Keywords

The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) is an evidence-based early intervention for young children with Autism Spectrum Disorder (ASD) between the ages of 12 and 60 months, which was developed by Geraldine Dawson and Sally Rogers. The intervention is based on principles of Applied Behavior Analysis (ABA) and incorporates a strong developmental focus. The treatment approach is largely play-based and emphasizes relationship-building and communication, with treatment objectives spanning several developmental domains delivered in a naturalistic format. The ESDM was developed as a downward extension of the Denver Model, originally designed for preschoolers with ASD between 24 and 60 months (Rogers, Hall, Osaki, Reaven, & Herbison, 2000; Rogers, Herbison, Lewis, Pantone, & Reis, 1986). Several aspects of the ESDM make the program well suited for an interdisciplinary approach, to be discussed in greater detail throughout this chapter.

History/Background of ESDM

In addition to origins stemming from the Denver Model, the ESDM is also informed by Pivotal Response Training (PRT; Koegel & Koegel, 1988; Schreibman & Pierce, 1993), Rogers and Pennington’s (1991) model relating early social capacities to interpersonal development in individuals with autism, and Dawson and colleagues’ (2004) model characterizing autism as a disorder of social motivation. Foundations in these models ensure that the ESDM incorporates relationship-building as a platform for developing social communication skills, using engaging dyadic exchanges within play routines, and considering all aspects of a child’s development. Treatment goals emphasize imitation and affective sharing. Further, these foundational models focus on enhancing a child’s social attention and motivation through shifting the value associated with social rewards, and on allowing for child choice and following the child’s lead.

ESDM in the Context of Naturalistic Developmental Behavioral Interventions (NDBIs)

The ESDM falls under the umbrella of Naturalistic Developmental Behavioral Interventions (NDBIs; Schreibman et al., 2015), which is a group of early interventions that share key characteristics. NDBIs combine applied behavioral and developmental sciences. Among their common principles are delivery in natural contexts (e.g., the child’s natural environment, or structured in a way that promotes generalization to the child’s natural environment), shared control between the child and clinician, natural contingencies/reinforcers, and use of a range of behavioral principles to promote developmental skill acquisition. In addition, some of the evidence-based features of these interventions include a solid basis in applied behavior analysis, clear procedures which are well-defined in intervention manuals, a means for assessing fidelity of implementation in a standardized manner, individually tailored treatment goals, regular assessment of treatment progress, and child-led teaching. Teaching opportunities are embedded within both object and social play activities, using techniques of modeling and imitation to teach new skills. A strong base of research supports the efficacy of NDBIs in producing positive outcomes for children with ASD. In addition to the ESDM, interventions that fall under the umbrella of NDBIs include PRT, Joint Attention Symbolic Play Engagement and Regulation (JASPER; Kaale, Smith, & Sponheim, 2012; Kasari, Freeman, & Paparella, 2006), and Social Communication/Emotional Regulation/Transactional Support (SCERTS; Prizant, Wetherby, Rubin, & Laurent, 2003), among others.

Modalities of ESDM Delivery

ESDM can be delivered in a number of different ways, including therapist-delivered (i.e., therapist working 1:1 with child), parent coaching (i.e., coach provides in-the-moment feedback to the parent on ways of interacting with the child that support social-communicative development, in the context of live activities during session), group (e.g., preschool and daycare settings), and telehealth (i.e., remote delivery via technology-based platform; see chapter “Telehealth Approaches to Care Coordination in Autism Spectrum Disorder” for an overview of other approaches to telehealth). Further, efforts are underway that seek to make the ESDM more accessible to culturally and linguistically diverse populations, including in low resource settings, that require an extensive understanding of what adaptations are necessary to support a successful intervention program. Currently, the ESDM therapist manual (Rogers & Dawson, 2010) is available worldwide in 16 languages.

Principles of ESDM

The ESDM draws from both transactional (Sameroff, 2009) and constructionist (Piaget, 1963) models of child development. As such, the cycle of the interactive relationship between child and caregiver is viewed as critical, involving exchanging emotions, and responding to the other’s temperament, thereby affecting behavior in both directions. Additionally, the basis in the constructionist model suggests that children actively shape their own social world through participation in motor, sensory, and socially interactive experiences.

