ESDM Research articles

Vivanti G., Stahmer A.

Can the Early Start Denver Model Be Considered ABA Practice?

Behavioral Analysis in Practice  | 2020

Abstract : The Early Start Denver Model (ESDM) is an evidence-based early intervention approach for young children with autism spectrum disorder. Although the ESDM is described by its authors as being rooted in applied behavior analysis (ABA), some states, agencies, and scholars consider the ESDM to qualify as ABA practice, whereas others do not. The purpose of this article is to examine the status of the ESDM in relation to the 7 dimensions established by Baer, Wolf, and Risley (“Some Current Dimensions of Applied Behavior Analysis,” Journal of Applied Behavior Analysis, 1(1): 91–97, 1968) to define applied behavior-analytic research and intervention, as well as to discuss implications for the field.

Rogers S. J., Estes A., Vismara L., Munson J., Zierhut C., Greenson J., Dawson G., Rocha M., Sugar C., Senturk D., Whelan F., Talbott M.

Enhancing Low-Intensity Coaching in Parent Implemented Early Start Denver Model Intervention for Early Autism: A Randomized Comparison Treatment Trial

Journal of Autism and Developmental Disorders  | 2018

Abstract : Short-term low intensity parent implemented intervention studies for toddlers with autism spectrum disorder (ASD) have found it difficult to demonstrate significantly improved developmental scores or autism severity compared to community treatment. We conducted a randomized comparative intent-to-treat study of a parent implemented intervention to (1) test the effects of an enhanced version on parent and child learning, and (2) evaluate the sensitivity to change of proximal versus distal measures of child behavior. We randomized 45 children with ASD, 12–30 months of age, into one of two versions of parent-implemented Early Start Denver Model (P-ESDM), the basic model, in which we delivered 1.5 h of clinic-based parent coaching weekly, and an enhanced version that contained three additions: motivational interviewing, multimodal learning tools, and a weekly 1.5-h home visit. We delivered the intervention for 12 weeks and measured child and parent change frequently in multiple settings. We found a time-by-group interaction: parents in the enhanced group demonstrated significantly greater gains in interaction skills than did parents in the non-enhanced group. Both interventions were associated with significant developmental acceleration; however, child outcomes did not differ by group. We found a significant relationship between degree of change in parental interaction skill and rate of children’s improvement on our proximal measure. Parents in both groups reported satisfaction with the intervention. These findings suggest that parent skills improved more in the enhanced group than the comparison group. Children in the two groups showed similar improvements. Rate of individual parent learning was associated with greater individual child progress on a measure quite proximal to the treatment, though not on standardized assessments.

Vismara L., McCormick C. E. B., Shields R.., Hessl D.

 Extending the Parent-Delivered Early Start Denver Model to Young Children with Fragile X Syndrome  

Journal of Autism and Developmental Disorders | 2018

Abstract: This is the first study to evaluate an autism intervention model, the parent-delivered Early Start Denver Model (P-ESDM), for young children with fragile X syndrome (FXS), a known genetic disorder associated with autism spectrum disorder. Four parent–child dyads participated in a low-intensity, parent coaching model of the P-ESDM to evaluate initial efficacy and acceptability. Parents improved in P-ESDM fidelity, implemented intervention goals to increase child learning, and found the experience moderately to highly acceptable. Visual examination and Baseline Corrected Tau effect sizes revealed mixed results across child measures. Findings suggest a potential therapeutic opportunity in need of larger, well-controlled studies of P-ESDM and other interventions for families of young children with FXS who face limited empirically-supported intervention options.

Cidav Z., Munson J., Estes A., Dawson G., Rogers S., Mandell D.

Cost Offset Associated With Early Start Denver Model for Children With Autism

Journal of the American Academy of Child & Adolescent Psychiatry | 2017

Abstract: Objective: To determine the effect of the Early Start Denver Model (ESDM) for treatment of young children with autism on health care service use and costs. Method: We used data from a randomized trial that tested the efficacy of the ESDM, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents, for 2 years. Parents were interviewed about their children’s service use every 6 months from the onset of the intervention to follow-up (age 6 years). The sample for this study consisted of 39 children with autism who participated in the original randomized trial at age 18 to 30 months, and were also assessed at age 6 years. Of this sample, 21 children were in the ESDM group, and 18 children were in the community care (COM) group. Reported services were categorized and costed by applying unit hourly costs. Annualized service use and costs during the intervention and post intervention for the two study arms were compared. Results: During the intervention, children who received the ESDM had average annualized total health-related costs that were higher by about $14,000 than those of children who received community-based treatment. The higher cost of ESDM was partially offset during the intervention period because children in the ESDM group used less applied behavior analysis (ABA)/early intensive behavioral intervention (EIBI) and speech therapy services than children in the comparison group. In the postintervention period, compared with children who had earlier received treatment as usual in community settings, children in the ESDM group used less ABA/EIBI, occupational/physical therapy, and speech therapy services, resulting in significant cost savings in the amount of about $19,000 per year per child. Conclusion: Costs associated with ESDM treatment were fully offset within a few years after the intervention because of reductions in other service use and associated costs. Clinical trial registration information: Early Characteristics of Autism;; NCT0009415. Key words: autism, cost, use, Early Start Denver Model, early intervention

