The Early Start Denver Model: A Guide for Parents

ESDM

The timing of social communication development can make a big difference for children who are at risk for Autism Spectrum Disorder (ASD). Many parents expect their one-year-old to be talking or saying a few words. However, language gets delayed because the prerequisite social communication skills are delayed or underdeveloped. This is why early intervention is vital when treating Autism and other developmental disabilities.

The Early Start Denver Model (ESDM) directly addresses babies’ and toddlers’ social communication deficits making it an ideal early intervention model. This article will explore the ESDM in more detail providing information about the intervention and how parents can actively participate in the process.

What is the Early Start Denver Model?

The ESDM is a type of behavior therapy for children with Autism between the ages of 12 months and 48 months old. This model is a blend of Applied Behavior Analysis (ABA) and developmental science. ESDM uses a play-based approach to naturally teach foundational communication and social skills to babies and toddlers. Therapy is provided by parents and trained therapists during the child’s daily routine at home or during playtime.

Children who have gone through the ESDM as babies or toddlers performed better in later programs that focused on language and social skills acquisition. This is because the intervention model helps to establish social communication behaviors in children at an early age. These skills then allow children with ASD to naturally seek out connections with others and provide the basis for a smooth transition into other therapy treatments.

Social communication refers to how we interact with one another. Many skill sets are directly tied to or subtly linked to our ability to communicate and interact socially. These skills typically develop early in a child through interactions with primary caregivers during everyday activities. Some examples of social communication are making direct eye contact, sharing smiles with others, babbling at people, and gestures such as waving or pointing.

Early signs of Autism are a lack of these skills. If they are not developing the child is missing out on opportunities to learn how to communicate for social purposes. For example, if a child does not understand or use gestures, he will likely have a problem with nonverbal communication when he gets older. If a child talks but only about special interests, he will likely have difficulty tuning into others.

Social communication skills are important for language development, classroom readiness, and relationships with others. A critical window to support the development of these skills is within the first three years of life. Early intervention programs, such as the ESDM, are crucial because the inability to learn in an integrated, socially focused environment can impact a child’s overall cognitive development.

Origins and Development of ESDM

At the time, there were very few treatment options available for young children being diagnosed with or at risk for ASD. Recognizing the need for a comprehensive intervention that could be delivered early in a child’s life and utilize parent involvement, Dr. Sally Rogers and Dr. Geraldine Dawson collaborated to create the ESDM. Their research was conducted at the MIND Institute at the University of California, Davis.

The ESDM originated in the 1980s as a group program for young children with ASD funded by the US Department of Education at the University of Colorado Health Sciences Center. This approach referred to as the Denver Model, was based on findings from child development research and early intervention research to build a curriculum and strategy that would build social, communication, cognitive, and play skills for children ages 2 to 5 years. The Denver Model was designed to also incorporate family members in the therapeutic process.

In the 1990’s the Denver Model expanded to include principles of ABA, intensive home programs, and inclusive group programs. Then in 2003, the ESDM was developed by Rogers and Dawson to specifically address the needs of babies, toddlers, and their families for parent involvement and intensive care.

The ESDM was designed to be a combination of developmental sciences, learning sciences, and behavioral sciences. While the intervention model is based on the principles of ABA, it took a play-based approach to make therapy more enjoyable for children and to avoid similar criticism of ABA, such as being too harsh and strict.

The first randomized control trial of ESDM was conducted in 2009 by Sally and Rogers. The results showed children who went through the ESDM made significant gains in cognitive, language, and social skills compared to those who received community treatment as usual.

The ESDM was manualized by Rogers and Dawson in 2010. Since then, over a dozen studies have been conducted, all showing positive results. Children who go through the intervention model learn more skills and perform better in later programs. The program has been translated into four languages and is used in over fifteen countries to help thousands of families with children diagnosed with ASD.

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Core Principles of ESDM

The ESDM is guided by several core principles that underscore its philosophy and approach. These principles are essential for achieving the supportive learning environment children with ASD need to thrive. The core principles are as follows:

  1. Play-based, relationship-focused approach – Play is the primary method for babies and toddlers for learning, facilitating engagement, increasing motivation to communicate, and social reciprocity. Therapists using the ESDM use child-led play to create opportunities for skill development by embedding teaching opportunities into everyday activities. Children with ASD learn best through naturalistic, play-based interactions designed to nurture warm relationships.
  2. Integration of behavioral and developmental sciences – ESDM integrates the principles of ABA such as reinforcement, shaping, and prompting to teach new skills in line with the developmental milestones.
  3. Focus on social interaction, communication, and learning – Social communication skills are fundamental to the outcome of children with ASD. Therefore, the ESDM prioritizes teaching these skills by targeting behaviors such as joint attention, imitation, and turn-taking. The intervention model fosters language development and builds social relationships through structured activities and naturalistic teaching strategies.
  4. Naturalistic teaching within a structured environment – The ESDM embeds teaching opportunities within the child’s natural environment and daily routine. The model maintains a structured framework that ensures consistency, predictability, and the systematic targeting of goals. However, this framework is presented during the child’s daily life and play routines.