The ESDM primarily aims to promote the child’s social initiative and social engagement through affectively rich interactions, where multiple treatment objectives are targeted simultaneously rather than in a sequential manner. Data collection is essential in monitoring treatment progress and making modifications to the treatment plan as needed. Further, the intervention spans and targets a range of developmental domains, as shown below:

Receptive communication

Expressive communication

Joint attention behaviors

Social skills

Imitation

Cognition

Play

Fine motor

Gross motor

Behavior

Personal independence

Key principles of the ESDM are well represented in the criteria for fidelity of implementation, as they indicate expectations for successful delivery of the intervention. These criteria lie at the core of an ESDM intervention program and describe characteristics of a successful interaction between the child and either the therapist (if therapist-delivered) or parent (if delivered via parent coaching). Fidelity of implementation is systematically tracked using a detailed coding system, and for the purposes of simply describing key principles, criteria are as follows:

Management of child attention

Antecedent-Behavior-Consequence (ABC) format—quality of behavioral teaching

Instructional techniques application

Adult ability to modulate child affect and arousal

Management of unwanted behaviors

Quality of dyadic engagement

Adult optimization of child motivation for participating in the activity

Adult use of positive affect

Adult sensitivity and responsivity to child communicative cues

Multiple and varied communicative opportunities occur in the activity

Appropriateness of adult language for child’s language level

Joint activity structure and elaboration

Transitions between activities

In addition to these overarching key principles, some additional principles apply uniquely to specific delivery modalities. For example, in group-delivered ESDM, peer interactions are meant to serve as the predominant mechanism for teaching. In this setting, children with ASD who might initially attend minimally to their peer group are supported in practicing parallel play and imitation as attention to peers increases over time. Having double sets of toys available, and facilitating face-to-face positioning, serve to support these aims. Additionally, in this setting children with ASD gain experience with transitioning between activities and participating in both small and larger group activities.

For parent-delivered ESDM, the interactions between the clinician and parent are of key importance. Rather than the coach serving in an “expert” role, the dyad is meant to be viewed as a partnership, where the parent has valuable expertise pertaining to his or her child to contribute to the intervention. The sessions are typically low intensity (i.e., one 60- to 90-min session per week) and the course of treatment can be relatively short (e.g., 12 weeks), although longer term coaching relationships are also possible. Parents are encouraged to spend time outside of session practicing strategies taught in session, by embedding practice into typical daily routines (e.g., mealtime, bathtime, playtime). During session, parent coaches employ a cycle of a parent–child activity (including live coaching) and discussion/reflection with the parent following the activity to generate changes in the parent’s behavior, which are intended to promote change in the child’s behavior. In reflection, the coach works actively to describe (rather than judge) the parent’s and child’s behavior, and to communicate support and respect for the parent. Ultimately, developing parental self-efficacy is a key goal, such that parents are not reliant on the coach to facilitate growth in their child.

Research Support for the ESDM

The ESDM has been empirically tested in a number of different trials, which have evaluated different modes of delivery (therapist- and caregiver-delivered). Research has demonstrated significant improvements in children’s developmental and adaptive skills, particularly following an intensive, long-term (i.e., two years) course of treatment. Emerging research has begun to investigate the effect of delivery via telehealth and group settings, as well as international applications of the ESDM since it was developed and has primarily been tested in the United States.

A number of Randomized Controlled Trials (RCTs) have evaluated the efficacy of the ESDM. Dawson and colleagues (2010) compared outcomes in 18–30-month-old children with ASD who received either intensive ESDM (delivered via therapist, alongside simultaneous parent coaching) for 2 years, or referrals to community providers for treatment as usual within the community. Results revealed that children in the ESDM group demonstrated significant improvements in IQ (i.e., cognitive functioning) and adaptive behavior, and were significantly more likely to have had their diagnosis reclassified to a more moderate presentation (i.e., pervasive developmental disorder—not otherwise specified), when compared to the community treatment group. Analysis of the IQ outcomes indicated that the positive effects were primarily related to gains in receptive and expressive language, rather than nonverbal IQ. Follow-up analyses from this study reflected the ability of the ESDM to produce normalized patterns of children’s brain activity relative to the community intervention group (Dawson et al., 2012). Specifically, the ESDM group and typical children showed increased cortical activation (decreased α power and increased θ power) when viewing faces, whereas the community intervention group showed the opposite pattern (greater cortical activation when viewing objects). Greater cortical activation while viewing faces was associated with improved social behavior. The sample of children who participated in the 2010 trial 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 (Estes et al., 2015). 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 post-treatment; however, 2 years later, the ESDM group demonstrated improved core autism symptoms and adaptive behavior as compared with the community-intervention-as-usual group. An economic analysis was then conducted to determine the effect of the ESDM on health care service use and costs in this sample (Cidav et al., 2017). In the post-intervention period, compared with children who had earlier received treatment as usual in community settings, children in the ESDM group used fewer hours of ABA, occupational/physical therapy, and speech therapy services, resulting in significant cost savings in the amount of about $19,000 per year per child.