Colombi C., Narzisi A., Ruta L., Cigala V., Gagliano A., Pioggia G., Siracusano R., Rogers S. J., Muratori F., and Prima Pietra Team

Implementation of the Early Start Denver Model in an Italian community

Autism (Sage Publications) | 2016

Abstract: Identifying effective, community-based specialized interventions for young children with autism spectrum disorder is an international clinical and research priority. We evaluated the effectiveness of the Early Start Denver Model intervention in a group of young children with autism spectrum disorder living in an Italian community compared to a group of Italian children who received treatment as usual. A total of 22 young children diagnosed with autism spectrum disorder received the Early Start Denver Model in a center-based context for 6h per week over 6months. The Early Start Denver Model group was compared to a group of 70 young children diagnosed with autism spectrum disorder who received treatment as usual for an average of 5.2 h over 6months. Children in both groups improved in cognitive, adaptive, and social skills after 3months and 6months of treatment. Children in the Early Start Denver Model group made larger gains in cognitive and social skills after 3 and 6months of treatment. The Early Start Denver Model group made larger gains in adaptive skills after 3months of treatment. Our results are discussed in terms of implications for intervention research and clinical practice. Our study supports the positive impact of the Early Start Denver Model in a non-English-speaking community.

Devescovi R., Monasta L., Mancini A., Bin M., Vellante V., Carrozzi M., Colombi C.

Early diagnosis and Early Start Denver Model intervention in autism spectrum disorders delivered in an Italian Public Health System service

Neuropsychiatric Disease and Treatment  | 2016

Background: Early diagnosis combined with an early intervention program, such as the Early Start Denver Model (ESDM), can positively influence the early natural history of autism spectrum disorders. This study evaluated the effectiveness of an early ESDM-inspired intervention, in a small group of toddlers, delivered at low intensity by the Italian Public Health System. Methods: Twenty-one toddlers at risk for autism spectrum disorders, aged 20–36 months, received 3 hours/wk of one-to-one ESDM-inspired intervention by trained therapists, combined with parents’ and teachers’ active engagement in ecological implementation of treatment. The mean duration of treatment was 15 months. Cognitive and communication skills, as well as severity of autism symptoms, were assessed by using standardized measures at pre-intervention (Time 0 [T0]; mean age =27 months) and post-intervention (Time 1 [T1]; mean age =42 months). Results: Children made statistically significant improvements in the language and cognitive domains, as demonstrated by a series of nonparametric Wilcoxon tests for paired data. Regarding severity of autism symptoms, younger age at diagnosis was positively associated with greater improvement at post-assessment. Conclusion: Our results are consistent with the literature that underlines the importance of early diagnosis and early intervention, since prompt diagnosis can reduce the severity of autism symptoms and improve cognitive and language skills in younger children. Particularly in toddlers, it seems that an intervention model based on the ESDM principles, involving the active engagement of parents and nursery school teachers, may be effective even when the individual treatment is delivered at low intensity. Furthermore, our study supports the adaptation and the positive impact of the ESDM entirely sustained by the Italian Public Health System. Keywords: early diagnosis, early intervention, autism spectrum disorder, Early Start Denver Model, Public Health System service

Davlantis K. S. & Rogers S. J.

The Early Start Denver Model: A play-based intervention for young children with autism spectrum disorders

American Psychological Association | 2016

Abstract: In 1943, renowned American psychiatrist Leo Kanner published the first scientific paper describing “early infantile autism.” Drawing from an entire career spent seeing children with developmental and psychiatric impairments, Kanner described a group of 13 children whose symptoms seemed similar to each other’s and unique from all other diagnostic groups of children he had seen. He focused on the major differences that set this group apart: their lack of reciprocal, affective social interactions with others; their unique communication impairments; their resistance to change; and their repetitive, stereotypic, and ritualized play patterns. A variety of empirical studies conducted over the past 60 years has delineated additional cognitive and affective differences in play in autism. The effect of autism on the development of symbolic play is so profound that it has been one of the defining features of the disorder in childhood (American Psychiatric Association, 2000). Difficulty with play has been found to be a more prominent symptom very early in life than the classic symptoms involving insistence on sameness and repetitive routines that Kanner emphasized (e.g., Bernabei, Camaigni, & Levi, 1998; Charman et al., 1997; Rutherford, Young, Hepburn, & Rogers, 2007; Williams, Reddy, & Costall, 2001). This chapter describes the theory and research support of the Early Start Denver Model (ESDM; Rogers & Dawson, 2010). The ESDM treatment components, implementation processes, and transportability methods are presented along with illustrative case examples. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Eapen V., Črnčec R., and Walter A.

