A new intensive program for very young children with autism has produced impressive results, leading to substantial gains in I.Q. and in listening skills after two years of therapy.
The program, called the Early Start Denver Model, or E.S.D.M., was part of a two-year study of 48 children as young as 18 months old. Half the children received the intensive therapy, while the rest received a community-based autism intervention, according to a report in the journal Pediatrics.
While children in both groups improved, the gains were greater in the Early Start program. At the conclusion of the study, the I.Q.’s of children who took part in the E.S.D.M. program had improved by about 18 points, compared with a 4 point improvement in the other group. Children in the treatment group also posted bigger gains in listening and comprehension skills. For seven of the children in the treatment group, the improvements were pronounced enough to warrant a change in diagnosis from autism to a milder condition, whereas only one child in the community-based intervention group was given a less severe diagnosis.
The intervention was developed by Sally J. Rogers, a professor of psychiatry and behavioral sciences at the University of California, Davis, MIND Institute in Sacramento, and by Geraldine Dawson, a University of Washington psychology professor who is chief science officer for the advocacy group Autism Speaks. On Christmas, the program will become available in a new book, “Early Start Denver Model for Young Children With Autism: Promoting Language, Learning and Engagement” (Guilford Press).
I recently spoke with Dr. Rogers to learn more about the E.S.D.M. program. Here is our conversation.
How is this intervention different from the kinds of community-based programs typically offered to children with autism?
First, the kids are really young. Another important fact is that the kind of intervention that is being used is different. This is a developmentally based intervention that really pays a lot of attention to the quality of relationships. It’s a playful interactive kind of intervention. Other interventions are more didactic or adult instructional. This is the first time a play-based interactive model has been tested and found to be successful.
When a parent hears that more interaction might help a child with autism, they worry they are being blamed for not interacting enough with their child. How do you answer those fears?
One of the things I always say when I start to talk about this is that parents of children with autism are very good at interacting with their child. It’s the children with autism who are not good at interacting. What can happen is when the children aren’t giving parents cues that they’re on the right track, the parents don’t know to continue. They think that if the children aren’t responding, they, the parents, are not doing something right.
With this kind of intervention, we really turn up the social volume. We teach parents to give really clear clues and to look for these really subtle signs that the children are enjoying what’s going on. We teach the parents how to maximize getting their message in and being aware of what’s happening.
But doesn’t autism make it difficult for a parent or teacher to engage with a child?
Autism is a disorder that really removes children from social interaction. What we’re doing is getting the social messages into the children in a very focused way. Many people think children with autism aren’t aware of other people or don’t enjoy social interaction, so you have to do other things to teach them.
That’s an important thing about this study. It’s showing that children with autism respond to playful interactions from people they like or people they love, and they learn from that just like typically developing children do. That’s an important message. When you learn how to embed teaching in playful interaction, these children enjoy it too and learn from it.
Can you explain how the new treatment is different from traditional methods used to teach children with autism?
Sure. A traditional way might be to say the word “ball.” The child is sitting at the table, and the adult holds the ball and says: “Say ball. Say ball.” If the child makes a sound that’s kind of like ball, they hand them an M&M or juice or a cracker. They do it again. “Say ball.” They want the child to say it a little more clearly. If they do, the child receives a reinforcement. If not, the ball goes away for a minute. If the child says something like “ba,” they get the reward.
So how would you teach a child using this new method?
In this interaction, there might be a little boy in a playroom with an adult. There’s a bucket of balls, and the adult is on the floor. The boy picks up a ball, and the therapist picks up a ball. The therapist empties out the bucket. Then she throws her ball into the bucket and says “ball.” He watches and throws. She says “ball” again. She reaches in and picks up the ball and says, “Do you want ball?” And she says, “ball,” and hands it to him. She picks up another ball and throws it into the bucket.
Each time he says something, she gives him the ball. The two are playing a game of throwing balls in a bucket. They throw to each other. They might be bouncing the balls. There is a lot of variation going on. The therapist is using the child’s interest to get him focused on saying the word. Having the ball is a reward for making sounds. She’s also working on throwing skills.
All of this is going on while they are smiling and having a good time, rolling it back and forth, practicing social play and turn taking. In this episode, you see the child has lots of learning activities. It’s the same thing the other child is learning, but now he’s doing it in a more meaningful way. He’s motivated to have it and say it. It’s a rich learning situation that’s a lot of fun and motivated by a child’s pleasure.
But what if a parent says his or her child simply isn’t interested in the ball?
Find the smiles. We start by finding something that child enjoys — something that makes that child smile, that makes him want to do it again. We start that activity, and he starts to participate. Then that child is going to give a cue that he wants it to go on again. It might be a look, a whine, a noise. The child has communicated he wants more. That’s how we start. We develop these play routines that children love and give children the sense they have control over them.
How is this different from what parents might do themselves?
Lots of times the parent will roll a ball to a child, and a child is not interested, and the parent feels like they’ve failed. They haven’t failed. It’s hard to get the attention of a young child with autism. It’s hard to build their motivation for things. It’s just a different way of interacting. When you’re talking about children as young as 18 months, it’s not easy to get a toddler sitting at a table quietly while you give them lessons. This was an approach to really capitalize on their own interests and the environment.
How much treatment did the control group receive?
It was a randomized study, so children were assigned to one or the other. The children in the comparison group got an intervention in a community setting. They received evaluations and diagnoses and were referred to community providers where the children got speech therapy, occupational therapy. The children in the other group got an intervention and quite a bit of it. The comparison children got 18.5 hours a week of intervention over the two years of study. The group receiving this model got 22 hours a week of intervention. The groups aren’t that different in number of hours.
How meaningful are the gains documented in this study, particularly the increase in I.Q.?
Every child in this study made progress. Children in lots of different interventions make progress. What we’re trying to do is close the gap. Often there is a gap between where they are and where their peers are. We’ve got to accelerate their development. When you see a change in scores like this, the rate of development is improving. The average I.Q. test score is 100. These children have standard scores around 60. At the end of two years, children in the intervention had standard scores of 78.5. That’s outside the range of what would be considered an intellectual disability.
How can parents learn more about this intervention?
All the material, the book, curriculum, the measurement tools, are available to the public online, and there is also a manual published by Guilford Press. It’s not simple. Parents require a lot of coaching into how to position themselves so they’ve got children’s attention; how to get children to watch them; how to pull gestures out of the children so the child is communicating; how to choose activities so they have maximal pleasure so the child is motivated. We teach multiple different kinds of skills. Inside one particular play activity, you can get a lot of learning in.