rogers and Dawson 2010). With origins from the Denver Model of 1981, the Early Start Denver Model (ESDM) is the only early intervention model validated in a randomized clinical trial for children as young as 18 months (Dawson et al. 2010). A manualized treatment, ESDM has gained acceptance as an efficacious program (Rogers and Dawson 2010). Published in 2010, the ESDM will require further longer term follow-up studies and replications to demonstrate consistency of results over time.
Early Markers of ASDs
The emergence of early symptomology of an ASD plays an integral role in the early identification and treatment of children with developmental delays. Displayed in the early stages of life, social communication deficits can be observed between the ages of 12 and 24 months (Baranek 1999; Warren et al. 2011). More specifically, children may demonstrate lack or loss of skills, including, but not limited to, vocalization, pointing, playing with a variety of toys, and responses to contextual cues (CDC 2009; Ghaziuddin 2005). While symptomology in the domain of atypical behaviors may surface, including repetitive movements with objects or body parts, these behaviors typically emerge later than those within social and communicative functioning (Ghuman et al. 1998). Early indicators of an ASD may include: lack of pointing, sharing interest, response to name, coordinating gestures, vocalizations, or eye contact. These indicators may suggest the presence of an emerging pervasive developmental disorder (Ghuman et al. 1998).
The majority of children with ASD do not receive a formal diagnosis until 4–5 years of age (Stone et al. 2000). In alliance with this figure, most interventions are designed for these older preschoolers. This trend does not reflect current research studies suggesting an ASD diagnosis can be made prior to 2 years of age, possibly as early as 12–18 months of age (CDC 2009; Ghaziuddin 2005). Identifying deficits in social interaction has been validated in identifying young children with autism (Ghuman et al. 1998). Many parents of children with ASD detect signs of ASD within the first 12 months of age (Baranek 1999). Children identified at earlier stages have demonstrated deviance in social or language development when compared to typically developing peers (Baranek 1999). With recent trends suggesting earlier identification, the need for interventions for children recently diagnosed as infants or toddlers has increased.
Why Earlier Intervention?
The discord between age of identification and age of treatment creates an urgent search for efficacious treatments for these youngsters. If able to diagnose ASD earlier and earlier, it is imperative that efficacious treatment programs are available to utilize with children of all ages. Few published studies have discussed the efficacy of intervention models for children less than 2 years (Warren et al. 2011). Can interventions utilized with older preschoolers be modified for use with toddlers? Recent trends have provided some promising results, including psychosocial, pharmacological, and behavioral interventions. Interventions may take many forms and be directed to treat comorbid conditions as well. Few existing sources compare the effectiveness of behavioral treatment interventions. The consequences include clinicians and families choosing among interventions based on availability, insurance coverage, or affordability (Warren et al. 2011). Thus, fragmented interventions are being provided to young children with ASD (Warren et al. 2011).
Multiple intervention approaches exist within various areas of child development. Children with ASD require intervention in the realms of communication and behavior, minimally (Warren et al. 2011). Communication interventions may include the assistance of speech/language pathologists in the form of enhancing social communication and interactions. Positive behavior support systems aim to identify environmental contingencies to focus on positive aspects of the environment and the child’s behavior. This approach is particularly helpful in the development of adaptive skills (Warren et al. 2011). While pharmacological and medical interventions exist for ASD, the focus will be placed upon behavioral interventions for purposes of this review.
In recent years, ABA, TEACCH, and SCERTS® demonstrated efficacy in the treatment of ASD. While these models and others have gained acceptance in the field of autism, challenges remain in the early intervention of ASD. One of the greatest difficulties in the field of autism involves the varying range of possible outcomes for diverse children receiving “identical” interventions (Howlin et al. 2009). Reviews of early interventions for autism highlight concerns of limitations. Howlin et al. (2009) conducted a systematic review of controlled studies of early intensive behavioral interventions (EIBIs) for young children with ASD. Through inclusion criteria, 11 studies were included. When examining group changes, EIBI yielded improvements in IQ scores when compared to comparison groups; yet at the individual level, a high level of variability was present (Howlin et al. 2009).
Current Intervention Programs
Methods in ABA have been utilized with children with ASD since the early 1960s. In 1987, Ivar Lovaas published findings for a group of children demonstrating improvements in both cognitive abilities and educational placement in response to intensive interventions (Warren et al. 2011). ABA is widely recognized as a helpful treatment for autism. Interventionists teach children with ASD by breaking a target skill into smaller components, performing each part in isolation. Once criterion is reached for components, teachers gradually add the components together to build a complex behavior (Warren et al. 2011).
Other supported interventions include the TEACCH program and the SCERTS® Model. Through Structured Teaching, the TEACCH model emphasizes building new skills as well as creating strategies to compensate for difficulties (Van Bourgondien and Coonrod 2012). TEACCH is based on the following general components: physical organization/structure, daily schedules, work systems, and task structure (Van Bourgondien and Coonrod 2012). Research studies utilizing the TEACCH program suggest children in the TEACCH program demonstrated greater improvements in development of cognitive, motor, and imitation skills (Van Bourgondien and Coonrod 2012).
The SCERTS® Model incorporates a focus upon SCERTS® (Rubin et al. 2012). The SCERTS® Model states it is implemented across a wider breadth of settings and “teachers” than other programs (e.g., family members, peers, teachers). The highlighted goal of the SCERTS® Model is in shifting the focal point to improving the quality of life for individuals with ASD over time that are predictable of long-term positive outcomes (Rubin et al. 2012). The SCERTS® Model supports child-initiated communication in “everyday” activities, differentiating it from a model of ABA (Rubin et al. 2012).
