Introducing the Early Start Denver Model (ESDM)

In 2010, the ESDM was named “top 10 medical interventions” by TIME Magazine.

This month's post was written by guest writer, Dr. Plern Pratoomas. Dr. Plern is an Early Intervention and Child Development Specialist, who is currently the only ESDM Certified Trainer in Thailand. When Dr. Plern first introduced the ESDM for children with Autism to me, I was left in awe. Many children who I work with have Autism, and the more I learned about the ESDM, the more I realised how beneficial this could be for their overall development. If you would like to know more about the ESDM, you can read about it below. 
Speak soon,
The Expat Speechie

What is the Early Start Denver Model (ESDM)? 
The ESDM is an intervention designed to address the challenges faced by young children with Autism. The overarching goal of ESDM is to bring the child back into the social world so they can engage in social learning. ESDM therapy prioritizes the building blocks required for social learning - by teaching early interaction skills such as imitation, joint attention, communication, and turn-taking, ESDM therapy aims to fill in the developmental gaps that are commonly seen in children with Autism. 

The ESDM uniquely combines two different approaches by blending together developmental principles and behavioral teaching techniques into one comprehensive intervention program. The ESDM is developmental in its approach, as it is grounded in developmental research and how typical children learn and grow. However, the ESDM is also behavioral because it incorporates teaching techniques and procedures from the field of Applied Behavior Analysis (ABA). 

At its core, the ESDM is relationship-based, which means that the way in which ABA teaching procedures are used in therapy is very natural and a heavy focus is on back-and-forth engagement, social communication, and social interaction. 

The ESDM uses a trans-disciplinary approach because Autism impacts all areas of a child’s development. One team member acts as a “team lead” and is responsible for providing the intervention, while experts from other fields provide ongoing feedback and consultation. In essence, there is only one treatment plan that incorporates a multidisciplinary perspective. This approach streamlines intervention for the family and ensures that the therapist focuses on the integration of skills across different developmental domains. 

What does the ESDM offer that other programs do not?
The ESDM is manualised with clear instructions and guidelines on assessment, teaching content, and teaching procedures. The ESDM is curriculum-based, which means that results from the assessment (“ESDM Curriculum Checklist”) determine the goals and objectives that an ESDM therapist will choose to target in the intervention. 

To ensure standardization of treatment and therapist skills, the ESDM has an ESDM Teaching Fidelity Rating System to measure and maintain the quality of therapy implementation. All of the above ensures that ESDM intervention is both customized to each child’s needs but standardized in regard to quality and content.

If you are more familiar with social-developmental interventions (e.g. DIR/Floortime, SCERTS, RTI), the ESDM might seem too behavioral. If you are more familiar with behavioral interventions, the ESDM may seem too developmental. Since ESDM is a unique blend of these two approaches, it is important to note the ways in which the ESDM is different from other interventions. 

The ESDM differs from most developmental interventions in these ways:

1. There have been a number of peer-reviewed studies published over the last 10 years that provide empirical support for the effectiveness of the ESDM in improving outcomes in infants and toddlers with Autism. Out of all developmentally-based early intervention programs available for young children with Autism, ESDM is the most studied model to date.
2. The ESDM is manualized and there are clear guidelines on how to conduct the assessment and deliver the intervention. The ESDM Fidelity Rating System ensures fidelity of implementation and maintains a standard for those learning and/or using the model.
3. The ESDM is data-driven and utilizes Response to Intervention. Therapists monitor child progress on a daily basis by using data-collection systems that track each child’s performance on his or her teaching objectives over time. When a child does not make progress on an objective, therapists use a decision tree to decide how they can adapt the intervention to ensure continued progress.
4. Within its developmental framework, the ESDM utilizes teaching practices that are grounded in Applied Behavior Analysis. ABA teaching procedures such as prompting, shaping, and chaining, are all part of ESDM intervention and therapists must be able to deliver high-frequency, intensive teaching during therapy sessions.

When comparing the ESDM to other behavioral approaches (e.g. Discrete Trial Training or other traditional ABA programs), ESDM is different in these ways:

1. The ESDM uses a curriculum that is based on scientific findings in child development research, thereby ensuring that the teaching content is functional and relevant to the lives of children and their families.
2. The ESDM focuses explicitly on reciprocal social interaction, the quality of relationships, positive affect, and adults’ ability to be sensitive and responsive to the child, which are often overlooked or not focal points in ABA programs.
3. The development of language is viewed from a developmental perspective, which posits that language development is social in nature and therefore, must be developed within the context of social interaction and engagement, rather than in a discrete or isolated manner that is more common in behavioral programs.

What does ESDM therapy look and feel like?
If you were to walk into an ESDM therapy session at its best, you would see:

• Well-developed activities with joint participation by both therapist and child
• Shared smiles and glances between therapist and child
• Both therapist and child co-constructing activities together and shared engagement throughout… lots of dyadic engagement and interaction
• Frequent turn-taking and a balance of control between therapist and child
• The therapist is skilled at presenting multiple learning opportunities and supports the child to be successful
• Parents are present and involved in sessions
• The therapist is responsive and sensitive to the child’s attempts to communicate and express him/herself
• Behaviors are managed skillfully by the therapist and the child is able to regulate arousal/affect and be ready for learning
• The therapist models ways the child can use to communicate a variety of different messages. The therapist respects and reinforces child’s attempts to communicate.
• There is a balance between object-based and social games during sessions

Where does ESDM therapy take place?
ESDM therapy can take place across many locations, including in the family’s home, at school/daycare, or out in the community. 

Who is the ESDM for?
As an early intervention program, the ESDM was developed to be used with infants, toddlers, and preschoolers with Autism. Children as young as 1 year old up to the age of 5 years can benefit from ESDM therapy. 

Who delivers ESDM treatment?
The treatment can be delivered by a range of early childhood professionals (e.g. Special Education, ABA, Speech and Language Therapy, Physical Therapy, Occupational Therapy, Psychology) or trainees who work with children with Autism and who have read the ESDM manual can deliver ESDM treatment within their own practice. However, ESDM Certified Therapists have been through additional, more rigorous training and have met fidelity of implementation with multiple children. 

What is the effectiveness of the ESDM for young children with Autism?
There is a growing body of research that demonstrates the effectiveness of ESDM intervention. For a list of published articles, please visit: https://www.esdm.co/research-articles

Finally, if you are a parent and think that the ESDM might be a good fit for your child, please contact Little Sprouts Children's Centre to inquire about Thailand’s first official ESDM program (managed and supervised by an interdisciplinary team of professionals, including supervision and training by an ESDM Certified Trainer).

If you are a professional and would like to pursue formal training and/or ESDM certification, please contact Plern Pratoommas at [email protected].  For more information about the official ESDM training/certification process, please visit: www.esdm.co

This article was written by Dr. Plern Pratoomas,
Early Intervention and Child Developmental Specialist,
ESDM Certified Trainer and Therapist.

Reference: 
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. Guilford Press.