Early Start Denver Model
Note on provider involvement: This provider has agreed to EIF’s terms of reference, and the assessment has been conducted and published with the full cooperation of the programme provider.
The Early Start Denver Model is an intensive therapeutic intervention. It is a targeted-indicated intervention for autistic children between the ages of 1 and 5 years. It is delivered at home or in a community or clinical setting, and aims to improve children’s cognitive, communicative and social-emotional skills through one-to-one therapy which is centred around play-based affective interactions and real-life activities, and based on principles of applied behavioural analysis.
ESDM is a naturalistic, play-based intervention, centred on teaching learning through social interaction. It is based on developmental psychological theories about how children typically learn and develop, especially how learning occurs within the context of social relationships by engaging in joint interactions in a shared activity, and learning to attend to important aspects of the environment needed for learning (e.g. in a routine such as playing 'peekaboo'). The programme integrates several approaches within therapy for autistic children, most significantly teaching techniques from Applied Behavioural Analysis: for instance, ‘shaping’ uses small steps to teach a bigger skill, ’prompting’ provides cues to help a child learn a skill, and ‘fading’ reduces the number of cues over time. Its overall goal is “to decrease the symptoms of autism that impair children’s ability to learn from everyday experiences and interactions”.
The manualised programme is administered one-to-one by a certified therapist, ideally working in an interdisciplinary team, in ten sessions 1.5–2 hours long for 20 hours a week. This continues for around two years, or until the ESDM Curriculum is completed. Every 12 weeks, the child's progress is reviewed using the programme checklist across a number of communicative, social and cognitive domains and new individualised learning objectives are set. They set discrete, quantifiable goals, e.g. "When the child is hungry, he will approach an adult and say, “I’m hungry,” spontaneously, with eye contact, several times per week, at home and at preschool" (Rogers, 2016:52). The therapist works with the child and parents to identify their priorities, and incorporates the child's own interests and preferences into the therapy. The sessions ideally take place in a familiar environment for the child, such as at home. Parent involvement is important in the programme, and parents are taught skills to embed ESDM techniques in everyday life. At preschool age, playdates with peers are incorporated.
The most rigorous evaluations of ESDM did not measure outcomes for children and young people’s wellbeing, or long-term effects. Additional research in this area would be valuable, particularly as some members of the autistic community advocate for shifting from ‘intervention’ (focus on changing autistic behaviour) to ‘support’ (focus on accommodation) (Davis et al., 2022) and parents of autistic children as well as autistic adults call for a focus on 'real world' outcomes, especially mental health and wellbeing (Autistica, 2016). For more on different approaches to autism interventions and support, the voice of the autistic community, and consideration of individuals' needs, see Davis et al., 2022.
References
Autistica. (2016). Your questions: Shaping future autism research. Available at https://www.autistica.org.uk/downloads/files/Autism-Top-10-Your-Priorities-for-Autism-Research.pdf
Davis, R., Nordahl-Hansen, A., den Houting, J., & Fletcher-Watson, S. (2022). Chapter 39: Helping autistic children. In P. K. Smith & C. H. Hart (Eds.), The Wiley-Blackwell Handbook of Childhood Social Development, 3rd Edition (pp.729–746). Available at https://osf.io/preprints/osf/zrfyp.
Rogers, S. (2016). Early Start Denver Model. In R. G. Romanczyk & J. McEachin (Eds.), Comprehensive Models of Autism Spectrum Disorder Treatment (pp. 45–62). Springer International Publishing. Available at https://link.springer.com/chapter/10.1007/978-3-319-40904-7_3
EIF Programme Assessment
Early Start Denver Model has evidence of a short-term positive impact on child outcomes from at least one rigorous evaluation.
What does the evidence rating mean?
Level 3 indicates evidence of efficacy. This means the programme can be described as evidence-based: it has evidence from at least one rigorously conducted RCT or QED demonstrating a statistically significant positive impact on at least one child outcome.
