02 Intro Course Material

UC Davis MIND Institute
ESDM Training Program
UCDE Online ESDM Introductory Course

Materials Packet
Required texts:
Early Start Denver Model for Young Children with Autism

Promoting Language, Learning, and Engagement
Sally J. Rogers and Geraldine Dawson

Find full information about this title online: www.guilford.com/p/rogers6
Early Start Denver Model Curriculum Checklist for Young Children with
Autism
Sally J. Rogers and Geraldine Dawson
Recommended texts:
An Early Start for Your Child with Autism
Using Everyday Activities to Help Kids Connect, Communicate, and Learn
Sally J. Rogers, Geraldine Dawson, and Laurie A. Vismara

Supplemental Materials Included:
Lesson 1.1—ESDM Principles
• List of publications (links included)
Lesson 2.1 – Using the Curriculum Checklist
• Parent Goal Sheet
• Curriculum Checklist (part of required materials)
Lesson 2.2—Writing a Treatment Plan
• Writing Objectives
Lesson 2.3—Baby Steps to Mastering the Data Sheet
• How to Write Objectives and Teaching Steps
• Sample Data Sheet
• Blank Data Sheet
Lesson 3.1—Deconstructing ESDM
• ESDM Fidelity Rating System
Lesson 3.3—Building Joint Activity Routines
• Ideas for Joint Activities & Sensory-Social Routines
• Joint Activity Routine elements
Lesson 3.4—Building a Treatment Hour
• Sample Data Sheet
Lesson 3.5—How Do I Take Data and Play?
• ESDM Model Objectives and Steps
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Lesson 3.6—She Won’t Stop Hitting Me!
• Flow Chart for Behavior Management
• Functional Behavior Support Plan
Lesson 3.7—Teaching Practices
• Appendix B of Treatment Manual (part of required materials)
• Fidelity Coding Sheet
Lesson 3.8-- It's Not Working!
• ESDM Play Partner Decision Tree (p131 of manual)
• Decision Tree—speech difficulties (p180 of manual)
Lesson 4.1
• Self-help book for parents called An Early Start for your Child with Autism
(recommended)
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ESDM Journal Publications

Sally J. Rogers and Bruce F. Pennington (1991). A theoretical approach to the deficits in infantile autism.
Development and Psychopathology, 3, pp 137-162. doi:10.1017/S0954579400000043.
http://dx.doi.org/10.1017/S0954579400000043
Rogers, S. J., & DiLalla, D. (1991). A comparative study of the effects of a developmentally based
instructional model on young children with autism and young children with other disorders of behavior
and development. Topics in Early Childhood Special Education, 11, 29–48.
http://tec.sagepub.com/content/11/2/29.full.pdf+html
Rogers, Sally J; Hayden, D; Hepburn, S; Charlifue-Smith, R; Hall, T; & Hayes, A. (2006). Teaching young
nonverbal children with autism useful speech: A pilot study of the Denver model and PROMPT
interventions. Journal of Autism and Developmental Disorders, 36(8), 1007 - 1024.
http://link.springer.com/article/10.1007%2Fs10803-006-0142-x
Rogers, Sally J; Vismara, Laurie A. (2008). The Early Start Denver Model: A Case Study of an Innovative
Practice. Journal of Early Intervention OnlineFirst, published on September 23, 2008 as
doi:10.1177/1053815108325578 http://jei.sagepub.com/content/31/1/91.full.pdf+html
Laurie A. Vismara, Costanza Colombi, and Sally J. Rogers (2009). Can one hour per week of therapy lead to
lasting changes in young children with autism? Autism, January 2009; vol. 13: pp. 93-115.
http://aut.sagepub.com/content/13/1/93.full.pdf+html
Wagner, A.L. & Rogers, S.J. (2011). The Early Start Denver Model: An intervention for toddlers with
autism. Pedagogisk Profil, 18, 12-15. http://issuu.com/shanecolvin/docs/pedagogiskprofil-num1-2011-
forweb
Vivanti, G., Dissanayake, C., Zierhut, C., & Rogers, S. J. (2013). Brief report: Predictors of outcomes in the
Early Start Denver Model delivered in a group setting. Journal of Autism and Developmental
Disorders, 43(7), 1717–1724. doi:10.1007/s10803-012-1705-7.
http://link.springer.com/article/10.1007/s10803-012-1705-7
Rogers, Sally J. and Vismara, Laurie A. (2008) 'Evidence-Based Comprehensive Treatments for Early
Autism', Journal of Clinical Child & Adolescent Psychology,37:1,8 — 38. DOI:
10.1080/15374410701817808. URL: http://dx.doi.org/10.1080/15374410701817808
Geraldine Dawson, Sally Rogers, Jeffrey Munson, Milani Smith, Jamie Winter, Jessica Greenson, Amy
Donaldson, Jennifer Varley (2009). Randomized, Controlled Trial of an Intervention for Toddlers With
Autism: The Early Start Denver Model. Pediatrics, Jan 2010, 125 (1) e17-e23.
http://pediatrics.aappublications.org/content/125/1/e17
Rogers, S. J., & Lewis, H. (1989). An effective day treatment model for young children with pervasive
developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 207–
214. http://dx.doi.org/10.1097/00004583-198903000-00010
Vismara, L. A., Young, G. S., & Rogers, S. J. (2013). Community dissemination of the Early Start Denver
Model: Implications for science and practice. Topics in Early Childhood Special Education, 32, 223-233.
doi:10.1177/0271121411409250. http://tec.sagepub.com/content/32/4/223.abstract
Rogers SJ, Estes A, Lord C, et al. (2012) Effects of a brief Early Start Denver Model (ESDM)-based parent
intervention on toddlers at risk for autism spectrum disorders: a randomized controlled trial. Journal of
the American Academy of Child and Adolescent Psychiatry 51(10): 1052–1065.
doi:10.1016/j.jaac.2012.08.003. http://www.sciencedirect.com/science/article/pii/S089085671200593X
Dawson, G., Jones, E. J. H., Merkle, K., Venema, K., Lowy, R., Faja, S., … Webb, S. J. (2012). Early Behavioral
Intervention Is Associated With Normalized Brain Activity in Young Children With Autism. Journal of the
American Academy of Child and Adolescent Psychiatry, 51(11), 1150–1159.
http://doi.org/10.1016/j.jaac.2012.08.018
Estes, A., Vismara, L., Mercado, C., Fitzpatrick, A., Elder, L., Greenson, J., et al. (2013b). The impact of
parent-delivered intervention on parents of very young children with autism. Journal of Autism and
Developmental Disorders, 44(2), 353–365. DOI 10.1007/s10803-013-1874-z
http://www.ncbi.nlm.nih.gov/pubmed/23838727
Laurie A. Vismara, Gregory S. Young, and Sally J. Rogers, “Telehealth for Expanding the Reach of Early
Autism Training to Parents,” Autism Research and Treatment, vol. 2012, Article ID 121878, 12 pages,
2012. doi:10.1155/2012/121878 http://dx.doi.org/10.1155/2012/121878
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Sally J. Rogers, Gregory S. Young, Ian Cook, Angelo Giolzetti and Sally Ozonoff (2010). Imitating actions on
objects in early-onset and regressive autism: Effects and implications of task characteristics on
performance. Development and Psychopathology, 22, pp 71-85. doi:10.1017/S0954579409990277.
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7150948&fileId=S09545794
09990277
Vismara LA, Young GS, Stahmer AC, Griffith EM, Rogers SJ. (2009) Dissemination of Evidence-Based
Practice: Can We Train Therapists from a Distance? Journal of Autism and Developmental Disorders.
2009;39(12):1636-1651. doi:10.1007/s10803-009-0796-2.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777219/
Vismara LA, Rogers SJ. Behavioral treatments in autism spectrum disorder: what do we know? Annu Rev
Clin Psychol. 2010;6:447–468. doi: 10.1146/annurev.clinpsy.121208.131151.
Rogers, S. J., Herbison, J., Lewis, H., Pantone, J., & Reis, K. (1986). An approach for enhancing the
symbolic, communicative, and interpersonal functioning of young children with autism and severe
emotional handicaps. Journal of Division of Early Childhood, 10, 135–148. DOI:
10.1177/105381518601000205 http://jei.sagepub.com/cgi/content/abstract/10/2/135
Rogers S.J., Vismara L., Wagner A.L., McCormick C., Young G., Ozonoff S. Autism treatment in the first
year of life: a pilot study of infant start, a parent-implemented intervention for symptomatic infants.J.
Autism Dev. Disord. 2014;44(12):2981–2995. DOI 10.1007/s10803-014-2202-y.
Fulton E, Eapen V, Črnčec R, Walter A and Rogers S (2014) Reducing maladaptive behaviors in preschool-
aged children with autism spectrum disorder using the Early Start Denver Model. Front. Pediatr. 2:40. doi:
10.3389/fped.2014.00040 http://journal.frontiersin.org/article/10.3389/fped.2014.00040/full
Rogers, S.J., Lewis, H.C., &c Reis, K. (1987). An effective procedure for training early special education
teams to implement a model program. Journal of the Division for Early Childhood, 11, 180-188.
http://jei.sagepub.com/content/11/2/180.full.pdf
Davlantis, K. S., & Rogers, S. J. (2016). The Early Start Denver Model: A play-based intervention for young
children with autism spectrum disorders. Reddy, Linda A. (Ed); Files-Hall, Tara M. (Ed); Schaefer, Charles
E. (Ed), (2016). Empirically based play interventions for children (2nd ed.). , (pp. 205-222). Washington,
DC, US: American Psychological Association, xii, 296 pp. http://dx.doi.org/10.1037/14730-011
3
Rogers, S. J., Hepburn, S. L., Stackhouse, T. and Wehner, E. (2003), Imitation performance in toddlers with
autism and those with other developmental disorders. Journal of Child Psychology and Psychiatry,
44: 763–781. doi: 10.1111/1469-7610.00162 http://onlinelibrary.wiley.com/doi/10.1111/1469-
7610.00162/full
Rogers, S. J., Bennetto, L., McEvoy, R. and Pennington, B. F. (1996), Imitation and Pantomime in High-
Functioning Adolescents with Autism Spectrum Disorders. Child Development, 67: 2060–2073.
doi: 10.1111/j.1467-8624.1996.tb01843.x http://www.ncbi.nlm.nih.gov/pubmed/9022229
Rogers, S. J., Hall, T., Osaki, D., Reaven, J., & Herbison, J. (2000). A comprehensive, integrated, educational
approach to young children with autism and their families. In S. L. Harris & J. S.
Handleman (Eds.), Preschool education programs for children with autism (2nd ed.). Austin, TX: Pro-Ed.
http://autismomx.org/nuevositio/wordpress/wp-content/uploads/2014/02/DenverModel.pdf
ROGERS, S . J. (2000) ‘Differential Diagnosis of Autism before Age 3’, International

Review of Research in Mental Retardation 23: 1–31.
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P-ESDM Parent Goals for Intervention
Today’s Date: _____/____/____
Parent: _____________________
Therapist: ____________________
1. What skills would you like to see your child develop or increase over the next 3 months?
2. What are the types of activities that you enjoyed doing the most/least with your child?
3. What are the most fun and most frustrating aspects of interacting with your child?
4. What do you hope to gain and learn from our work together?
5. How do you prefer to learn? What methods are most/least helpful when learning
something new?
6. What fears or worries do you have about beginning our work together?
Rogers & Vismara ©2012

Writing Objectives
Targeted Curriculum item (s):
Antecedent:
Behavior:
Criterion:
Antecedent:
Behavior:
Criterion:
Writing Objectives
Antecedent:
Behavior:
Criterion:
Antecedent:
Behavior:
Criterion:
Writing Objectives
Antecedent:
Behavior:
Criterion:
Antecedent:
Behavior:
Criterion:
Writing Objectives
Antecedent:
Behavior:
Criterion:
Antecedent:
Behavior:
Criterion:
Name Session Date: _________ Developed by
RECEPTIVE
1. 6.
1 2 3 4 1 2 3 4
SOCIAL INTERACTION
7.
1 2 3 4
2.
1 2 3 4
8.
1 2 3 4
3.
1 2 3 4
9.
1 2 3 4
EXPRESSIVE
4.
1 2 3 4
IMITATION
10.
1 2 3 4
5.
1 2 3 4
Name: Session Date: _________ Developed by
11. FINE MOTOR
1 2 3 4 16.
1 2 3 4
COGNITION 1 2 3 4
12.
1 2 3 4
BEHAVIOR
15 min 30 min 45 min 1 hr
13.
1 2 3 4
1 Severe behavior (e.g. aggression, SIB, frequent/intense tantrums

2 Mild Behavior (e.g. noncompliance, some tantrums but able to
participate in activity
3 Some behavior problems (e.g. fussy, whiny, some noncompliance
but able to participate in most of activity
4 No problem behavior but difficulty staying on task
PLAY SKILLS 5 Compliant, on-task, working at ability level
14. 6 Above average performance for child, pleasant, excited about
1 2 3 4 activity
In each 15 min period mark a + for completed consistently; -

for not performed; +/- for inconsistent responding and N for
no opportunity (or leave blank)
15.
1 2 3 4
Writing Objectives
Targeted Curriculum item(s):
Antecedent:
Behavior:
Criterion:
Teaching Steps/Task Analysis:
□ Each objective is broken down into 4-6 teaching steps

□ First Step: Baseline level of skill
□ Last step: Mastery level of skill
□ Intermediate steps define progress towards mastery
Teaching steps:
SAMPLE DATA SHEET Time of Session:_________________ Date:___________
DATA SHEET IMITATION
Spont imitates 5+ actions on objects, both novel and familiar w/in 5
EXPRESSIVE secs for 80% of opps
Vocalization w/ intent to request objects or activities 5+xs 80% opps 1 2 3 4 5 6 7
1 2 3 4 5 6 7 1-2 actions fpp (b)
Reaches for obj (b) 1-2 actions, ppp
Voc 1x 1-2 actions, spont
Voc 2x 3-5 actions, vp
Voc 3x 5+ actions, spont across 3+ adults, settings, and
activities 4 out of 5 tx ssn
Voc 4xs
COGNITIVE
Voc 5+xs 80% opps across 3 diff adults, setting, and
vocs 4 out of 5 tx ssn
Matches 5+ pairs of identical pictures with 80% accuracy
Ask for help by handing the object to the adult 5+x per session 1 2 3 4 5 6 7
1 2 3 4 5 6 7 1-2 pairs fpp (b)
1x fpp (b) 1-2 pairs 50% opps
1x ppp 1-2 pairs 80% opps
1x spont 3-4 pairs 50% opps
2-4xs 50% opps 3-4 pairs 80% opps
2-4xs 80% opps 5+ pairs 80% opps 3+ adults,
settings, and activities 4 out of 5 tx
5xs 50% opps ssn
5+ xs 80% opps across 3+ adults, settings, and PLAY SKILLS
help opps 4 out of 5 tx ssn
Play appropriately with 8 or more different one-step toddler toys
RECEPTIVE LANGUAGE involving for 5+ toys 80% opps
Points or pats to 3+ pics when adult asks “Where is ___?” or “Show e.g. shapes in shape sorter, balls in ball 1 2 3 4 5 6 7
me ____” , 80% of opps maze, pegs in peg board, taking apart pop
1 2 3 4 5 6 7 beads
Points or pats 1x fpp (b) 1 toy ppp (b)
Points or pats 1x ppp 1 toy 50% opps
Points or pats 1x indep 50% 1 toy 80% opp
Points or pats 1x indep 80% 2-4 toys 80% opps
5-7 toys 80% opps
Points or pats 2x indep 80%
8+ toys 80% opps across 3+ adults, toys, and
Points or pats 3+x indep 80% settings 4 out of 5 tx ssn
across 3+ adults, items & books 4 out of 5 tx
ssn
15 30 45 60 1 hr 1 hr 1 hr
Follow a proximal point to place objects in containers or puzzle pieces min min min min 15 30 45
in puzzle 4-5xs min min min AVG
e.g. puzzles, shapes in the shape sorter and during 1 2 3 4 5 6 7
clean up -put items in bag
BX
1 x fpp (b)
1x ppp
ROUTI
1x spont
NE
2-3xs spont
4xs spont
5 xs across 3 adults and activities 4 out of 5 tx ssn BEHAVIOR CODES
SOCIAL INTERACTION 1 Severe behavior (e.g. aggression, SIB, frequent/intense tantrums
st
Responds to greeting with E.C., gesture &/or vocalization @ 1 opp 2 Mild Behavior (e.g. noncompliance, some tantrums but able to
1 2 3 4 5 6 7 participate in activity
3 Some behavior problems (e.g. fussy, whiny, some noncompliance but
E.C. (b)
able to participate in most of activity
E.C. + wave fpp 4 No problem behavior but difficulty staying on task
E.C. + wave ppp 5 Compliant, on-task, working at ability level
E.C. + wave spont 6 Above average performance for child, pleasant, excited about activity
E.C. + voc w/ vp ROUTINE CODES
E.C. + voc spont G Greeting S Snack
F Floor activity Q Quiet
E.C. + voc or wave across 3+ adults
R Sensory social routine T Table activity
over a 2 day period O Outside C Closing
ESDM Fidelity Rating System

Administration and Coding Guide
This tool provides a method for assessing the fidelity with which a parent is using ESDM
principles in a learning interaction with a young child. It is built to be used in rating videotapes
of activities which parents and children are carrying out together. The “parent” may also be
another caregiver, or a paraprofessional using the techniques. Mastery level of performance
with an individual child is defined as: a mean total score of 80% with no scores under 3
achieved over several consecutive activities.
This tool is also quite helpful for self-assessment for ESDM learners and for accomplished
therapists (or parents) conducting self-review. Ongoing monitoring of fidelity is also an
important part of professional practice for all therapists who have achieved mastery in order to
avoid drift. It is strongly suggested that therapists submit their own videos to peers and others
for periodic coding.
We have also used this tool to assess fidelity in vivo for clinical purposes, but we do not have
inter-rater reliability studies of the live coding system.
From Rogers & Dawson ©2010