Subsequently, a multi-site, single-blind, randomized trial evaluating the efficacy of ESDM with 118 children with ASD between the ages of 14 and 24 months was published (Rogers et al., 2019). Children were randomly assigned to receive either ESDM (3 months of weekly parent coaching, followed by 24 months of therapist-delivered treatment in homes or daycare settings for an average of 15 h per week, while parents continued to receive 4 h of coaching per month) or community intervention for a period of 27 months. In light of the 2010 RCT which showed positive effects for language, the primary outcome was receptive and expressive language based on the Mullen Scales of Early Learning. Results revealed a significant treatment effect on receptive and expressive language skills for the ESDM group. Both the ESDM and community group showed similar significant gains in overall developmental quotient and adaptive behavior. Overall, results partially replicated the findings of Dawson and colleagues (2010).

In addition to these RCTs, several other studies have investigated lower-intensity ESDM delivered via parent coaching and other modalities. Rogers and colleagues (2012) conducted an RCT with 98 toddlers at risk for ASD (ages 14–24 months) and their families. Specifically, the study examined the efficacy of parent coaching in ESDM over 12 weeks of low-intensity intervention, compared to community treatment as usual. Significant and roughly equal gains were observed in both groups; however, children in the treatment as usual group required a significantly greater number of hours of intervention to generate comparable outcomes to that of the ESDM group. Current research is being conducted to examine how to make ESDM parent coaching most effective as a low intensity (and thus less costly) form of intervention.

Vismara and colleagues investigated ESDM parent coaching delivered via telehealth (Vismara et al., 2018). Parents of children with ASD were randomized to receive either 1.5 h per week of parent training delivered via telehealth, plus access to ESDM online learning resources, or 1.5 h per month of parent training delivered via telehealth, plus access to non-ESDM online learning resources; study participation spanned a period of 12 weeks. Following intervention, those in the ESDM parent training group showed greater gains in parent fidelity and program satisfaction relative to those in the control group. With regard to child outcomes, communication skills improved in both groups. Vismara and colleagues highlighted the feasibility of this modality of delivery while noting that more research is needed to better understand the potential positive effects of this treatment for improving outcomes in young children with ASD.

Vivanti and colleagues (2014) have spearheaded efforts to adapt the ESDM to a group-based setting, specifically a group-based community childcare. While children with ASD in both the ESDM group (15–25 h per week of ESDM over 12 months, in a group childcare setting) and active control group (who received a different intervention in a similar setting) gained cognitive, adaptive, and social skills, those in the ESDM group showed a relatively greater rate of development and greater gains in receptive language skills. Finally, Zhou and colleagues (2018) conducted a non-randomized controlled trial in China with toddlers with ASD between the ages of 1.5 and 2.5 years. The intervention consisted of 26 weeks of high-intensity parent coaching, compared to the control group of community treatment as usual. Following intervention, children in the ESDM group showed greater improvement in language development, social affect, and parent-reported social communication and symbolic play. Further, parents in the ESDM group reported experiencing significantly reduced parenting stress relative to those in the community treatment as usual group.

The evidence base for the ESDM continues to expand, investigating novel modalities of delivery, applications to diverse cultures, long-term follow-up, and other important approaches including treating infants showing early signs of ASD. Future research seeks to more clearly identify active ingredients of the ESDM intervention, determine optimal levels of training and supervision necessary to support an effective intervention program, compare variations of dosage and teaching style, and examine enhancements offered to the ESDM through technologically assisted modifications. Continued long-term follow-up studies will reveal how intervention in the early years contributes to later outcomes, allowing for further examination of the cost offset generated by high-quality early intervention for ASD.