There are Gains, But can we Tell for Whom and Why? Predictors of Treatment Response Following Group Early Start Denver Model Intervention in Preschool - Aged Children with Autism Spectrum Disorder

Autism Open Access | 2016

Abstract: There is significant variability in treatment outcomes across different interventions for Autism Spectrum Disorder (ASD) and between individuals receiving the same intervention. This is likely related to the considerable phenotypic variability in ASD, which is posited to arise from a developmental cascade whereby a primary deficit in attention to social stimuli leads ultimately to widespread and diverse behavioural and functional difficulties. Purpose: To provide data on predictors of treatment outcome in a cohort of preschool - aged children with ASD receiving a group Early Start Denver Model (ESDM) intervention. Methodology: Forty-nine children (mean age 52 months) with ASD receiving group ESDM over 10 months were assessed pre - and post-intervention for ASD symptoms, developmental level, and adaptive functioning; together with measures of parental stress and coping. Results: Lower initial ASD symptomatology, particularly higher social affect and play skills, and younger age at entry to intervention predicted better outcomes. Conclusion: Reflective of hypotheses from the developmental cascade theory, younger age at entry predicted treatment gains, supporting efforts to include children in comprehensive treatment promptly. Moreover, greater initial social impairments led to relatively poorer outcomes, potentially suggesting that children with greater social affect difficulties may require a higher dose, or modified intervention, to that used in this study.

Ozturka Y., Vivanti G., Uljarevicc M., Dissanayek C., and the Victorian ASELCC Team

Treatment-related changes in children’s communication impact on maternal satisfaction and psychological distress

Research in Developmental Disabilities | 2016

Background: Parents of children with autism have been found to have reduced psychological well-being that has usually been linked to the stress related to managing their child’s symptoms. As children’s behavior and cognitive functioning are subject to change when suitable early intervention programs are put in place, it is plausible that positive treatment-related changes in the child will have a positive impact on parental distress. Aims: We undertook an individual differences study to investigate whether maternal psychological distress is affected by the outcomes of children receiving intervention. Methods and procedures: The participants comprised 43 mothers of preschool children with ASD enrolled in an early intervention program for 12 months. Outcome and results: Child and family factors were linked to maternal psychological distress. However treatment-related changes in children’s communication, as assessed on the Vineland Adaptive Behavior Scales II, and parenting satisfaction uniquely contributed to psychological distress above and beyond other factors. A mediation analysis indicated that mothers whose children make treatment gains in communication skills experience lower levels of psychological distress as a consequence of higher levels of parenting satisfaction. Conclusions and implications: The findings highlight improvements in everyday adaptive communication skills in children with ASD impact on mothers’ satisfaction and distress

Vismara L., McCormick C. E. B., Wagner A., Monlux K., Nadhan A., Young G.S.

Telehealth Parent Training in the Early Start Denver Model: Results From a Randomized Controlled Study

Focus on Autism and Other Developmental Disabilities | 2016

Abstract: Telehealth training may benefit parents’ use of early intervention for children with autism spectrum disorder (ASD). This study is one of the few randomized trials to compare telehealth parent training in the Early Start Denver Model (P-ESDM) with a community treatment-as-usual, early intervention program. Parents were randomized to 12 weekly 1.5- hr videoconferencing sessions with website access to P-ESDM learning resources or to monthly 1.5-hr videoconferencing sessions with website access to alternative resources to support their intervention. Telehealth training facilitated higher parent fidelity gains and program satisfaction for more of the P-ESDM than the community group at the end of the 12-week training and at follow-up. Children’s social communication skills improved for both groups regardless of parent fidelity. Findings suggest the feasibility of telehealth training with improved parent intervention usage and satisfaction from the program. However, the impact of these effects on children’s development over time is yet to be understood.

Vivanti G., Dissanayake C., and The Victorian ASELCC Team

Outcome for Children Receiving the Early Start Denver Model Before and After 48 Months

Journal of Autism and Developmental Disorders | 2016

Abstract: The Early Start Denver Model (ESDM) is an intervention program recommended for pre-schoolers with autism ages 12–48 months. The rationale for this recommendation is the potential for intervention to affect developmental trajectories during early sensitive periods. We investigated outcomes of 32 children aged 18–48 months and 28 children aged 48–62 months receiving the ESDM for one year (approximately 20 h per week). Younger children achieved superior verbal DQ gains compared to their older counterparts. There were no group differences with respect to non-verbal DQ and adaptive behavior (with both age-groups undergoing significant change), or ASD severity (with neither age-group showing improvements on the ADOS). The association between verbal DQ gains and age at intake was moderated by baseline verbal level.

Estes A., Munson J., Rogers S. J., Greenson J., Winter J., Dawson G.

Long-Term Outcomes of Early Intervention in 6-Year-Old Children With Autism Spectrum Disorder

