TTaking into account the level of prevalence that ASD presents worldwide today and the proliferation of treatments with a multiplicity of professionals involved; There is a need to begin implementing a type of global approach that takes into account the different affected areas.
A global approach is based on the premise that intervention in one area will impact others at the same time. It is a type of economical approach, parents can carry out much of the process with the help of the main therapist; maximizes coherence and repetition of instruction, as well as providing a unified intervention. That is, the main therapist is the one who communicates with the parents, simplifying communication for the family.
The (ESDM) is an early behavioral intervention model for children with autism ages 1 to 5 years. It was created in 2000 by Sally Rogers and Geraldine Dawson as an extension of the Denver model that they had already developed.
It is an integrative model influenced by:
- The original Denver Model (1981)
- The model of interpersonal development in autism (Rogers and Pennington);
- The hypothesis of difficulties in social motivation in autism;
- Pivotal Behavior Training (PRT).
The teaching practices and procedures focus on strategies from the original Denver model, the (Applied Behavioral Analysis) and the approach.
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According to Rogers and Lewis, like the original Denver model, this program seeks to train children with ASD to become active participants in the social world and to increase initiative in interactions with other people. It emphasizes the emotional aspects and the therapeutic relationship, in the development of communication and play skills.
ESDM is an evidence-based practice and research ( and ) shows that it mitigates the impact of symptoms and improves the quality of life of the person suffering from the condition as well as increases communication skills and IQ scores.
The program includes a developmental curriculum that defines the specific skills that would need to be acquired in a given time and a series of specific learning strategies to teach them. This development curriculum has four levels and is divided into the following areas:
- Responsive communication
- expressive communication
- Joint attention behaviors
- Social skills with adults
- Social skills with peers
- Imitation
- Cognition
- Game
- Fine motor
- Gross Motricity
- personal independence
Program structure
The program is structured as follows: the skills that the child possesses are evaluated, using the curriculum checklist. The person who carries out this evaluation is the main therapist, who writes the learning objectives, designed so that they can be achieved in 12 weeks. Objectives are written keeping in mind ABA principles with different steps to achieve complete acquisition. At the end of those 12 weeks, new objectives are reassessed and written, taking into account the current evaluation. The core of intervention is made up of the parents and the main therapist.
The primary therapist is the primary contact with the parents. He is the link between the different professionals involved. In addition, she supervises and gives suggestions so that the model can be applied with the greatest possible fidelity. Depending on the requirements of the case, the patient may need the intervention of a particular discipline. For example, if a marked difficulty prevails at the language level, or in the sensory area, the intervention of specific professionals on the subject will be necessary. Therefore, it is necessary to have an interdisciplinary team (see graph 1), which will support the main therapist by providing specific knowledge of her discipline. At the end of the three months of intervention, the rest of the professionals help the main therapist to update the objectives, the intervention plan and evaluate its progress.
The teaching framework of the model is the routines of joint activities, that is, the scenario where the learning of different skills takes place. Brunner already referred to this in 1975, defining it as an activity in which two partners do the same “cooperative activity, attending to the same objects, playing or working together in a joint activity.” The most valuable tool for the model is the social element of routine. “In joint activities, playmates look at each other, give each other materials, imitate each other, communicate with each other and share smiles and fun.”
ESDM activity routines are characterized by: following the child’s interests and choices; target objectives from different areas of development; integrate different objectives into one activity. The fundamental element that is needed is the commitment of both partners in the game. They should be short, 2 to 4 minutes. There are two types of routine:
- Routines with objects: a toy or exchange object is used. This routine allows for a triadic situation where the aim is to develop joint attention skills.
- Sensory routines: The center of attention is on the playing partner, it is a dyadic interaction in which two people are involved in the same activity, reciprocally. “Mutual enjoyment and interaction dominate the game.”
When the program is carried out in the office, the child enters with the parents or a caregiver who has to take a passive role, becoming boring, if the child seeks them out; The therapist must become the center of the child’s attention. One of the objectives is for the parent or caregiver to see how we interact with the child, and learn how to apply the objectives. In addition, we can take the opportunity to evaluate the interaction and reciprocity that the child has with her parents.