ESDM Methodology

Early Start Denver Model methodology

The ESDM contains a Curriculum Checklist which is a 480-item assessment tool that spans 0 to 48 months and covers all developmental domains. The focus areas are:

  1. Social communication emphasizes the development of social interaction skills such as joint attention, imitation, and turn-taking.
  2. Cognitive skills focus on promoting a child’s cognitive skills such as problem-solving, memory, and executive functioning.
  3. Language and communication targets the development of expressive and receptive language skills such as vocabulary.
  4. Adaptive behavior addresses self-help skills such as dressing and feeding to promote independence and appropriate behavior in various settings.

The child is assessed against the assessment tool before beginning an ESDM program. The assessment enables professionals to know exactly where to start teaching the child and identifies skills and the areas that need improvement.

From that assessment, a very comprehensive and individualized program is developed for the child with 24 to 36 objectives that span a 10-week quarter. Each of those objectives is broken down into teaching steps which will work to build the child’s development from the undeveloped version of the behavioral skill to the more developed version of the behavioral skill over those 10 weeks. Data is collected against those objectives daily to monitor progress and adjust objectives as the child progresses.

The core principles are used to implement the child’s program and objectives within joint activity routines or relationship-based play. ESDM sessions resemble play during which the child and therapist are engaged in fun activities.  The activities are carefully constructed using a theme that is elaborated to allow for variation of play, increased motivation, and improved flexibility.

There are choices given to the child and the adult helps the child make those choices to capture motivation at the start of an activity. The sessions include a balance where the adult has as many turns as the child during which they share a gaze, a smile, materials, and turns. Through these processes, the child learns that the adult is a fun play partner and worth attending to.

In addition to the therapy sessions, parent involvement is a crucial element of the intervention model. Parent involvement strengthens the bond between the parent and child and builds a social relationship, while also creating opportunities for consistent learning and skill generalization outside of therapy sessions.

Parent training sessions focus on teaching parents to integrate strategies and techniques into their child’s daily life. This includes creating a structured home environment, promoting social communication, and facilitating play and learning opportunities.

Efficacy and Benefits of ESDM

Numerous studies have shown the efficacy of the ESDM. Dawson, Roger, et al (2010) compared 48 children ages 18 to 30 months old in two groups. The first group received the ESDM, and the second group received any alternative available treatment. After two years, the group that received the ESDM treatment option not only experienced an average IQ increase of 17.6 points but continued to experience growth in play and social skills. The second group had a 7-point increase in IQ and experienced more delays regarding adaptive behavior.

Additionally, it was noted that the ESDM group experienced more changes in their diagnosis from ASD to Pervasive Development Disorder, Not Otherwise Specified (PDD, NOS) as compared to the second group. The trials also showed that children with ASD who experienced 20 hours per week of instruction time at a young age performed better in later programs focusing on language and social skills, regardless of the severity of learning issues.

This study was replicated by Holehan and Zane in 2019 which produced similar effects. Numerous other studies have shown improvements in communication and social skills, enhanced cognitive and adaptive skills, and the promotion of independence and school readiness.

Eligibility and Suitability for ESDM

The ESDM was specifically designed to be used with children between the ages of 12 and 48 months who have been diagnosed with ASD or are at risk of developing ASD. However, the program can be used throughout the preschool years and with children with other developmental disorders or delays.

When selecting an intervention approach, it is first essential to determine the individual needs of the child. Babies and toddlers who display early signs of ASD such as impaired social communication, social interaction, and language delays are suitable candidates for the ESDM as the model directly addresses these deficits.

The ESDM is a flexible intervention model that can be adapted to meet the individual needs of each child. For example, ESDM can be designed to focus on alternative forms of communication such as sign language or AAC devices for nonverbal children. In addition, goals can be modified. For example, instead of targeting spoken language, program objectives can focus on prelinguistic skills such as joint attention and gestural communication.

Implementing ESDM at Home

Parents play a critical role in the child’s development and progress during the ESDM intervention. A component of the ESDM program is to train parents in the techniques and strategies involved so they can incorporate them into their daily lives and promote the generalization of learned skills.