Interdisciplinary Care Within Early Intervention

Common Disciplines/Types of Interventions Serving Very Young Children

For very young children on the autism spectrum, some commonly recommended treatments include ABA, speech therapy, occupational therapy, developmental preschool, and medical/psychiatric intervention, in the event of co-occurring concerns or diagnoses. Each child has unique needs that necessitate a different set of recommended treatments. A comprehensive diagnostic evaluation for ASD (typically conducted by a psychologist or developmental pediatrician, involving gold-standard tools for characterizing ASD, developmental history, and a cognitive/developmental assessment; see chapter “Interdisciplinary Evaluation of Autism Spectrum Disorder” for more details on interdisciplinary evaluation of ASD) may identify what treatments would be beneficial, or what additional follow-up testing would be warranted.

Examples of Collaboration Across Disciplines

While ASD is characterized by deficits in social communication and social interaction and the presence of restricted and repetitive behaviors and interests, associated difficulties are common, including motor and speech-language deficits, difficulties with learning and attention, co-occurring medical conditions (e.g., problems with sleep, feeding, seizures), and behavioral challenges (e.g., self-injury, aggression). Thus, it is wise to coordinate care across disciplines in order to most effectively serve the child and family. Additionally, when considering the early intervention period, most locations in the United States experience a transition in care when the child turns 3 years old, and services generally provided through the state early intervention program discontinue as the child becomes eligible for services through the public school system (i.e., developmental preschool programs, which commonly provide speech language therapy, occupational therapy, and other supports; chapter “Transition to Early Schooling for Children with ASD” provides an overview of the transition to early schooling). In order to facilitate a smooth transition and to continue to advance progress toward goals, collaboration across disciplines and teams remains critical.

How an ESDM Therapist Collaborates with Other Disciplines

ESDM is by nature a model well suited to collaboration across disciplines. The ESDM, including the ESDM curriculum, was created by an interdisciplinary team comprised of clinical and developmental psychologists, occupational therapists, and speech-language therapists. The ESDM therapist manual promotes the formation of an interdisciplinary treatment team, with both a designated team leader and parents at the center (Rogers & Dawson, 2010). The ESDM therapist is not meant to function independently or in isolation, and is ideally part of an interdisciplinary treatment team, where disciplines work together to develop and deliver the intervention plan. In doing such, the importance of effective and consistent communication cannot be understated. Two common ways of supporting effective communication include the use of a treatment notebook (consisting of individual daily data sheets and progress notes for each clinician delivering treatment) and regular team meetings focused on addressing the specific needs of the child and ensuring that the treatment goals and strategies are aligned and synergistic.

Several aspects of the ESDM make it a good fit for coordination of care across disciplines, and there are many ways in which an ESDM therapist might collaborate with other disciplines. First, professionals from a range of fields may be qualified to become trained as ESDM therapists. Training requirements mandate an advanced degree, but do not necessitate training in any particular specialty. For example, backgrounds of ESDM therapists include special education, psychology, psychiatry, speech-language therapy, occupational therapy, and behavior analysis. Thus, when communicating with fellow ESDM therapists either for peer supervision, discussions around reliability, or other topics, it is likely that one would collaborate with individuals from outside one’s own discipline. Additionally, since the ESDM targets skills from across a range of developmental domains, it becomes important to consider perspectives of those who may have relatively greater expertise in particular areas. For example, a speech-language therapist may be more comfortable addressing items/questions related to the Receptive and Expressive Communication domains, while an occupational therapist may have greater familiarity with the Personal Independence items. Participation in peer supervision with others trained in the ESDM facilitates an excellent opportunity for care informed by an interdisciplinary perspective.

Second, while a child’s ESDM therapist is working toward improving skills across domains, it may additionally be appropriate to communicate with the child’s other therapists. For example, multiple therapists using similar language and teaching techniques increase consistency, positively contributing to a child’s ability to acquire the target skills. The child’s other therapists may also be a valuable source of information regarding the child’s skills, both during the curriculum assessment (administered with the ESDM Curriculum Checklist for Young Children with Autism; Rogers & Dawson, 2009) when the ESDM therapist is formally addressing the child’s current skillset, as well as during treatment, to have an outsider’s prospective on progress, effective strategies, etc. An ESDM therapist might use information previously gathered from a recent comprehensive diagnostic evaluation, or from recent treatment progress notes, when scoring the curriculum assessment, as final codes are generated from a combination of observed behavior, parent report, and other/teacher report. An outside therapist may also provide feedback on whether improvements observed during ESDM sessions appear to have generalized to other settings.