Journal of the American Academy of Child and Adolescent Psychiatry | 2015

Objective: We prospectively examined evidence for the sustained effects of early intervention based on a followup study of 39 children with ASD who began participation in a randomized clinical trial testing the effectiveness of the Early Start Denver Model (ESDM) at age 18 to 30 months. The intervention, conducted at a high level of intensity in-home for 2 years, showed evidence of efficacy immediately posttreatment. Method: This group of children was assessed at age 6 years, 2 years after the intervention ended, across multiple domains of functioning by clinicians naive to previous intervention group status. Results: The ESDM group, on average, maintained gains made in early intervention during the 2-year follow-up period in overall intellectual ability, adaptive behavior, symptom severity, and challenging behavior. No group differences in core autism symptoms were found immediately posttreatment; however, 2 years later, the ESDM group demonstrated improved core autism symptoms and adaptive behavior as compared with the community-intervention-as-usual (COM) group. The 2 groups were not significantly different in terms of intellectual functioning at age 6 years. Both groups received equivalent intervention hours during the original study, but the ESDM group received fewer hours during the follow-up period. Conclusion: These results provide evidence that gains from early intensive intervention are maintained 2 years later. Notably, core autism symptoms improved in the ESDM group over the follow-up period relative to the COM group. This improvement occurred at the same time that the ESDM group received significantly fewer services. This is the first study to examine the role of early ESDM behavioral intervention initiated at less than 30 months of age in altering the longer-term developmental course of autism. Key Words: early, intervention, autism, long-term, outcomes

Schreibman L., Dawson G., Stahmer A., Landa R., Rogers S., McGee G., Kasari C., Ingersoll B., Kaiser A. P., Bruinsma Y., McNerney E., Wetherby A., Halladay A.

Naturalistic Developmental Behavioral Interventions: Empirically Validated Treatments for Autism Spectrum Disorder

Journal of Autism and Developmental Disorders | 2015

Abstract: Earlier autism diagnosis, the importance of early intervention, and development of specific interventions for young children have contributed to the emergence of similar, empirically supported, autism interventions that represent the merging of applied behavioral and developmental sciences. ‘‘Naturalistic Developmental Behavioral Interventions (NDBI)’’ are implemented in natural settings, involve shared control between child and therapist, utilize natural contingencies, and use a variety of behavioral strategies to teach developmentally appropriate and prerequisite skills. We describe the development of NDBIs, their theoretical bases, empirical support, requisite characteristics, common features, and suggest future research needs. We wish to bring parsimony to a field that includes interventions with different names but common features thus improving understanding and choice-making among families, service providers and referring agencies. Keywords Early intervention Naturalistic Developmental Behavioral

Ryberg, K.

Evidence for the Implementation of the Early Start Denver Model for Young Children With Autism Spectrum Disorder 

Journal of the American Psychiatric Nurses Association | 2015

Background: The Early Start Denver Model (ESDM) is a manualized comprehensive therapy for toddlers with autism spectrum disorder. It emphasizes interpersonal engagement through synchrony, rhythms, and reciprocity to decrease symptom severity and accelerate cognitive, social-emotional, and language development. Objective: To systematically review evidence regarding the use of the ESDM as an intervention for young children with autism spectrum disorder. Design: PubMed, Scopus, Web of Science, Embase, and CINAHL were searched from 2010- 2015 using predetermined inclusion criteria. Study methodology, participant characteristics, and outcomes were evaluated and quality of evidence was assigned. Results: Eight articles met inclusion criteria and consisted of two randomized controlled trials, four controlled trials, and two observational cohort studies. Evidence quality ranged from low to high. Conclusions: The ESDM is an effective intervention that improves cognition, language, and adaptive behavior. ESDM strategies delivered in community group settings and in the home by parents have potential to be efficacious and feasible. Keywords: Early Start Denver Model, autism

Rogers S. J., Vismara L., Wagner A. L., McCormick C., Young G., Ozonoff S.

Autism Treatment in the First Year of Life: A Pilot Study of Infant Start

Journal of Autism and Developmental Disorders | 2014

Abstract: The goal of early autism screening is earlier treatment. We pilot-tested a 12-week, low-intensity treatment with seven symptomatic infants ages 7–15 months. Parents mastered the intervention and maintained skills after treatment ended. Four comparison groups were matched from a study of infant siblings. The treated group of infants was significantly more symptomatic than most of the comparison groups at 9 months of age but was significantly less symptomatic than the two most affected groups between 18 and 36 months. At 36 months, the treated group had much lower rates of both ASD and DQs under 70 than a similarly symptomatic group who did not enroll in the treatment study. It appears feasible to identify and enroll symptomatic infants in parent-implemented intervention before 12 months, and the pilot study outcomes are promising, but testing the treatment’s efficacy awaits a randomized trial. Keywords: ASD Infants Early intervention Parents Early Start Denver Model.

Webb S. J., Jones E. J. H., Kelly J., Dawson D.

The motivation for very early intervention for infants at high risk for autism spectrum disorders

International Journal of Speech-Language Pathology | 2014


Abstract: The first Autism Research Matrix (IACC, 2003) listed the identifi cation of behavioural and biological markers of risk for autism as a top priority. This emphasis was based on the hypothesis that intervention with infants at-risk, at an early age when the brain is developing and before core autism symptoms have emerged, could signifi cantly alter the developmental trajectory of children at risk for the disorder and impact long-range outcome. Research has provided support for specifi c models of early autism intervention (e.g., Early Start Denver Model) for improving outcomes in young children with autism, based on both behavioural and brain activity measures. Although great strides have been made in ability to identify risk markers for autism in younger infant/toddler samples, how and when to intervene during the prodromal state remains a critical question. Emerging evidence suggests that abnormal brain circuitry in autism precedes altered social behaviours; thus, an intervention designed to promote early social engagement and reciprocity potentially could steer brain development back toward the normal trajectory and remit or reduce the expression of symptoms. Keywords: Autism spectrum disorders , ASD , communication , speech , language , intervention .