Code Definitions
The scores used in the fidelity system carry the following meaning when applied to video coding
of an individual joint activity routine:
5 A score of 5 represents the best possible example of this teaching technique or skill. This sample
represents optimal examples of the teaching skill, and the coder does not see anything that the
parent could have done to improve on this behavior. This is expert level performance.
4 A score of 4 represents a competent but not optimal example of this teaching technique. The skill
might have been performed in a more refined or expert way by a master ESDM therapist, but there
are no mistakes in the execution of this skill and it represents a completely acceptable display of this
skill. This is a fully competent level.
3 A score of 3 represents a parent behavior that is performed with strengths, but also some
weaknesses. Overall there are more strengths than weaknesses, but there are evident oversights or
mistakes according to the specified criteria. A person at this level in most of his or her teaching needs
more refinement of his or her skills before they are using ESDM competently. The individual will
continue to work with children, but requires additional supervision and feedback to improve
competency in these areas. This is a mixed level of competence.
2 A score of 2 represents a flawed display of this teaching behavior. There is some effort to use the
specified teaching practice but there are more weaknesses than strengths in this example. This is not
an acceptable level of performance and a person at this level needs more training and supervision in
this technique before working alone with children.
1 A score of 1 represents an absent or a poor example of the specified practice. A person at this level
needs full training in the model before working alone with children.
Note: If live coding, one way to code that simplifies the challenge is to use a Rapid Assessment
of Fidelity (using a 3 point scale rather than a 5 point scale). In this situation, one can use a
score of 3 to denote a performance that would be at the 4 and 5 levels on the full scoring
system – a competent performance. For live coding, you can use a score of 1 to code a non-
competent performance that would have received a 1 or 2 on the 5 point system. For live
coding, a score of 2 can be used to indicate a performance that has both strengths and
weaknesses and would be coded a 3 on the 5 point rating system.
2
Procedure for Coding Fidelity of Treatment Implementation
Instructions to Raters
1 If rating from video recording, watch the recording in a confidential setting with minimal verbal or
visual distractions.
2 Review the child’s objectives and the teaching plans just prior to coding, and keep them available to
check as needed. The treatment being delivered should correspond to the treatment objectives and
plans.
3 Read the language defining each behavior and anchor for every score, to be sure that your codes are
well anchored by the scale. Don’t rely on your memory or knowledge of the teaching practices or
coding definitions.
4 Take brief notes during the session that you observing, in order to remember examples of parent
behavior. Note delivery of antecedents, reinforcers and prompts, communications and their varied
functions, and elaborations, and so on, since you should not replay the recording to observe more
than once.
5 When rating, be aware of rater biases including halo or recency effects so that a problem in one
aspect of the teaching does not then bias your ratings of other behaviors in that segment or other
segments you observe.
6 Observe each activity one time through without stopping. Make notes as needed and begun to code.
You may replay to observe something a second time as needed, especially to capture child
communications and parent responses, if notes are not sufficient. Do not use slow motion and do not
replay more than once.
7 When a coaching problem has occurred, decide what the main difficulty is and code the item most
closely related to the problem accordingly. Do not let one problem behavior be coded in multiple
items. However, if one problem then leads to another, then both should be coded. If you are not sure
where to code the problem, just code it in one of the related items. As long as you don’t count it
twice, the scoring will not be affected by having it in one rather than another row.
8 If you are caught between two codes, then give the higher code. However, if the reason for the two
codes is that the parent behavior changed over the activity, then the problematic teaching behavior
should not be cancelled out by improvements later in the session. Rather, both aspects are important
to capture and a score assigned that reflects both the less adequate and the more adequate aspects.
9 Fidelity. In our training programs, a parent (or therapist) is considered to have achieved fidelity to the
model if they have no scores under 3 and a mean score of 85% or above on three consecutively coded
sessions.
3
P-ESDM Parent Fidelity Rating System
A. Management of Child Attention
Note: This item targets the child’s visual and auditory attention to the parent and to the
materials; that is, the ability of the parent to get the child’s attention on a teaching activity and
then “step into the spotlight” - the center of the child’s visual attention, so that the child
attends to the parent. If there are potential distractions in the environment, but they are not in
the way and the child is not distracted by them and is attending nicely to the teaching targets,
do not reduce the score.
1 Parent does not have child attention initially, either due to poor choice of activity or due to
environmental problems (distracted by materials, or uncomfortable and poorly seated, or the child
and parent are not positioned well in relation to each other). The parent does not take any steps to
alter the situation and continues, either fully prompting an inattentive child or having a child escape
or otherwise not participate.
2 Parent does not have child attention initially, due to style of presentation of activity or
environment, but appears aware of problem. Parent tries to attain child attention but is
unsuccessful and does not find a solution which results in a teaching episode. The activity
continues unsuccessfully or is aborted and is not replaced by a more successful teaching activity.
3 Parent has child attention on self or materials at start of activity but does not sustain attention
through the teaching task due to problems of timing, pacing, or teaching techniques. Or, the
parent does not have child attention at the start of the activity but recognizes the problem,
corrects it, and gains the child’s attention so that some teaching can occur. Or, the child is solely
focused on the materials and does not attend to the parent’s face or body. However, the quality
of the teaching activity in terms of opportunities for child learning has been compromised.
4 Parent has child attention at the beginning of the episode and sustains it for enough time to
conduct teaching activity. However, parent could have extended attention further or supported
better attentional distribution between parent and task with additional techniques.
5 Parent has child attention at the beginning of the episode and maximizes and sustains it through
a well-developed teaching activity and needed adjustments through multiple practice
opportunities. The child shows coordinated or alternating attention to parent and teaching
activity. Demonstrates optimal management of attention.
4
B. ABC Format – Quality of Behavioral Teaching
This item rates the clarity of the teaching interactions, frequency of teaching interactions, and
the appropriate use of repetitions during the activity. The following elements go into the score:
• ABC format: Did the parent use a clear ABC format in the teaching episodes? In skillful
teaching, the parent’s antecedents, child behaviors, and delivery of appropriate
consequences: reinforcement or correction stands out clearly. It is clear to the observer
what behavior the parent is trying to elicit. Direct reinforcement is delivered
contingently and quickly.
• Teaching trials occur frequently during the play – at least every 30 seconds on average.
• Number of repetitions: Were the number of repetitions for each skill appropriate for
child learning or maintenance? The parent shows good judgment about how often a skill
should be repeated based on learning needs and child motivation. New skills receive
more repetition than mastered skills without loss of child motivation. The purpose of
the repetitions is to shape more accurate performances.
1 The child is or is not watching the very active parent with interest, but there are very few teaching
exchanges in the activity – less than one per minute. Use this code if the parent is “entertaining” the
child by creating interesting spectacles that do not require many child responses.
2 Parent provides some teaching trials and is trying to teach rather than entertain. The parent has child
attention and motivation. However, the majority of trials lack a clear ABC structure.
3 Parent provides a number of teaching trials and they occur at least every 30 seconds. The majority of
trials have a clear ABC structure, though there is room for improvement in control of the ABC
structure. Or repetitions are not well matched to learner needs.
4 Parent provides many teaching trials, more than one every 30 seconds. Most teaching trials have a
clear ABC structure. Repetitions appear appropriate to needs. This is competent teaching.
5 Many teaching exchanges occur during the activity – on the average they occur every 10-20 seconds.
The A, B, and C segments are quite clear, and it is obvious what child behavior the parent is trying to
elicit and what behaviors are being reinforced. The number of repetitions is well matched to the
child’s learning needs. This is optimal teaching.
5
C. Instructional Techniques and Application
Efficacious application of instructional techniques: Did the parent use shaping, fading,
prompting, and/or chaining techniques appropriately, and was error correction managed well
to elicit and teach new behaviors?
Definitions
Prompting and fading: parent consistently applies skillful prompting (typically least to most)
and fading and reinforcement techniques to support successive approximations towards target
skill. Child becomes more independent in the teaching episode, demonstrating teacher’s skillful
use of prompt fading and choice of target behavior. Prompts are faded quickly and provide
“invisible” support for new learning.
Chaining: Child flows through teaching sequences smoothly and in response to the desired Sd’s.
The steps of the task analysis are at appropriate steps, prompts and reinforcers are handled
skillfully, and the timing allows the child to participate maximally in the process. Chaining often
occurs to teach clean up and set up activities, and in multistep play and language objectives.
Management of Errors: Child makes very few errors, because parent is handling the task well.
Parent generally uses a least to most prompting hierarchy and quickly adapts the teaching to
minimize errors, generally after two sequential failures. Parent chooses target behaviors of
appropriate levels of difficulty so that child performs correct responses independently rapidly
and consistently.
1 Consistently poor quality teaching. There are marked problems in the three areas listed above
and they occur throughout the episode.
2 The teaching is problematic in that it is inconsistent in its quality, with two of the targeted areas
showing marked weaknesses.
3 Some aspects of the teaching appear satisfactory but the teaching contains marked problems in
one area or mild to moderate problems in two targeted areas. The child is learning but the
problems detract somewhat from child learning and there is room to improve quality of
teaching.
4 Good application of principles. There is room for refinement in one or two of the areas but it
does not detract significantly from child learning.
5 This segment contains optimal examples of the principles above. The parent skillfully uses
fading, shaping, prompting, and chaining techniques to increase the child’s independent
performance of the learning objectives during the learning activity.
6
D. Parent Ability to Modulate Child Affect and Arousal
Use this item to address parent management of child emotional state, or activity level: such
characteristics as a tired, lethargic or under-aroused child, a passive, perhaps avoidant child, a
child who is whining, escaping, frustrated, distressed, upset with someone’s coming and going,
upset because a favorite toy was put away, or an overactive, high energy child who is not
settling into an activity. This is not about overt behavior problems – those get coded in a
different item. This is about optimizing a child’s mood, state, or activity level for participation in
learning. Did the parent skillfully modulate problems with child affect and arousal through
choice of activities, tone of voice, level of parent activity, and other interventions? If there are no
problems with child affect or arousal, score 5: Rationale – the parent skills are maintaining
optimal learning state.
1 The child demonstrates affect/arousal problems that prevent participation. Child state or
activity level prevents participation with the learning activity, and the parent does not
attempt to alter the child’s state, or makes such poor choices that the parent actually
aggravates the child’s problem.
2 The child demonstrates affect/arousal problems that impair participation. The parent
attempts to alter child states but is not successful due to lack of skill or missed opportunities.
Child state continues to limit learning opportunities in this episode.
3 The child displays problems with affect or arousal. The parent uses strategies that improve
child’s state or activity level so that some teaching exchanges occur. However, child continues
to show less than optimal learning state throughout the episode due to some lack of skill or
missed opportunities on the parent’s part and this limits teaching opportunities.
4 Child displays problems with affect or arousal during activity. Parent management did not
contribute to the affect/arousal problems, and the parent modulates problems with child
affect and arousal in the episode in ways that re-establish child engagement for learning. Or,
the parent appears sensitive to the child needs and tries every conceivable way imaginable to
help the child modulate states.
5 Child does not display any problems with arousal or affect during this episode. Or, the child
shows some affect/arousal problems and the parent shows great skill in finding ways to
optimize the child’s state quickly resulting in a very successful learning activity with many
learning opportunities and an engaged child.
7
E. Management of Unwanted Behaviors
When a problem behavior occurs, does the parent seek or demonstrate a clear understanding
of the function of behavior and use appropriate techniques to elicit more appropriate
behavior? Unwanted behaviors involve aggressive acts to other, self-injury, crying, marked
fussing or screaming, significant stereotypies, throwing or destroying materials, active,
oppositional refusal to follow instructions. Lack of cooperation, poor attention, overactive
avoidance, whining, passivity would not be coded.
1 The parent compounds the problem through overt reinforcement of unwanted behavior, or
by ignoring early evidence of difficulty and waiting until a bigger problem erupts. The parent
misses many clear opportunities to appropriately manage the behaviors to redirect and re-
engage the child.
2 The parent does not compound the problem through reinforcing unwanted behaviors, and
the parent attempts to manage the behavior. However, the behavior does not improve
because of poor management strategies.
3 The parent does not compound the problem and applies strategies that help the child return
to a learning state and participate in the activity. However, the parent has missed more than
one clear opportunity or lacks clear strategies for regaining child, cooperation and/or
appropriate behavior. Use this code also if the unwanted behavior goes on too long before
being managed.
4 The parent manages the behavior competently and the situation improves through the
episode. Child learning occurs, and the parent has not missed intervention opportunities or
techniques. However, there is an obvious additional step the parent could have taken to
improve the situation faster or further. Use this code also if parent management did not
contribute to the behavior problem, the parent understands the function of the behavior, or
tries to, and the parent applies appropriate strategies for redirecting, eliciting a more
appropriate behavior, and not reinforcing the unwanted behavior, even if the behavior
problem continues through the episode.
5 No unwanted behaviors as defined above occurred during this episode, or, they occur but
parent management did not contribute to the unwanted behaviors. The parent manages the
behavior skillfully and uses positive techniques that successfully redirect child, elicit a more
appropriate behavior, and re-establish child engagement and positive affect for learning as
soon as possible. This represents optimal management of the situation.
8
F. Quality of Dyadic Engagement
This involves a type of social engagement in which parents and children are acting in a
coordinated fashion. At its best, the child is aware of the parent’s activities and of the parent as
an interactive partner, and the child demonstrates this through shared gaze, directed,
intentional communicative exchanges, and smiles. Both partners lead, and both follow. In a
more structured, material based activity, dyadic exchanges may not occur throughout the
activity, but rather in moments of socially engaged, enjoyable, reciprocal acts. These are
expected to occur somewhere in every teaching episode.
1 There is no example of dyadic engagement. Parent never takes a turn, other than to model the first
instruction. The parent directs the teaching episode but does not join in the activity. There is no
socially engaged or reciprocal exchange. Requiring the child to perform a skill is not a turn for this
code.
2 There is one example of turn taking or dyadic exchange, but there are several missed opportunities
for more and the teaching episode would have been improved by adding them.
3 There is more than one example of turn taking and/or reciprocal, dyadic exchange, but the parent
misses a clear opportunity for turn taking, resulting in the parent being too much of an onlooker or
director. Or, child does not seem aware of parent turn; does not give materials to parent or watch
parent’s turn.
4 Turn taking or reciprocal engagement occurs multiple times in the episode (can be repeated acts all
at once). Child and parent are aware of each other’s turns and intentionally share gaze, smiles, and
some communication. Parent is competent at creating turn taking and dyadic engagement
exchanges.
5 Turn taking and dyadic engagement occurs throughout the episode. The child is actively involved in
parent turns, including giving toys, co-constructing, helping, or cuing the parent’s turn. Reciprocity
and social engagement permeate the teaching activity and this is an optimal example of
incorporating reciprocal dyadic engagement into teaching.
9
G. Parent Optimizes Child Motivation for Participating in the Activity
Note: This item is not about managing child states of arousal or emotion. That is covered in an
earlier item. This item refers to the child’s energy and motivation to perform this specific
teaching task multiple times, through the number of trials the parent requests. If problems of
motivation in this episode lead to problems with state or unwanted behaviors, then all the
appropriate items would be coded. Child choices are a very important aspect of this item. In a
naturalistic teaching episode, this involves child choice of materials/activity. In an activity that
does not involve objects (songs, play), the parent may “offer” the activity, but parent still
follows child lead in determining whether to continue or not. In a parent-directed teaching
episode, this can include child choice of reinforcers, or child choice of a preferred activity in
which a didactic teaching episode will be embedded. Valuing child choice does not preclude
modeling a new toy or activity, or taking a child through an activity for the first time to
introduce it, even if the child is mildly protesting. However, it does preclude continuing an
activity in the face of marked child protest or disinterest unless the activity is necessary for child
safety, hygiene, and so on. A parent who is consistently suggesting a new activity to the child –
“Let’s play food, okay?” is not giving adequate opportunity for choices. This is not a problem
when done once in a while, but if it occurs more often than that then the parent is being too
directive and not creating and following child choices and leads.
Motivation for child participation can be optimized by the following:
• Interspersing maintenance and acquisition trials.

• Good reinforcer management, including reinforcing child attempts, reinforcement
schedules, use of Premack principle, and use of intrinsic reinforcers where possible:
• Giving child choices and following child leads.
• Choosing activities well and creating interesting activities with materials
• Ending or changing activity before child becomes bored or tired.
10
1 The child is not motivated by this activity and the parent does not use any of the above
techniques to improve motivation. Parent chooses the activity and provides no child
choice. Child does not show interest in the activity, does not attempt the task or is fully
prompted through it.
2 The child is not motivated by this activity. The parent chooses the activity and uses one
or more of the above strategies to try to increase motivation but is not successful and
the child does not perform the teaching task under his or her own effort, or the child
performs once and does not continue. The parent provides one or two choices only to
the child and misses multiple opportunities to give choices.
3 The child demonstrates some motivation for the activity and makes several responses to
the teaching task. Parent uses at least three of the above techniques to involve or
sustain child interest and participation. Parent provides two or more opportunities for
child choice but misses clear opportunities for choices. However, there are problems
with motivation that parent could have addressed by better application of the above
techniques.
4 The child chooses the activity or becomes motivated to perform the task due to
successful parent application of principles. The parent applies the above principles in a
skillful way and this results in multiple teaching opportunities. Child has several
opportunities to make choices within the episode.
5 The episode demonstrates a highly motivated child who chooses the activity and is very
interested in the activity. The child engages repeatedly in the learning activities that are
presented, responds consistently to parent instruction, and initiates repeated
communicative behaviors requesting the learning activities. The parent demonstrates
optimal use of the four variables above. The parent is adept at making small
adjustments and creating many child choices to maintain high motivation throughout
the activity.
11
H. Parent Use of Positive Affect
1 Parent does not display positive affect during the episode in face, voice, or style. The
parent is inappropriately business- like or the parent may display a negative affective
state.
2 The parent uses unnatural, unmodulated, or otherwise inappropriate displays of positive
affect – too strong, too artificial-- resulting in an unnatural and/or overly intense display
poorly matched to child state.
3 The parent is rather neutral or flat, or is inconsistent effectively throughout the episode,
and the activity is one in which one would typically see more positive affective display.
Quality of the social interaction would be enhanced by somewhat warmer affect.
4 The parent displays genuine natural levels of positive affect, including a general
background of positive feeling, during the episode.
5 The parent displays rich, genuine and natural positive affect throughout the episode
matched by child positive affect. Positive affect permeates the episode, is well matched
to child needs and capacities, does not over arouse the child, and serves teaching well.
12
I. Parent Sensitivity and Responsivity to Child Communicative Cues
This refers to parent’s attunement to child states, motives, and feelings. A sensitive and
responsive parent acknowledges communicative cues, whether verbal or gestural, by
verbalizing or by acting contingently according to the child’s communication so that the child
has been “heard.” Or, in the face of an affective cue, the parent responds empathically to the
child’s emotional state by mirroring the emotion and communicating an understanding of it.
The parent does not reinforce unwanted behavior, but acknowledges the child’s cues and
responds appropriately given the situation. The parent uses a range of techniques including
modeling, restatement, expansion, of child utterances, and repetition of child utterances
embedded in meaningful activities.
1 Parent appears insensitive and unresponsive to virtually all child cues in this episode. The parent
carries out their own agenda and ignores child cues. Or, the parent uses a directive teaching style
and does not provide any opportunity for child communications, so that there are no child cues
or communications in this episode.
2 The parent responds to two of the child’s cues but not to the majority of them, either because
the parent is not attending, not interpreting, or is directing and thus overriding child
communications.
3 The parent shows some sensitivity and responsivity to the majority of the child’s communicative
cues, but the parent does not respond sensitively and responsively to a minority of child-directed
communications when optimal teaching would dictate some type of response.
4 The parent shows sensitive and contingent responding to the majority of child communications.
There are one or two misses, but they are mostly due to other factors: lack of clarity of the child
cue, the teaching plan, or attention to another aspect of the environment, rather than being due
to lack of sensitivity or responsivity.
5 The parent demonstrates optimal sensitivity and responsivity to child cues. The parent is
maximally attuned to the child’s communications, both directed and undirected. The parent
reads the child very well or makes every effort to interpret the child’s meaning. The parent uses a
full range of responses: restatement, modeling, expansion, affirmation through repetition.
13
J. Multiple and Varied Communicative Opportunities Occur in the
Activity
This item addresses the number of pragmatic functions expressed in child communications and
elicited by the parent. Examples include requesting, commenting, naming, protesting/affirming,
seeking help, being “all done”, greeting, or imitating parent’s sounds or gestures with eye
contact. Children’s imitation of a parent action on an object, without accompanying gaze,
vocalization, gesture, and so on is not considered a communication for this item.
1 Opportunity for child communication is virtually absent. Object oriented activities do not contain
a communicative component; sensory social routines involve the parent acting on the child
rather than creating opportunities for child communication.
2 Opportunities to practice communication only occur for one function – like requesting or naming.
Use this code also for parent directed, drill and practice format.
3 There are several communicative opportunities that occur in naturalistic communicative
situations and more than one type of communication is practiced or used. However, there is over
reliance on one pragmatic function (like requesting or protesting). Or, there is too much
repetition of a single word where the situation clearly calls for some vocabulary expansion at
least through modeling. Clear opportunities to practice existing communication objectives that
apply in this activity are missed.
4 There are multiple, varied communicative opportunities in the activity. Several communication
objectives are addressed, and/or several different pragmatic functions, vocabulary use, or
syntactic combinations are practiced. The parent is competent in teaching varied language and
using techniques to model and expand child utterances even though one or two opportunities
were missed.
5 This is an optimal example of the parent scaffolding multiple communications involving several
different communicative functions throughout the episode as specified in the child’s objectives,
including opportunities to request, protest, comment, ask for help, greet, name, expand, and so
on. The range of pragmatic and communicative opportunities fit well with the child’s language
level. For an object-oriented activity, there are multiple child communications per minute. For a
sensory social routine, child communication (including gaze and smiles) occurs approximately
every 10 seconds. The parent uses a range of techniques including modeling, restatement,
expansion of child utterances, and repetition of child utterances embedded in meaningful
activities. No clear opportunities for child communication were missed, and child’s
communication objectives are woven throughout the activity.
14
K. Appropriateness of Parent Language for Child’s Language Level
Is the parent’s language appropriate for expanding the child’s language level in terms of
vocabulary, syntax, and pragmatics? This includes comments to the child, language models, and
appropriate narration of the actions or themes involved in the activity.
1 Parent language is not appropriate for child in any dimension. Parent vocabulary and/or
syntax is consistently too complex or too simplified. Or pragmatics are inappropriate,
with language used only to instruct, direct, and name. One up rule is not followed.
2 Parent language is syntactically appropriate for child (one up rule), but parent uses
language only to give instructions, name objects, and praise (“good talking”), rather than
to communicate in pragmatically appropriate ways.
3 Majority of parent communications are appropriate syntactically (one up rule),
semantically, and pragmatically,(i.e. they fit the child objectives) but there several
instances of obvious errors in two or more of these in an utterance or opportunities to
narrate child’s behavior and actions are missed.
4 Parent language is generally appropriate syntactically, semantically, and pragmatically.
Though there may be a miss here or there, the parent is generally using language that
represents the child’s current understanding level, with more mature language provided
as models, narrates appropriately and shows consistent use of one-up rule.
5 Parent language is consistently appropriate developmentally and pragmatically for the
child’s verbal and nonverbal communicative intent and capacity. Parent generally follows
the one-up rule, responds to child’s communications with appropriate language, narrates
child and parent acts or themes appropriately, and uses language to demonstrate a
variety of pragmatic functions, semantic relations, and syntactic combinations.
15
L. Joint Activity Structure and Elaboration
The parent (or therapist) develops a four-part joint activity: (1) a set-up in which child chooses
activity and helps parent set up the theme; (2) a middle in which both participate equally,
building, co-constructing the activity; (3) elaboration to encourage flexible, varied use of actions
and materials by using multiple materials and varied schemas, or through theme and variation,
or through narrative frames; and (4) an ending in which the timing to close down the activity
was fitting and the child is well-supported through the transition to the next activity. The parent
targets multiple objectives from different developmental domains.
Note: If the child needs parent directed, mass trial teaching to learn, activities can still be
elaborated by having child help take out, put away, and choose materials, or by interweaving of
social exchanges. Thus, this item applies to all kinds of teaching approaches.
1 Parent focuses on teaching only one objective but is not successful. Activity does not contain a
clear structure involving set up, theme, and closure. Activity lacks elaboration component and so
either ends too soon, missing teaching opportunities, or is too repetitive.
2 Parent teaches one objective successfully. Activity does not contain a clear structure involving set
up, theme, and closure. Parent tries but is unsuccessful at eliciting any other learning behaviors
on multiple objectives or elaborating responses. Lack of success is due to lack of parent skill.
3 Parent provides clear structure involving at least three parts: set up, theme, and closure. There is
some attempt at elaboration and parent teaches more than one objective, but misses multiple
opportunities to elaborate and sustain the activity or address more objectives. The activity lacks
or appears overly repetitive or underdeveloped for this child.
4 Parent provides clear structure involving all four parts: set up, theme, variation, and closure.
Parent demonstrates competence in elaborating the activity sufficiently to sustain interest in the
activity through all four parts. Parent creates a variety of opportunities and successfully teaches
objectives from multiple domains.
5 Parent provides an optimal four part joint activity including a well-developed closure. Parent
demonstrates optimal and imaginative elaboration of this activity, targeting many objectives.
Parent supports the child’s learning by combining skills from objectives in different domains in
flexible teaching. (Note: If the child needs many repetitions to master this skill and the child is
highly motivated, then do not score down due to lack of theme and variation. However, there
should always be more than one child objective targeted in an activity.)
16
M. Transitions between Activities
Does the parent skillfully transition between activities or locations to maximize child attention,
motivation, and independent physical transition to new activity? (Note: If no transitions are
present on the video at either the beginning or the ending of the activity, then score this as N/O
[no opportunity] and do not use the item to calculate level of fidelity.
1 There is no real transition. The activity ends/begins abruptly with negative effect on
child attention, motivation, or interest. The transition is abrupt because the child leaves
the activity or child is physically led through the transitions. There is no effort to help
the child shift attention, or to draw the child’s interest and awareness to new activity.
Child may be physically moved from one location to another and wait with nothing to
do while the parent gets an activity.
2 There is a transition but the parent leads the child through the transition, either by
physically moving the child from one activity or location to another without encouraging
independence in the transition, or by choosing the activity without any child choice and
directing the child into the start of the activity without any child initiation.
3 Transition is accomplished by shifting child interest to a new activity without physically
leading child. However, the activity choice is not optimal, either because there is not
enough variation from the last activity or because the child’s obvious needs or choices
(quiet to active, active to calm, change of location, change of pace) are not acted upon
in choosing the next activity.
4 The transition is smooth and the child moves independently in the transition. The
parent engages the child in the new activity, via some type of child choice or child
initiation. The new activity represents variation in terms of location, activity level, or
teaching domain.
5 Transition is optimally managed. Parent scaffolds child’s shift of interest by closing
down one activity at the appropriate time and bringing up another, so that the child’s
learning in both activities is maximized and interest flows from one activity to the next
with minimal down time. Child chooses and initiates the next activity.
17
P-ESDM Parent Fidelity Coding Sheet
Parent______________________ Rater and Date_____________________

