Vivanti, G., Dissanayake, C., Duncan, E., Feary, J., Capes, K., Upson, S., Bent, C. A., Rogers, S. J., & Hudry, K. (2019). Outcomes of children receiving Group-Early Start Denver Model in an inclusive versus autism-specific setting: A pilot randomized controlled trial. Autism, 23(5), 1165-1175.
Reviewed by: Amanda Austin, PsyM, School Psychology Doctoral Student, and Robert H. LaRue, PhD, BCBA-D, Graduate School of Applied and Professional Psychology, Rutgers University
Why research this topic?
An ongoing and fundamental question of debate among educational policymakers, caregivers, and school personnel is whether children with disabilities should be educated in inclusive or specialized settings. While many argue that children with ASD should be educated in the least restrictive environment with opportunities to interact with typically developing peers, others posit that individuals with ASD should receive intervention in specialized settings that are “autism-friendly” and are tailored to the needs of the population. Interest in this topic has become more prevalent in early intervention (EI), as a growing number of toddlers are being diagnosed with autism spectrum disorder (ASD). Research on EI interventions, such as the Early Start Denver Model (ESDM), has begun to find promising outcomes for this age group. Although a few studies have examined EI outcomes in children across inclusive and specialized settings, none have utilized a randomized design to directly compare outcomes.
What did the researchers do?
Forty-four children between the ages of 15 and 32 months were randomly assigned to receive a manualized EI program – a group-based adaptation of the Early Start Denver Model (G-ESDM) – in either an inclusive or autism-specific treatment setting. The Early Start Denver Model uses a set of teaching procedures and a curriculum informed by developmental research, applied behavior analysis, and other related fields to target skills needed to engage in social learning and naturalistic social interaction. Treatment was implemented for 10-11 months. The following domains were evaluated using empirically-supported direct and self-report measures prior to and following treatment: (a) spontaneous vocalization, (b) social interaction, (c) imitation, (d) child developmental ability across verbal and nonverbal cognition, (e) adaptive behavior, (f) autism symptoms, and (g) stress associated with the parenting role. Spontaneous vocalization, social interaction, imitation, and developmental ability were assessed by clinicians who were blind to group assignment. Measures of adaptive behavior, autism symptoms, and parenting stress were completed by the children’s caregivers. The ESDM fidelity scale was used to assess implementation fidelity of the intervention, and the Sustained Shared Thinking and Emotional Well-Being (SSTEW) scale was used to evaluate quality of the early childhood education environment of each classroom.
What did the researchers find?
The researchers found significant improvements across all domains regardless of the intervention setting. Children in both settings demonstrated significant increases across all seven proximal and distal outcome measures, with no evidence of superior gains among children in one setting over the other. Significant and comparable reductions in maternal stress were also found across the intervention settings. Additionally, a negative association was found between age and verbal ability, suggesting that younger children had better outcomes on the language measure. Regarding implementation fidelity, staff in the inclusive setting were only able to achieve over 80% fidelity in the final year of implementation and required more substantial support from the ESDM-certified team, whereas staff in the specialized setting achieved over 80% fidelity during all three years of the study.
What are the strengths and limitations of the study?
This study was the first to examine the relative benefits of EI for participants with ASD by randomly assigning them to inclusive and specialized settings. It also utilized clinicians who were blind to group assignments to reduce bias when evaluating outcomes. One potential limitation could be a lack of generalizability due to the resources needed to successfully implement the intervention. Staff received intensive training and ongoing coaching during the intervention which may be difficult to replicate in other locations. Participants were also of high socioeconomic status and programs had favorable staff-child ratios, which may be difficult to replicate with other populations and settings.
What do the results mean?
The results of the study suggest that that Group-Early Start Denver Model can lead to significant gains for young children with ASD in both inclusive and specialized settings. Fidelity rates indicate that the intervention was feasible to implement in the specialized setting and that it was more challenging for staff to implement in the inclusive setting. The researchers also suggest that low dropout rates are indicative of family acceptability of the intervention. Finally, the results suggest that children who started EI at a younger age had better outcomes in verbal cognition.
Citation for this article:
Austin, A, & LaRue, R. H. (2021). Research Synopsis: Outcomes of children receiving Group-Early Start Denver Model in an inclusive versus autism-specific setting: A pilot randomized controlled trial. Science in Autism Treatment, 18(4).