Vivanti G., Rogers S. J.

Autism and the mirror neuron system: insights from learning and teaching

Philosophical Transactions of the Royal Society B | 2014  

Abstract: Individuals with autism have difficulties in social learning domains which typically involve mirror neuron system (MNS) activation. However, the precise role of the MNS in the development of autism and its relevance to treatment remain unclear. In this paper, we argue that three distinct aspects of social learning are critical for advancing knowledge in this area: (i) the mechanisms that allow for the implicit mapping of and learning from others’ behaviour, (ii) the motivation to attend to and model conspecifics and (iii) the flexible and selective use of social learning. These factors are key targets of the Early Start Denver Model, an autism treatment approach which emphasizes social imitation, dyadic engagement, verbal and nonverbal communication and affect sharing. Analysis of the developmental processes and treatment-related changes in these different aspects of social learning in autism can shed light on the nature of the neuropsychological mechanisms underlying social learning and positive treatment outcomes in autism. This knowledge in turn may assist in developing more successful pedagogic approaches to autism spectrum disorder. Thus, intervention research can inform the debate on relations among neuropsychology of social learning, the role of the MNS, and educational practice in autism.

Vivanti G., Paynter J., Duncan E., Fothergill H., Dissanayake C., Rogers S. J., The Victorian ASELCC Team

Effectiveness and Feasibility of the Early Start Denver Model Implemented in a Group-Based Community Childcare Setting.

Journal of Autism and Developmental Disorders | 2014

Abstract: A recent study documented the efficacy of the Early Start Denver Model (ESDM) delivered in a 1:1 fashion. In the current study we investigated the effectiveness and feasibility of the ESDM in the context of a long-day care community service, with a child-staff ratio of 1:3. Outcomes of 27 preschoolers with ASD undergoing 15–25 h per week of ESDM over 12 months were compared to those of 30 peers with ASD undergoing a different intervention program delivered in a similar community long-day care service. Children in both groups made gains in cognitive, adaptive and social skills. Participants in the ESDM group showed significantly higher gains in developmental rate and receptive language. Keywords Autism spectrum disorder Early Start Denver Model Effectiveness Community implementation Early intervention.

Sullivan K., Stone W. L., Dawson G.

Potential neural mechanisms underlying the effectiveness of early intervention for children with autism spectrum disorder

Research in Developmental Disabilities | 2014

Abstract: Although evidence supports the efficacy of early intervention for improving outcomes for children with autism spectrum disorder (ASD), the mechanisms underlying their effectiveness remain poorly understood. This paper reviews the research literature on the neural bases of the early core deficits in ASD and proposes three key features of early intervention related to the neural mechanisms that may contribute to its effectiveness in improving deficit areas. These features include (1) the early onset of intensive intervention which capitalizes on the experience-expectant plasticity of the immature brain, (2) the use of treatment strategies that address core deficits in social motivation through an emphasis on positive social engagement and arousal modulation, and (3) promotion of complex neural networks and connectivity through thematic, multi-sensory and multi-domain teaching approaches. Understanding the mechanisms of effective early intervention will enable us to identify common or foundational active ingredients for promoting optimal outcomes in children with ASD.

Fulton E., Eapen V., Črnčec R., Walter A., Rogers S.

Reducing maladaptive behaviors in preschool-aged children with autism spectrum disorder using the Early Start Denver Model

Frontiers in Pediatrics | 2014

Abstract: The presence of maladaptive behaviors in young people with autism spectrum disorder (ASD) can significantly limit engagement in treatment programs, as well as compromise future educational and vocational opportunities. This study aimed to explore whether the Early Start Denver Model (ESDM) treatment approach reduced maladaptive behaviors in preschool-aged children with ASD in a community-based long day care setting. The level of maladaptive behavior of 38 children with ASD was rated using an observation-based measure on three occasions during the intervention: on entry, 12 weeks post-entry, and on exit (post-intervention) over an average treatment duration of 11.8 months. Significant reductions were found in children’s maladaptive behaviors over the course of the intervention, with 68% of children showing a treatment response by 12 weeks and 79% on exit. This change was accompanied by improvement in children’s overall developmental level as assessed by the Mullen scales of early learning, but not by significant changes on the Vineland Adaptive Behavior Scales-II or Social Communication Questionnaire. Replication with a larger sample, control conditions, and additional measures of maladaptive behavior is necessary in order to determine the specific factors underlying these improvements; however, the findings of the present study suggest that the ESDM program may be effective in improving not only core developmental domains, but also decreasing maladaptive behaviors in preschool-aged children with ASD.

Canitano R.