Child and date__________________________________________________
Item Activity 1 Activity 2 Activity 3 Activity 4 Activity 5 Activity 6
A. Management of child attention
B. ABC format
C. Instructional techniques
D. Modulating child affect/arousal
E. Management of unwanted
behavior
F. Quality of dyadic engagement
G. Parent optimizes child

motivation
H. Parent use of positive affect
I. Parent sensitivity and

responsivity
J. Multiple varied communicative

opportunities
K. Parent’s language for child’s

level
L. Joint activity and elaboration
M. Transition between activities
Comment Columns for Note Taking
18
Summary Sheet for Parent Fidelity Scores
Across a 12 Week Period
Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12
19
Early Start Denver Model Fidelity Coding Sheet
Therapist: Rater & Date:
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
F. Use of turn taking
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
I. Adult sensitivity
and responsivity
J. Multiple varied
communicative
functions
K. Adult language
L. Joint activity and

elaboration
M. Transition
between activities
Comments
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
and responsivity
J. Multiple varied
communicative
functions
K. Adult language

elaboration
M. Transition
between activities
Comments
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
and responsivity
J. Multiple varied
communicative
functions
K. Adult language

elaboration
M. Transition
between activities
Comments
Ideas for Joint Activities & Sensory-Social Routines
Songs:
 Row Row Row Your Boat
 Motor Boat
 Ring Around the Rosie
 If Your Happy and You Know It
 Wheels on the Bus
 Itsy Bitsy Spider
 Open Shut Them
 Slippery Fish
Activities:
 Chase
 Catch
 Water/Sand table
 Balloon
 Peek-a-boo
 Patty cake
 This little piggy
 Up/Spinning/Swinging/airplane/rocking/cuddling
 Motor “sandwich” (applying deep pressure with 2 pillows)
 Tickles
 Spinning or rolling objects
 “Walk, Walk, Walk, and Stop!” Chant (jump, run, etc.)- use visuals
 “Bunny hop” with a bunny (child can engage with toy or us)
 Making food (chocolate milk, Kool-Aid, etc)
 Cause-effect toys (pop-up, music)
 Hand lotion
 Brushing
 Bouncing on a ball
 Playing with vibrating toys
 Act like animals
 Bouncing on lap and singing
Joint Activity Routine Elements
Step 1: Set up theme, develop theme
Step 2: Theme – take turns, collaborate, teach objectives
Step 3: Add variations (e.g., new actions, new objectives)
Step 4: Close the activities and transition to a new one

RECEPTIVE
1. 6.
1 2 3 4 1 2 3 4
SOCIAL INTERACTION
7.
1 2 3 4
2.
1 2 3 4
8.
1 2 3 4
3.
1 2 3 4
9.
1 2 3 4
EXPRESSIVE
4.
1 2 3 4
IMITATION
10.
1 2 3 4
5.
1 2 3 4
11. FINE MOTOR
1 2 3 4 16.
1 2 3 4
COGNITION 1 2 3 4
12.
1 2 3 4
BEHAVIOR
13.
1 2 3 4

1 2 3 4 activity

15.
1 2 3 4
SAMPLE DATA SHEET Time of Session:_________________ Date:___________
DATA SHEET IMITATION
Spont imitates 5+ actions on objects, both novel and familiar w/in 5
EXPRESSIVE secs for 80% of opps
Vocalization w/ intent to request objects or activities 5+xs 80% opps 1 2 3 4 5 6 7
1 2 3 4 5 6 7 1-2 actions fpp (b)
Reaches for obj (b) 1-2 actions, ppp
Voc 1x 1-2 actions, spont
Voc 2x 3-5 actions, vp
Voc 3x 5+ actions, spont across 3+ adults, settings, and
activities 4 out of 5 tx ssn
Voc 4xs
COGNITIVE
Voc 5+xs 80% opps across 3 diff adults, setting, and
vocs 4 out of 5 tx ssn
Matches 5+ pairs of identical pictures with 80% accuracy
Ask for help by handing the object to the adult 5+x per session 1 2 3 4 5 6 7
1 2 3 4 5 6 7 1-2 pairs fpp (b)
1x fpp (b) 1-2 pairs 50% opps
1x ppp 1-2 pairs 80% opps
1x spont 3-4 pairs 50% opps
2-4xs 50% opps 3-4 pairs 80% opps
2-4xs 80% opps 5+ pairs 80% opps 3+ adults,
settings, and activities 4 out of 5 tx
5xs 50% opps ssn
5+ xs 80% opps across 3+ adults, settings, and PLAY SKILLS
help opps 4 out of 5 tx ssn
Play appropriately with 8 or more different one-step toddler toys
RECEPTIVE LANGUAGE involving for 5+ toys 80% opps
Points or pats to 3+ pics when adult asks “Where is ___?” or “Show e.g. shapes in shape sorter, balls in ball 1 2 3 4 5 6 7
me ____” , 80% of opps maze, pegs in peg board, taking apart pop
1 2 3 4 5 6 7 beads
Points or pats 1x fpp (b) 1 toy ppp (b)
Points or pats 1x ppp 1 toy 50% opps
Points or pats 1x indep 50% 1 toy 80% opp
Points or pats 1x indep 80% 2-4 toys 80% opps
5-7 toys 80% opps
Points or pats 2x indep 80%
8+ toys 80% opps across 3+ adults, toys, and
Points or pats 3+x indep 80% settings 4 out of 5 tx ssn
across 3+ adults, items & books 4 out of 5 tx
ssn
15 30 45 60 1 hr 1 hr 1 hr
Follow a proximal point to place objects in containers or puzzle pieces min min min min 15 30 45
in puzzle 4-5xs min min min AVG
e.g. puzzles, shapes in the shape sorter and during 1 2 3 4 5 6 7
clean up -put items in bag
BX
1 x fpp (b)
1x ppp
ROUTI
1x spont
NE
2-3xs spont
4xs spont
5 xs across 3 adults and activities 4 out of 5 tx ssn BEHAVIOR CODES
SOCIAL INTERACTION 1 Severe behavior (e.g. aggression, SIB, frequent/intense tantrums
st
Responds to greeting with E.C., gesture &/or vocalization @ 1 opp 2 Mild Behavior (e.g. noncompliance, some tantrums but able to
1 2 3 4 5 6 7 participate in activity
3 Some behavior problems (e.g. fussy, whiny, some noncompliance but
E.C. (b)
able to participate in most of activity
E.C. + wave fpp 4 No problem behavior but difficulty staying on task
E.C. + wave ppp 5 Compliant, on-task, working at ability level
E.C. + wave spont 6 Above average performance for child, pleasant, excited about activity
E.C. + voc w/ vp ROUTINE CODES
E.C. + voc spont G Greeting S Snack
F Floor activity Q Quiet
E.C. + voc or wave across 3+ adults
R Sensory social routine T Table activity
over a 2 day period O Outside C Closing
RECEPTIVE
1. 6.
1 2 3 4 1 2 3 4
SOCIAL INTERACTION
7.
1 2 3 4
2.
1 2 3 4
8.
1 2 3 4
3.
1 2 3 4
9.
1 2 3 4
EXPRESSIVE
4.
1 2 3 4
IMITATION
10.
1 2 3 4
5.
1 2 3 4
11. FINE MOTOR
1 2 3 4 16.
1 2 3 4
COGNITION 1 2 3 4
12.
1 2 3 4
BEHAVIOR
13.
1 2 3 4

1 2 3 4 activity

15.
1 2 3 4
ESDM Model Objectives & Steps

Expressive Language
1. When a parent imitates her playful sounds back to her, S will make the sound again and direct it toward her
parent, 75% of opportunities, across multiple activities and both parents, for three consecutive days.
Date Activity Skill Mastery Steps

1. Makes vocal sound back to parent 1X during a
social game or song.
2. Makes vocal sound back to parent 1X during
each social game or song, and toy play.
3. Makes vocal sounds back to parent 25% of opportunities
during each social game or song, and toy play.
4. Makes vocal sounds back to parent 50% of opportunities
during each social game or song, and toy play.
5. Makes vocal sounds directed to parent 50% of opportunities
during each social game or song, toy play, book play, meal or
snack, and bath or diaper change.
6. Makes vocal sounds directed to each parent 75% of
opportunities during 3 activities per day.
2. When a parent imitates S’s vocalizations, she will continue the game for 3 rounds at least once daily,
observed in 3 different activities and with both parents, for three consecutive days.
Date Activity Skill Mastery Steps

1. Occasionally vocalizes in response to parent’s sounds 1X
during 1 activity.
2. Vocalizes in response to parent’s sounds 1X during 3
different activities.
3. Vocalizes in 2 back-and-forth rounds (Parent-child-Parent-
child) with parent during 1 activity.
4. Vocalizes in 2 back-and-forth rounds (P-c-P-c) with parent
during 3 different activities.
5. Vocalizes in 3 back-and-forth rounds (P-c-P-c-P-c) with
parent during 1-2 activities.
6. Vocalizes in 3 back-and-forth rounds (P-c-P-c-P-c) once per
day, for 3 consec days, observed with both parents and in in
3 diff. activities.
Receptive Language
3. When S is holding an object and her parent says, “Give me,” and extends hand to request, she will
place the object in her parent’s hand, 3 times per day, with both parents and in at least five different
activities and materials.
Date Started Date Mastered Skill Mastery Steps

1. Gives object to parent when asked and with full physical help at
least 3X/day.
2. Gives object to parents at least 1X/day when parents extend hand
very close to object, point to palm, and say, “Give me.”
3. Gives object to parents at least 2X/day when parents extends
hand a few inches from object, point to palm and ask, in 3
activities and materials.
a few inches from object and ask, in 3 activities and materials.
a few inches from object and ask, during 3 activities and
materials.
6. Gives object at least 3X/day for both parents, when parents
extend hand and ask, during at least 5 different activities and
materials.
4. During object-based play (e.g., blocks, animals and barn, figurines and house) when an adult provides
an instruction involving “in” and “on,” the child will place or retrieve 5 or more items in 80% of
opportunities, in 4 of 5 consecutive treatment sessions across 2 or more adults, 2 settings.

1. Places objects in and on with full physical prompts.
2. Places objects both in and on with gestural prompts in 80% of
opps.
3. Places objects both in and on indep 50% of opps.
4. Places objects both in and on indep 80% of opps.
5. Places objects both in and on 80% of opps across 3 adults, 2
settings and 5 objects
Joint Attention
5. When the child has an object (e.g., a preferred toy, completed artwork, an accomplished Lego tower)
and the adult asks, “Show me,” the child will extend the object towards the adult and look to the adult,
80% of opportunities, 4 of 5 consecutive sessions, across 3 or more adults, objects and settings.

1. Extends object towards adult with full physical prompt (B).
2. Extends object towards adult with partial physical or gestural 80%
of opps.
3. Extends object towards adult indep 25% of opps.
6.Extends object towards adult w/eye contact indep 80% of opps
across 3+ adults, settings and objects
Social Interaction
6. When a therapist greets the child at eye level, with eye contact and “hi/bye (name)” delivered within
2-3 feet, the child will respond with eye contact and gesture and/or vocalization at the first opportunity
in 4 of 5 consecutive treatment sessions across 3 or more adults and settings.

1. Child will occasionally look at adult when
greeted.
2. Child will make eye contact or vocalize or wave
when greeted from 2 ft away @ 1st opp.
3. Child will make eye contact or vocalize or wave
when adult 3 ft away @ 1st opp.
4. Child will make eye contact and vocalize or wave
when adult 2 ft @ 1st opp.
5. Child will make eye contact and vocalize or wave
when adult 3 ft away @ 1st opp across 3+ adults
and 3+ settings.
Imitation
7. When an adult models one of 4 different common actions (e.g., eat, sleep, run, jump) being carried
out by figures as part of a pretend play routine, the child will imitate having the figure carry out the
action in 80% of opportunities for 4 of 5 consecutive treatment sessions across 3 or more adults, 2
settings, and 3 or more different figures.

1. Child occasionally has figure imitate 1 action.
2. Child has figure imitate 2 actions with partial physical
prompt 80% of opp.
3. Child has figure imitate 4 actions with partial physical
prompt 80% of opp.
4. Child has figure imitate 4 actions with gestural prompt
80% of opp.
5. Child has figure imitate 2 actions 50% of opps.
6. Child has figure imitate 4 different actions 80% of opps
across 3+ adults, 2+ settings, 3 figures,
Fine Motor Skills
8. During constructive or symbolic play,, the child will string up to 3 or more large beads on thick string,
pipe cleaner or straw either independently or following demonstration or verbal instruction 80% of
opportunities in 4 of 5 treatment sessions across 3 or more adults, in 2 different settings, and
demonstrated on 3 different types of beads and string.
Behavior
9. When the child requests a preferred activity or food item by bringing it to an adult, and an adult says,
“First (less preferred) activity, then (more preferred) activity,” the child will engage in the less
preferred activity until it is complete or for at least 30 seconds without protesting by crying, whining, or
otherwise fussing at least two times per treatment session for 4 of 5 consecutive treatment sessions in
2 settings, for 3 or more adults (including mom) and for 3 less preferred activities.
Personal Independence
10. When washing hands the first time during a session or day, the child will carry out all the steps of
hand washing except for turning water on with no more than gestural or partial physical prompts, 4 of
5 consecutive days or sessions across 3 adults and 2 settings.
11. When the child requests a preferred beverage that is presented in a cup with a straw and handed to
or placed in front of child, the child will put his mouth on the straw and take a drink at the first
opportunity, for 4 of 5 consecutive treatment sessions or days, across 3 diff. cups, 3 diff. straws, 2
adults and 2settings.
P-ESDM Functional Behavior Assessment and Management Form
Problem Behaviors – Severity Assessment

Problem Behaviors Frequency Duration Environments +/-
Rogers & Vismara, 2012 1

Problem Behaviors – Functional Assessments
Problem Behaviors Function(s) Gains? Function(s) Avoids Antecedents? What do I wish he/she would do instead?
2
Rogers & Vismara, 2012
Positive Behavior Management Plan
Unwanted Behavior Substitute Behavior Antecedent Management: Consequence Management Plan
Prevention Plan
Crisis Management Plan:
Parent Support Plan:
3
Daily Data Collection Form for Problem Behavior and Substitute Behavior
Date: ___________
Behavior 1-Did not 2- Occurred 3- Occurred 4- Occurred 5- Occurred 6- Occurred multiple times per hour
occur once 2-3 times many times hourly
today
4
Yes Improving?
Continue
Complete Deliver
Yes
FA; develop ESDM plan No
PBSP & PSBP
Not?
Assess. Seek
Significant consult.
risk of
injury?
Yes
Continue
No Deliver Behavior
ESDM decreasing?
plan.
No Do FA
and write
PbSP
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
and responsivity
J. Multiple varied
communicative
functions
K. Adult language

elaboration
M. Transition
between activities
Comments
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
and responsivity
J. Multiple varied
communicative
functions
K. Adult language

elaboration
M. Transition
between activities
Comments
Child and Episode:
A. Management
of child attention
B. ABC Format
C. Instructional
techniques
D. Modulating child
affect/arousal
E. Management of
unwanted behavior
/dyadic engagement
G. Child motivation
is optimized
H. Adult use of
positive affect
and responsivity
J. Multiple varied
communicative
functions
K. Adult language

elaboration
M. Transition
between activities
Comments
ESDM Play Partner Decision Tree

ACTION FIRST STEP SECOND STEP THIRD STEP FOURTH STEP
PLAN
Supportive Select a time when child is playing in Now begin to narrate or describe Slowly start to involve yourself in Next, offer help. When he’s not
Play an activity that he enjoys. Approach child’s actions. Think of yourself as a play by offering items or materials to looking, put things in containers he
Partner him while commenting positively on sportscaster, commenting on what child. Do not touch materials that he cannot open or show him new toys
his play. Sit near or next to him, read materials or items the child is using has already claimed. Instead go for that he cannot operate on his own.
his body language to determine his and how he is playing with them. extras that are not in his grasp. You Be sure to give the item right back as
tolerance. If he fusses, back up and Remember to speak in single words. can still label items and actions with soon as you have helped. The goal is
if not move near him. Don’t worry Continue to praise and describe and single words. The goal is to hand for the child to be facing you so he
about touching materials or don’t worry about touching them over when the child is facing can see your help with the materials
teaching, yet. Just sit and watch, materials or teaching, yet. The goal is you and watching your handling of without an expectation yet that he
smiling and praising his efforts. The to slowly increase your involvement the materials, although eye contact use a specific behavior to request the
goal is to have him accept your without challenging him. from the child to receive the material material from you.
presence. is not yet necessary.
Interactive Follow Steps 1-4 from above and For every three times you imitate For every three times you offer him a For every 3 times you provide a fun
Play assuming child is still engaged, then him, give him a choice that relates to choice, ask him to do something in reward, have the child respond to
Partner proceed with the following: what the current play activity. If the the play. It could be to put an item in your teaching opportunity using a
Imitate all of child’s actions, game involves cars, should we crash a certain spot, to show or give you nonverbal behavior. This could be a
including sounds, gestures, and play. or roll; if pegs, should we stack or something, or to try something new gesture, body movement, or eye
Pick up the same materials he has bang; if face-to-face, do we tickle or with the material. Whatever it is, contact. It has to relate be directed
and create the same movements, sing song? If snack, is it juice or fruit? make sure there is a fun reward toward you and relate somehow to
using single words to express the Let him choose however he wants following his compliance. Remember the activity. Remember to accept
actions. The goal is to capture the to, regardless of eye contact, but that the consequence has to be attempts and reward. The goal is to
child’s eye contact, both on your remember to label his decision using worth the effort, or he’s less likely to have the child use an intentional
handling of the materials and to single words. The goal is for the child cooperate the next time. The goal is behavior in response to your
your face, and to find his smile in the to become more active in decision- for the child to become more active antecedent, followed by the
game. making and to increase the length of in play and to take turns following rewarding consequence (i.e., the
the activity. your ideas in play. material, the action, the game).
ESD900 Early Start Denver Model Lesson 1.1
Slide 1: ESDM Principles

Welcome. In this section of the Early Start Denver Model introductory course we’ll be talking about the basic
principles of the Early Start Denver Model.
Slide 2: The MIND Institute
The Early Start Denver Model is the product of a number of teams in a number of universities across decades.
The main developers are me, Sally Rogers and my colleague and friend, Geraldine Dawson. We worked
together in Gerry’s site at the University of Washington to bring this particular intervention to trial and to bring it
to you. We want to thank the participating families and children who have taught us so much about how to help
them, help their children progress and I want to acknowledge the University of Colorado at Denver Team
headed by Jean Herbison and Diane Osaki for their contributions to the original Denver Model, Jamie Winter,
who worked with Gerry Dawson at the University of Washington, Laurie Vismara, who worked so closely with
me developing the parent coaching model of this, and Cheryl Dissanayake, Cynthia Zierhut and the team at La
Trobe University in Melbourne, Australia, for developing the group model that we’ll mention today.
Slide 3: The WH Questions
In this particular section of the course we’re going to be talking about the WH Questions, the “who, what, when,
where and why” questions that underlie the principles of Early Start Denver Model.
Slide 4: Timeline
People often think of this as a recent development in the treatment literature but, in fact, the Early Start Denver
Model goes back a very long way, all the way to 1981, when I received a grant to start a preschool program for
young children with autism, following developmental principles at the University of Colorado. In that same era,
Gerry Dawson was working in research on parent and child relationships in autism and on social interactions.
And so our work began in the labs and with clinical patients as we started to learn about the presentation of
autism early on. We quickly moved from our research in the preschool program to papers describing it and a
dissemination project in which we tried to work with other folks who could quickly learn the intervention and
show us we were on the right direction. By 1987, we were already thinking about how to incorporate principles
of applied behavior analysis into the model without losing the developmental features.
And in 1995 we had our first experiences with using Denver Model in an inclusive setting where most of the
children had typical development and we were using the principles to include children with severe autism into
regular preschool programs, embedding all of their learning objectives inside group activities. In 2003 Gerry
Dawson and I started our collaboration, moving the Denver Model down into young populations, incorporating
more formal principles of applied behavior analysis, mostly the model called PRT, pivotal response training,
into it and moving into the infant/toddler period. Gerry also was working from a very large treatment and
research grant and that was the original funding for our work. I received further funding in 2008 to carry out a
multi-site randomized controlled trial and in 2010 we published the first outcome paper and the treatment
manuals and curriculum, which you have in front of you. “The Parent Manual” and the “Telehealth and Parent
Coaching” papers followed quickly so that, by 2012, we had demonstrations of findings with parents leading
the intervention and also a manual written specifically for parents.
And in 2013 our work was recognized by Time Magazine as one of the Top 10 Scientific Accomplishments of
the Year. A second treatment grant was awarded to our setting to compare the results of Early Start Denver
Model to other, well-established interventions. And last year, in 2014, we published a paper on our “Application
of Principles to Infants.” That paper created quite a bit of stir even though it involved only 7 infants, most of
whom did very, very well in the intervention. And so, this is an intervention that is continually being updated but
has a 30+ year history behind it of research and practice. I’m sure that future versions of this course are going
to have some differences because it is a constantly-evolving, empirically-based model, which is continually
being updated.
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Slide 5: Developmental Framework

