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The Early Start Denver Model is an approach for working with children with autism spectrum disorder (ASD). Autism is a complex brain disorder involving communication and social difficulties as well as repetitive behavior or narrow interests. There is currently no cure for ASD and treatments are limited. The Early Start Denver Model blends elements from both behavioral and developmental frameworks into a unified treatment targeting multiple facets of child development. The diverse scientific approaches combined in this model are Applied Behavior Analysis, developmental science, and developmental neuroscience. The Early Start Denver Model offers a theoretical and practice approach to promoting language, learning, and engagement that blends multiple, complementary models into one. Given that parents are often conflicted when selecting treatments for their children, this behaviorally and developmentally integrated model may offer a solution to the problem of parents being forced to choose between significantly disparate interventions for their children.

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Definition
''' The Early Start Denver Model (ESDM) is a comprehensive developmental behavioral early intervention approach intended for children with autism, ages 12 - 48 months. The approach fosters interaction and engagement in young children with autism in their natural environments and can be delivered by trained therapists, educators, and parents. The National Research Council recommends that intervention for children with autism be structured, implemented as early as possible, and prescribed at a high intensity. The ESDM meets these outlined criteria. Psychologists Geraldine Dawson, Ph.D., and Sally Rogers, Ph.D., adapted the Denver Model of intervention for the purpose of reaching children diagnosed with autism at earlier ages. Children who participated in the Denver Model demonstrated significant gains in social skills from pre- to post-testing.

The four foundations of the ESDM are the original Denver Model, Rogers and Pennington's Model of Interpersonal Development in Autism, the Social Motivation Hypothesis of Autism, and Pivotal Response Training, a behavioral intervention based in Applied Behavior Analysis. The ESDM is defined by two main characteristics: The delivery of the ESDM is flexible in that it can be implemented in group or home programs by therapy teams or parents and it may be applied in individual therapy sessions in either clinical or home-based settings. Teaching techniques employed by the model include practices from Applied Behavior Analysis, Pivotal Response Training, and the Denver Model. Additionally, teaching opportunities are embedded within the context of play, address multiple objectives across developmental domains, and occur at a very high rate. Learning trials are defined by a three-term contingency (i.e., antecedent-behavior-consequence) that allows therapists and parents to selectively increase desirable, adaptive behaviors and decrease undesirable or maladaptive behaviors.
 * 1) A specific developmental curriculum that defines the skills to be taught at any given time
 * 2) A specific set of teaching procedures used to deliver the curriculum

Individualized treatment plans require the use of the Early Start Denver Model Curriculum Checklist, an assessment tool that evaluates current skill levels at commencement. Following initial assessment, learning objectives are established with the goal of attainment within a 12-week period. Ongoing assessment with the Curriculum Checklist at each 12-week interval allows progress to be evaluated and new, appropriate learning objectives to be instituted. Specific, developmentally sequenced skills comprise the Curriculum Checklist; these skills fall within ten broad domains of functioning:
 * Receptive communication
 * Expressive communication
 * Joint attention
 * Imitation
 * Social skills
 * Play skills
 * Cognitive skills
 * Fine motor skills
 * Gross motor skills
 * Self-care skills

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Treatment Selection
''' Delays in the selection of effective treatments and misinformed treatment decisions can adversely impact outcomes for children with autism. Immediacy of treatment for children with autism is a primary recommendation from the National Research Council publication Educating Children with Autism. According to Metz and others, a lack of knowledge about the diagnosis of autism and a lack of knowledge about how to evaluate evidence-based interventions leads to ill informed decisions. Instead of treatment models being selected because efficacy was demonstrated through rigorous research (e.g., randomized, controlled trials), parents often rely on recommendations from professionals in non-medical fields, autism books, unsubstantiated print media, and other parents' recommendations. Although practical and ethical considerations have rendered randomized, controlled trials nearly impossible, meticulous studies demonstrating successful interventions have emerged. The American Academy of Pediatrics recommends that all children be screened for autism at 18 months of age, but few evidence-based interventions are known to be efficacious with this age group. A randomized, controlled trial conducted on the efficacy of the ESDM offers evidence of a successful intervention for very young children diagnosed with autism.

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Completed Research
' A randomized, controlled trial to evaluate the efficacy of the ESDM was conducted and published in the journal Pediatrics''. Findings indicate that children as young as 18 months can benefit from treatment. This study demonstrated the efficacy of the model in four domains: Improving cognitive functioning, improving language abilities, improving adaptive behavior, and reducing the severity of the ASD diagnosis (e.g., from autism to pervasive developmental disorder not otherwise specified). This study importantly highlights the opportunity for very young children with autism to make significant gains. In addition to identifying possibilities for young children to make gains, the findings draw attention to the need for early diagnosis. Early and intensive intervention is recommended by the National Research Council, yet many youngsters are not diagnosed with autism until the age of three. Forty-eight children ages 18 to 30 months and diagnosed with ASD participated in this study. Random assignment to one of two groups allowed comparisons to be made between the Early Start Denver Model intervention and referral to community providers for intervention available in the community. Compared to children referred for services available in the community, children who participated in the ESDM showed significant improvements in IQ, language and adaptive behavior, and autism diagnosis. Further research is necessary to determine whether or not gains will be sustained by ESDM participants over a longer term than two years.

In 2012, Geraldine Dawson and colleagues published a follow up analysis of the 2010 randomized clinical trial and demonstrated that children who had received ESDM intervention showed brain responses to social stimuli that were similar to those of typical children. Specifically, they showed greater EEG activation while viewing social stimuli as compared to nonsocial stimuli, as measured by degree of EEG alpha and theta power. In contrast, children with autism who did not receive ESDM showed the reverse pattern, greater activity when viewing objects. This was the first study to demonstrate that early behavioral intervention not only can improve children's behavioral development but can improve patterns of brain activity.

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Current Research Studies
''' The National Institute of Health Autism Centers of Excellence (ACE) program has funded a research team at the University of Washington to follow the 2009 study's participants to determine whether the effects of the ESDM may be sustained over a longer period. Dr. Sally Rogers, a co-developer of the model, is currently leading a multi-site, randomized clinical trial of ESDM which is also funded through the ACE program. Researchers at the UC Davis MIND Institute are currently conducting four research studies surrounding the Early Start Denver Model:
 * 1) Intensive Treatment for Toddlers with Autism (Early Steps): The purpose of this study is to compare the effects of the Early Start Denver Model intervention with the commonly used intervention approaches available in the Sacramento, California area. Participants are 12 - 24 months old.
 * 2) Initial Investigation of Prevention of ASD in Infants at Risk (Infant Start): The purpose of this study is to develop an intervention for infants ages 6 - 13 months who already have some symptoms of autism.  It will be delivered by parents during their everyday play and child care routines and will occur over a period of up to 12 weeks.
 * 3) Expanding the Reach of Toddler-Treatment in Autism Spectrum Disorder (Remote ESDM): The purpose of this study is to develop and test the use of telemedicine technology to deliver a manualized, parent-implemented intervention for families of children with ASD, ages 18 - 48 months.  The intervention will use an Internet-based video conferencing program to teach families how to integrate the parent curriculum of the Early Start Denver Model (ESDM) into natural, developmentally and age-appropriate play activities and care-taking routines in their homes.
 * 4) Enhanced ESDM Parent Delivery: The purpose of this study is to improve the learning rates, language acquisition, and overall development in children with autism aged 12 - 30 months. The project aims to do so via modifying and strengthening the effects of an existing, manualized parent-delivered intervention for toddlers with autism, the Early Start Denver Model parent coaching approach.

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