New experimental treatments for core social domain in autism spectrum disorders

Frontiers in Pediatrics | 2014

Abstract: Current therapeutics in autism spectrum disorders (ASD) only treat the associated symptoms, without addressing core social dysfunctions. A paradigm shift in research of the pathogenesis of ASD, its synaptic abnormalities and altered signaling in multiple dynamic systems, have led to new experimental treatments for treating the core social abnormalities of ASD. NMDA antagonists, especially memantine, have been introduced in clinical trials addressing glutamatergic transmission in children and adolescents with ASD. GABAergic signaling has been targeted in trials using the GABAB receptor agonist arbaclofen for ASD patients with promising results. Oxytocin has been recognized as implicated in social development and affiliative behaviors. Preliminary findings from clinical trials using oxytocin in children with ASD show encouraging improvements in social cognition, but larger studies are needed. In two of the single gene disorders associated with ASD, Insulin Growth Factor (IGF-1) is a new treatment that has been tested in Rett syndrome and Phelan-McDermid syndrome (Chromosome 22 deletion syndrome). IGF-1 has been demonstrated to reverse the reduction in the number of excitatory synapses and the density of neurons that characterize these conditions in animal studies and it is being introduced as an experimental treatment. As a novel approach to verify treatment efficacy, neural processing modifications were recently evaluated by fMRI after a pivotal response training intervention. Another study of neural changes in response to treatment examined variations in EEG signaling in patients after an Early Start Denver Model (ESDM) intervention.

Vismara L., Young G., Rogers S. J.

Community Dissemination of the Early Start Denver Model: Implications for Science and Practice 

Topics in Early Childhood Special Education (Hammill Institute on Disabilities) | 2013

Abstract: The growing number of Autism Spectrum Disorder cases exceeds the services available for these children. This increase challenges both researchers and service providers to develop systematic, effective dissemination strategies for transporting university research models to community early intervention (EI) programs. The current study developed an abbreviated training workshop to teach the Early Start Denver Model (ESDM) to 24 community EI practitioners and examined their fidelity of implementation posttraining and 4 months later. Practitioners successfully implemented and self-assessed their delivery of the ESDM teaching strategies compared with fidelity ratings by expert trainers by the end of the workshop. Those who submitted follow-up materials met fidelity in their direct delivery, whereas their self-assessment of skill delivery appeared lower compared with trainers' fidelity ratings. Findings are discussed about the immediate gains and challenges of community-based dissemination of the ESDM, and the priority for continued research in implementation science to support and sustain intervention delivery.  

Eapen V., Črnčec R., Walter A.

Clinical outcomes of an early intervention program for preschool children with Autism Spectrum Disorder in a community group setting

BMC Pediatrics | 2013

Abstract: Available evidence indicates that early intervention programs, such as the Early Start Denver Model (ESDM), can positively affect key outcomes for children with Autism Spectrum Disorder (ASD). However, programs involving resource intensive one-to-one clinical intervention are not readily available or deliverable in the community, resulting in many children with ASD missing out on evidence-based intervention during their early and most critical preschool years. This study evaluated the effectiveness of the ESDM for preschoolaged children with ASD using a predominantly group-based intervention in a community child care setting. Methods: Participants were 26 children (21 male) with ASD with a mean age of 49.6 months. The ESDM, a comprehensive early intervention program that integrates applied behaviour analysis with developmental and relationship-based approaches, was delivered by trained therapists during the child’s attendance at a child care centre for preschool-aged children with ASD. Children received 15–20 hours of group-based, and one hour of one-to-one, ESDM intervention per week. The average intervention period was ten months. Outcome measures were administered pre- and post-intervention, and comprised a developmental assessment - the Mullen Scales of Early Learning (MSEL); and two parent-report questionnaires - the Social Communication Questionnaire (SCQ) and Vineland Adaptive Behaviours Scales– Second Edition (VABS-II). Results: Statistically significant post-intervention improvements were found in children’s performance on the visual reception, receptive language and expressive language domains of the MSEL in addition to their overall intellectual functioning, as assessed by standardised developmental quotients. Parents reported significant increases in their child’s receptive communication and motor skills on the VABS-II, and a significant decrease in autism-specific features on the SCQ. These effects were of around medium size, and appeared to be in excess of what may have been expected due to maturation. Nonetheless, these results need to be confirmed in a controlled study. Conclusions: This study suggests community dissemination of ESDM using predominantly group-based intervention may be an effective intervention. Making ESDM accessible to the wider ASD community in child care settings has the potential for significant clinical and economic benefits. Further studies are indicated in this area, including those with younger children, and which incorporate a control group and standardised ASD assessments.

Estes A., Vismara L., Mercado C., Fitzpatrick A., Elder L., Greenson J., Lord C., Munson J., Winter J., Young G., Dawson G., Rogers S.