There are several variables that define the Denver Model and the Early Start Denver Model and separate it, in
some ways, from every other intervention for young children with autism that are currently in the field. I’m
going to take you through all the main variables that define it and then we’ll do a little compare-and-contrast so
that you can see how it’s similar to and different than other well-known interventions for young children.
As I said already the Early Start Denver Model, or ESDM, comes from a developmental framework. It’s
grounded in research in how typically-developing children grow up over the first 5 years of life. We understand
autism as a developmental disorder, a biological condition that affects virtually every area of a young child’s
development, not only social interaction and communication but also motor development, imitation skills and
even slows down the child’s ability to learn to take care of themselves in everyday life. We see autism as
affecting virtually every area of development and those are our targets for our intervention.
Because of the developmental framework, our curriculum follows the developmental sequences in each of the
domains of early-childhood development and we’ll talk about that in more detail in another section of this
course.
Both the curriculum items and the principles overall target all affected developmental areas, and so, wherever
a child is behind, compared to their peers, we are going to be writing treatment objectives and directing focus
on helping them acquire needed skills and accelerate their development so that they’re coming closer to
typically-developing peers. We want to minimize as much as possible the developmental delay associated with
early autism, and we want to build on the principles of infant/toddler learning. Infants and toddlers are
experiential, hands-on learners. The quality of their relationships with caregivers and other adults has a
significant influence on their speed of learning and their willingness to pick up skills from other people to
imitate them and to want to be like them. Those are important characteristics for children with autism as well.
Young children learn the most from the routines of everyday life. That’s where language and meaning are
embedded in experiences that they learn over time and participate in with people that they care about and we
want infant-based learning for children with autism to often also be based in routines. Infants and toddlers are
multi-modal learners. They learn from an activity through all of their senses. They learn from visual information,
auditory information, they learn from the touch and feel of what’s happening as action sequences play out in
their routines and we want to capitalize on the multi-modal learning abilities of young children with autism. We
don’t want to restrict them to just doing one thing or focusing on one picture or one-color-at-a-time. We want
them to be able to bring in all of the learning information that’s available in a routine so that they can learn as
rapidly as possible.
A final principle of infant/toddler learning that we build on is a principle from a Russian psychologist named
Vygotsky. He talked about the fact that children are most ready to learn a skill that is just beyond what they
can already do. He called this the proximal zone of development and ESDM and the Curriculum Tool that we
have helps us identify these proximal zones of development. We can easily see in the curriculum what skills a
child has acquired, what skills they’re on the verge of acquiring and what skills are still completely beyond them
and it helps us focus in on this zone of proximal development so that we can help children learn quickly and
feel the success of rapid movement both for themselves and for the people who are teaching them.
Slide 6: Transdisciplinary & Generalist
In addition to the developmental framework, one important variable of the Early Start Denver Model is the
focus on using a trans-disciplinary team to support the work with a child. We’ve just said that autism affects
all areas of development and if all areas of development are affected then we need people with expertise in
all areas of development to help guide a child’s learning in all of these different domains. And so somewhere
in the team that’s backing up a therapist and a child and a parent, we need to make sure that there is a
physician available to consult about medical needs, a behavior analyst available to consult about behavioral
issues and data keeping, a psychologist who’s ready-and-able to help us understand cognitive development,
parent/child relationships and learning styles, a speech pathologist who can help us tailor the communication,
both verbal and non-verbal communication, to a child’s next steps of communication development, a motor
therapist, an occupational or physical therapist who can help us help children refine their fine and gross motor
skills and an early educator who knows so much about play and how to bring many different learning activities
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together inside a piece of well-organized play.
Now in some situations all those professionals are going to be working together in an interdisciplinary team and
in other situations may be in different places. The physician may be the child’s pediatrician. Some of the staff
may be coming from the school staff. Other staff may be people who are providing services for a child through
private practice but somewhere or other we want to make sure that these disciplines are available to the parent
and the lead professional so that we have solid disciplinary expertise as we build a comprehensive treatment
plan. However in the way that we work in the Early Start Denver Model, all these people are not direct
therapists for the child. We use a generalist model in which one team member partners with a parent to
organize and carry out a comprehensive treatment strategy. That one therapist – the team leader – could be
from any of these disciplines and it’s their job to take the disciplinary recommendations and to integrate it into a
comprehensive treatment plan that can be carried out by the parent and embedded into daily activities at home
and can also be carried out by any staff, at preschool or one-to-one treatments, who can be coming in or whom
the child can be going out to see.
We’ll talk more about the many different ways we can use this treatment plan in another section of this course
but the importance right now is that the professionals provide kind of a holding circle around the parent and the
lead therapist who do the day-to-day work with the child, the treatment planning and the monitoring of what’s
happening. And the other consultants and professionals really provide ongoing expertise and consultation to
this child whom they know through assessment and through ongoing progress meetings.
Slide 7: Theory: Interactional Effects of Autism
A third principle of the Early Start Denver Model has to do with the way that we understand how autism affects
young children and when you have this understanding it helps you generate a lot of answers for yourself about
questions that may come up. The theory that underlies our understanding of children’s difficulty engaging in
social learning was first articulated by two professionals: Peter Mundy, who’s now at The Mind Institute as well,
who wrote a very influential paper in 1995 and Gerry Dawson and her colleagues who wrote a similar paper,
independently developed in 1998. They both laid out a theory of autism in which the biological substrate of
autism has the specific effect on the salience or the reward value of social stimuli for the infant and toddler who
is developing behavioral symptoms of autism from the biological underlay.
Following their principles children who are developing autism do see and experience social interaction but they
don’t find it quite as rewarding as most other children do and, as you know, typically developing children are
very drawn to social experiences. They love watching other babies. They’re very intrigued by the antics of their
siblings and other children on the playground. They want to be interacting with their parents and are bringing
toys, constantly interrupting the flow of parent activities because they enjoy interaction so much, so we could
say for most typically-developing children, the strength of social rewards far outweighs the strength of kind of
other kinds of environmental rewards in general unless there’s a brand-new toy or something exciting has
happened that pulls them into their interest in environmental variables.
So, we think of a young child who’s developing autism as having a different set of weights, a set of social
interaction being up here as in terms of its importance and environmental stimuli being down here you can think
of social interaction being somewhat less rewarding and so that means that people are going to be doing more
competing against environmental variables for the child’s attention than is the case typically. The child isn’t
innately drawn to faces, voices and peoples’ activities the way most babies are. And if you think about how the
infants and young children learn language, learn imitation, learn all of their social skills, they really learn it from
watching and imitating and interacting with other people. We don’t sit a baby down and say, “If you want
something put your hand out and I will give it to you.” No, we just put our hands out and we get things from
babies and they put their hands out and we put things into them and they learn this through the back-and-forth
of social interaction.
So imagine now that we have a baby in this kind of infant/toddler period who’s not watching very much, who’s
not putting themselves in the middle of social interaction, who’s kind of off in the periphery of the room
examining the fringe on the carpet or the strings on the draperies or all of the toys that are along the shelves or
in the basket in that living room. That baby’s not in the middle of the social interaction in the family and they’re
not getting all these lessons in language, in meaning, in gesture and in the transmission of information, back-
and-forth, between child and parent, the transmission of emotion, the transmission of the pleasure of shared
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experience. They’re missing out on lots of learning opportunities because they themselves are not putting
themselves in the mix of the social life of the family.
You could see autism as depriving the child just by its very nature of many social learning opportunities and
even if we’re only talking about maybe half the opportunities that are available in a day, if we think about day-
after-day-after-day and year-after-year in an infant and toddler’s key period of learning language, meaning and
the social back-and-forth that goes along with life in society, that is key learning. So not having those learning
lessons would be enough to cause a lot of difficulty for that child but we have to take it even a step further
because one of the things we have learned about brain development over the past few decades is that babies
aren’t born with a kind of miniature mature brain that’s already ready, has a formed language center and is
ready to go like an adult brain. An infant’s brain is actually built. It’s sculpted from the experience that an infant
has. Infant networks are built from experience to process language, to process social engagement, to process
emotion and infants, over time, build up networks that are being used and things that aren’t being used start to
get pruned away, so that that infant brain becomes more and more efficient over time.
The implications of that for a young child with autism are significant because if the social learning and
communication and language learning aren’t developing in this key period that’s evolutionarily prepared for just
those learnings, that child is at risk of having just those kinds of skills kind of pruned away and that capacity not
activated during the time when, biologically, it’s ready to be activated. And, so, the lack of social learning also
affects brain development and psychological development with long-term implications for what the child is going
to be ready and able to learn later on in the same way that it is so difficult for adults who are 30 and 40 to pick
up a new language, a child with autism who has not learned to speak in the first 5 or 6 years of life is going to
be facing language development the way one of us would face picking up a brand-new language at a much
more mature point of view. They don’t have the neuro-readiness for it.
Slide 8: ASD Specific Deficits Impede Social Learning
And so, we’ve been talking about these ASD, autism spectrum disorders, with specific deficit, this difficulty in
attributing strong reward value, as the way it impedes social learning. And I’ve been pointing out to you key
areas that infants lean on to learn all that they learn in the first few years of life. They lean on their inherent
interest in other people, their initiative for getting interactions going and their preference for social information
over other kinds of information. Young children with autism don’t have that same weight.
We want to create that. Young children lean on imitation of all kinds, imitation of what people do with objects,
imitation of what people do with their faces and their bodies and their voices and their sounds, and we use that
to learn how to handle tools, take care of ourselves, play with other children, speak, gesture and carry out the
tasks of the day. Young children with autism are very impaired in their imitation abilities and we need to help
them learn how to easily learn from other people by watching them.
Joint attention is a particular skill that toddlers develop, which allows them to coordinate their back-and-forth
communications with a person along with the object that they and the other person are sharing. There’s a
triangle of communication that allows a toddler to map what’s happening with this object onto the meaning that
they and their social partner are creating around it, and it’s a very fast way of picking up language and
concepts about that object. That’s another area that is very specifically affected in autism and has significant
impact on language learning. We can habilitate that skill and we need to.
Verbal and non-verbal communication are significantly delayed in most young children with autism and if that is
not affected that’s one of the best predictors of better-versus-less-good outcomes in adulthood. We want to
make sure that we have moved both kinds of communication as far along as possible in the first five years of
life to give a young child with autism a solid base for moving into school learning, reading, writing and
conversation skills with others.
Play skills actually don’t come naturally to children. We tutor our young children in how to play appropriately
with toys, how to use props and carry out symbolic play. This is a cultural phenomenon in which western
cultures do a lot of preparedness for academic learning and a lot of teaching of social interactions through
pretend play. This is another area that because it’s learned from other people is quite affected in autism and is
a critical learning tool for young children in terms of peer relations. If young children with autism are going to
develop strong peer relations, they’ve got to be able to learn how to play with other children and with the toys
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and the props that children their age use.
Slide 9: ESDM Goals
And so we’ve walked ourselves right into the main goals of Early Start Denver Model treatment.
Number 1, we’ve got to bring toddlers with autism back inside the social circle of family life during their waking
hours because that’s where the critical learning occurs. Second, we’ve got to teach them the building blocks of
social learning that we’ve just talked about: Imitation, joint attention, verbal and non-verbal communication,
social engagement. Third, we want to accelerate their learning rates so that the gaps that they already have
when we first meet them at age 12 or 18 or 24 or 30 months can be filled in before those gaps get bigger. It’s
much easier to fill in a gap of 6 months with an 18 or 24-month-old with autism who’s 6 months behind their
peers than it’s going to be when that child is 4 and that gap is now 2 years’ big. That’s why we wanted to fill in
with intensive teaching.
And so, in a nutshell, Early Start Denver Model strives to strengthen the reward value of social interaction. We
strive to increase the child’s repertoire of social-communication skills. We want to increase their learning rates
if their learning rates are below average and we want to prevent these experiential alterations in neural and
psychological development that can come from not being a part of the social communicative framework of
learning during the all-important infant/toddler preschool-learning period.
Slide 10: Multiple Methods of Delivery
In order to create these kinds of learning experiences and to have young children with autism inside the social
life of the family and other environments through their waking hours, we have got to maximize their learning
opportunities by having them involved in routines everywhere. And so inside the ESDM you will see a lot of
emphasis on routines of daily life. We’re talking about not just group learning, which is an important activity for
children who are old enough to be in a group or who are in a daycare center or in a situation where there are
other children, but we’re also talking about maximizing learning opportunities in every activity that parent and
child involve in. Activities like going to the grocery store, like taking a bath, getting dressed, diaper changes,
going outside to water plants, as well as swing on the slides or take a walk, feeding the pets in the household.
All of these activities have very rich learning opportunities for children and so we have to create learning
opportunities that help young children with autism understand what’s going on in everyday life.
There’s no one right way to use the Early Start Denver Model. There are multiple ways that you can combine
the materials that we have and the approaches into delivering interventions for young children, based on your
situation, you region, the funding and the parent’s wishes. One of the ways that we have delivered Early Start
Denver Model is through a combination of parent coaching, on a weekly or biweekly basis, and intervention,
delivered one-on-one by paraprofessionals who are either working in children’s homes or in a clinic somewhere
between 15 and 20-hours-a-week. We call that the intensive model. In that situation, parents are learning the
principles and applying them in daily routines at home and the people who are working with the child are
applying those principles in the clinic or home setting through toy-and-care activities.
Slide 11: Maximize Learning Opportunities
A second way that we have used ESDM and studied it is through parent-implementation only, in which the
parents learn the approach, learn how to embed it in daily activities, learn about how to address their children’s
specific learning needs and embed learning throughout their daily life with children.
This is a model that works well in some kinds of deliveries of infant/toddler services when there’s a home
visitor one or two or three-times-a-week, and this is also a model that may work well in people who live in rural
settings and families in other countries for whom a much less intensive approach is what’s offered. We have
demonstrated that parents can do a very good job implementing this intervention and we’ll talk more about how
to do that in another segment.
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Slide 12: Deliver ESDM in Daycare Centers

