Of Brain Waves and Faces: The Promise of the Early Start Denver Model for Autism
An autism therapist tries to engage a toddler in a game of Ring-around-the-Rosie, but the girl heads for a door and then drops to the floor. The therapist quickly changes the game to imitate the 1-year-old, first lying on the ground, then getting up and turning in circles. The girl looks at the therapist, smiles and follows the therapist's lead. Success! What began as an attempt to engage a disinterested child ends up as a fun game.
This exchange, recorded on video, is an example of the Early Start Denver Model (ESDM) in action.1 ESDM is an autism therapy that made news in 2012 with reports that it "normalized" some toddlers' brain activity.2 Parents have looked to autism interventions for cures since psychologist O. Ivar Lovaas reported, in a groundbreaking study in 1987, that recovery is possible.3 But the ESDM study provided the first physical evidence – in the form of brain wave tests – that an autism intervention works. Time magazine named it one of the top 10 medical breakthroughs in 2012.4
The Denver Model study used electroencephalography (EEG), a technique in which electrodes are placed on the scalp to measure electrical activity in the brain. The researchers found that children in the Denver Model program, along with typically-developing children, paid more attention to faces than to toys, while children with autism in other therapy programs did not.2
The finding is important because, experts say, at the core of autism is a problem with the ability to relate to people and learn from the social world.5, 6 The normal brain patterns after participating in the Denver Model were related to improvements in the children's social behavior, researchers said.2
Researchers studied 48 children aged 18- to 30-months with autism spectrum disorders. They randomly assigned the children to receive either two years of Denver Model therapy or two years of conventional therapies in their communities. The community therapy (or control) group received treatments from early-childhood development centers, speech therapists, occupational therapists and/or Applied Behavior Analysis (ABA) providers. Both groups received a similar number of hours of treatment per week.2
The researchers did not use the word "recovery," but they reported that toddlers who underwent Denver Model therapy showed more improvement in intelligence, autism symptoms, language and daily living skills than those who received conventional interventions.2
After the study ended, the researchers continued to follow the children from the ESDM group and found they made more gains in intelligence quotients (IQ) and language, Denver Model creator Sally J. Rogers, Ph.D., said in an interview with SSC@IAN. By age 6 or 7, the children had achieved average scores on IQ and language tests. A future article will report on those gains, she said.
Evolution of the Denver Model Therapy
Dr. Rogers began developing the model in 1981, with the goal of changing children's "social experiences" to prevent or correct the deficits of autism.6
Later that decade, Dr. Lovaas published research about his success with a form of ABA. His 1987 study said almost half of the 19 children in his behavioral program essentially "recovered" from autism. The children underwent treatment during "most of their waking hours" from both therapists and their parents.3
Subsequent studies have confirmed the effectiveness of intensive behavioral intervention, although one study that sought to test Lovaas' work found that 27 percent of the children achieved normal academic and intellectual functioning, fewer than Dr. Lovaas had reported in the original study.6
The therapy pioneered by Dr. Lovaas differs from Denver Model therapy in several aspects. During a typical ABA session, a child might sit at a table with a therapist and learn tasks by completing a series of short drills. This is called Discrete Trial Training. The child may be rewarded for a correct answer with praise, a piece of candy or a toy.
After Dr. Lovaas published his work, Dr. Rogers considered incorporating some aspects of behavioral therapy into the Denver Model. "There was important science going on in behaviorally-based interventions," she said. Could ABA be married to the play- and relationship- based method she was developing?
Dr. Rogers said she realized that Dr. Lovaas's discrete trial training didn't mesh with her analysis of communication and development. "It's such an adult-directed model," she said. "Children have so little input into the [therapy] activities themselves. That's not where communication is going to come from. Communication develops inside relationships between partners who share responsibility and control within the relationship."
Another form of ABA called Pivotal Response Training® seemed to fuse ABA and play, proving that it could be done, she said.