The Impact of Parent-Delivered Intervention on Parents of Very Young Children with Autism

Journal of Autism and Developmental Disorders | 2013


Abstract: This study investigated the impact of a parentcoaching intervention based on the Early Start Denver Model (P-ESDM) on parenting-related stress and sense of competence. This was part of a multisite, randomized trial comparing P-ESDM (n = 49) with community intervention (n = 49) for children aged 12 and 24 months. The P-ESDM group reported no increase in parenting stress, whereas the Community group experienced an increase over the same 3-month period. Parental sense of competence did not differ. Number of negative life events was a significant predictor of parenting stress and sense of competence across both groups. This suggests that a parent-coaching intervention may help maintain parental adjustment directly after a child is diagnosed with ASD. Keywords Early intervention Parent Stress Autism spectrum disorder Early Start Denver Model

Vivanti G., Dissanayake C., Zierhut C., Rogers S. J., Victorian ASELCC Team

Brief Report: Predictors of Outcomes in the Early Start Denver Model Delivered in a Group Setting

Journal of Autism and Developmental Disorders | 2013

Abstract: There is a paucity of studies that have looked at factors associated with responsiveness to interventions in preschoolers with autism spectrum disorder (ASD). We investigated learning profiles associated with response to the Early Start Denver Model delivered in a group setting. Our preliminary results from 21 preschool children with an ASD aged 2- to 5-years suggest that the children with more advanced skills in functional use of objects, goal understanding and imitation made the best developmental gains after 1 year of treatment. Cognitive abilities, social attention, intensity of the treatment and chronological age were not associated with treatment gains. Keywords Autism Intervention Early Start Denver Model Predictors of outcomes Social learning. 

Rogers S. J., Estes A., Lord C., Vismara L., Winter J., Fitzpatrick A., Guo M., Dawson G.

Effects of a Brief Early Start Denver Model (ESDM)–Based Parent Intervention on Toddlers at Risk for Autism Spectrum Disorders: A Randomized Controlled Trial

Journal of the American Academy of Child and Adolescent Psychiatry | 2012

Objective: This study was carried out to examine the efficacy of a 12-week, low-intensity (1-hour/wk of therapist contact), parent-delivered intervention for toddlers at risk for autism spectrum disorders (ASD) aged 14 to 24 months and their families. Method: A randomized controlled trial involving 98 children and families was carried out in three different sites investigating the efficacy of a parent delivery of the Early Start Denver Model (P-ESDM), which fosters parental use of a child-centered responsive interaction style that embeds many teaching opportunities into play, compared to community treatment as usual. Assessments were completed at baseline and 12 weeks later, immediately after the end of parent coaching sessions. Results: There was no effect of group assignment on parent– child interaction characteristics or on any child outcomes. Both groups of parents improved interaction skills, and both groups of children demonstrated progress. Parents receiving P-ESDM demonstrated significantly stronger working alliances with their therapists than did the community group. Children in the community group received significantly more intervention hours than those in the P-ESDM group. For the group as a whole, both younger child age at the start of intervention and a greater number of intervention hours were positively related to the degree of improvement in children’s behavior for most variables. Conclusions: Parent-implemented intervention studies for early ASD thus far have not demonstrated the large effects seen in intensive-treatment studies. Evidence that both younger age and more intervention hours positively affect developmental rates has implications for clinical practice, service delivery, and public policy. J. Am. Acad. Child Adolesc. Psychiatry, 2012;xx(x): xxx. Key Words: Early Start Denver Model (ESDM), early intervention, toddler, parent– child interaction, autism.

Dawson G., Jones E. J. H., Merkle K., Venema K., Lowy R., Faja S., Kamara D., Murias M., Greenson J., Winter J., Smith M., Rogers S. J., Webb S.

Early Behavioral Intervention Is Associated With Normalized Brain Activity in Young Children With Autism

Journal of the American Academy of Child and Adolescent Psychiatry | 2012

Objective: A previously published randomized clinical trial indicated that a developmental behavioral intervention, the Early Start Denver Model (ESDM), resulted in gains in IQ, language, and adaptive behavior of children with autism spectrum disorder. This report describes a secondary outcome measurement from this trial, EEG activity. Method: Forty-eight 18- to 30-month-old children with autism spectrum disorder were randomized to receive the ESDM or referral to community intervention for 2 years. After the intervention (age 48 to 77 months), EEG activity (event-related potentials and spectral power) was measured during the presentation of faces versus objects. Age-matched typical children were also assessed. Results: The ESDM group exhibited greater improvements in autism symptoms, IQ, language, and adaptive and social behaviors than the community intervention group. The ESDM group and typical children showed a shorter Nc latency and increased cortical activation (decreased a power and increased y power) when viewing faces, whereas the community intervention group showed the opposite pattern (shorter latency event-related potential [ERP] and greater cortical activation when viewing objects). Greater cortical activation while viewing faces was associated with improved social behavior. Conclusions: This was the first trial to demonstrate that early behavioral intervention is associated with normalized patterns of brain activity, which is associated with improvements in social behavior, in young children with autism spectrum disorder. J. Am. Acad. Child Adolesc. Psychiatry; 2012; 51(11): 1150–1159. Clinical trial registration information—Early Characteristics of Autism; http://; NCT00090415. Key Words: autism, early behavioral intervention, Early Start Denver Model, event-related potentials, brain activity.

Vismara L., Young G., Rogers S. J.