A third way that we’ve delivered Early Start Denver Model and studied it with good results involves delivery
inside a daycare center. Our Australian colleagues have published several papers on how to take the
principles of ESDM and embed them in typical daycare centers where children are present from early morning
until evening in groups, large groups, really, with a number of staff on the floor, working with children’s
objectives and using the principles. You can read much more about all of these in the manual that we’ve
provided, the readings that are in the papers and articles that you’re going to find as well as all the points that
we’re going to cover in this course.
Slide 13: ESDM Treatment Practices
The final defining variable that we’re going to discuss in this topic today has to do with sources of the
treatment practices inside Early Start Denver Model and they come from 3 main sources. First, as I’ve
mentioned before, is the Denver Model itself, with its emphasis on developmental principles, social
communication, the science of the pragmatics of communication learning and its emphasis on play. The
second main influence comes from pivotal response training, which is a naturalistic intervention, built on
behavioral analysis principles, tested through single-subject design and designed to affect social
communication. PRT echoes through ESDM in many areas of treatment as you’ll see in the Fidelity Measure
when we get to that section. The third main influence on ESDM treatment practice comes from general applied
behavior analysis or the science of learning; understanding of the effects of antecedents, behaviors and
consequences on building and shaping a child’s behavioral repertoire.
Slide 14: Compare and Contrast: Core Features
One of the most unique features of ESDM is its ability to fuse and truly integrate developmental practice and
applied behavior analysis into a seamless delivery for young children.
And now I have a little exercise for you. Before we end this segment, I want you to think about what is involved
in your own practice with young children with autism. You might have been listening and saying, “But I already
do that,” “I already do that,” “I already do that.” Well, I want you to really think for a minute about what it is that
you already do.
In front of you, you see a worksheet in which there’re several columns that lay out the principles I’ve just gone
over for you, the principles that define Early Start Denver Model, developmental principles, flexible delivery,
solid areas of science behind it, transdisciplinary team, a written curriculum and a written treatment manual. I
want you to think about other treatments that you know well, think about the intervention that you use and see
how many of these boxes you can fill, other interventions that you may be interested in learning or that you’ve
already studied. Practice those as well. I think that you will find very few interventions that can fill every single
box as solidly as Early Start Denver Model does.
Slide 15: Conclusion
I hope it was helpful for you to think a little bit about the approach that you use in your own practice,
deconstructing it and seeing how it maps against the principles of Early Start Denver Model.
This is how we’re going to close this particular lesson and we have two more lessons in this module. Next
we’re going to be watching a young child with ASD enter and go through the Early Start Denver Model and
follow him up a couple of years later so that you get a chance to see what the progression looks like for many
children who receive the intensive version of this.
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Slide 1: Child Video’s
In this set of videos we're going to watch a toddler named Colson, who's 22 months at the start of this
intervention, as he progresses first through parent coaching and then through 2 years of intensive treatment.
He is the youngest of three children in his family. His older brother and sister are developing fine and his
parents have come with the diagnosis of autism to meet with us. You'll see Laurie Vismara and me here
working with the family in one of the earliest sessions of parent coaching as we're just getting to know them. I
want you to watch him particularly for the meaning of his communications to see whether you can interpret the
messages he's sending to the adults in the room.
Slide 2: Video 1
Slide 3: First Visit
Could you understand his communications? It's very hard for me. It seems like as soon as he seems to want
something and he gets it then he doesn't want it and he bats it away or hits the person who gave it to him.
Then they try to take it away and then he throws a tantrum about that. He's giving very mixed messages and
his parents are very confused, as are the two therapists in the room, about what this little boy wants and how
to help him get organized about his own experiences.
The tantrum is a pretty impressive one and it went on a long time. When I asked the dad at the end of this
session, "So how often do you have one of these tantrums? Is this something that happens once a week,
every few days, once a day? What's it like for you?" He kind of laughed at me and said, "Try once an hour.
This is our life. This is what it is to live with Colson in our house." Then I really appreciated what a little intense
little boy this was and how hard it was for his parents to figure out what to do for him.
Slide 4: Therapist Interaction
In our parent coaching sessions the parents are interacting with the child for 55 of the 60 minutes but there's
often a little opportunity in which the therapist gets drawn into an activity with the child or uses an opportunity
to show the parents something that's making some difficulty for them. So what you're seeing here is a little
interaction between Laurie and Colson that lasts just a few minutes and is probably the only therapist
interaction of this whole hour of treatment. Let's watch what happens.
Slide 5: Video 2
Slide 6: After a Few Weeks of Treatment/After One Year of Treatment
That's a big difference isn't it in just a few weeks? Here we see a little boy who's got great eye contact, who's
mirroring back smiles, who's taking turns with the therapist, who's following kind of the gist of the rules of the
little game that they've developed. He is giving her things, taking things from her, watching for cues about
what's coming next. It's a very fast progression into socially rich games and important interactions with people.
This is something we very, very often see, this very rapid transition for children as they start to learn how the
interactions are going to go and what kinds of effects they can have on the adults. The parents were having the
same kinds of successes as Laurie is in this room and it's because of what the parents are doing at home that
Colson is able to bring this kind of play skill now into the room with Laurie.
This video is taken a year after the one you've just seen. In this video we see one of our paraprofessional
ESDM therapists working at home with Colson who's now receiving 15 hours a week of ESDM as well as
parent coaching. The routine is a book activity and the book is about emotions. Let's watch a little bit of this as
this young therapist and Colson make their way through a book.
Slide 7: Video 3
Slide 8: After One Year of Treatment/After Two Years of Treatment
He's made quite a bit of progress in a year, hasn't he? There's language now. He's talking and it's not just
single words. He's got little phrases. He understands adjectives and verbs and emotions. He comments. He
understands the pictures. He shows empathy to his therapist who's pretending to be sad when they read the
page about sad and he's pretty gleeful when they roar like lions and share their anger.
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He's developing into a rich, socially connected little boy who loves social interaction and is very comfortable in
the world of words and pictures. His behavior problems have fallen away and he's doing very well at home with
his brothers and sisters and parents. There are no more tantrums. He's moving well in every domain; self-care,
play, language, interactions with peers.
This last video of Colson is taken at the end of first grade. He's six going on seven. You will see what he's
learned in the way of conversation. He's working with a psychologist. They're doing an assessment and the
topic is an upcoming vacation that his family is going to take to Disneyland. Let's listen.
Slide 9: Video 4
Slide 10: After Two Years of Treatment
It's hard to believe he's the same child that we saw in the first of these videos. He really doesn't have any
problems with people. He is, as you can see, a very well-connected, highly conversational boy who can tell a
good story, ask appropriate questions, shares enjoyment of activities, has a rich, full set of facial expressions
and gestures and conveys what his meaning is very skillfully. He's in typical school doing very well. He has
friends. He's an athlete and there are really no problems left that relate to his earlier diagnosis. He's a busy
guy. You can see a lot of movement there and he's got a lot of energy.
At the start of my career I would have thought that this is a miracle. I couldn't believe way back then that a child
with autism could have this kind of outcome in just a few years. But one of the things I've learned through my
work in Early Start Denver Model is that while it's still a miracle, it's always a miracle, this is not an atypical
outcome. We see this kind of outcome just as much as we see other outcomes in the children that we treat. So
I've learned to expect that we see rich language development, great social relationships, a sense of humor and
great conversation skills in the children that we work with. It never stops trilling me.
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Slide 1: It’s the Data!
We're on the last lesson of this first module. And you might have been asking yourself what's the big deal
about Early Start Denver Model? Why is there so much talk about this intervention?
Slide 2: 2010 Outcomes From RCT of ESDM Versus Community Care
The answer is the data. The papers that have come out on Early Start Denver Model are demonstrating that
the children who are receiving these interventions, at least in the research studies, are having very good
outcomes.
The first paper that was published was published by Geri Dawson from the center that she ran that did the
initial work and development of Early Start Denver Model. She produced a randomized control trial in which 48
children with autism between the ages of 18 and 30 months were assigned to either Early Start Denver Model
with parent coaching every other week and 15 hours a week with therapists in their home. Or they were
assigned to community intervention – whatever the families could get at Seattle at the time. Children stayed
within the study in their assigned group for two years. And we evaluated them every year to look at their
learning rates, their language abilities, their social skills at home, their self-care skills and a number of other
dimensions of their development.
The paper that she published caused a lot of stir, partly because randomized controlled trials are very rare in
early intervention studies of autism. They're hard to do and expensive. But second, was because of the number
of significant differences that she found between the children.
In this slide you see that, at baseline, the children were very well matched on IQ. That's the scale along the left
of that graph. Both groups of children have an IQ of around 60 at the start. And that's a pretty typical IQ range
for children who are an average age of 24 months, with autism and without other medical or genetic conditions,
which was how this group was defined.
A year later on IQ the children receiving Early Start Denver Model had gained about 17 IQ points where the
children in the comparison group had only gained about five. That was a statistically significant difference.
And another year later, the children in the Early Start Denver Model group now had a mean IQ of about 80, no
longer in the range of intellectual disability, while the community group, as a group, had a mean IQ of 66 – only
a six point gain over their initial scores.
And surprisingly, the number of hours of intervention that these two groups got were very similar. The
community children got a lot of intervention as well. They got community preschools, they got special services
for autism, they got speech therapy, they got occupational therapy. But they didn’t make the kind of progress
that children in ESDM made.
And this is something we've seen in earlier studies as well. Children getting an eclectic range of interventions
tend not to make as much progress as children getting a very focused, very carefully manualized, organized
intervention. The graph on your right represents language development in these children. And we see a very
similar picture to the IQ changes. We see on the scale that while an average score is 50, both groups are
clustering at about 25 on the T-scores for Mullen receptive language. We see one year later, the ESDM group
is doing better than the community group, but there's not a significant difference. But at two years, there is a
significant difference and a quite a bit of improvement in the children receiving ESDM compared to the children
in the community group. We found this for both expressive and receptive language development.
We saw similar gains as well on the Vineland Scales on the overall functioning that children showed in
everyday life at home and in community routines when compared to their typical peers. The children with the
ESDM show significant advantages compared to the community children in adaptive behavior, receptive and
expressive language and in IQ scores.
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Slide 3: Who Does It Help? Language and IQ Effects
Many people right now are asking the question, "Which intervention is better for which kinds of children with
autism?" And we ask that same question in this data from the Seattle study.
We first asked whether the child’s initial IQ score predicted how well they would do in terms of IQ gain over the
two years of their studying. And you may know that many other treatment studies have asked this question, and
found that initial IQ does in fact predict the amount of change children will make. So we ask this question by
dividing the group in half by IQ and assembling the group of children in both treatments who had IQ's below 60
and comparing their progress over time to the children who had IQ's above 60 at the start of the intervention.
In this graph you'll see that the bottom diagram represents children in the lower IQ group. And what you see is
that the children in red, or the community group, made some gains over time and the children in blue, who are
the ESDM group, made more gains over time. In fact, the ESDM group made a 14 point gain in IQ over these
two years. And this represents a 27 percent increase in their progress over baseline. The children in the
higher IQ group, the ESDM group, make as you can see, more gain than does the community group. The
children in the ESDM made a 22 point gain over this two year period, which represents a 32 point increase in
their scores over baseline.
So if you compare the gain of the lower and the higher IQ groups, 27 percent to 32 percent, there's only 5
percent difference in that. That's not a big difference. Both groups of children are making significant gains in
IQ and they're making significantly more gains than are the community children. IQ does not predict who will
do well in this treatment. Both groups did.
We see that in both language groups, the children in the ESDM group make gains over time and
proportionally, there's not a significant difference in the comparison of the amount of gain they make to
baseline in either the higher or the lower group. Language at start does not predict the amount of gain the
children will make in language. We also see that the ESDM group is doing better than the community group in
both of these groups.
Slide 4: Autism Severity Moderates IQ Effects ESDM Advantage Persists
However, the same is not true for autism severity. The severity of children's autism as measured by their
ADOS scores does tell us something about the amount of gain they're going to make.
This slide shows you that the ESDM group in red is compared to the community groups in blue. The two bar
graphs on your left show the children with more severe autism. And what we see is that, first of all, the ESDM
group does better than the community group, and it is significantly better. However, compared to the bar
graph on the right, you can see that the children with more severe autism in the ESDM group don’t do nearly
as well in terms of IQ gain as do the children who have milder autism to begin with. However, while autism
severity does moderate the amount of IQ gain the children make in ESDM, both groups do better than they do
in the treatment group. So, this is a treatment that helps children with severe autism, though it doesn’t help
them as much as it does in terms of IQ gain for children with less severe autism.
Slide 5: Changes in ASD Characteristics
What about changes in their autism symptoms?
We did not find significant differences in their ADOS scores. That's the Autism Diagnostic Observation
Schedule – a gold standard instrument for diagnosing autism. On that measure these group didn’t differ. But
we did find significant differences on two other measures of autism severity.
The diagnostic system they were using was the DSM IV the Diagnostic and Statistical Manual of the American
Psychiatric Association. And in the DSM IV there are three different classifications we were looking at: Autistic
disorder, which involves the most severe symptom set; pervasive developmental disorder not otherwise
specified, or PDDNOS, which represents a milder set of symptoms in this cluster; and then some children we
thought might improve so much they didn’t have diagnoses in either of these categories.
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We didn’t find that in this group. But we did find that many of the children changed categories from the
beginning of the study to the end. And we found that in the community group, for children who changed
categories, we found they tended to change from a milder diagnosis to a more severe. A quarter of them
moved from the PDDNOS diagnosis to the autistic disorder diagnosis whereas only five percent of the children
who moved went the other direction from more severe to less severe. The ESDM group showed the opposite
pattern. Of the children who moved, only eight percent went from a milder to a more severe diagnosis whereas
a full 30 percent of the children who moved –moved from a more severe to a less severe diagnosis. And that's
a statistically different proportion of children making that kind of change.
We had a second measure, as well, that demonstrated differences in the children's autism diagnoses at the
end of treatment. And these were teacher ratings. The teachers, of course, had no idea the children were even
in the study. And yet when teachers of the preschools that these children were attending rated the children's
social approach behavior and rated their problematic autism specific problems, they showed that the children
who had received ESDM showed more social approach behavior, did better, than the children in the community
group. And they showed fewer of the autism specific problems than the community group did. So in two
different kinds of measures we see changes in autistic symptomatology in the children who received ESDM
that showed some improvement of symptoms.
Slide 6: Brain Changes in EEG Responses after 2 Years of ESDM 15 hr per wk
Probably the most important study that's been published thus far on ESDM effects was published by Geri
Dawson and her colleagues in 2012. And this study looks at the brain responses of children to social and non-
social stimuli.
This is a really important study for us because this is not about learned behavior that children have been
taught over time. This is looking at a very fast brain response to children's immediate attention to a
photograph. In the situation you see there pictured in front of you, children are sitting looking at a computer
screen and they're wearing an EEG net, which is monitoring the electrical activity at their scalp level. The
children are shown either the picture of a face – a woman's face or the picture of a toy – both in color and both
for equal lengths of time.
And what we're monitoring is how fast their brain response is. How fast and how big the electrical activity is in
the first few milliseconds after this event is shown in front of them. Typically developing children, of whom we
have a whole group in this study, show a faster and a stronger electrical brain response to faces than they do
to toys. And this is a finding that's been shown repeatedly in the literature.
What of the children who had completed two years of Early Start Denver Model? What did they show in this
paradigm? They showed the response of the typically developing children too. They show faster, stronger
brain responses to faces than they do to toys. What did the children in the community group show after two
years of treatment? They show the opposite response. Their response has been shown to be associated with
autism – a stronger, bigger response to toys than to faces.
That's what I was telling you about at the beginning – the salience –the relative salience of social to non-social
stimuli. For children in the study and children in general, young children with autism, they tend to show a big
response to toys and not much of a preference for people. Whereas typically developing children show that
preference for people even at this level of automatic brain response.
I told you that a big goal of Early Start Denver Model was to help children develop a greater reward value,
greater preference for social stimuli. Here's the first evidence that it may be happening. That even at an
automatic level we may be able to help children reassign the value of social stimuli and show their preference
at a very automatic level. This is the paper that won the Time magazine award.
Slide 7: Quote
How does treatment lead to this kind of a biological response? A Nobel Prize winner, who spent his life
studying learning processes, Psychoanalyst Eric Kandel, wrote in 2006 that therapy works by altering the
structure and the function of the brain. He says that the mechanism underlying learning is the ability of neurons,
those individual brain cells, to change the strength and the number of the connections they make with
each other. That when learning happens, including the kinds of learning that's going on inside Early Start
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Denver Model, when learning of any kind happens, neurons are getting more and more connected and the
electrical impulses and the chemical impulses that are moving back and forth across those connections are
getting stronger and stronger. And that's what we assume is underlying that strong, fast response that we see
in the EEG study.
Teaching children behaviorally creates brain responses. And of course that's how we led into this, that infant
learning shapes and sculpts a child's brain and the learning potential. That's what we're trying to do in Early
Start Denver Model. And this is the evidence that that's happening. It happens in every intervention. If children
are learning, something is happening at the brain level. The point here is that it's learning in the direction that
we want – in the direction of social attunement and social attention.
Slide 8: ESDM Advantages Maintain
As you probably know, in the history of early intervention studies, there's a long history of finding an effect on
the children immediately after the intervention happens. But you probably also know that it's hard to see those
effects maintained over time. There tends to be a drift back to an earlier way of being and doing after
intervention stops. So it's a very important question in early intervention studies in autism to determine whether
the early intervention effects hold strong after the specific intervention stops.
Annette Estes, a colleague at Washington, published a paper just a few months ago in 2015 which asked this
particular question and in this study she demonstrated two important findings. First of all, that the children who
received Early Start Denver Model did not show any loss of their accelerated learning rates over the two to
three years of time between the time their intervention ended at age four, and the time that she followed them
up at age six to seven.
In fact, we find continued acceleration of their development. We find that their IQ scores are even a little higher
now, well within the normal range. And their language scores as well have increased as have their Vineland
Scores. In addition, they continue to show an improvement over the community group whose scores also
increased in those two years in several areas.
The ESDM group continues to show an advantage – a significant advantage in nonverbal IQ, in some aspects
of their adaptive behavior skills, and we see now a reduction in their ADOS scores as well. They show
significant reduced number of symptoms in both repetitive behavior and in social interactions as well as their
total scores compared to the community group.
How can they continue to accelerate when they are actually getting less specialized help after their ESDM
ended than did the community group? One reason may be because the way that we are working with children
fostering their spontaneity and their initiative for self-motivated learning may help them actually create their
own learning opportunities as typically developing children do. They may well be able to extract the learning
from their environment themselves and so continue on their course of learning more and more through more
and more participation and learning opportunities around them. I don’t know the mechanism underlying this.
But there are very few studies that have been able to demonstrate that the children have maintained their
scores. And I was very happy to see that we could find this in the Early Start Denver Model.
Slide 9: Replication Study 2014
I'm sure you know that a scientific finding isn’t a fact until it's been able to be replicated, until independent
scientists have been able to make the same findings using the same methods as the original study. And until
we had any replication studies, we didn’t know whether we would be able to replicate the ESDM initial
outcomes.
I'm happy to report to you that we have that kind of replication study. It was published in 2014 by Australian
colleagues Giacomo Vivanti, Cheryl Dissanayake, and colleagues at La Trobe University in Melbourne,
Australia. They used the Early Start Denver Model in the way that it's described in the manual and using the
curriculum tool. And they applied it to a group of young children in a daycare center run by the university on the
campus.
Twenty seven children participated in the university autism classroom at La Trobe University in the daycare
center. And the scientists carefully assembled a comparison group of children, 30 children in that group.
Mean age of 40 months, very well matched to the children in the daycare center at La Trobe. They were
matched well on IQ, on language and on autism severity. These comparison children were in a specialized
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autism classroom, very up to date, and run by the public service in Australia as part of a national effort to
improve services for young children with autism.
Slide 10: Replication: ESDM in Groups
Both groups of children were followed over one year. And the same kinds of measures that I've been reporting
were used for these children – measures of IQ, adaptive behavior, language, and autism severity. Both groups
of children received 15 or more hours a week of intervention across this whole year.
The graph that you see on your left represents IQ gain over this year of time. And you see this graph looks very
similar to what I showed you before from the Washington study. Both groups of children are well matched with
IQs far below average at the time they entered the intervention.
One year later we see that both groups of children have made significant progress, however, we see that the
group with ESDM has made far more progress than the comparison group. The ESDM groups has gained
about fourteen points in their IQ scores over this year. The other group of children have gained about eight
points.
The slide on the upper right shows you the adaptive behavior gains that were made by the groups and while
the differences are not as great in adaptive behavior as they were in IQ, we still have a significant acceleration
in the ESDM group compared to the autism classroom group.
The lower right hand graph shows you language data and you see a slide that replicates the IQ data. A very
much steeper progress and significant gain in the ESDM group compared to the autism classroom. A gain of
almost 20-some points on language measures in just 12 months of intervention beginning at age 3 and a half
and going to age 4 and a half.
The data were gathered by people who were blind to the child's intervention background and under very
carefully controlled conditions. And so here we have an independent replication of ESDM, which data mirrors
almost exactly what Dawson and colleagues published from the University of Washington.
Slide 11: Costs of Both Treatments: Return on Investment
The final piece of data that I want to share with you today is an analysis carried out by David Mandell and Geri
Dawson that looks at the cost benefit of Early Start Denver Model from the original University of Washington
sample compared to community treatment. This is a very important question because, as you know, one of the
barriers to providing high-quality early intervention for children who need it is the cost of services.
In this study Dr. Mandell and his colleagues assembled all of the costs of all of the treatment the children
received both in the community and through the Early Start Denver Model going back from the beginning of the
children's lives through the follow-up period.
You see that the black line in front of you represents the point at which the study begins. And the dotted vertical
line next to it represents the point that the study ends. The scale on the left represents the cost per child. And
the scale along the x-axis in the bottom shows you the years before and after the beginning of intervention. I
want you to look at the black line – the black vertical line at the point where the study begins. And I want you to
look at the purple line that's diagonal which represents the ESDM group compared to the pink line, which
represents the community group.
At the point of intersection you see that there's more money being spent on children receiving ESDM than is
being spent on children in the community group. That’s because these children are 24 months of age and
there is not a lot of community expenditure for children under the age of three. And you see that that continues
almost to the age of four. However, at the age of four when the second vertical line extends, that's when the
study ends.
We see that at that point, there now is as much money being spent on the community children as there is on
the children with ESDM. Because preschool has now stepped in, and children are receiving many more hours
a week of service through school mandates according to the public laws. Furthermore if you look past the
dotted line for the next three years, you see that these lines reverse. And the amount of money being spent on
the children in the ESDM group is now lessening over time compared to the amount of money being spent on
the community group, which is increasing over time.
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Why is this? It's because from age four on, the children who received Early Start Denver Model are receiving
and needing fewer specialized services than are the community children. The children who had attended
ESDM are now getting many more of their services in settings like every other child gets them – regular
preschools, regular classrooms, going to gym class rather than physical therapy. Whereas the children in the
community group continue to get more specialized services for the years after the study ended.
And so this data, which is not yet published but has been presented in several national meetings – this
represents what we have always assumed would be true of high-quality early intervention. And what has been
demonstrated for children of poverty situations. And children who were at risk for developmental delays for
other reason. That expenditure in high-quality early intervention reduces costs for these children later on in
their educational years.
We have assumed this would be true with autism, but these are the first data that have actually worked from
real numbers from real children to demonstrate that this may in fact be true for autism as well for children from
other kinds of risk settings.
And with this we are done with our tour of the data and we are ready to move on to another module. I know that
data is not the most fuzzy topic that we have in early intervention, but data is critical in choosing early
intervention approaches. We are in the age of empirically based data and needing empirically based
treatments. Early Start Denver Model is one of the early intervention approaches that have a solid data base
behind it.
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Slide 1: Using the Curriculum Checklist
Hi and welcome back. We are about to begin the module that involves how to develop the treatment plans that
you will follow as you use Early Start Denver model. Now I’m sure that you’ve been in settings before where
you’ve had to develop treatment plans or IEP objectives or something like that and then, unfortunately, for
many of us, previous experiences with this have kind of felt like a waste of time. It’s an exercise, has to be
done but it may not have much meaning, real meaning to your everyday treatment experiences with a child.
Slide 2: Treatment Plans are Critical
In ESDM the treatment plans are critical to everything that we do with a child. They’re like having a destination.
Instead of just saying, “I want to go on vacation but I have no idea where,” so where are you going to go, to
saying, “I want to go here, I want to go to that place.” And for those of you who know me, this map is showing
you Canyonlands. I love the Utah canyons and that’s where I want to be every September. Having a
destination is incredibly important in figuring out where you’re going to head off on this trip. And that’s what the
treatment plan does.
It gives us a destination and then it marks the route.
Slide 3: Objectives
This module has 3 lessons and in these 3 lessons we’re going to take you through, exactly, how to build the
treatment plan, the specific goals, the steps for getting to the goals and the datasheets you will need to track
yourself along. By the time we are done with this you will have a piece of paper in your hand that will allow you
to walk into a session tomorrow with a child and know exactly what to do.
Slide 4: Write a Treatment Plan
When we’re writing a treatment plan in Early Start Denver Model, we’re writing a plan that lays out where we’re
headed for the next 12 weeks. In our minds we are planning ahead for just a 3-month period and we’re going
to write a full set of goals for that 3-month period.
Slide 5: Parent Interview
So we lead off this progress by asking parents, “What are your goals for the child for the next 3 months?
What’s the most – what are the 3 or 4 most – important things you would like to see your child be able to do 3
months from now that they can’t do now?” And I always start with that and there’s a form for you in your packet
that gives you a Parent Goal Sheet that you may want to ask parents to talk through with you as you write that
out. Later we’ll talk about what to do with parent goals and how to integrate them into your data but that’s a
starting point.
Slide 6: Build 12 Week Goals/Objectives
The next step that we do is to build the 12-week goals from the Curriculum Assessment Checklist and that’s
where we’re headed right now, talking about the tools that we use to extract the information to build 12-week
objectives.
Slide 7: ESDM Curriculum Checklist
And the tools that we use are available for you inside the blue therapist manual, “Early Start Denver Model for
Young Children with Autism Manual” and the curriculum tool, which accompanies it. The Curriculum Checklist
provides you with the items that you’re going to assess the child on to lay out the developmental domains in all
areas for them and to understand what they can do now and where they’re headed next. And the blue manual
defines each of those items and also tells you in detail how to administer the Curriculum Checklist.
Slide 8: Curriculum Content
The Curriculum Content is divided into roughly the domains that we see in child development between the
toddler and the preschool period. There are 4 levels and on each level there are receptive and expressive
language domains, fine and gross motor domains, social interaction, cognition, play and adaptive behavior.
Other domain areas like imitation or joint attention or pre-academics come in-and-out at the level at which
they’re appropriate for a typically-developing child.
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The 4 levels organize all of these domains according to what we expect to see in about the 9-18-month period
for Level 1, the 18-24-month period, roughly, for Level 2, the 24-36-month period, roughly, for Level 3 and the
36-48-month period, roughly, for Level 4.
Slide 9: Inside the Domains
Inside the domains though you’re going to find kind of an interesting format in which the language and the
social items tend to be more immature and the motor items tend to be more mature inside that one
developmental domain. Why is that? It’s because we’ve built this to follow the profile for a young child with
autism and, in the early years, children with autism typically are having their most mature skills in the motor
areas and their least-mature skills in the area of social communication, which we’ve been talking about. And so
this curriculum is really built for them and it allows you to assess, inside a level, all of the areas of a child’s
development without having to jump around quite so much.
Slide 10: Play/Routines Based Assessment – The Setting
How do we use this tool? It’s not a sit-down-with-a-child-and-administer-item-after-item-after-item-to-see-
whether-or-not-they-perform-it. It’s not set up like a standardized test. This is a play-based assessment in
which we want to be in a friendly, child-type setting with toys around, child furniture, parent-in-the-room-with-
us. And we want to work our way through a set of play activities in which the child can grow increasingly
comfortable playing with mom, playing with you and, inside the play activities, reveal their skills.
Slide 11: Play/Routines Based Assessment – The Assessment
And so you are going to be walking into a room that’s already prepared with some interesting materials. A child
starts to play, you join the mother and the child or the father and the child in whatever is beginning and, as that
child starts to play and you start to play along, you find ways of doing little probes for the language they’re
using in their play, the motor skills they’re using in their play, the symbolic or constructive play skills that they’re
demonstrating, the social reactions they’re having to people and the cognitive concepts that underlie what
they’re doing, so forth and so on.
You do a piece of play with them – 10 minutes maybe – and then as mom-and-child are sitting there with the
materials, you pull your Curriculum Checklist out and you score along in terms of what you’ve seen thus far,
and the seen you score, the items you haven’t seen, you wait and then you start another piece of play. And so
you follow along through an hour to an hour-and-a-half of play, proceeding in this way, talking with the parent,
watching what the child is doing with you, with the parent and gathering the information that’s available to you
about what the child can do on the curriculum items that you’re assessing.
Slide 12: Scoring the Curriculum
How do you score the Curriculum Checklist? It’s not a checklist like that. It’s not a matter of just yes, yes, yes
or no, no, no, no, no.
We want a richer set of data than that and so you’ll see that there are 4 columns here. In the first column it’s
what you yourself observe in this hour. The second column is what the parent’s telling you about what the child
can do and while they don’t have to tell you about every single item, some of it’s going to be clear: The child
does it, the mom knows the child can do it, the father says he does that all the time. He really loves that toy and
you know that that’s a well-mastered skill but some things, like using a toilet, you’re not going to be able to
watch in your assessment hour and you’re really dependent on the Parent Report. Any area in which the child
is not performing today, you may ask the parent, “Is this what the child does at home? Is this what you’re
seeing” so that you can get the parents’ description to help you understand what the child’s mastered. The third
column allows you to bring in information from other professional reports that you might have about the child,
the Speech and Language Report, the Developmental Pediatrician’s Report.
For those 3 columns we use a specific set of scores. We use the plus to indicate that this is a mastered skill;
the child performs it consistently when they have the opportunity, they do it across settings, they do it across
people and they do it across materials. This is a mastered skill and we score that with a plus. For a skill that is
partially mastered, we use a plus/minus. Now what do we mean by that? We mean the child may perform it
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inconsistently. We may mean the child performs it but they may need a little more help. It’s not completely
independent or they may do it in one environment but not in another or they may do it at home but not at
school. So it’s not mastered but it’s coming into the child’s skill repertoire. Here we are in the zone of proximal
development. These are important for us to know. That’s a plus/minus and we’re using the same code for the
Parents’ Report as for our own. The third score is an example of which you’ve given the child the opportunity
and they don’t do it. You have no examples even with many opportunities that this child can do this skill. That’s
a minus and you would ask the parent the same thing and when they say, “It’s rare,” he rarely does it. I know
he can. I know he can put a spoon in his mouth but he rarely does it. That’s basically a fail, a minus.
The final category – N/O – is used when you haven’t given the child an opportunity to show you whether or not
he can do it or if the parent says, “I don’t want that mess, I never give him a spoon.” That’s “no opportunity” so
we use that to indicate the child hasn’t had an opportunity to learn it and we don’t know whether he can do it or
not.
Those are the codes for the first 3 columns; the final column allows us to integrate all the data that we have
and to make a final assessment about whether this skill is mastered, partially acquired or not yet in the child’s
repertoire and we use this separate set of codes for this to mark it aside and so we will score an A for skills
that are well-mastered, generalized, consistent. We’ll use a P to demonstrate this partial zone or this zone of
proximal development. We’ll use an N for unwilling or unable. It is not in their repertoire and we use the X for
they have not had an opportunity to learn it. That’s the coding that’s used in the Curriculum Checklist.
Slide 13: Where to Start
So how do you know where to start and how do you know how far to go in scoring? You don’t really know
where to start.
The child walks in the door and they begin to play and, as the child plays, you start to see immediately, “Are
they talking to their parent,” “are they gesturing,” “what are they doing with the materials?” The child’s first
actions help you center in on a set of play skills, a set of communication skills or a set of social skills that start
to help you figure out what level the child is beginning on. I’m sure you’ve greeted that child in the doorway.
Did they great you back? Do they have the word for “hi?” Do they gesture? Those are specific items and they’ll
plant you inside a level that you’re going to start to fill out.
You want to fill out each domain so that you have a good representation of the child’s acquired skills in that
domain and a good representation of the not-yet-acquired skills, and so whatever you first see is going to be
an expressed skill. It’s going to be an A or a P skill and that helps you know where to start. As you and the
parent provide probes, if the child isn’t able to perform any of the probes that you give him, independently then
you know you’re going to go backwards, down that domain, until you find skills that are easy for the child and
you want to start with these easy skills because you want the child to be motivated to play along. You want
this to be fun and interesting for the child and generally following children’s leads tells you where the child is
comfortable.
Slide 14: Using the Checklist
So you want to figure out where those A’s are and then you want to work your way through the profile, across
your hour or hour-and-a-half so that, by the end, you have a set of A’s, a clear set of P’s and a set of N’s. That
range of the P’s and the first N’s defines where you’re going to be writing your objective. Now beware that you
may have to skip from one level to another. It’s very often the case that the A’s will be at the kind of more
mature level of one set of skills but that you’re going to move into the next level to finish them.
Slide 15: Using the Checklist
It may also be the case that the child is at Level 1 for expressive language and at Level 2 or maybe even Level
3 for another set of skills. There are some children who are quite mature but have great difficulty speaking but
it doesn’t matter what levels you’re crossing as long as you keep it with the idea that you need a solid set of
basal scores of acquired skills, a solid set of ceiling scores of skills the child can’t do yet and that middle
ground, of each domain, you have the information that you need.
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Slide 16: Checklist Exercise