Trends in Interventions
While medical interventions of risperidone and aripiprazole have demonstrated decrease in problematic behaviors for some children, side effects are often considerable (Warren et al. 2011). Behavioral interventions attempt to elicit positive responses from children as they develop skill sets. Warren et al. (2011) identified 78 early behavioral interventions for ASD in a systematic review. The systematic review uncovered few studies of “adequate” quality. Most studies utilize small sample sizes and varying duration/frequencies of administration (Warren et al. 2011). At the present time, a dearth of studies exists directly comparing different treatment modality outcomes (Warren et al. 2011).
Currently, ABA coupled with TEACCH approaches is recommended as a service delivery model in which significant results can be gained (Van Bourgondien and Coonrod 2012). According to Warren’s 2011 review, Lovaas-based interventions reported improvements in language, adaptive behavior, and cognitive skills in comparison to “eclectic” treatments found in the community (Warren et al. 2011). While some evidence exists that suggests change in IQ in Lovaas-based interventions, it is not clear whether these changes predict long-term consequences. Currently, the literature does not provide a wealth of information regarding baseline information of children to predict long-term outcomes (Warren et al. 2011).
A promising intervention developed by Sally Rogers and Geraldine Dawson joins elements of ABA and “relationship-based approaches” to target children identified with ASD as infants and toddlers (Dawson et al. 2010). With origins from the Denver Model, the ESDM was created to be implemented with children as young as 18 months (Dawson et al. 2010). With similarities and differences between ESDM and other models, the model possesses characteristics akin to SCERTS® (Rubin et al. 2012), Relationship Development Intervention (Gutstein 2005), Pivotal Response Training (PRT), and Developmental Individual-difference Relationship (DIR)/Floortime (Rogers and Dawson 2010; Greenspan and Wieder 2005). The authors claim that the model is differentiated from aforementioned models due to explicit behavioral lessons, the incorporation of data, and the incorporation of “all developmental domains” (Rogers and Dawson 2010, p. 33). This promising new model may respond to the need for earlier interventions reflecting age of identification in the field of ASD.
Introduction to the ESDM
Can researchers determine if intervention earlier than 24 months is effective for children in reducing or eradicating language impairments and social deficits associated with ASD? A promising intervention program developed by principal investigators, Sally Rogers and Geraldine Dawson, targets infants, toddlers, and preschoolers with ASD. Developed through collaborators at the University of Washington, the M.I.N.D. Institute, and University of Colorado Health Sciences Center, the ESDM is based on ABA techniques coupled with a more naturalistic, relationship-based approach that highlights decades of research on typical child development. ESDM integrates social-communicative development, imitation skills, social motivation, and naturalistic behavioral intervention approach (Rogers and Dawson 2010).
ESDM utilizes play therapy and positive reciprocal interactions to integrate a developmental curriculum designed for individuals based on current abilities and interests. Utilizing knowledge of typical development in infants, Rogers and Dawson created a model to accommodate this developmental trajectory in children at risk for ASD (Rogers and Dawson 2010). In practice, toddlers may be instructed in speech via nonverbal communication of smiles, gestures, and eye contact (i.e., skills that typically precede speech in typical children but which toddlers with ASD have not practiced). At the current time, ESDM is the only early intervention model validated in a randomized clinical trial for use with children with ASD as young as 18 months of age (Dawson et al. 2010). It has been found to be effective for children with ASD across an array of learning abilities. The ESDM couples the two modalities of autism intervention with the majority of research support. Results suggested that children possessing more significant learning challenges benefited from the model as much as children without great learning challenges (Rogers and Dawson 2010).
Origins
ESDM stems from the original Denver Model of 1981, Rogers and Pennington’s 1991 model of interpersonal development, pivotal response training, and the model of social motivation of Dawson et al. 2010. Components of the original Denver Model have been implemented into the ESDM, including: (1) child’s choice of activities, (2) positive affect toward the child, (3) turn taking and reciprocity, (4) empathic response toward the child, (5) fostering of communicative opportunities, (6) flexible variation in activities, (7) developmentally appropriate verbal and nonverbal language, and (8) scaffolding interests and behaviors through transitions (Rogers and Dawson 2010). The original Denver Model was deemed efficacious in peer-reviewed journals in 1989 as Rogers and Lewis reported gains in symbolic play and social communication (Rogers and Dawson 2010).
Those Serviced Under the ESDM
Unique to the ESDM, the model is an intensive intervention for toddlers with ASD coupling relationship-based approaches with ABA. ESDM is targeted at children aged 12–36 months with ASD. While the model targets toddlers, the programming continues through ages 48–60 months in refining skills. Originally, the program was developed with preschoolers aged 24–60 months in mind. However, recent changes in early identification of ASDs warranted a program to be utilized with recently screened and identified toddlers (Rogers and Dawson 2010). ESDM is not intended for children older than 60 months of age or younger than 9 months of age. Prerequisites for the development of programming include an interest in object use and combining two objects in play. Children that meet these prerequisites can receive interventions from the ESDM. For children that are functioning at the level of 48 months, interventionists may need to develop an advanced curriculum, as the ESDM curriculum may not capture deficits or appropriate interventions (Rogers and Dawson 2010).
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