Telehealth for Expanding the Reach of Early Autism Training to Parents

Autism Research and Treatment | 2012

Although there is consensus that parents should be involved in interventions designed for young children with autism spectrum disorder (ASD), parent participation alone does not ensure consistent, generalized gains in children’s development. Barriers such as costly intervention, time-intensive sessions, and family life may prevent parents from using the intervention at home. Telehealth integrates communication technologies to provide health-related services at a distance. A 12 one-hour per week parent intervention program was tested using telehealth delivery with nine families with ASD. The goal was to examine its feasibility and acceptance for promoting child learning throughout families’ daily play and caretaking interactions at home. Parents became skilled at using teachable moments to promote children’s spontaneous language and imitation skills and were pleased with the support and ease of telehealth learning. Preliminary results suggest the potential of technology for helping parents understand and use early intervention practices more often in their daily interactions with children

Vivanti G., Dissanayake C., Zierhut C., Rogers S. J., Victorian ASELCC Team

Brief Report: Predictors of Outcomes in the Early Start Denver Model Delivered in a Group Setting

Journal of Autism and Developmental Disorders | 2012

Abstract: There is a paucity of studies that have looked at factors associated with responsiveness to interventions in preschoolers with autism spectrum disorder (ASD). We investigated learning profiles associated with response to the Early Start Denver Model delivered in a group setting. Our preliminary results from 21 preschool children with an ASD aged 2- to 5-years suggest that the children with more advanced skills in functional use of objects, goal understanding and imitation made the best developmental gains after 1 year of treatment. Cognitive abilities, social attention, intensity of the treatment and chronological age were not associated with treatment gains. Keywords Autism Intervention Early Start Denver Model Predictors of outcomes Social learning.

Vismara L. & Rogers S.

Behavioral Treatments in Autism Spectrum Disorder: What Do We Know?

Annual Review of Clinical Psychology | 2010

Abstract: Although there are a large and growing number of scientifically questionable treatments available for children with autism spectrum disorder (ASD), intervention programs applying the scientific teaching principles of applied behavior analysis (ABA) have been identified as the treatment of choice. The following article provides a selective review of ABA intervention approaches, some of which are designed as comprehensive programs that aim to address all developmental areas of need, whereas others are skills based or directed toward a more circumscribed, specific set of goals. However, both types of approaches have been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD. Implications of these findings are discussed in relation to critical areas of research that have yet to be fully explored.

Dawson G., Rogers S., Munson J., Smith M., Winter J., Greenson J., Donaldson A., and Varley J. 

Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model

Official Journal of the American Academy of Pediatrics | 2009

Abstract: Objective: To conduct a randomized, controlled trial to evaluate the efficacy of the Early Start Denver Model (ESDM), a comprehensive developmental behavioral intervention, for improving outcomes of toddlers diagnosed with autism spectrum disorder (ASD). Methods: Forty-eight children diagnosed with ASD between 18 and 30 months of age were randomly assigned to 1 of 2 groups: (1) ESDM intervention, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents for 2 years; or (2) referral to community providers for intervention commonly available in the community. Results: Compared with children who received community-intervention, children who received ESDM showed significant improvements in IQ, adaptive behavior, and autism diagnosis. Two years after entering intervention, the ESDM group on average improved 17.6 standard score points (1 SD: 15 points) compared with 7.0 points in the comparison group relativeto baseline scores. The ESDM group maintained its rate of growth in adaptive behavior compared with a normative sample of typically developing children. In contrast, over the 2-year span, the comparison group showed greater delays in adaptive behavior. Children who received ESDM also were more likely to experience a change in diagnosis from autism to pervasive developmental disorder, not otherwise specified, than the comparison group. Conclusions: This is the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of ASD diagnosis. Results of this study underscore the importance of early detection of and intervention in autism. Pediatrics 2010;125:e17–e23.

Vismara L., Colombi C., Rogers S.

Can one hour per week of therapy lead to lasting changes in young children with autism?

Autism (Sage Publications) | 2009

Abstract: Deficits in attention, communication, imitation, and play skills reduce opportunities for children with autism to learn from natural interactive experiences that occur throughout the day. These developmental delays are already present by the time these children reach the toddler period. The current study provided a brief 12 week, 1 hour per week, individualized parent–child education program to eight toddlers newly diagnosed with autism. Parents learned to implement naturalistic therapeutic techniques from the Early Start Denver Model, which fuses developmental- and relationship-based approaches with Applied Behavior Analysis into their ongoing family routines and parent–child play activities. Results demonstrated that parents acquired the strategies by the fifth to sixth hour and children demonstrated sustained change and growth in social communication behaviors. Findings are discussed in relation to providing parents with the necessary tools to engage, communicate with, and teach their young children with autism beginning immediately after the diagnosis.

Vismara L. & Rogers S.

The Early Start Denver Model | A Case Study of an Innovative Practice

Journal of Early Intervention | 2008

Intervention was implemented with an infant identified at 9 months of age with a behavioral profile consistent with autistic spectrum disorder. The intervention approach, the Early Start Denver model, consisted of a 12-week, 1.5-hr-per-week individualized parent–child education program. Results of this case study demonstrated that the parent acquired multiple teaching tactics that were associated with growth in the infant’s social communication behaviors. Improvements were also noted with respect to the severity of behavioral indicators related to autism between 18 and 24 months of age. Findings are discussed in relation to providing an intervention model that may equip parents with the necessary intervention skills to engage, communicate with, and teach their very young children with or at risk for autism.

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