Are you ready for an exercise? I want you to try scoring a curriculum while you watch a video. You’re about to
see little Simon.
He’s a 16-month-old, a younger brother and he and his mom are here for a first curriculum assessment with me
as we begin a parent coaching intervention. You’re going to see different episodes from this video clip, which
lasted about an hour and 15 minutes and I want you to have your Curriculum Checklist in front of you and be
taking notes as you see Simon and his mom and me play along with different activities. At the end of the
video, I want you to go back through your Curriculum Checklist, item-by-item and compare each item to the
manual description, the blue manual, to make sure that you’re using the defined description of that behavior and
then I want you to sign a code in the observer column and, if the mom gave you information, assign a code
in the Parent Report as well. Once you’ve coded every behavior that you can be sure to use the N/O’s for “no
opportunities,” then go to the Acquisition List, the final column, and assign one of those final codes – Acquired,
Partial, Not Yet or No Opportunity – so that you have really experienced what it’s like to use this tool. Check the
screen for what to do with your scores after you’re finished.
Slide 17: Summary
I trust that you had a reasonable experience using the Curriculum Checklist, that this was not particularly
difficult and that it was easy for you to see how following the child along in play allowed you to see lots and lots
of different behaviors. I also hope that you saw how important it was that the mother was right there playing
along with him and that she was very involved in this activity, both supporting the child and also giving me
information. You have an opportunity to share your observations and some of your reactions to this video and
this tool in the forum. Feel free to talk with the other students who are taking this course and see what you’ve
learned from them and also give them the opportunity to learn from you. See you for the next lesson soon.
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Slide 1: Writing a Treatment Plan
Hi, and welcome back. Today's lesson focuses on how to write a treatment plan in the ESDM style.
Slide 2: Treatment Objectives Define Your Destination
And I know that you all have a lot of experience with treatment plans. And probably you think that (a) they're
not very useful to you, or (b) it takes an awful lot of time. But they are absolutely crucial for working in ESDM.
I can't imagine walking into a treatment session without my plan in my hand. For me, a plan defines where I'm
going. And it defines how I'm going to get there.
Slide 3: Identify & Map Your Destination
We've been talking about the seven steps for developing this whole set of written plans. And in the last lesson
we talked about the parent interview and the curriculum checklist. Today we are focused on writing the 12
week objectives.
And inside the objectives we're going to be deciding for each domain in the curriculum, how far we really think
we can really take this child in 12 weeks.
One of our goals, as you know, is to teach as much as possible to try to fill in the gaps the children already
have. So we want to move them as far along in each level, in each domain, as the child can move. But we
want to be very realistic about this. We don’t want the parent to be disappointed, we don’t want to be
disappointed ourselves and we don’t want to be setting out objectives that are unrealistic. So we need to use
our clinical judgment to make the best estimate of how far we can get in 12 weeks given the amount of
teaching that we have.
Slide 4: Select & Sequence Learning Steps
How do we do this? We are going to begin by focusing inside one of the domains. And thinking about where
that zone of proximal development is. You've defined the acquired skills, you've defined a set of partial
accomplishments and you've defined some areas that children cannot pass yet. And so inside each of those
domains you're going to looking down through the items that are not yet acquired to find a point which the child
should be able to achieve in 12 weeks of good teaching at whatever kind of delivery that you have.
Now what we don’t do in ESDM is to simply use the next item as an objective or to take items exactly from the
curriculum, and plug them in as objectives. If we did that, we would never be able to move children through the
curriculum. There's simply too much to teach. But as you look through a curriculum domain you'll see the same
item come up again and again in slightly more mature versions. And so you're going to think about those little
steps as maybe steps towards the 12 week goal and aim down farther in that.
Slide 5: Linking Items into One Objective
You may also see several items that come together well and could be brought into a single objective so that
you could be linking several items into one objective. One way of moving through a curriculum domain is to
look for items that join together nicely into a single objective. Here's an example in which the therapist has
linked together an item involving giving to an outstretched hand, an item involving following verbal directions,
and an item involving following verbal gestures.
Here's the objective – when an adult provides one of five verbal instructions either with or without a gesture,
the child will perform the requested action like giving, looking, standing up, sitting down, or cleaning up at eighty
percent of opportunities with multiple adults in multiple settings and routines. So you see there are three
different items that are being joined in one objective. And that's really moving through a lot of space in that
curriculum.
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Slide 6: Bundling Items
Another way that we do this is to take items from different domains that fit together well in a single objective. In
this particular example, you're going to see a play item, a fine motor item, and an imitation item all brought
together in a single objective.
When the adult demonstrates toddler toys, the child will repeat the same action, that's the imitation, with
several pieces on ten different toys – that's a play item. Examples – stacking blocks, cups, pegs, or rings –
eighty percent of opportunities with three consecutive days – two or more partners and settings. There are also
fine motor objectives, aren’t there, in that – because those toys are coming from the fine motor domain.
And so here you can see how much mileage you can get from one objective covering a number of different
skills in three different domains. That's what we want to do. We don’t want to write hundreds of objectives item
by item by item. We want to pull these related skills together in action patterns that make sense for children to
do with adults.
Slide 7: Writing Objectives
Now I've read a couple objectives through to you. And there's a pattern. You may be picking it up already to
them.
We write objectives in a very specific format. There are four sections typically to an objective. Three of which
are required. The four sections are the context in which this skill might be practiced, the antecedent – or the
stimulus that pushes the child off into the behavior that they're going to display – it's also known as the Sd, the
discriminative stimulus in ABA language. The child's behavior – and we want to be talking about behaviors that
are functional for the child in everyday life, those usually marked by active verbs.
And finally the criterion by which we're going to assess mastery. And for us, criterion is mastery. We don’t want
to say 50 percent accomplishment as the criterion. If that's all we think a child can accomplish in 12 weeks,
then that objective is set too high. We want to set an objective that the child can fully master, 80 percent or so
o f opportunities. And part of mastery is generalization across multiple people, multiple settings, and multiple
materials.
And so there are the four parts – the context, the antecedent, the behavior and the criterion. Of these four, the
context is not necessary. Sometimes the behavior and the other pieces themselves define when it will be done.
Be careful, lots of times people confuse a context with an antecedent. Context is only setting. It's not a
stimulus.
Slide 8: Social Objective
Okay, let's break down a few objectives into these boxes so you can see how the language fits these particular
categories and start to get the rhythm of these kinds of objectives. Here's a social objective – during sensory
social routines – that's the context – when the adult briefly stops a game – there's an antecedent – a child will
spontaneously continue the routine using vocalizations or gaze combined with gesture – there's the behavior –
and finally the criterion – in three of four pauses during five different routines on three consecutive days with
two or more partners. Okay, there's a well written objective in the ESDM pattern.
Slide 9: Expressive Communication Objective
Let's see how that translates into an expressive communication objective. Context – during treatment sessions.
Antecedent – when an adult offers a desired activity or object and then pauses. Behavior – the child will request
by vocalizing combined with gaze or gesture within two seconds of presentation. Criterion – ten or
more times in a 60 minute session across three different activities, people, and settings for three consecutive
days
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Slide 10: Imitation Objective
All right, are you getting it? You're getting the pattern? I'm going to do one more. And then you're going to try
one on your own. Here's an imitation objective – context – during a play activity. Antecedent – when an adult
demonstrates a conventional play action with an object. Behavior – the child will independently imitate the
action, like driving a car, flying the airplane, or stirring a spoon in a bowl. Criterion – three or four opportunities
in three consecutive playtimes with two or more partners at home and at preschool.
Slide 11: Try One Yourself
Okay, are you ready to try one for yourself? I want you to go back to the curriculum checklist you filled out for
little Simon and pick one of the domains in which you've got some acquired items, some partial past item, and
some failed items to find. I want you to try to write an objective for him from the data that you have, thinking
ahead about 12 weeks, and just making your best guess about what you could do with Simon and his mom.
How you could take them along over a 12 week period.
So try the format – context, antecedent, behavior, and criterion. And use the ones we've already covered as
models.
Slide 12: Test Yourself
Okay, now you can test yourself on this. Did you need to define a context? It's not necessary, you know. Is the
antecedent a measureable event? Could you count the behavior or the stimulus that's making up the
antecedent? Behavior – it's not the next curriculum item, is it? I hope you remembered to move down into the
curriculum going as far as you think is reasonable in 12 weeks. And maybe you tried to link a couple of
different steps or bundle some items from different domains to make a richer, more interesting activity set
inside that objective. Do you think it's achievable in 12 weeks? And could I count that behavior if I was sitting
in the room taking data? And finally the criterion – did you find mastery? Which means that he's successful
most of the time without being prompted. And did you include generalization of settings, materials, partners?
If so, you've written a beautiful ESDM objective. Congratulations!
Slide 13: Treatment Plans Save Time!
Now I imagine that this did not take you a minute or less. You probably had to think a while about how to do
this objective. And it is going to feel slow in the beginning. I don’t want you to get discouraged about that.
You're learning a new way of thinking, a new pattern of behavior and it does take some thought and practice at
the beginning. Once you have done this a while, this becomes very fast. I can think of them and get them
down as fast as I can type. And the reason that I think this is so worthwhile is that once you have laid these
out, you don’t have to do a single other thing for a treatment plan or an objective for the next 12 weeks. You
know where you're going. You know where you want to end up. And you know how you're going to measure it.
So in the end, taking this much time in the beginning gets you farther. And it saves you time. I encourage you
to practice it and not get discouraged quickly. This will come.
Why don’t you share the objectives that you wrote with your colleagues who are taking this course. You can
take a look at theirs, they can take a look at yours and you can get some good ideas from the colleagues you
are working with.
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Slide 1: Baby Steps to Mastering the Data Sheet