This programme does not receive a rating of 4 as it has not yet replicated its results in another rigorously conducted study, where at least one study indicates long-term impacts, and at least one uses measures independent of study participants.
The Programme Assessment applies only to the Early Start Denver Model delivered one-to-one; the Parent Early Start Denver Model (P-ESDM) and Group Early Start Denver Model (G-ESDM) were not assessed.
A rating of 5 indicates that a programme has a high cost to set up and deliver, compared with other interventions reviewed by EIF. This is equivalent to an estimated unit cost of more than £2,000.
Child outcomes
According to the best available evidence for this programme's impact, it can achieve the following positive outcomes for children:
Enhancing school achievement & employment
Early Start Denver Model
Key programme characteristics
Who is it for?
The best available evidence for this programme relates to the following age-groups:
- Toddlers
- Preschool
How is it delivered?
The best available evidence for this programme relates to implementation through these delivery models:
- Individual
Where is it delivered?
The best available evidence for this programme relates to its implementation in these settings:
- Home
- Children's centre or early-years setting
- Out-patient health setting
How is it targeted?
The best available evidence for this programme relates to its implementation as:
- Targeted indicated
Where has it been implemented?
Argentina, Australia, Austria, Belgium, Brazil, Canada, Chile, China, Denmark, Ecuador, France, Germany, Ireland, Israel, Italy, Japan, Kuwait, Mexico, New Zealand, Nicaragua, Peru, Poland, Portugal, Romania, Russia, Singapore, Slovakia, South Africa, South Korea, Spain, Sweden, Switzerland, Taiwan, Turkey, Ukraine, United Kingdom, United States
UK provision
This programme has been implemented in the UK.
UK evaluation
This programme’s best evidence does not include evaluation conducted in the UK.
Spotlight sets
EIF does not currently include this programme within any Spotlight set.
Early Start Denver Model
About the programme
What happens during delivery?
How is it delivered?
The Early Start Denver Model is delivered in ten sessions of 2 hours’ duration each per week for around two years by a practitioner, to individual families.
What happens during the intervention?
- During a session, the therapist and child engage in a series of short joint activities, which may include playing alongside each other, interacting with the same object, playing together with the same object or playing a game such as 'peekaboo'. These create a social-emotional context for learning. In these interactions, the therapist seeks to help the child attend to key information in their environment which is needed for language and social development (e.g. faces, action, emotions).
- At preschool age, child-child play dates are also incorporated into the intervention.
- Parents are also given training to use techniques from the Early Start Denver Model and encouraged to implement them at home throughout the day. For example, they are taught to follow the child's lead and talk about what the child is already engaging in (rather than directing the child's attention elsewhere).
- The programme has a manual, and a Curriculum Checklist which enables individualised objectives to be set for each child across a number of domains (receptive and expressive communication, joint attention, imitation, social skills, play skills, cognitive skills, fine and gross motor skills, and self-care skills). These are assessed every 12 weeks.
- It is intended that the therapist is supported by a multi-disciplinary team including child psychologists, speech and language therapists and occupational therapists.
What are the implementation requirements?
Who can deliver it?
Certified
therapists have at least a BSc or BA in a relevant degree (e.g. Early Years
Education, Psychology, etc.) and a MSc or MA and have successfully completed the
ESDM training and certification process.
What are the training requirements?
The training includes:
- reading of the ESDM published manual (Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement, by Rogers & Dawson, 2010),
- introduction workshop online,
- advanced workshop
- at least 2 cases of practice,
- supervision hours
- certification process
Booster training is recommended.
How are the practitioners supervised?
Practitioners are supervised by their ESDM trainer.
What are the systems for maintaining fidelity?
Interaction videos are assessed for fidelity. Supervision is available.
Is there a licensing requirement?
There is no licence required to run this programme.
How does it work? (Theory of Change)
How does it work?
- Positive relationships provide a rich learning context in which children develop communicative skills, including language and social interaction.
