Table 20.

2   (continued)
408

Author(s) and Year Sample Outcome measures Treatment procedures Findings Nathan and Gorman
(2002, 2007) criteria
Ozonoff and Cath- 22 ss; 2–6 yrs of age; 18 PEP-R; CARS Tx group = therapist & parent Tx group improved significantly Type 2 Study:
cart 1998 boys; 4 girls; all diag- designed tx plan; 10 weeks more than control group on − RCT,
nosed with autism of 1 h/TEACCH-based home PEP-R subtests of imitation, fine − Blind assessments,
program services with trained motor, gross motor, and nonver- − Incl/excl criteria,
graduate students + 1 h clinic bal conceptual skills, and overall − Standardized dx
visit/week at beginning & PEP-R scores battery,
gradual decrease to 1 sx/2–  + Comparison group,
3weeks toward end; 1/2 h − Tx fidelity,
of tx by parents/day; control − Tx manual
group = community tx as usual
# = number, mos months, wk week, yr year, bx behavior, dx diagnosis, hx history, h hour, s second tx treatment, sx  session, sig. significant, ss  subjects, ASD Autism Spectrum
Disorder, PDD-NOS  Pervasive Developmental Disorder-Not Otherwise Specified,  +  present in the study, – absent in the study, incl/excl criteria inclusion/exclusion criteria,
A/M  assess and monitor HMTW Hanen’s More than Words, and PECS Picture Exchange Communication System and DD Developmental Delay, min minute and RCT random-
ized control trial, FEAS Functional Emotional Assessment Scale, FEDQ Functional Emotional Developmental Questionnaire and SICD Sequenced Inventory of Communication
Development
ADI Autism Diagnostic Interview, ADOS Autism Diagnostic Observation Scale, CARS Childhood Autism Rating Scale, CBRS  Child Behavior Rating Scale, CSBS DP Com-
munication and Symbolic Behavior Scales Developmental Profile, ESCS Early Social-Communication Scales, ISCQ Infant Social-Communication Questionnaire, ITSEA  Infant
Toddler Social Emotional Assessment, M-CHAT Modified Checklist for Autism in Toddlers, MBRS Material Behavior Rating Scale, MCDI MacArthur-Bates Communicative
Developmental Inventory, MLU mean length of utterance, MSEL Mullen Scales of Early Learning, PEP-R Psychoeducation Profile Revised, PDD-ST-II Pervasive Develop-
mental Disorders Screening Test-II,RBS Repetitive Behavior Scale, TABS Temperament and Atypical Behavior Scale, TBPA Transdisciplinary Play Based Assessment, VABS 
Vineland Adaptive Behavior Scale
A. L. Wagner et al.
20  Developmental Approaches to Treatment of Young Children with Autism Spectrum Disorder 409

of the main features of each study reviewed, in- attention to others and engage in social interac-
cluding the sample, outcome measures, treatment tions, by assigning each child to a primary teach-
procedure, findings, and Nathan and Gorman er, by fostering peer relationships, and by mod-
(2002, 2007) study type representing method- eling and prompting social behaviors (Rogers
ological rigor. et al. 2001). Families are integral to the Denver
Following Table 20.2 is a brief description of Model programs. Parents of children attending
the main tenants of each treatment approach, in- the Denver Model programs are encouraged to
cluding a summary of the developmental compo- observe and participate in their children’s class-
nents of each approach. A review of the selected room. In addition, parents are given a chance to
efficacy studies that met the search criteria for discuss their child’s development or other issues
each approach follows. Next is an overall sum- related to parenting a child with ASD during their
mary of the empirical evidence for developmen- weekly one-on-one consultation with a child psy-
tal treatment approaches for young children with chologist or psychiatrist or during monthly par-
autism, including a discussion of study limita- ent support group meetings with other families
tions. The chapter concludes with recommenda- in the program.
tions for the future, both in terms of additional The Early Start Denver Model (ESDM) is a
efficacy and effectiveness studies, as well as the comprehensive early developmental intervention
development or modification of treatment ap- for children as young as 12 months of age with
proaches to meet the developmental needs of ASD. ESDM was designed by Rogers and Daw-
younger children with autism. son (2010), and is based upon the Denver Model.
At the heart of ESDM are the empirical knowl-
edge base of infant-toddler learning and develop-
Developmental Approaches ment and the effects of early autism. ESDM is
typically provided in the home by trained thera-
Denver Model and Early Start Denver pists and parents during natural play and daily
Model (ESDM) routines. However, current studies are examin-
ing group delivery in preschools and childcare
The Denver Model, created in the 1980s at the centers. The aim of ESDM is to increase the rate
University of Colorado Health Sciences Center, of development in all domains for children with
is a developmental approach for preschool edu- ASD and to simultaneously decrease the symp-
cation for children from 2 to 5 years of age with toms of autism. In particular, this intervention
autism (Rogers et al. 1986; Rogers 2005). The focuses on boosting children’s social-emotional,
Denver Model is administered to small groups cognitive, and language skills, as development in
of young children with autism in a classroom these domains is particularly affected by autism.
setting for 4–5 h per day, 12 months a year. The ESDM also uses a data-based approach and em-
core features of the Denver Model include: (a) pirically supported teaching practices that have
an interdisciplinary team that implements a de- been found to be effective from research in ABA.
velopmental curriculum addressing all domains ESDM fuses behavioral, relationship-based, de-
for each child’s individual needs; (b) a focus on velopmental, and play-based approaches into an
interpersonal interactions and engagement; (c) a integrated whole that is individualized and stan-
focus on reciprocal, functional and spontaneous dardized. Teaching objectives are based on the
use of imitation, facial expressions, and objects; Early Start Denver Model Curriculum Checklist,
(d) an emphasis on verbal and nonverbal commu- a play-based assessment tool that lists behav-
nication; (e) a focus on the cognitive aspects of iors in each developmental domain in the order
play; and (f) the importance of developing part- in which they occur in typical development. In
nership with parents (Dawson and Rogers 2010, ESDM, a primary therapist, supported by an in-
p. 15). The Denver Model strongly emphasizes terdisciplinary team comprised of occupational
social relationships by using positive affect in so- therapists, speech pathologists, child psycholo-
cial interactions as a motivator for children to pay gists, behavior analysts, physicians, and special
410 A. L. Wagner et al.