Hi. We're in the last lesson in the section on building a treatment plan. And in the lesson you finished before,
you learned how to write an objective in the ESDM format.
Slide 2: Destination for Treatment Plan
And you know that what that gave you was a place to aim your teaching for the next 12 weeks so that you
know where you want to end up with that child at the end of this teaching period. However, does that objective
tell you what to do tomorrow to get to that destination? I don’t think so. It tells you the endpoint, but it doesn’t
tell you the route.
Slide 3: Route for Treatment Plan
In this particular lesson, we're going to focus on how we're going to get to the destination we've marked for
ourselves. What the route's going to be that we'll take our teaching through to arrive at our final destination.
Slide 4: Developing the Treatment Plan
And so in terms of our seven points about developing the treatment plan, we're right here. We're going to be
talking about breaking those 12 week objectives into steps and writing a set of teaching steps to span that 12
weeks. And those teaching steps are also going to become a daily data sheet so that we can keep track of
where the child is during our treatment sessions.
Slide 5: Steps for Teaching
The steps for teaching are literally a staircase for you that begin where you are right now with this child. The
very first step is the child's acquisition skill – the one that you've marked A on this particular objective. And the
steps are going to proceed in tiny little baby steps along to the mastery step – the fully formed objective that
you wrote.
And so here's a piece of good news. You've already written two of the steps. You know what the acquisition
step is and you can take that from the curriculum. And you know what your mastery step is, you can take that
from your objective. And now all you have to do is fill in the middle. In this particular example we have six
steps. It just fits the objective. You might have fewer – though if you can accomplish a 12 week objective in
less than 4 or 5 steps, it's probably too easy.
Slide 6: Ascending Levels
I like six steps because that means every couple of weeks I'm going to be at another level. Some skills take
more steps. It really is how many steps it's going to take you to task analyze, or break that objective down, and
to work backwards and forwards from where you are to where you're going. So step one is the already acquired
skill, which is the mastery step on which we're going to spend a fair amount of time on so that the
child can get reinforced for some easy skills and so they don’t lose their current maintenance skills.
Each step adds another little piece that helps you move from the beginning to your mastery step. It may be a
few more pieces or a few more toys. It could be that you're reducing your prompts. It could be that the child is
adding more and more behaviors to this, more vocabulary words for instance. But whatever it is, these are
small steps that you are pretty sure you can teach in a week or two. And each one will lead you in a systematic
way to mastery.
Slide 7: Teaching Example
Let's look at an example here. Think about Simon, this is written for him. What does he do right now in
sensory social routines with his mom? He mostly watches them. He likes to watch her do the routines but
except for that peekaboo routine, he doesn’t participate himself.
What did we want to see him be able to do in six weeks? I'd like to see him be able to combine his eye contact
and either his voice or some gestures to continue the game that she started. In three of the four times, she
pauses just like he did in the peekaboo game. And I'd like to see that in five different routines. She already
plays three of them that we saw. We saw patty-cake, we saw little man played on the palm of his hand and we
saw peekaboo. I want to see her build that up into five more routines so that we see him being a more active
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participant and not just a watcher. And we want to see them in two different contexts like therapy session and
home. And the two different people like dad and mom.
All right, so we know right now that he likes to watch his mom. What would be a slightly more sophisticated
step that Simon could take that we think we could establish in a couple of weeks? How about this one – either
using his eye contact or his voice or an action to get her to continue in one time, in one pause, in a couple of
routines he really likes. That's probably pretty achievable because he uses gaze well and makes a lot of eye
contact during these activities. So there is a baby step to step two.
What about step three? In this one we're going to look for him to add something to that gaze, either a vocal
sound or some kind of action – maybe reaching to her, maybe making a noise, maybe clapping his hand. And
we want him to continue three different routines in two or three pauses. So we're adding a behavior, we're
adding a routine and we're adding a little more consistency.
In step four we are changing the behavior, but we want to see this happen in four different routines in three or
four pauses – so again, a bigger repertoire of games and a more consistent performance.
Step five we add the fifth routine. Just build his repertoire out a little bit more.
And step six, now we have him combining gaze with voice or gaze with action in three or four pauses in five
SSR's, that was on the last one. But now we've added the generalization piece – two or more contexts with
two or more people.
So there are little baby steps for Simon that will take him from where he is to where we want him to be in 12
weeks. And I'm happy to let you know that he did accomplish this in the 12 weeks of his parent coaching.
Slide 8: Writing a Teaching Tool
All right, now I want you to take a turn doing this. Here's an objective for you, let's go over it together. This was
written for Simon. When an adult offers him a preferred toy or activity, he will use a conventional gesture. That
means one you'd recognize, or that anybody would recognize to request. And he will combine gaze with
request 3 more times in a 20 minute period for 3 consecutive sessions across 3 different gestures like a give
me gesture, a pointing gesture, a reaching gesture, hands up for pick up – things like that – and for three
different adults, both at home and in the clinic.
All right, you have data on Simon for this in your curriculum tool. You know where to start, right? With the first
step, the baseline, which is your A code, that is the closest to this objective. And you know what step six is. It's
the mastered objective. It's right in front of you. I want you to start trying to build the stair step from step one to
step six. Or backwards from step six to step one. Personally I find it easier to go backwards a few steps like
six, five, four and then I go to one, and go to two, and make sure that three and four meet up in the middle.
There's no right or wrong way. You'll find a preference for this. Go ahead and give it a try.
Slide 9: Check Your Work
All right, you've completed your steps for Simon's objective. Here's a way to check your work. Do all of the
steps match the objective? Once in a while people bring in new ideas. And they aren’t part of the objective at
all. Make sure that you haven’t added anything that isn’t in the objective. Does the first steps reflect an
acquired skill? Does the last step represent the full mastery skill with generalization? Do the other steps
represent small gains that seem reasonable for him to get to in two week periods? If so, you've written a
beautiful set of steps. Congratulations.
You might want to go on the forum, and share your experience with your colleagues who are also working on
this step right now.
Slide 10: Goal Sheet
Now you have these beautiful steps. And I'd write them out in goal sheet right underneath the objectives so
that when I create a treatment plan, it's really an objective and a little table that holds those steps with a
column that says when I started this step and a column that says when I finished this step. And that's my
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written treatment plan. And that's helpful for me and it's helpful for the parents. But it doesn’t give you a very
good way to take data.
Slide 11: Goal Sheet/Data Sheet
So I want to show you a little piece of magic here. Here are our six steps. And here we have a data sheet. And
all we have to do is move those steps into a vertical pattern, put some coding columns on the back and now we
can turn this into a data sheet. Look, there are the steps we just wrote. And now they're ready to take data.
We've got a column on the right hand side for each 15 minute period.
In ESDM, because we're using an interactive routines-based way of teaching, we can't take trial by trial data
very easily. Instead we have learned to take interval data. And we use every 15 minutes as the time to take
data. I use my phone to time myself in 15 minutes. And when my phone chimes, I just let the activity that I'm in
end or let the child to play alone. And turn around and take data.
Slide 12: Data Sheet
Now we don’t have to take data on every single step, because we only got one step targeted at a time. And I
always mark my targeted steps in yellow. So I want to make sure that I'm taking data on the targeted step and I
look ahead to see whether the child is past a more advanced step. Try to keep track of that, too, because
sometimes children will go faster than we planned. And they'll move right along through this. And it's hard to
even keep up with them.
If the child hasn’t demonstrated that skill, and the opportunities you've given them in this 15 minutes, then look
at the step before. That's the last step he acquired and that's a step that should be on maintenance. Did he
past that? Make sure that you mark it. We want to know how he performs in this activity. If this wasn’t an
activity that let you teach these skills, then just mark a no opportunity.
All right, so now we have a way of keeping data on that particular objective. What about all the rest? We can
turn those tables into an easy to use data sheet by cutting and pasting each of the little tables you've made for
the steps and putting them all together, shrinking the fonts way down, putting them in two columns, front and
back on a page, highlighting the target skill in yellow for each of the objectives. And remember, the
maintenance scale is the one right before. And then we have a data sheet that is ready for the next 12 weeks
of teaching.
All that we have to do is to update where the highlighting is as the child moves through the objectives
m a s t e r i n g step-by-step-by-step. So I keep the blank one on my computer, I look at my data after a
session. And if a child has now passed a step, we simply move the highlighting forward. And then my data
sheet is ready for the next session. We can also do this on an iPad, in Excel. There are many different ways
that you can do this electronically as well as paper and pencil systems.
Slide 13: Simon Video
Before we end this, I thought you might like to see Simon grown up a little bit. He's now six or seven years old
in this video. And he's talking about a picture that he's looking at. It's a picture of kids swimming – a bunch of
kids playing in a swimming pool. And he's going to talk a little bit about swimming with the evaluator. It's pretty
amazing how much language and social skill children with autism can develop after some years of therapy.
Simon has had two years of parent coaching and intensive Early Start Denver Model. And he's now doing very
well academically on target in a regular classroom, doing well at home with his brothers and sisters, and
participating in all the activities any other six or seven year old boy would. It's fun to see him again.
Slide 14: Common Questions
We've now completed this whole module on building the treatment plan. And I want to talk with you about a
couple of questions that often come up from audiences before we leave this. One of the questions that always
come up comes from people who are working with children who are chronologically older than the children that
you're seeing here, but who are developmentally at the same levels that the children are who are appropriate
for their Early Start Denver Model.
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As you know we target the age group 12 months to 4 years as the starting point for ESDM. We don’t see this
as an appropriate intervention for children who are older than 5. And the reason for that is that this curriculum
and the way of interacting, the kinds of toys and the kinds of games we're playing with these children are really
early childhood activities. This is not how 6 or 8 or 10 or 12 year old children play even though they may have
intellectual difficulties, language difficulties, or ASD.
We want children to be playing with materials that are appropriate for their age group and finding ways to
participate in activities that their age group would carry out. And so ESDM as it's written in the manual really is
for younger children. For older children we need a more functional age appropriate way to their curriculum.
A second question that often comes up is how long it takes to write a treatment plan like this once people are
skilled in it and how many objectives to write? I'm going to start with the second question first. The number of
objectives that you're going to write has a lot to do with how intensive the child's treatment is going to be. The
more hours a child is getting, the more can be taught during that period. Our rule of thumb in our own work is
to write at least 10 to 12. Even if the delivery is once a week parent coaching, I'd write 10 to 12 objectives for a
child. If a child's getting our intensive version, 15 to 20 hours a week of individual treatment plus parent
coaching, then we tend to write 25 or so objectives – four or so in each domain. So somewhere between that,
at least a couple in each domain no matter how little treatment the child is getting. And always for a 12 week
period.
Sometimes people say, "Well I'm only seeing them once a week. I'd rather write them for six months. It's
easier." Yes, it's less work to write them for six months, but you know what, the child won't make as much
progress. We all know that the longer the timeline stretches, the more we take our time getting to the deadline.
And our kids don’t have any time to waste. So you want a 12 week objective. And you want a step that's going
to get you teaching immediately. That holds us to accountability and to a tight timeline. And that helps children
progress.
The final question that people will ask is about how long can I expect this will take. And I would say that at the
end of 12 weeks, once you're skilled at this, you should assume you're going to spend two hours or so after an
assessment turning your curriculum data into objectives into steps and into a data sheet. But that's 2 hours in a
12 week period.
And for those of you who are writing IEP objectives and have to show benchmarks, you can see that the
benchmarks are built into this even within the steps. So that everything is laid out for you. If you have to write a
12 week objective because of the system that you're in, and that you start with a one year objective, that's
fantastic. That will help you do this even more easily. Write your 12 month objective. And then write your first
quarter objectives. And there are your first set of benchmarks.
So I hope you take the time to try this method, because we have found it so important to the kind of progress
our children make. As I said to you before, I wouldn’t dream of going into a session without my data sheet. And
I feel completely dependent on it. And I know that I'm a better teacher, and I do much more teaching because I
have that data sheet in front of me. I’m going to teach every objective on the data sheet in a one hour session.
That’s what we expect from ourselves, and that’s what you can expect from yourself too.
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Slide 1: Deconstructing ESDM
Welcome to a new module. We're starting a set of lessons today that are going to be defining how to do the
treatment inside Early Start Denver Model. Now that you have a treatment plan, we need to activate it. And
we're going to begin by watching a video of an expert therapist working with a little girl. And we're going to take
this apart so that you can really start to look for yourselves at what's involved in this intervention.
Slide 2: Video
In this video you're going to see two-year-old Karina working with Dr. Jamie Winter. And this is the third hour
that the two of them have spent together. And you're going to see the therapist working on a number of
different skills inside this little clip. It's about ten minutes. I want you to think about two things as you watch this
video. I want you to think about what are the objectives that the therapist is teaching. I want you to write down
what you think the objectives are that are on her data sheet. The second assignment you have is to think about
what are the teaching techniques that she's using to teach those objectives. There are a set of behaviors that
define what therapists are supposed to do. And I want you to try to figure out what those are – all right? Go
ahead. Let's just watch the tape. And then we'll come back to each of these points.
Slide 3: What is the Therapist Teaching? Expressive Language
All right, now you've had a chance to look at this little piece of therapy. I want you to write down on a list what it
is you think the therapist is trying to teach. What are this child's 12 week objectives?
All right, here are the objectives that the therapists wrote for her for this 12 weeks. Let's see how many of
these you identify.
In the expressive language domain, I saw the therapist work on requesting with gaze, requesting with voice
and requesting with gesture. I also saw a lot of opportunities for pointing. But I didn’t see any prompted
pointing. And I didn’t see any model pointing. So, I don’t think that was the target in this section. I saw the
therapist working on more by modeling a lot – more of this, more of that, drum more drum. And I saw the
therapist looking for the child to name objects. And I saw the little girl saying fast, slow, high, down, more. So,
she's working on several expressive language objectives.
Slide 4: Social Interaction
Now let's look at the social objectives. The child was doing a great job joining in with the adult using her
sounds for eye contact, for actions and smiles in this little piece of play. I also saw the therapist skillfully pull
out initiating as well as responding to and continuing interactions back and forth between child and adult. And
we saw the little girl sit for a long time – a lot more than three minutes, which is what her objective is for staying
in a social activity with an adult.
Slide 5: Receptive Language
What about receptive language? We saw the child following a number of instructions. We saw her following
gestures to an object, but not a point. And we saw her identifying some objects.
Slide 6: Imitation
We saw a lot of work on imitation, didn’t we? We saw the therapist working on imitating single actions on
objects, imitating multiple actions on objects, imitating gestures, imitating actions the child couldn’t see when
they banged the drum over their heads. And we saw the child imitating sounds and words that the therapist
was making.
Slide 7: Cognition
Finally we saw some trial and error problem solving. That's a cognitive objective that they had – when she was
fumbling around trying to figure out how to hold that drum so that she could lift it up. And we saw her
combining two different actions on toys. For instance, when she handed the drum to Jamie and then handed
her the stick. Or when she first raised the drum and then banged on it.
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Slide 8: Activity Review
So, in that one single activity we saw the therapist practice more than half of this child's objectives for the
whole 12 weeks. That's what we mean by intensive teaching. Finding activities that allow you to bring lots of
objectives in, and practice each one many times. I think that's a big reason why children in this particular
intervention move so quickly. They get lots of practice in activities that are motivating for them.
Slide 9: What is therapist doing?
All right, now we're going to switch gears. And we're going to think a little bit about what is the therapist doing.
What were the qualities of the therapy and the therapist that stood out to you? If you had to say what
techniques she was using to teach this child, what would you write down? Go ahead and make a list. And after
we are done with this lesson, share the list with the other people who are taking this course as well. See what
they saw that you might have missed. You can look at the video again too. It will seem much richer the second
time through.
Let's go through the specific teaching practices that many people point out. They point out how attentive the
child is, and how motivated she is to be playing with these objects. They point out the clarity with which the
adult is giving an instruction. It's really clear what the antecedent, what the behavior and the consequence is –
isn’t it? And if you think about what the reinforcing consequence is, lots of times people say, "Oh, it's the social
attention." But you know what I think it is more than anything, I think this child is very motivated to see the adult
bang the drum and to imitate her. And then we see her starting the adult again and again and again to bang
the drum. She is highly motivated.
What else is the therapist doing? She's got a lovely positive style. There is a lot of fun in this. They're playing.
They're getting lively. The little girl laughs and carries on. So, she gets her very animated but not over
animated. She can manage the child's arousal. So, she keeps the learning activity exciting and interesting. You
might talk about how often the child has a chance to lead the interactions.
Who do you see is the main leader in this activity? Is it the child? Is it the adult? Or is it pretty balanced in
terms of who's leading and who's following? I see it as a pretty balanced set of interactions where sometimes
the adult leads, and the child follows. And sometimes the child leads, and the adult follows. And that balance is
important.
We see one of the therapists’ techniques for establishing that motivation when she starts with the blocks, which
the little girl has looked at. That's the cue that the therapist used to select those blocks in the beginning. But as
she tried to engage her, it was clear she wasn’t interested in the blocks anymore. And rather than bringing the
child to the blocks and trying to get her attention there, she followed the child over. Looked at what the child
was interested in. Picked up a second object and followed the child's own goals into that activity. There's
where the motivation came from.
She was also quite sensitive to the child's cues, wasn’t she? She brought in some variations, but the child
didn’t want the variations. She wanted to go back to banging the drum. And so the therapist acknowledged it,
and went back to the drum. There were lots of communication opportunities. The child got to comment. They
got to laugh together. They shared smiles and affect. The child requested objects. She requested action. She
requested up and down, fast and slow.
There were lots of opportunities for the child to communicate both with gesture and with voice and with gaze.
And we saw the therapist use some skillful waiting until the child made eye contact in order to begin so that
she could reinforce eye contact as a way to start an interaction.
Did you write something down about the adult's language level? Her sentences are very short. And the child's
sentences are very short. The child's a one-word speaker. And the adult is basically in a one to two or three-
word phrase.
You might have noticed that that activity was getting pretty repetitive. And the therapist tried to find a way to
end it, or change it a few times. How did she do that in the end? It was a nice smooth transition, wasn’t it? She
found a way to interest the child in something else. And then she did a quick trade. That was really a beautiful
transition, because she never lost the child's attention. And you had the sense this teaching would just move
on, or onto a different toy, and some different objectives without any break in the interaction.
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Slide 10: Compare Your Work
Well, if you will compare the list that you made to the ESDM fidelity tool, which is in your packet, you'll see that
we've just brought life to these fidelity items. We've talked about every single item on this fidelity sheet –
managing child attention, the use of antecedence behaviors and consequences in the teaching, the clear
instructional techniques involving prompting, prompt fading, shaping and chaining activities together, the skillful
that she modulated child affect and arousal to keep this child in what we talk about as the optimum arousal
level for learning. There were no unwanted behaviors. Children who are happy and highly motivated tend not
to need them.
Slide 11: Quality Engagement/Language/Joint Activity Structure
The quality of dyadic engagement was very high. There was a rich partnership between the two – both
contributing to the activities, both interacting with the other, a co-construction of the game and very balanced
interactions. The child was highly motivated. And positive affect was expressed throughout by both people.
We've already talked about sensitivity and responsivity to the child's cues. But we haven’t talked about the
many different ways she used language. She used language to comment, to request, to indicate a preference,
to share emotion. She's demonstrating a number of different pragmatic functions of language. That's a fidelity
item. And we talked about the adult's language fitting the child's MLU.
We haven’t quite mentioned the joint activities structure yet, but I want to point out to you the very clear setup,
which was long in this activity. It took a while for them to land on the drum. But that whole setup leading to the
theme of the activity, which was banging the drum, helped bring the two people together into this activity. And
establish a highly motivating routine.
The theme was followed by a number of variations so it didn’t get too repetitive – the fast and slow, the up and
down, the tickle games and peekaboo games that followed so that there were a number of variations and a
clean transition to another activity following a child's choice – and without losing child attention.
Congratulations. You've just identified yourself the main features of ESDM teaching. In the following lessons,
we're going to take this apart, and talk about how to build it up piece by piece so that you can use all of the
same techniques in the service of your treatment plan. Here's a chance to see the same little girl now at age
six talking with the evaluator during an assessment. You’re going to see a very fun exchange about a 6 year
old girl thinking about a wedding.
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Slide 1: Becoming a Play Partner
In this lesson we're going to be talking about how to get that kind of playful interaction going – that you just saw
such a lovely example of with Jamie and the drum. I'm sure you were watching that and thinking, "Well, this
child doesn’t have autism the way the kids that I work with do." But you know what, she does. And children
with autism are capable of this kind of interaction with a skilled therapist. But it's not how the very first moments
start. Those very first moments can be very difficult. And I'm sure you've had the experience of being in the
presence of a little child with ASD and their family and wanting to get some interaction going and having that
child either treat you as if you didn’t exist, or as if you were the most horrible person in the world and avoid you
at all costs. How do we actually get these interaction started?
Slide 2: Good Conversation
Well first of all, we need to remember that every good conversation starts with good listening. Whether we're
talking about our relationships with our significant others, or our relationships with the little children with ASD
that we treat, we have to be good listeners and get attuned to what our partner is talking about.
Slide 3: Active Listening
How do we demonstrate active listening to a small child with autism? Well, we do it first of all by not placing
any demands. The easiest way to demonstrate interest without demands is just to show interest – nodding in
approval, smiling at what the child's doing, just commenting on what they're saying. For a child who is
avoidant, I don’t sit in front of them, and I don’t get too close. I sit a little bit to the side and I just show interest
in what they're doing – “Wow, that's cool.” “It's a big tower.” “Boom.” – things like that. And believe it or not, we
have evidence that shows that children with autism hear that, and they understand it as positive.
Another way to show interest and to be an active listener is to narrate. I was just doing a little bit of that by
commenting on it. But you can talk a lot in those little one to three word utterances that we talked about to a
child – “big truck”, “loud noise”, “funny bear” – things like that. With affect, with sound effects, it creates interest
and it lets the child know that you're attuned to them. You'll also naturally speak in turn to their rhythms. And so
they'll start to feel the synchrony of your speech, your gestures, and your actions as it fits their toy. Be careful
not to be too animated or too loud. We're trying not to be intrusive. Just to be a good listener and to show that
we're tuning into what they're doing. The next two ways involve a little bit more intrusion into the child and so I
build up to these.
The next role is helper. You can demonstrate a lot of understanding about what a child is doing, and support
for them by helping them – so looking for a place to assist them. If they're struggling with something, try to
stabilize it. If they're reaching towards something, push it closer, make it easier for them. If there are several
different pieces that they want, pick one up, and hand it over so they have more of the things that they already
like. Finding ways to help them in their goal without taking over, without taking a turn. Just help them be more
successful. That's a very powerful message that says, "I see what you want to do. I'm going to help you do it.
It's a good goal. And I'm with you here."
And then finally, imitating the child. Now this is the most intrusive of these four active listening techniques. And
so you want to maybe work up to this. Imitating a child is the most easy to do when you have your own
materials that are identical to the child's. So, this is where it's very helpful to have two of things, like we saw
Jamie and the drum. It was very helpful that she had a second drum with her own sticks. And toys that you
offer early on should have enough materials that you could pick one up, and copy the child. If there are not
double toys, and the child has all the toys, you might take a piece quickly. Imitate what the child is doing, and
hand it right back. So, again, it's clear you're not asking for anything from them. You're not taking their
materials away. You just think what they're doing is cool, and you want to do it too. If there aren’t multiple
pieces, and the child is having a great time with his xylophone, if you're lucky that stick will drop at some point
and you can quickly pick it up, take a little turn and hand it right back. Little quick turns can also demonstrate
you're imitating the child doing exactly what they do so they are still leading but now you're interesting and
you're part of it too. There are a number of studies by Geri Dawson and others that have shown that children
with autism really attend when we imitate them.
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So, here's a little stair step of ways to become a more and more important helping partner for a child without
taking over any demand roles, without placing any requirements on the child at all. You know, many children
won't need you to be this gentle. But these are techniques that will be useful for a child who is actively avoidant
or who is on purpose not attending to you. You're just kind of working your way inside their activity and their
sphere of interest and making it go better because you're there making it more fun. That's a way to start off.
Slide 4: Video
We're going to look at an example next of a very skillful therapist. This is Laurie Vismara working with just
these techniques with a child. Let's watch the video. And then let's identify the techniques she's using.
Slide 5: Active Listening Techniques Used
All right, you may have guessed from the way this video starts that this little boy is not very happy to be in this
room or to be with her or to have her engaged in these materials. And yet look at what she creates. How did
she do that? Let's think about the starting moves that she made. What did she pick up? She picked up an extra
piece of material that the child liked and she handed it over quickly. She built things that he was interested in,
and rolled them across the room for him making interesting things happen. She never asked him to do
anything. And when he lost a piece of material, she rolled it right back. But he thought that was pretty
interesting and so he rolls it back to her and she imitates him and rolls it right back. And pretty soon they have
a lot of imitation going on back and forth. And then she can start to do a little bit of teaching. At the point that
she picks that stick up to get eye contact, you see the transition from just being an active listener with no
demands to starting to put some demands in and starting to teach. She teaches look-to-request. She's working
on look-to-voice and name and they're building this interesting imitation activity. But she starts this through
these very careful and very skilled active listening techniques and you see how quickly it turns into a balanced
set of play in which she can teach.
You may want to share the points that you thought of as you watch this with the people who are watching
online with you. This is a rich piece of video and you've seen some very skillful therapists here in these last
videos. Are you picking up some similarities between them? Do you see the techniques that we talked about in
the last lesson coming up in this one as well? Think about these things because we’re heading more and more
deeply into this in the next lessons.
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Slide 1: Building Joint Activity Routines
Welcome back. We've been talking about how to enter into some interaction with a child; now we're going to
talk about how to build out these lovely activities that you've been seeing therapists do.
Slide 2: Joint Activity
This lesson is focused on how to develop these joint activity routines. Let's think a minute about what these
words mean. When we talk about a joint activity we mean people are going to be doing it together, that the
adult and the child are going to be taking turns, joining together in the activities, sharing the materials, looking
at each other, moving items back and forth, communicating about what they're doing and building on each
other's ideas. This is a partnership that is co-constructing an activity to do with these toys.
What about an activity? What's an activity? An activity means there is energy being put out. The two partners
are moving and doing, there is liveliness to this. The child is having a hands-on learning experience the adult is
also participating in and the two of them are building an organized set of actions. That's the routine part. Then
order to this is going to come about that you could describe - first, this happened, then this happened, then this
happened, then this happened.
There is also a goal, this is a goal directed activity. If it's an action with objects, the child has a goal in mind for
what to do with these objects. If it's an interaction that does not involve objects, then the goal may be having
fun, doing a song together, doing a dance together, chasing each other - but there's a goal. We want to make
sure the child has a goal and that we understand it.
Finally, with energy and a goal is effort. It requires a little bit of effort for the child and the adult to pull this off.
It's not just to relax, lay back and enjoy what somebody is doing to you. It's putting forth effort to accomplish or
reach your goal.
Slide 3: Four Easy Steps
A joint activity routine involves four easy and simple steps. You have already seen them occur in the drum
routine. There is a clear setup. The setup is from the beginning of the interaction until the two partners land on
a theme. The next step is the theme. What's a theme? It's what you are doing. Jamie and her little girl Karena
were banging the drum. That was the theme, banging. Laurie and her little guy were rolling the sticks, rolling
was the theme of that play. So, the setup leads to a theme and the theme goes back and forth a few times with
both partners involved in the theme. But themes can get repetitive and there's no more learning to be gained
when a theme becomes too repetitive. In each of these examples you see the adult bringing variations.
What do the variations do? They extend the activity, they allow more language to occur, they allow more
objectives to be taught, they keep it stimulating and interesting. It brings the child's curiosity up. They also
require the child to be flexible in their play and introduce more and more ideas for what to do with this object.
That's good for little children, especially little children with autism who tend to not be so flexible in their play.
Finally, somebody's running out of ideas or energy for this activity and it needs to close down. But we want an
orderly closing, we don't want children just walking away or escaping from the activity. We want a decision to
come that we are finished now. We are going to put this away and we are going to start something else. So we
want an organized closing and a clear transition to another activity. Like that beautiful closing you saw Jamie
do a couple of lessons ago.
Slide 4: Activities
Now, we have a setup, we have a theme, we have variations and we have a closing. Here come the activities
in which you are going to embed objectives. Setup can involve a number of objectives: making a choice of
materials, pointing to the box that you want, opening a lid together, getting all the pieces out and spreading
them out on the paper, choosing a color, choosing a marker, choosing a paintbrush and choosing colored
paper to draw on. There are a lot of language activities involved in this or matching activities or actions on
objects or imitations as we setup a piece of play.
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A theme involves other kinds of objectives. It may involve actions with objects, like stacking or taking out or
putting pieces in a puzzle or matching shapes. It could be reading a book, naming all the animals or doing the
animal sounds. It could be drawing and copying straight lines or circles. Whatever the first action is, there's the
theme. As you already know from your bundled objectives, you can get several different domains and items
covered inside a single theme.
The variations allow you to bring more objectives into this activity without having to setup a whole new activity.
So, if you first started by talking about putting the pieces in maybe now you're going to be talking about the
colors of the pieces or the names of the shapes or tracing around the shapes on a piece of paper which brings
in fine motor objectives into a shape sorter. You might be taking turns and making from an animal puzzle into a
food puzzle or you might bring out some play food to feed the animals in the puzzle. That becomes a variation.
You might take those animals and have them walk, have them lie down, have them go to sleep. Those are all
variations on an animal puzzle theme that would work.
Finally, you brought in as many objectives as you can and the variations, are losing their steam. So, it's time to
close it down. The closing allows for a number of objectives as well. Closings are a place where a lot of