- Therapists and parents develop positive relationships with the child. In addition, therapists use a range of Applied Behavioural Analysis techniques in a developmentally appropriate, play-based way to teach a range of skills, including communication skills.
- Parent training helps parents to implement ESDM techniques in everyday life.
- In the short-term, it is intended that children develop their communication, which may involve verbal or non-verbal communication, social-emotional, cognitive, play and self-care skills; parents also learn ESDM techniques.
- In the long-term, it is intended that children’s communication, social-emotional, cognitive, play and self-care skills improve.
Intended outcomes
Enhancing school achievement & employment
Contact details
Ifigeneia Mourelatou
Recognition Health
[email protected]
Early Start Denver Model
About the evidence
The Early Start Denver Model’s most rigorous evidence comes from an RCT which was conducted in the US.
This study identified statistically significant positive impact on one child outcomes.
A programme receives the same rating as its most robust study, which in this case is the Sulllivan (2013) study, and so the programme receives a Level 3 rating overall.
Study 1
| Citation: | Sullivan (2013) |
|---|---|
| Design: | RCT |
| Country: | United States |
| Sample: | 48 children aged between 18 and 30 months old (range in treatment group 18-30 months, mean 23.9 months, standard deviation 4 months) diagnosed with autism (meeting criteria for autistic spectrum disorder or Pervasive Developmental Disorder – Not Otherwise Specified based on the DSM-IV). |
| Timing: | Post-test |
| Child outcomes: | Improved receptive and expressive language |
| Other outcomes: | None measured |
| Study rating: | 3 |
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2010). Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. https://doi.org/10.1542/peds.2009-0958
Sullivan, K. A. (2013). The Early Start Denver Model: Outcomes and Moderators of an Intervention for Toddlers with Autism. [Doctoral Dissertation, University of Washington ]. https://digital.lib.washington.edu:443/researchworks/handle/1773/24294
Dawson et al., (2010) is excluded from contributing to the programme rating due to methodological limitations.
Study design and sample
The first study is a rigorously conducted RCT. This study involved random assignment of children to an ESDM treatment group and a business as usual control group . This study was conducted in the US , with a sample of children aged between 18 and 30 months at the start of the study, with a diagnosis of autism. Most children were White (72.9%), with Asian (12.5%), Latino (12.5%) and multiracial (14.6%). The male-to-female ratio of 3.5:1 reflects the diagnosis rates of autism at the time.
Measures
Expressive and receptive language was measured using the Mullen Scales of Early Learning (Expressive Language and Receptive Language subscales ) (direct assessment).
Gesture and positive affect was measured using the Communication and Symbolic Behaviour Scales – Developmental Profile (subscales) (direct assessment).
Findings
This study identified statistically significant positive impact on a child outcome. This includes receptive and expressive language.
Dawson et al (2010) describes additional outcomes from study 1 described above . The conclusions that can be drawn from this study are limited by methodological issues pertaining to a lack of intention-to-treat analysis, so it received a Level 2+ and does not contribute to the overall programme rating. In this case:
- At post-test, social, communication, motor and daily living skills were measured by the Vineland Adaptive Behaviour Scales] (parent report) )
- This study identified statistically significant positive impact on a number of child outcomes. This includes Mullen Scales of Early Learning and Vineland Adaptive Behaviour Scales.
Other studies
The following studies were identified for this programme but did not count towards the programme's overall evidence rating. A programme receives the same rating as its most robust study or studies.
Other evaluation studies of ESDM were identified but excluded for the reasons given:
Aaronson, B., Estes, A., Rogers, S. J., Dawson, G., & Bernier, R. (2021). The Early Start Denver Model Intervention and Mu Rhythm Attenuation in Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 1-10.https://doi.org/10.1007/s10803-021-05190-7
Sample too small.