educators, assesses the child and identifies devel- comparing two different treatment methods, this
opmental objectives to target during intervention. study also considered the profiles of the children
Parents learn to deliver ESDM by using the play- that responded best to both treatments; these
based interactive approach to embed learning “best responders” had mild to moderate symp-
opportunities into their daily routines with their toms of autism, and better motor imitation and
children. In intensive delivery of ESDM, each joint attention skills when compared to children
child receives direct intervention one-on-one who did not respond as well to either treatment
from members of a team of trained ESDM inter- method.
ventionists, as well as from his or her parents. Two studies investigating the efficacy of
Both the Denver Model and the ESDM meet ESDM are described in Table 20.2, one of which
all five criteria of a developmental approach to is a Type 2 study because it had single-subject de-
treating young children with autism. The creators sign and one that is a Type 1 randomized control
of these approaches self-identify the treatments trial (Nathan and Gorman 2002, 2007).
as “developmental.” Treatments are based on a The Type 2 study of the efficacy of ESDM
typical developmental framework, follow the (Vismara et al. 2009) included a sample of eight
principles of developmental science, are delivered subjects ranging from 10 to 36 months of age
in the context of relationships, are child-centered with diagnoses of ASD at some point during the
and play based. Both approaches are compre- treatment. Each parent–child dyad received 12
hensive. Whereas the Denver Model is adminis- weeks of one-on-one coaching using the ESDM
tered primarily in a therapeutic preschool setting model. Parents achieved ESDM treatment fidel-
by trained teachers and specialists, the ESDM is ity by the sixth treatment session and children
administered in the clinic and at home by trained demonstrated positive changes in social commu-
intervention therapists guided by an interdisciplin- nication behaviors, such as imitation and spon-
ary team. Both approaches include a parent train- taneous verbal utterances. Together, these two
ing component with an expectation that parents single-subject studies demonstrate that parents
use the techniques with their children during daily can learn to use ESDM when interacting with
play activities and caregiving routines at home. their young children over the course of 12 par-
There are a handful of studies published in ent-coaching sessions. Children in these studies
peer-reviewed journals that report the efficacy of demonstrated associated increases in social com-
the Denver Model before it was officially called municative behaviors during parent–child play
by this name (Rogers et al. 1986, 1987; Rogers over the course of the parent training; however,
and Lewis 1989; Rogers and DiLalla 1991). Con- because of the study designs, causal relationships
sequently, the systematic search criteria of this lit- between implementation of ESDM and child out-
erature review resulted in only one efficacy study comes cannot be assumed.
of the Denver Model, as described in Table 20.2. The final ESDM study included in this re-
In 2006, Rogers and colleagues reported a Type view is a Type 1 study, a randomized, controlled
2 study using a single-subject study design that trial that evaluated the efficacy of intensive
included the randomization of a sample of ten ESDM treatment (Dawson et al. 2010). Forty-
nonverbal male subjects from 20–65 months of eight children diagnosed with ASD between 18
age to either the Denver Model treatment group and 30 months of age were randomly assigned
or the PROMPT treatment group, which is a neu- to either the ESDM group or the community
rodevelopmental approach for speech production treatment group. The children in the ESDM
disorders. Each group received 12 weekly 1-hour group received intervention by trained thera-
therapy sessions and 1 hour of parent-delivered pists within 2-hour sessions occurring twice per
intervention at home each day. After the 12 day for 5 days per week for 2 years (on average,
weeks of treatment, there were no significant dif- ESDM children received 15.2 hours of ESDM
ferences in the acquired language skills of each and 5.2 hour of additional community therapy
group, as eight of the ten children used five or per week). In addition, parents were trained
more new words spontaneously. In addition to and asked to use ESDM strategies during daily