An ESDM therapist might coordinate care with clinicians from other disciplines to develop a consistent response to challenging or disruptive behavior. For example, in the case of a child who demonstrates severe headbanging, an ESDM therapist might first request permission from the child’s caregiver(s) to rule out the possibility of a medical explanation for this behavior, possibly by consulting with the child’s pediatrician and/or neurologist. Next, the therapist might request to involve the child’s ABA therapist, speech-language pathologist, and occupational therapist in an effort to determine (1) whether the function of the behavior has been determined, (2) how communication delays may be impacting the child’s behavior and whether alternative communication strategies have been employed, and (3) if there are sensory techniques that would be appropriate to use in session.

A scenario in which it may be appropriate to lean more on other members of the child’s treatment team is when the child’s progress fails to advance as expected. A detailed decision tree denotes appropriate steps to take should this occur, including modification to teaching approaches in order to increase the likelihood of successful learning (Rogers & Dawson, 2010). For example, modifications entail a hierarchy of steps starting with the addition of reinforcers, then increasing structure, and finally incorporation of visual supports. The final step of adding visual supports suggests enhancements including adding visual symbols/icons to receptive language tasks, using a Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH; Mesibov, Shea, & Schopler, 2004)-style work system for teaching tasks involving sequencing, and adding picture exchange systems to support more effective communication (e.g., Picture Exchange Communication System (PECS); Bondy & Frost, 1994).

The Structured Teaching approach of TEACCH posits four important components, including structuring the environment appropriately to the needs of the individual, using visual strengths to support relatively weaker areas, using special interests as motivation, and supporting spontaneous functional communication (Mesibov & Shea, 2010). Many of these tenets may sound similar to the ESDM, although the ESDM does not typically include visual supports unless deemed necessary due to lack of progress, after consulting the decision tree (Rogers & Dawson, 2010). PECS is a form of augmentative and alternative communication aimed at enhancing communication by first teaching children to exchange pictures with a communication partner to request desired items (Bondy & Frost, 1994). Subsequently, the system progresses to more advanced forms of picture exchange communication. This can be an impactful addition to the ESDM when progress is slow and when children are affected by significant difficulties with communication. When the ESDM decision tree indicates the need to consider supports such as TEACCH or PECS strategies, it would be sensible to collaborate with a therapist with expertise in these systems to ensure they generate maximal benefit.

The objectives and steps generated from the ESDM curriculum assessment are commonly shared with other therapists in order to communicate a child’s current skill level and treatment plan. A completed curriculum assessment identifies the approximate age range where the child’s skills fall across all domains, and this information is used to develop treatment objectives broken down by small steps. Through sharing this information with other therapists, the treatment team can coordinate goals and priorities, and ensure consistency across therapies where possible. This alignment and reduction of competing goals may also help to facilitate parent understanding and engagement in home practice.

As described, the ESDM approach provides a multitude of opportunities to collaborate and coordinate care with other disciplines. Since the ESDM targets development across a range of domains (e.g., receptive communication, expressive communication, social skills, play, motor, personal independence), it is an intervention ripe for drawing upon the expertise of those beyond the therapist’s own discipline. Further, individuals who seek training in the ESDM are not required to have a background in a particular discipline, which is indicative of the intervention model’s appreciation for a diverse range of perspectives. An ESDM treatment program benefits from two-way communication with other clinicians who may interact with the child, including but not limited to speech-language pathologists, occupational therapists, psychologists, and physicians. Additionally, even when caregivers are not directly involved in the intervention (i.e., when delivered through modalities other than parent coaching) frequent communication with caregivers is critical to successful implementation, and the development of a good treatment plan relies on input from caregivers. The ESDM represents an example of an intervention model particularly well suited for interdisciplinary care coordination in order to optimize efficiency and effectiveness of treatment and to generate best possible outcomes for very young children on the autism spectrum.