The ESDM program includes a parent manual that offers multiple ways parents can help children build skills during typical routines while involving the entire family in the therapeutic process. Parents should pay attention to what the child likes, follow their lead, actively participate in the activity, and have fun doing it. The parent manual covers:

  1. Sensory social skills
  2. Interacting with others
  3. Using appropriate nonverbal communication
  4. Imitating behaviors appropriately
  5. Appropriate play skills
  6. Speech and language development

ESDM strategies can be seamlessly implemented in the child’s home environment during the family’s routine. Therefore, it is not disruptive to other family members. For example, during mealtime, parents can work on requesting items like a particular food from the table, using utensils, or identifying food items.

Parents can also work on building communication through activities such as modeling language, expanding on the child’s verbal language, and providing visual support, such as picture cards to help with communication. Parents should encourage the child to request what they want and provide positive reinforcement in response. Praise and encouragement should be frequently used during parent-child interactions.

Professional Support and Services

ESDM-support

The individuals who offer ESDM range from psychologists, developmental pediatricians, board-certified behavior analysts, occupational therapists, speech and language pathologists, and early intervention specialists. All therapists must have specific training and certification in ESDM. This ensures that a certified professional who has the knowledge and skills to successfully use the ESDM teaching strategies will be working with your child.

A multidisciplinary team will enhance the effectiveness of ESDM intervention and provide the most comprehensive care. The team members will include the professionals listed above as well as parents and family members who receive training and supervision from the professionals. From the treatment team, one person is identified as the lead therapist who will conduct the ESDM sessions. The remaining team members should consult with the lead therapist as needed, especially during the assessment and goal-setting phase.

Many types of private health insurance companies are required to cover services related to ASD. However, this depends on the kind of insurance you have and the state you live in. All Medicaid plans must cover treatments that are medically necessary for children under the age of 21. If a doctor recommends ESDM and deems it medically necessary, Medicaid must cover the cost.

Some children are eligible to receive ESDM through their early intervention program which is offered in each state to children under 3 years of age who are not developing at the same rate as peers. These services are free or at a low cost, dependent on your family’s income.

Challenges and Considerations

Implementing the ESDM can pose several challenges that parents must consider before beginning the process. The intervention model requires a significant investment in resources such as time and money. The program’s design requires frequent therapy sessions with trained professionals, parent training, and structured playtime. This can become difficult for parents who must balance other commitments. The frequent sessions by trained professionals can also impose a financial burden on families, which is particularly true in cases where insurance does not cover the service.

It can also be challenging to gain access to a professional specifically trained to administer ESDM strategies. There are some areas where the intervention is not widely available, this can lead to inconsistent delivery, delays in services, and an overall ineffective program.

Managing expectations is another crucial aspect because progress within the ESDM program is not always linear. Therapists must collect data daily to track progress so that interventions can be adjusted accordingly. This will also allow parents to gain an understanding of the skills the child has learned. Parents must understand that each child will progress at their own pace and measurable outcomes can take time to emerge.

Parental Involvement and Empowerment

Parents need to be involved in the intervention by choosing goals they feel are significant and by learning the strategies from the therapist. As parents become trained and more confident in their skills, they can use the program at home which allows the child to receive additional benefits.

Parents also need to be educated on ESDM to ensure their child is receiving the best care from an appropriate therapist. Some questions parents should consider asking are:

  1. Who will be conducting the sessions?
  2. What training will be offered to parents?
  3. Where will sessions be conducted?
  4. How will you determine treatment goals?
  5. Are you trained to offer ESDM therapy?
  6. How will you monitor progress?
  7. What type of progress should we expect?

Rogers, Dawson, and Vismara wrote a training manual that can be used by parents called “An Early Start for Your Child with Autism – Using Everyday Activities to Help Kids Connect, Communicate, and Learn” which contains suggested activities that can be implemented during the daily routine or playtime. In addition, the UC Davis Health MIND Institute website provides a monthly updated list of all trained ESDM providers worldwide.

Conclusion

In conclusion, the ESDM is an effective, evidence-based intervention for children with ASD or at risk for developing ASD. Its goal is to give children with ASD the best possible chance to thrive and to establish a relationship between parents and their children. This is achieved through its emphasis on early intervention, individualized support, and collaboration between parents and therapists. Its blend of behavioral and developmental sciences provides an intervention that targets key areas of development such as social communication skills, cognition, and adaptive skills.

References 

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), 17-23.

Holehan, K. M., & Zane, T. (2019). Is there science behind that: The Early Start Denver Model? Science in Autism Treatment, 15(2). 

Rogers, S.J., & Dawson, G. (2010) The Early Start Denver Model for Young Children with Autism: Promoting language, learning, and engagement. NY: Guilford.

Rogers, S.J., Dawson, G., & Vismara, L.A. (2012) An early start for your child with autism: Using everyday activities to help kids connect, communicate and learn. New York:  Guilford Press

Rogers, S.J., Vismara, L.A., and Dawson, G. (2021) Coaching parents of young children with autism: Promoting connection, communication, and learning. NY: Guilford Press.

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