Chiang, C. H., Lin, T. L., Lin, H. Y., Ho, S. Y., Wong, C. C., & Wu, H. C. (2022). Short-term low-intensity Early Start Denver Model program implemented in regional hospitals in Northern Taiwan. Autism, https://doi.org/10.1177/13623613221117444
Comparison group design (non-randomised)
Colombi, C., Narzisi, A., Ruta, L., Cigala, V., Gagliano, A., Pioggia, G., ... & Prima Pietra Team. (2018). Implementation of the early start denver model in an Italian community. Autism, 22(2), 126-133. https://doi.org/10.1177/1362361316665792
Comparison group design (non-randomised)
Cucinotta, F., Vetri, L., Ruta, L., Turriziani, L., Benedetto, L., Ingrassia, M., ... & Gagliano, A. (2022). Impact of Three Kinds of Early Interventions on Developmental Profile in Toddlers with Autism Spectrum Disorder. Journal of Clinical Medicine, 11(18), 5424. https://doi.org/10.3390/jcm11185424
Retrospective chart review study design
Dawson, G., Jones, E. J. H., Merkle, K., Venema, K., Lowy, R., Faja, S.,& Webb, S. J. (2012). Early behavioral intervention is associated with normalized brain activity in young children with autism. Journal of the American Academy of Child and Adolescent Psychiatry, 51(11), 1150–1159. doi:10.1016/j.jaac.2012.08.018.
High attrition / small sample size.
Devescovi, R., Colonna, V., Dissegna, A., Bresciani, G., Carrozzi, M., & Colombi, C. (2021). Feasibility and outcomes of the early start denver model delivered within the public health system of the friuli venezia giulia Italian Region. Brain sciences, 11(9), 1191. https://doi.org/10.3390/brainsci11091191
Comparison group design (non-randomised)
Estes, A., Munson, J., Rogers, S. J., Greenson, J., Winter, J., & Dawson, G. (2015). Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(7), 580-587. https://doi.org/10.1016/j.jaac.2015.04.005
High attrition / small sample size
Estes, Annette, Paul Yoder, John McEachin, Gerhard Hellemann, Jeffrey Munson, Jessica Greenson, Marie Rocha, Elizabeth Gardner, and Sally J. Rogers. "The effect of early autism intervention on parental sense of efficacy in a randomized trial depends on the initial level of parent stress." Autism 25, no. 7 (2021): 1924-1934.https://doi.org/10.1177/13623613211005613
Parent outcomes.
Feng, J. Y., Li, H. H., Shan, L., Wang, B., & Jia, F. Y. (2019). Clinical effect of vitamin D 3 combined with the Early Start Denver Model in the treatment of autism spectrum disorder in toddlers. Zhongguo Dang dai er ke za zhi= Chinese Journal of Contemporary Pediatrics, 21(4), 337-341. 10.7499/j.issn.1008-8830.2019.04.007
No Business As Usual control group.
