Updated by Frank Cicero, PhD, BCBA and Erin Leif, PhD, BCBA-D
Association for Science in Autism Treatment

Description:

The Early Start Denver Model (ESDM) is a commercially available, standardized, naturalistic developmental behavioral intervention designed for the treatment of young children (aged 12-48 months) with or at risk for an autism spectrum diagnosis (ASD). The ESDM was developed and manualized in 2010 by combining the naturalistic/developmental approach of the original Denver Model with the behavioral teaching techniques of Pivotal Response Treatment (PRT) (Rogers et al., 2021). The treatment focuses on nine skill domains that are important for children with autism, including receptive communication, expressive communication, social skills, imitation, play skills, cognitive skills, gross motor skills, fine motor skills, and adaptive functioning. The behavioral components of the ESDM prioritize motivation in natural environments, responding to multiple cues, self-management of behavior, self-initiation, and generalization taught through techniques such as response prompting, shaping, and reinforcement. These behavioral techniques are combined with naturalistic and developmental strategies such as ensuring positive affect from adults, incorporating play and social routines into therapy sessions, and following developmental skill sequences. Treatment is often provided by trained therapists as well as trained parents in natural settings. In the ESDM, learning objectives are individualized based on baseline assessments and progress is evaluated every 12 weeks using a standardized ESDM Curriculum Checklist. For more information on the ESDM refer to this website.

Research Summary:

Several systematic reviews of the ESDM have been conducted since its development in 2010. Waddington et al. (2016) was the first systematic review specifically evaluating the effects of the ESDM as primary treatment. Twelve studies were included in the final analysis evaluating the data of 209 participants. Although all studies employed the ESDM as the primary intervention, treatments varied significantly in intensity and duration. Results indicated some positive outcomes for most studies in the review, specifically in the areas of cognitive skills, language ability, imitation, attentiveness, and social initiation. Results for other adaptive behaviors and autism symptoms, however, were mixed with 50% of studies reporting negative results. Data of the reviewed studies need to be interpreted with caution due to low ratings of methodological rigor as per criteria by Reichow (2011) and Reichow et al. (2008).

Baril and Humphreys (2017) conducted a second systematic review of studies employing the ESDM as primary treatment for young children with ASD. A total of 10 articles were included in the final analysis reviewing the data of 200 child participants. As in Waddington et al. (2016), a wide variability in intervention intensity and duration was noted. Although data indicated some positive treatment results across outcome measures, research rigor for seven of the ten studies was noted to be weak, with the remaining three studies noted to be adequate. No studies in the review received a strong rating. Additionally, nine of the ten studies reviewed included at least one of the original developers of the ESDM as researchers. This potentially limits the objectivity of the findings. Finally, studies showed mixed results regarding whether the ESDM is a more effective treatment than other options. The overall results of the systematic review indicated that the ESDM is a “promising” but not yet evidence-based practice for the treatment of ASD.

The most recent systematic review of the ESDM, at the time of the current treatment summary, was published by Fuller et al. (2020). Unlike previous reviews, studies were only included if they compared the results of ESDM to a non-ESDM comparison group, some of which involved eclectic or non-empirically validated treatments. Twelve studies were included in the final analysis reviewing data for 640 participants (286 receiving EDSM treatment and 354 in control groups). The overall treatment effect size, across outcome measures, was found to be moderate and statistically significant. This indicates an overall advantage for children in the ESDM treatment groups as compared to children in the control groups. Positive effects were noted mostly in cognitive and language skills. Consistent with the studies included in previous systematic reviews, the studies included in Fuller et al. (2020) varied widely in intervention intensity, duration, and outcome measures. No significant differences were noted in the domains of autism symptomatology, adaptive behavior, social communication, and restricted/repetitive behavior. Many of the studies with significant effect sizes came from the same research lab, used non-randomized control designs, reported results based on potentially subjective parent reports, and used non-blinded assessors. Given these research limitations, their results should be interpreted with caution.

Despite limitations noted in the studies included in the systematic reviews, recent research continues to report positive results with the use of the ESDM with early learners with ASD. For example, Contaldo et al. (2020) studied the effects of the ESDM on various outcome measures in 32 children with ASD who had not yet received any treatment. Dosage of treatment varied by amount and format (group vs. individual sessions). Data were collected at baseline and after one year of the ESDM intervention. Results showed improvements in communication skills, adaptive behavior, and ASD severity. However, the study lacked a control group, used a pretest-posttest experimental design, and results revealed heterogeneity in participant outcome. Results, therefore, should be considered preliminary. As another example, Colombi et al. (2018) studied the effects of the ESDM on autism symptoms in 22 children receiving services in Italy between the ages of 18 and 48 months. Results were compared to the results obtained from a “treatment as usual” control group (but did not include a comparison to another empirically validated model of early intervention, such as Early Intensive Behavioral Intervention). Children in the ESDM group received six hours of individual intervention weekly divided into three, two-hour sessions. Treatment procedures followed the ESDM protocol outlined by Rogers and Dawson (2010). Results indicated significant skill gains of the ESDM group participants over the control group participants at three and six months of treatment for cognitive and language skills and at three months (but not six months) for adaptive behavior. Limitations included a lack of randomization to groups, lack of fidelity monitoring for the control group treatment, lack of assessors naïve to the treatment assignments, and an older mean age for participants in the control group.