The typical duration of an ESDM session is one hour. Blocks of 15 minutes are carried out, with intervals to write down the objectives worked on in that block as well as the type of activity carried out, the mood and behavior of the child. During these intervals, which should not be more than 3 or 4 minutes, the child is given a toy or a story to wait for. In this way, you can also train the ability to play independently, the ability to wait and observe if the child comments and shares the enjoyment with another.
The therapist must become a true social partner. To become a social partner, the therapist or adult who is administering the program at the time must follow the child’s interest. The positive mood must dominate the experience, ensuring that the activity is interesting and reciprocal and increasingly complex through turn-based games, imitation of actions and the incorporation of interesting effects in the theme to vary the activity. This last point is key so that the activity does not become stereotyped, a behavior that tends to prevail in ASD. It must be guaranteed that the child learns new experiences, intersperse objective language, stimulate imitation, develop symbolic aspects of play and maintain dyadic and reciprocal social activity. The social partner is tasked with ensuring that the child’s language appears frequently, whether through requests, comments, or expressing her mood.
As this program is implemented by multiple people, it is necessary to evaluate the quality of implementation to ensure that the model is being applied with the highest fidelity possible. This is done by observing a 5-minute session, where different points are taken into account such as: the management of the child’s attention; if the ABC format (antecedent, behavior, consequence) is followed; if the techniques implicit in the teaching process are applied; the adult’s ability to modulate the child’s mood or emotional state and activity level (the adult is able to foster an optimal mood for learning); the use of appropriate strategies for managing problem behaviors; the quality of dyadic interactions; if you can motivate him and maintain motivation in the activity; if you show a positive emotional/affective state during the exchange; if he responds with sensitivity and a positive response to the child’s communicative signals; if it generates activities or situations that give rise to several and diverse communicative opportunities; if he adapts his language to the child’s language (the “plus 1” rule is used); if it achieves an adequate structure and variation of joint activities and finally, if it adequately manages the transitions between one activity and another.
Conclusion
- The ESDM model is a global approach for the child and his or her family; it is a family-oriented approach in which the child-parent triad is the fundamental scenario to achieve adequate progress, which requires a deep commitment on your part.
- It uses behavioral analysis strategies from a naturalistic perspective, that is, it works in and with the child’s environment.
- Monitoring is carried out through a progressive development sequence, where progress can be evaluated day by day and identifying whether there is progress or not.
- It focuses on interpersonal exchange within the routines of joint activity, with the essential commitment of both playmates.
- The teaching of language and communication occurs within a positive relationship based on affection.
- The most notable aspect of the model is its flexibility in implementation since it can be applied in different contexts such as the office, an integrated center, home or school.
Bibliographic references:
- Rogers S., Dawson G. (March 2017), Vismara L., “An Early Start for your Child with Autism. Using Everyday Activities to help Kids Connect, Communicate and Learn.” (2012) Ed. The Guilford Press.
- Rogers, S and Dawson, G. “Denver model of early intervention for young children with autism. Stimulation of language, learning and social motivation.” 2nd Ed. Autism Ávila.
- Sperdin, Holger Franz and collaborators. (February 2018), “Early alterations of social brain networks in young children with autism”; elife sciences
- Lewis John, Evans Alan and colleagues. (August 2017), “The emergence of Network Inefficiencies in infants with Autism Spectrum Disorder”; Society of Biological Psychiatry.
- Redcay Elizabeth, et. to the. (2005), “When in the brain enlarged in autism? “A meta-analysis of brain size reports”; Society of Biological Psychiatry, Volume 58, Issue 1, 1 – 9.
- Williams, J.H.G. et al. (2001), “Imitation, mirror neurons and autism.” Neuroscience and biobehavioral reviews 25 4, 287-95.
- Rogers, S and Dawson, G. “Denver model of early intervention for young children with autism. Stimulation of language, learning and social motivation.” 2nd Ed. Autism…