What Sets the Denver Model Apart from other autism treatments
The Denver Model incorporates some principles of ABA, such as breaking down a task into small steps and teaching each step in sequence, but does not use discrete trials. It also stresses the therapist's relationship with the child – a relationship built on play that capitalizes on the child's interests. That may mean lying on the floor and tapping the ground with hands and feet, as the therapist demonstrated in the video with the girl, rather than going through flashcards at a table.
"Years ago we would say, 'Find that smile,'" recalled Terry Hall, who helped develop the model in Denver, Colorado, and still practices the therapy.
"It's like a dance," said Ms. Hall, senior instructor and speech-language pathologist at JFK Partners at University of Colorado Denver. "There's a leading and a following you do to incorporate a child's choices into the teaching, which facilitates the child's opportunity to be an initiator and not only a responder in social interactions."
"For this reason, it's not that the intervention is all child-directed or all adult-directed. There's a place for both of those roles and you're always trying to achieve the balance of sharing the responsibility for initiating and maintaining pleasurable social interactions with others while building skills," Ms. Hall explained.
The Denver Model's future
The National Autism Center, a nonprofit group that promotes evidence-based practices, considers ABA to be an "established" or proven treatment. The Denver Model is listed as an "emerging" treatment, which means the center believes more research is necessary to prove its effectiveness.7 That rating could change, however, when the group updates its list later in 2013.
In fact, more research is in store for the Denver Model, including a larger study at multiple sites, Dr. Rogers said. "Replication studies" seek to validate one study's results by repeating its procedures with other participants and seeing whether similar results can be achieved.
Despite the publicity surrounding the 2012 study, it may be hard to find an ESDM consultant. The U.S has only about three dozen certified therapists, most of them in the West. There is also a smattering of therapists in Australia, Canada, Italy and Mexico.8
Some of the shortage may be due to the fact that the manual and curriculum guide were published only three years ago.9 "It's still pretty new in manual form," Hall said. "To build capacity, it will take a little while."
- Autism Speaks Video Glossary. Retrieved from http://www.autismspeaks.org/what-autism/video-glossary.
- Dawson, G., Jones, E.J., Merkle, K., Venema, K., Lowy, R., Faja, S. Kamara, D., Murias, M., Greenson, J., Winter, J., Smith, M., Roger, S.J. & Webb, S.J. (2012) Early behavioral intervention is associated with normalized brain activity in young children with autism. J Am Acad Child Adolesc Psychiatry. 2012 Nov;51(11):1150-9. View abstract.
- Lovaas, O.I. (1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol. 1987 Feb;55(1):3-9. View abstract.
- Park, A. (2012, Dec. 4). Top ten medical breakthroughs: Hope for reversing autism. Time. Retrieved from http://healthland.time.com/2012/12/04/top-10-health-lists/slide/hope-for-reversing-autism
- Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J., Estes, A. & Liaw, J. (2004). Early social attention impairments in autism: social orienting, joint attention, and attention to distress. Developmental Psychology, Vol 40(2), Mar, 2004. pp. 271-283. View abstract.
- Volkmar, F.R., Paul, R., Klin, A. & Cohen, D. (Eds.) (2005) Handbook of Autism and Pervasive Developmental Disorders, (3rd ed., Vol. 2) Hoboken, NJ: John Wiley & Sons, Inc.
- A Parent's Guide to Evidence-Based Practice and Autism. (2011). National Autism Center. Retrieved from http://www.nationalautismcenter.org
- UC Davis MIND Institute website. Retrieved from http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/pdf/esdm_certtherapists.pdf
- Rogers, S.J. & Dawson, G. (2010) Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. New York, NY: The Guilford Press. See also Rogers, S.J. & Dawson, G. (2010) Early Start Denver Model Curriculum Checklist for Young Children with Autism. New York, NY: The Guilford Press.
Photo of Dr. Rogers reprinted with permission of the Regents of the University of California.