In a very recent study, with a stronger level of research rigor, Rogers et al. (2021) conducted a randomized, multisite investigation of the effects of the ESDM on various outcome measures across domains as compared to the effects of Early Intensive Behavioral Intervention (using 1:1 discrete trial teaching) in 87 toddlers with ASD. Treatment intensity included two levels, 15 or 25 hours per week of intervention, delivered for 12 months. After comparing outcome measures for treatment groups, no evidence was found that treatment style (ESDM or EIBI) resulted in differentiated results for any of the four outcome measures (autism severity, expressive language, receptive language, or nonverbal ability). No relationship was found between effectiveness at different dosages and pre-treatment symptom severity. The ESDM researchers concluded their discussion by postulating that ensuring treatment fidelity, adhering to standardized treatment procedures, conducting frequent progress assessment, delivering treatment across settings, and integrating treatment into everyday life by coaching caregivers may be more important to the outcome than the “brand name” of the intervention that is used. In Rogers et al (2021), EIBI was described as primarily consisting of discrete trial teaching, which may not accurately represent how contemporary EIBI programs are delivered. EIBI programs often include naturalistic intervention (e.g., incidental teaching, play-based learning opportunities), as well as teaching in the context of routines and daily activities. Therefore, it will be important that future ESDM research includes contemporary EIBI practices implemented with high fidelity in their comparison group.

Recommendations:

Evidence in support of the ESDM is continuing to be gathered; however, methodological issues prevent the model from being considered a fully evidence-based treatment at this time (Whitehouse et al., 2020). The effects of the ESDM were not specifically investigated as part of the National Autism Center’s National Standards Project, Phase 2 (NAC, 2015) nor as part of a third-generation review of evidence-based autism treatments conducted by Hume et al. (2021). Although lack of inclusion in these comprehensive reviews does not indicate the ineffectiveness of the ESDM, it did not allow the ESDM to be considered a current evidence-based practice for ASD as per those Task Force findings.

As treatment data continue to be gathered, via studies with greater methodological rigor, future systematic reviews and meta-analyses may support the ESDM as an evidence-based practice for the treatment of young children with ASD. Additional randomized control studies, conducted by independent researchers, using naive raters, and objective outcome measures (and measures of treatment fidelity) are required. It is also very important to conduct component analysis studies to determine the differential and combined effects of the behavioral versus developmental aspects of the ESDM. Although studies show positive effects of the ESDM, one wonders if the addition of the developmental components of the ESDM increases or decreases the effectiveness of the treatment over behavioral intervention in isolation. Negative side effects of the ESDM do not, however, seem to be reported in any studies. As research is continually accruing on this intervention, it is possible that the strength of the evidence may change over time. We look forward to updating this summary as more research is published (specifically those that compare ESDM to contemporary, rigorous EIBI programs) and when task force reports look more specifically at the ESDM.

Selected References:

Systematic Reviews of Scientific Studies:

Baril, E. M., & Humphreys, B. P. (2017). An evaluation of the research evidence on the Early Start Denver Model. Journal of Early Intervention, 39(4), 321-338. https://doi.org/10.1177/1053815117722618

Fuller, E. A., Oliver, K., Vejnoska, S. F., & Rogers, S. J. (2020). The effects of the Early Start Denver Model for children with autism spectrum disorder: A meta-analysis. Brain Sciences, 10(6). https://doi.org/10.3390/brainsci10060368

Waddington, H., van der Meer, L., & Sigafoos, J. (2016). Effectiveness of the Early Start Denver Model: A systematic review. Review Journal of Autism and Developmental Disorders, 3(2), 93-106.

Task Force Findings

Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-020-04844-2

National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2. Author.

Whitehouse, A., Varcin, K., Waddington, H., Sulek, R., Bent, C., Ashburner, J., Eapen, V., Goodall, E., Hudry, K., Roberts, J., Silove, N., & Trembath, D. (2020). Interventions for children on the autism spectrum: A synthesis of research evidence. Autism CRC, Brisbane

Selected Articles and Scientific Studies:

Colombi, C., Narzisi, A., Ruta, L., Cigala, V., Gagliano, A., Pioggia, G., … & Muratori, F. (2018). Implementation of the Early Start Denver Model in an Italian community. Autism: The International Journal of Research and Practice, 22(2), 126-133.

Contaldo, A., Colombi, C., Pierotti, C., Masoni, P., & Muratori, F. (2020). Outcomes and moderators of Early Start Denver Model intervention in young children with autism spectrum disorder delivered in a mixed individual and group setting. Autism: The International Journal of Research and Practice, 24(3), 718-729.

Rogers, S. J., Yoder, P., Estes, A., Warren, Z., McEachin, J., Munson, J., Rocha, M., Greenson, J., Wallace, L., Gardner, E., Dawson, G., Sugar, C. A., Hellemann, G., & 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

Other References:

Holehan, K. M., & Zane, T. (2019). Is there science behind that?: The Early Start Denver Model. Science in Autism Treatment, 16(2).

Holehan, K., & Zane, T. (2019). A response to Vivanti et al. Science in Autism Treatment, 16(10).

Reichow, B. (2011). Development, procedures, and application of the evaluative method for determining evidence-based practices in autism. In B. Reichow, P. Doehring, D. V. Cicchetti, & F. R. Volkmar (Eds.), Evidence-based practices and treatments for children with autism. (pp. 25-39). Springer Science + Business Media. https://doi.org/10.1007/978-1-4419-6975-0_2

Reichow, B., Volkmar, F. R., & Cicchetti, D. V. (2008). Development of the evaluative method for evaluating and determining evidence-based practices in autism. Journal of Autism and Developmental Disorders, 38(7), 1311-1319. https://doi.org/10.1007/s10803-007-0517-7

Vivanti, G., Vismara, L., Dawson, G., & Rogers, R. (2019). Evaluations of scientific research need to be based on scientific approaches: A Reply to “Is There Science Behind That?: The Early Start Denver Model” by Holehan & Zane, 2019. Science in Autism Treatment, 16(10).

Citation for this article:

Cicero, F., & Leif, E. (2022). A treatment summary of Early Start Denver Model. Science in Autism Treatment, 19(4).

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