Gao, D., Yu, T., Li, C. L., Jia, F. Y., & Li, H. H. (2020). Effect of parental training based on Early Start Denver Model combined with intensive training on children with autism spectrum disorder and its impact on parenting stress. Zhongguo Dang dai er ke za zhi= Chinese Journal of Contemporary Pediatrics, 22(2), 158-163. 10.7499/j.issn.1008-8830.2020.02.014
No Business As Usual control group / full text only available in Chinese>
Laister, D., Stammler, M., Vivanti, G., & Holzinger, D. (2021). Social-communicative gestures at baseline predict verbal and nonverbal gains for children with autism receiving the Early Start Denver Model. Autism, 25(6), 1640-1652. https://doi.org/10.1177/1362361321999905
Pre- post-design
Laister, D., Vivanti, G., Marschik, P. B., Fellinger, J., & Holzinger, D. (2021). Enhancement of social communication behaviors in young children with autism affects maternal stress. Frontiers in Psychiatry, 12, 797148. https://doi.org/10.3389/fpsyt.2021.797148
Pre- post-design
Li, H. H., Li, C. L., Gao, D., Pan, X. Y., & Jia, F. Y. (2018). Preliminary application of Early Start Denver Model in children with autism spectrum disorder. Zhongguo Dang dai er ke za zhi= Chinese Journal of Contemporary Pediatrics, 20(10), 793-798. 10.7499/j.issn.1008-8830.2018.10.002
Full text only available in Chinese
Normand, J. L’Early Start Denver Model (Modèle de Denver): étude contrôlée dans une population d’enfants avec Trouble du Spectre de l’Autisme. Masters thesis. https://dumas.ccsd.cnrs.fr/dumas-01062874
Small sample size / comparison group design
Rogers, S. J., Estes, A., Lord, C., Munson, J., Rocha, M., Winter, J., ... & Talbott, M. (2019). A multisite randomized controlled two-phase trial of the Early Start Denver Model compared to treatment as usual. Journal of the American Academy of Child & Adolescent Psychiatry, 58(9), 853-865. https://doi.org/10.1016/j.jaac.2019.01.004
Methodological issues; this study was assessed at rated NL2
Rogers, S. J., Yoder, P., Estes, A., Warren, Z., McEachin, J., Munson, J., ... & Whelan, F. (2021). A multisite randomized controlled trial comparing the effects of intervention intensity and intervention style on outcomes for young children with autism. Journal of the American Academy of Child & Adolescent Psychiatry, 60(6), 710-722. https://doi.org/10.1016/j.jaac.2020.06.013
Superiority trial: no Business as Usual control group
Sayid, H. A. (2020). Early Start Denver Model Developing Social Skills For Virtual Autism Children. Al-Adab Journal, 1(135 Supplement 1). https://www.iasj.net/iasj/article/194905
Small sample size
Vismara, L. A., Young, G. S., Stahmer, A. C., Griffith, E. M., & Rogers, S. J. (2009). Dissemination of evidence-based practice: Can we train therapists from a distance?. Journal of Autism and Developmental Disorders, 39, 1636-1651. https://doi.org/10.1007/s10803-009-0796-2
Pre- post design
Waddington, H. (2018). Evaluation of low-intensity therapy and parent training for young children with autism based on the early start Denver model. Doctoral Thesis. University of Wellington http://hdl.handle.net/10063/7070
Pre- post- design / small sample size
Waddington, H., Curtis, S., van Noorden, L., Sigafoos, J., van der Meer, L., & Whitehouse, A. (2022). Evaluation of Low-intensity Therapist-Delivered Intervention in Addition to Parent Coaching for Young Children with Autism Spectrum Disorder. International Journal of Disability, Development and Education, 1-21.https://doi.org/10.1080/1034912X.2022.2120601
Pre- post- design / small sample size
Wang, J., Gu, D., Sun, Y., Jia, F., & Li, H. (2019). Efficacy analysis of Early Start Denver model in children with autism spectrum disorder. Chinese Journal of Behavioral Medicine and Brain Science, 684-688. https://pesquisa.bvsalud.org/portal/resource/pt/wpr-754184
Full text only available in Chinese
Xu, Y., Yang, J., Yao, J., Chen, J., Zhuang, X., Wang, W., ... & Lee, G. T. (2018). A pilot study of a culturally adapted early intervention for young children with autism spectrum disorders in China. Journal of Early Intervention, 40(1), 52-68. https://doi.org/10.1177/1053815117748408
Small sample size
Zelmar, A., Herman, L., Tenant, G., Bouveret, L., Touzet, S., & Geoffray, M. M. (2018). Impact of the ESDM on the development of children with ASD in a European French-speaking population: First results of the intervention implementation. Revue d'Épidémiologie et de Santé Publique, 66, S416.https://doi.org/10.1016/j.respe.2018.05.490
Implementation of ongoing study
Through our searches we also identified further studies which were excluded as they were either not evaluations or evaluated a different version (P-ESDM or G-ESDM); a list of references is available on request.
Published July 2024