cognitive objectives can happen. In putting things away, we can help children practice matching things,
matching identical objects by having the pieces go in different boxes or matching colors or matching types of
objects. Categories can be done in a closing activity. Finally, putting the pieces in, putting a lid on and putting it
on a shelf, there are three steps all chained together in a nice complex routine. So, lots of different objectives,
language, social, cognitive, imitation and motor objectives, can be fit into a single activity routine. The example
that you looked at with Jamie and the drum showed you how many different kinds of objectives could be fit into
a simple activity just banging on a drum. The joint activity gives you a chance to do a lot of teaching in a lot of
areas.
Slide 5: Critical JARs
We talk about two different main kinds of joint activity routines. One involves play with objects, that's what I've
been playing about. The advantage of doing an activity routine involving objects is that they give you that setup
that allows you to work on joint attention. In play with objects, you have the three points of a triangle, the child,
the adult and the object. That triangle of attention is the framework for working on joint attention behaviors,
sharing, giving, pointing and commenting. That all important skill, both at the non-verbal and the verbal levels,
that's such an important scaffold for language development and is so difficult for young children with autism.
Play with objects is the normal framework for joint attention.
Slide 6: Critical JARs
The other kind of critical joint activity routine that we practice in ESDM is sensory social routines. These are
routines in which the objects are not very important, what's really important inside a sensory social routine is
the dyadic exchange between the two people. These are routines in which people are face to face. The child is
giving you a lot of eye contact with a lot of facial expression, shared smiles, laughter, pleasure, reaching out to
make things happen. The strength of sensory social routines is this dyadic interaction. This really highlights
how two people communicate face to face. All the information is in the face and in the gesture and children are
captivated by the physical presence of the partner. These two kinds of joint activity routines together highlight
key areas of social learning that young children with autism need in order to move forward in their
communication development.
Slide 7: Video 1
Here's a video involving a joint activity routine with a little girl who has got some language. I want you to watch
this routine, both to identify the main parts of it and particularly to see how much teaching goes on in the setup.
This therapist is so skilled at using the setup to practice a bunch of objectives that all hang together inside this
activity. So watch this and see what you think.
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Slide 8: Video 1 Recap
Every time I see this video, I appreciate just how much teaching goes on in the setup phase and yet how
partnered it is. The little girl clearly has a goal and the therapist helps her get there bit by bit by bit. You can
see the objectives that are being worked on, asking for things that aren't present, solving problems that lie in
front of you, using language as a way of constructing the activity. I think this is a very skillful piece of teaching.
Slide 9: Video 2
Now let's look at a sensory social routine. This is the kind of activity in which what is important is the
interpersonal activity between the two social partners. Here we see Laurie Vismara working with a little girl.
Let's see how this game evolves.
Slide 10: Video 2 Recap
Did you see how Laurie started to introduce the "Ring around the Rosie" game? But because of the little girl's
interest, the two of them shifted and they co-constructed a different activity. I would call it up-down. The theme
of this activity is up and down. But it doesn't stay there, does it? It evolves into a set of variations, including
spinning, jumping, kicking and slapping on the floor, all held inside this up and down framework.
We see how skillfully Laurie keeps the activity level high but not too high and the emotional level very
interesting but not overly arousing. How do we know the child isn't over aroused? Because she's always in
control of her own behavior, she's not disorganized by the high affect she's experiencing. She's choosing what
she wants to do and she does it. For me, that's the difference - if you know a child who is aroused but in the
service of learning and a child who is over aroused and can no longer take advantage of the learning.
What about the closing? We saw Laurie talk for a minute to the mother and then remembered that this child
was finished with the activity and go back to set the closing to say that we're all done now. So, we do see the
four parts in this activity, in addition to some comments made to the mom in the middle, while the little girl took
a break.
Would you like to see that little girl grown up to age six? Here she is talking about a trip to SeaWorld and her
experience with the whales.
Slide 11: Video 3
It's fun to watch the children grow up, isn't it? We haven't picked best examples for you with best outcomes.
We're just following up the children that we have follow up videos for. So you can see how children come up
through the Early Start Denver Model intensive training package.
Slide 12: Construction of JARs
We've been talking about joint activities and the construction of them. You know that they have four steps and
you know how to build the steps and to identify them. You also know how those four steps package and hold
the objectives that you're working on so that you can be teaching inside each of those phases and teaching all
the way through.
Let's step back a little bit from the construction of the joint activity to think about they're working for us and why
they are such beautiful mediums for teaching. I think about joint activities as serving the roles of both scaffolds
and spirals.
Slide 13: Scaffold
What's a scaffold? What does a scaffold do? A scaffold helps support a structure that's being built, that's not
stable enough or sturdy enough yet to stand up on its own. As the edifice is built and becomes stronger and
stronger internally, the scaffold is removed bit by bit so the structure now stands by itself. I think it's interesting
to think about what the adult is doing inside the activity as the scaffold. The adult is using the materials, the
teaching techniques, the prompts, the ideas, to scaffold the child's learning and to scaffold children's
development in all of these domains. We're scaffolding children to move ahead, to build the next structures in
cognition, in language, in finding growth motor skills, in their knowledge of the world and of interactions.
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As in the early steps of a new objective, we're providing a lot of scaffolding through prompts, through
simplification, through demonstration. As the child's learning progresses, we can start to pull that support away
because we see children becoming more and more skilled at carrying that out. They're more spontaneous,
they can do it independently, they can apply that to more and more different kinds of skills. So, inside a joint
activity, we scaffold the children with the learning steps. Then we step back and we become a partner in which
the child is carrying out more of the initiative, taking more of the first steps and we follow through as we see
their own internal structures and learning structures emerge. Scaffolding is a really good example of how we
want to work in the Early Start Denver Model, not only providing the initial structure but carefully taking it away
as the child is ready to take on more for themselves.
Slide 14: Spiral
Joint activity routines also form spirals. What is a spiral? Spirals ascend, think of staircases. They move you
upwards in a plane. The joint activities spiral with repetitions and variations. What starts at the first level of a
building as you're building your steps to go farther, the play is becoming more sophisticated, the language is
becoming more sophisticated. The themes are becoming more complex and the organization of the activity
allows it to become a far more complex routine than it was at the beginning.
The first activity with new material in, let's say, a new puzzle routine may be simply the introduction of in and
out with a simple piece. But within 12 weeks, this is a child who may be able to walk to a shelf, bring down a
box of puzzles, select one out, put it in front of him, take out all the pieces, give you some, put it back together
and put it away. What a complex structure has been built around doing a puzzle and how many learning pieces
have been put in place? That's what I mean about the spiraling of complexity. And, how we can quickly move
the child to a much more mature way of interacting with the materials and the communications inside that joint
activity routine as it's played out over many sessions.
Slide 15: Frameworks for Joint Activity Routines
Finally, what are the frameworks for joint activity routines? We need to think about every routine that a young
child is involved with. So far, we've been talking mostly about play with toys and play in sensory social routines
without toys. But a child's life is full of lots of routines. There are certainly bathing and washing routines, hand
washing, face washing, hair brushing and taking a bath. There are book routines. Dressing and diapering
involve a number of routines every day for a young child.
Parents typically engage toddlers in some version of household tasks. They may help throw Kleenex in the
trash, put toys in bins. Outside, children may hold the hose to water the flowers. If dad's washing the car, they
may hold the sponge and rub it against the hubcap. Household tasks are an important set of activities for
children. Meal times and snack times, of course, are terrific times for teaching a number of skills and to create
orderly routines around meals. Outdoors, play in terms of play structures, taking a walk, using bicycles, playing
with balls, playing in little swimming pools, there are a number of routines that are built around every type of
equipment or activity that happens outside.
The child that you're working with may have many other routines in their lives. They may go to the grocery
store with mom and dad. The family may go to McDonald’s for a meal once a week. They may have picnics on
the front lawn. Identifying and understanding the routines in the lives of the children that you're serving will help
you help the parent think about building joint activity routines into the places and the activities that they do with
their child. Every place the family goes is going to need an activity for that child. You can help families figure
those out and make them more pleasant experiences for child and parent and learning opportunities for
children.
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Slide 1: Building a Treatment Hour
Are you ready to put all these elements together and build it into a treatment hour? You've got all the pieces
that you need. Let's talk about how to do that now.
Slide 2: What to Teach?
First of all, let's think about what you're going to teach in this particular hour, whether we're talking about a
home visit that you're making or a treatment hour with a child one-on-one or an activity period inside a
preschool. When I think about an hour of intervention, whether I'm working one-on-one with a child or with a
parent, I plan to teach all the objectives on my data sheet. I want to reach every one of them and it's certainly
possible. As you can see, if you can get 11 objectives into a 10 minute activity, certainly, you could get 20
objectives into a 60 minute activity. So, in terms of what you're going to teach, plan to address all of the
objectives on your data sheet. Second, I think you've realized by this point that your teaching activities are your
joint activity routines. You're going to build joint activity routines and you're going to embed the objectives
inside what's happening in that activity just the way you did it for the curriculum assessment. You did a set of
joint activity routines for that curriculum assessment and treatment is going to go the same way.
Slide 3: Three Organizers
There are three organizers that we use to put together an ESDM treatment session. As you first start to do this
you're going to want to write this out and have a plan. Later, it comes pretty naturally to you and really all you
need is your data sheet. What are the three organizers? First of all it's time. You know how long your session
is and that session is going to be broken into a set of activities. Each activity is going to lead to the next one.
Each closing is also an opening. What you're working for are a set of joint activities, organized activities that
flow from one to the next, to the next, to the next, in three, to five, to eight minute intervals across the time
period that you have. So, you have time and a set of activities. Second, you have a set of activity types that
you're going to carry out. We all know the kinds of activities that we do in early childhood education. We work
on social interactions. We work on play with objects. You know about sensory social routines. We also work on
pretend play with little children. We carry out book activities. We do gross motor activities with them. We do art
activities with them. We feed them. Self-care is always a part of taking care of a young child, isn't it? Whether
we're washing hands before a meal, wiping hands off after a meal, changing a diaper, putting a dry shirt on
and substituting it out for a wet shirt, taking shoes off when we come into a session, putting them back on at
the end. It's easy to weave self-care objectives into time with a little child. Sessions naturally begin for
everybody with greetings. Hellos and goodbyes, those usually frame the first and the last things that you do.
For a child who's three or four, pre-academics become an activity area as well. So, now, we know we have a
group of activities. We know a set of activity types that we want to put into those activity slots. The third
organizer is the child's objectives. We have a set of objectives that we want to cover. Some activities lend
themselves to certain objectives better than others. One rule in ESDM to know from the beginning is that every
activity needs to have a social communicative objective worked on in it. So, your expressive language,
receptive language and social objectives are going to be present somewhere in every single activity. It's up to
you to figure out what those will be.
Then you start to look at the other ones, gross motor activities easily go with the gross motor play, bringing out
trampolines, tricycles, tubes to crawl through and things like that. Art activities lend themselves well to fine
motor skills. Self-care activities blend themselves well around snack time and art and anything that involves
water. We talked earlier about how cognitive activities go nicely inside the cleanup, the various materials, as
well as puzzle activities, fine motor skills. Fine motor and cognitive objectives go well together. You see
imitation can happen everywhere. We use imitation in terms of modeling actions to do with objects. We use
imitation in gestures, in song and sensory social routines. So, imitation is also easy to put into every kind of
activity that we do for a young child. Hopefully, you can start to see now how you can fill in your activity slots
with these different types of activities and then start to figure out which objectives you're going to put into these
different activities knowing that your language objectives are going to be hid inside each one of them.
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Slide 4: Fitting Objectives Into Activities
I want you to do a little planning for yourself right now around a child that you know, a child you've already
written objectives for and I want you to take some moments here to use this time schedule on your left with
these activities spelled out. I want you to take the objectives for a child that you're working with and plant them
into these activities. I want you to put a language objective in every activity block. I want you to make sure that
every objective that you have is worked on somewhere in these nine activities. Go ahead and take a few
minutes to do that. See whether you could imagine how the flow of the session would go if you used this kind
of way to build your teaching activities.
Slide 5: Organizational Framework Observation
Now that you have this organizational framework in place, I want you to go back and look at little Simon's
video, the one that you looked at in the curriculum assessment. I want you to pay attention to the flow of
activities that the therapist is using, how she moves from a setup, to a theme, to variations, to a closing,
activity, after activity, after activity, after activity, and the kinds of different developmental skills that she's
pulling out inside all of those, with communication embedded into each one. The purpose of that was a
curriculum assessment. It's a very good example of what a therapy session would look like with Simon
because it's exactly the same format. Look at how smoothly it flows. Look at where she stops to take data and
how he gets to be more active, take a little break and things just flow along from activity to activity with a child
who's pretty well organized and participating throughout all of the things he does in that period.
Slide 6: Simon Video
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Slide 1: How Do I Track Data and Play?
Hi, and welcome back. We've been spending a lot of time talking about how to get play activities going with
children and keeping them busy and learning through an hour or so of treatment. I haven’t forgotten about the
data that's sitting in the background and I hope you haven’t forgotten about it either because as you know we
need to take data through this session, we've got to keep track of child progress on objectives so that we know
we're moving forward. We aren’t doing this to have children be happy and play. We want that to happen but
we're doing this to help children learn and data is what tells us whether or not we're achieving our goals.
Slide 2: Developing the Treatment Plan
In terms of our treatment plan – remember we created a data sheet from our teaching steps. And in this
particular lesson we're going to be talking about using the data sheet and then creating a way to summarize
the data sheet so you will have a summary data from every session that will help you make decisions about
where your teaching is going. Remember your data sheet? The data sheet is your friend. This will not only help
you organize yourself through the treatment session but it will also help you know that you and the child are
making good progress.
Slide 3: The Data Sheet
You want your data sheet beside you, and right at your fingertips at all times because you are going to pick it
up about every 15 minutes and keep data. I also have my clipboard beside me with my data sheets on it, and a
pencil tied to it so that I can easily reach it, and take data without moving from my spot in the play activity. That
way the child can keep playing along for a few minutes before we close out the activity and I can capture
what's happened. All right, so let's review what we're doing here. We've talked about the fact that each of the
columns under each of these objective blocks represents a 15 minute period. So, you're going to start playing
and you're going to set your phone or some kind of timer. And every 15 minutes when that timer chimes, you're
going to look for the next spot in your interaction with the child or you could just take a minute or two break
without interrupting the child, letting them play by themselves or with their parent for a minute while you take
data. You're going to identify the point at which you can take data, pick up your checklist and pencil, and then
you're going to start to read through each of these blocks to see what have you seen in this activity. What have
you seen in the last 15 minutes? On each objective did you see the highlighted skill occur? You are going to
mark them in this way. You are going to mark a plus if it occurred, and occurred at the level that the step
specifies.
You're going to use a minus if you tried to teach that skill, and the child did not accomplish it at the highlighted
level – at the acquisition level. So, you've got a pass – it was accomplished and a fail – it wasn’t accomplished.
Occasionally you were caught between those two points. And if you're caught, feel free to use a plus/minus to
show that it was partially expressed but not fully. Now this activity may not have allowed you to practice this
particular objective. If so, use the N/O. And you're going to mark the highlighted skill for sure. If your target skill
was passed, you don’t have to make any other marks in that block – although I personally always look at the
steps to come because sometimes children will be accomplishing a higher step than your highlighted one and
if so, you may be able to move ahead faster. However if your highlighted was not fully accomplished, then you
have to rate the step right behind it, which is your mastery step, your maintenance skill. You want to make sure
that maintenance is still in the child's repertoire. We want to make sure we've got a pass somewhere in this
skill if it was practiced. And you need to identify at what level of performance the child showed you this skill.
Slide 4: Practice Gathering Data
Now you're going to have a chance to practice gathering data as if you were the therapist. You're going to
watch a sensory social routine that this therapist carries out with a little boy. It's the song, "Slippery Fish". I
want you to watch it all the way through and at the end of the activity I want you to fill out the fidelity sheet
that's in front of you. Let's take a look at how many objectives this therapist could get into this activity. This
gives you an opportunity to function from the therapist point of view, and really look at all the behavior. You
may want to play it twice because you may have missed some the first time. There is a lot to code in this
interaction.
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Slide 5: Video
Slide 6: Charting the Data
The data sheet is going to give you a picture of the child's performance today. But it's not going to tell you
whether the child is moving head, whether they're not making any progress, or whether they're actually not
expressing skills as mature as you've seen before unless you do something with the data. Doing something
means charting the data. You've got to keep from session to session to session about progress and there are a
number of ways to do it. Your packet is going to show you several ways to chart the data. You're going to pay
a lot of attention to the date at which each step is mastered for each objective, that's going to be the reflection
of progress. And remember, you want to try to teach the full objective in 12 weeks, so that means you want to
see the steps being mastered roughly every week or two. Now it's interesting – sometimes children take a long
time to pass the first few steps and then they kind of get it and the last ones come along. But we want to make
sure that the child is making progress from week to week.
You want to see more passes in the second week or the second session than you did the first even if the step
isn’t mastered.
Slide 7: Comparing Data
Comparing data from day to day and making forward progress is critical to knowing how to continue to teach.
There are several examples in front of you. The blue manual also shows you several different ways to
summarize data. One way or another you need to be finding a way to summarize the percent of passes at a
step week-by-week and the points at which the child is making progress from one step to the next, that will let
you know whether or not you're on track. We'll come back in another lesson to talk about what to do if the child
isn’t progressing. At this point your job is to figure out a summary system from all of the choices in front of you
to track progress.
One of the hardest kinds of learning to chart is a complex learning skill that involves a lot of steps and a lot of
chaining together. Self-care skills often fall into this category. Here's an example of how to chart a complex skill
like this. In this particular objective, the child's goal is to learn to dry himself after a shower. This is written for a
four year old. And we see the therapist is keeping the data involving what body part the child has dried without
being cued. And so we see the therapist listing the body parts on the left – head, face, trunk, arms, legs, feet,
and back – and giving each of these a score of one. We see the therapist can total the number of points that
have been dried independently and that reflects how many body parts the child dried without help that day. The
therapist then turns this into a daily graph just based on the number of body parts – not what body part has
been dried. For several weeks of data, we see the child's data day by day by day. We see him starting at his
baseline level of three body parts and then making some incremental gain, having a couple days where
somebody dried him completely – he didn’t do any independent drying. Maybe that was a weekend, and
people were off the program. And then he came back adding some more skills than we'd seen before. For the
next few days he's up there with almost all the body parts being done independently. And we see some up and
down in the data. And so, towards the end we see that he can dry all these body parts, the child is going to be
getting consistency across the date – not teaching individual skills any longer. This is a graph that gives you a
great deal of knowledge and, summarizes a very complex skill in a way that is easy to interpret in terms of
what are our next teaching steps need to be.
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Slide 1: She Won’t Stop Hitting Me!
Hi, and welcome back. We are still in the module on delivering the treatment plan and you may have been
thinking somewhere across all these lessons, “How come they never talk about problem behavior? How come
all I am seeing are these happy, cooperative children?” Well, I don’t want you to think that we don’t see
problem behavior. Absolutely, we see problem behavior, most often in the first few treatment sessions, when
the child has not learned the routines yet. Let’s take a look at the kinds of problem behavior we very often see
in two year olds who start off with us.
Video 1
Slide 2: Problem Behavior
Problem behavior was an important target for this mother. This girl did a lot of hitting, a lot of throwing and a lot
of non-cooperative falling, crying and getting out of demands. It was an important target and we needed to deal
with it. That's part of why we want to make sure to get parent goals at the very beginning. We may want to be
focusing on language but parents need help with behavior. When we ask them first then we know we have to
address it.
How do we address problem behavior inside Early Start Denver Model?
Slide 3: Problem Assessment Chart
The approach that we use inside ESDM is a positive behavior support approach for problem behavior. Let's
walk through a set of steps that help the therapist know exactly what they need to do first.
The first thing that we do is identify the problem behaviors that the parents are concerned about or that we are
seeing and ask ourselves, is there a significant risk of injury to the child or others or major destruction? If the
answer is no, as it often is with these very young children, we pay attention to the problem behaviors; we take
data on the problem behaviors; but we do not do a particular manipulation around them in the beginning.
Instead, we start to deliver the ESDM treatment plan that you have already designed, just as it's written.
We often find that starting by getting children's attention, following their leads, using materials they like and
having a much more play-based, fun, friendly, interactional style does a great deal just by itself to reduce
problem behavior. Also, as you know, we're giving them ways of communicating their desires, as well as their
protests right away. Those may often substitute for the problem behaviors so easily that we don't have to do
anything else.
How do we know whether delivering the ESDM plan is going to be helpful? We are taking data and we're
looking at the behavior counts day by day. If the behavior is decreasing, we know that we're on the right track.
The ESDM plan by itself is handling the problem behavior and we are not going to do anything else, other than
monitor problem behaviors until they get to a range of acceptability. If the answer is yes, the behavior is
decreasing, we continue with the plan as written.
However, if the behavior is not decreasing, then we need to take additional steps immediately. In that case, we
need to do a functional assessment of behavior and develop a positive behavior support plan. We're going to
be talking about both of those in a minute. As we do the functional assessment and the positive behavior
support plan, we feed that back into the original ESDM plan. We add the behavior support plans that have
been needed to the child's daily treatment program. We incorporate that whole package into their treatment
and we continue to monitor behavior to make sure that the behavior is decreasing. It's the data that tells us
whether we have done the right manipulations or not. We're going to keep going until those behaviors are
reducing in frequency.
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However, if the behavior problem does lead to a significant risk of injury, then we have to take a different route.
We can't afford to wait to see if the treatment plan will reduce behavior when the child is at significant risk. So,
we immediately complete a functional assessment and develop a positive behavior support plan right along
with the treatment plan. We gather data as we implement both and we make sure that the behavior is
decreasing. If it is, then we know we're on the right step and we continue with the plans as written.
If the behavior is not decreasing, then we seek consultation among our own team. If we have run out of ideas
from outside, because we have got to find a way to reduce behaviors that are causing child risk, you'll see we
seek a consult. We make a change in the positive behavior support plan, we feed it back to that first step,
continue to take data, changing the treatment plan as needed until we see that the data are reflecting our
success at finding the right combination of treatment strategies that will help this behavior.
Slide 4: Functions of Behavior
We're talking about the functions of behavior when we talk about a functional behavior assessment plan. If this
is a term that's not familiar to you, it's very important to do some additional reading on what the functions of
behavior are. There are a number of good references for this which we'll talk about in a minute, but, basically, I
want to give you a template to get you started here. When we think about how a behavior functions for a child,
we think about two main functions that child behaviors have. A behavior generally functions to help a child gain
access to rewards: things they like, people that they like, activities or opportunities that represent pleasure for
them. That's one main function of behavior.
The second main function that we see is to avoid or escape situations, demands, unpleasant environments or
other kinds of situations that are causing the child discomfort or have, in the past, caused discomfort. We start
by saying, this behavior that the child is showing, that is a problem behavior, what does it gain? What are the
consequences of this behavior? Is it leading to something the child wants or is it leading to escape or
avoidance of something the child doesn't want? In the video example you just saw, you saw this function in
both ways. The child received social attention and affection after her hits. That was a gain, she gained
attention. However, she was also avoiding and escaping the task that was given to her. So, we saw an avoid
and an escape function. It's not at all unusual to see certain behaviors carrying multiple different functions.
Let's take this to the next level now. Let's look at the gains box for a minute. We see that a child can be gaining
positive feedback from internal stimuli or from external stimuli. We gave examples before about external
stimuli, getting attention and getting toys that they want. What's an internal stimulus that provides the child with
a gain situation or a pleasure? We see that a lot in self-comforting behaviors that children do. They may stroke
their cheeks with a favorite blanket. They may play with their hair as a way of self-soothing or suck their
fingers. Those are examples of a gain, a behavior that's being supported by positive, internal stimulus.
If we look at the other side of the box, the “avoid and escape” box, we're looking at stimuli either internal or
external, which in the past have caused the child to stress. So they're now seeking to escape from that
particular consequence. What's an external stimulus that causes distress? Being asked to do something again
and again that's not fun or that's too difficult for you, or that's only under somebody else's instruction without
you having any choice, or something that's noxious, a food you're being asked to eat that tastes terrible, a
texture, a finger paint that you don't like, somebody's vocal tone that may be harsh to your ears.
What's an example of an internal stimulus that might make a child want to seek avoidance or escape? A food
that's caused a stomach upset in the past, or the smell of it that makes the child feel nauseated, a very noisy
situation, a toy that makes a buzzer or a beeper sound that's too loud. Being asked to eat something when
you're not hungry is another example of an internal stimulus that would lead you to avoid a situation.
One more layer and then we're going to move on from this but it's important to realize that external stimuli both
come from people and they also come from objects in the environment. I know very often when I'm teaching
and I ask someone what's the gain? What's the external gain a child is getting from a situation? They are very
quick to mention the social attention or the praise they're getting from the teacher. But it's very important to
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realize that children with autism are also quite rewarded by the objects and the activities themselves. They like
certain activities, like the drum that you saw early on in this and they liked watching the adult do it. They like
the activities and the objects just for their own reinforcing principles. Even when an adult is present and
rewarding a child, that may or may not be the reinforcement the child's experiencing. It may be coming from
the activity itself.
It's the same with avoidance and escape behaviors. Social attention and tasks and events are also both forms
of external stimuli that lead the child to avoid or escape a situation. Being corrected, being disapproved of,
having an adult who's handing them materials they don't like may form an association with certain adults that
they don't want to interact with. As we mentioned before, tasks and certain events themselves, children may
have found un-pleasurable or uncomfortable in the past. They recognize the materials, they recognize the box
and they want no part of it.
Slide 5: Books
We have to understand the functions of the problem behaviors the child is presenting in order to develop an
appropriate treatment plan. There are a number of excellent texts on the market written for teachers, therapists
and the rest of us who are not behavior analysts. Texts like these will walk you through the process and help
you isolate the functions of the behavior and help you come up with plans to try as well as data systems to use.
Slide 6: Example FA and PBSP Package: For Parents
Let's look at an example of a functional assessment and positive behavior support package that was
developed primarily for parents in a parent coaching project. This is not a highly sophisticated set of tools or
language but it did the trick. There are four parts to this. There is the functional assessment of behavior, we've
just talked about what that involves a little bit; the positive behavior support plan, which we'll talk about next; a
crisis management plan, which needs to be in place for parents when there are very dangerous behaviors
involved; and a parent data sheet so the parents can be tracking the effect of the approach on the child
behavior.
Slide 7: Functional Behavior Assessment
Here are the set of problem behaviors that parents identified for a young two year old. He had a number of
problem behaviors: head banging, high pitched screaming and shrieking, hitting other people and trying to hit
and hurt other people, throwing objects, clearing surfaces and flipping chairs. Those are a lot of behaviors to
work on. They are too many and too frequent to work on all at once. When we asked the parents what was the
top priority, it was head banging because of the danger involved. We decided to take data on the other
problem behaviors and do a functional behavioral assessment on head banging. That was our starting point.
Slide 8: Functional Behavior Assessment 2
What did we learn about head banging from the functional assessment? First of all, we learned that he
received a great deal of attention, affection and comfort following his head banging episodes. Parents
interrupted them, they moved him away from dangerous places, hey comforted him, they tried to calm him
down. So, there are many gains associated with head banging. We also learned that it had a strong avoidance
function. He avoided any demand, any instruction, any request would lead to this child to banging his head
against a wall or against the floor and the harder, the better.
The antecedents that led into the behavior were when a parent said no to him, when a parent provided an
instruction for him or when the parents were busy, like on the telephone or washing dishes and ignored some
of his screaming and fussing. He would eventually work his way up to head banging.
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Then we asked the parents the magic question. What do I wish he would do instead? I think parents and all of
us are often really just focused on getting rid of the behavior. But when we think about these behaviors as
having many functions for the child, these are very well supported behaviors. Every child needs a way of
getting attention and affection, a way of saying no to demands and a way of interrupting a busy parent. If we
don't want them head banging, we better give them another tool that's going to work because we're not going
to be able to eliminate a behavior when this is the only way the child has of getting these needs met.
We talked with the parents about this and we said what do you wish he would do instead of head banging to
get your attention? They said we wish he would ask us. This is a child who could speak. Just ask us. Play with
me; mommy look and those kinds of things. Now we had some language targets for this. In terms of avoiding
demands, they wanted a child who would say “I don't want to.” “I'm all done.” “I don't like it.” These were within
this child's behavioral capabilities at that point. So, these were excellent target behaviors.
Slide 9: Positive Behavior Support Plan: Head Banging
Now we have the most important pieces of information that we need to build a positive behavior support plan.
We know what the problem behavior is – head banging. We know what's maintaining head banging. We know
all the reinforcers that are maintaining it. We also know a substitute behavior within the child's capabilities that
the parents would like to see in place of this behavior and that's using words to request and refuse using
approaches and language for affection and attention and also being able to share objects for attention. Those
are three behaviors that were already a part of his behavior plan from the curriculum assessment and would
also serve the function of substituting for head banging.
Now we needed to think about how to put these in place in a way that we could prevent head banging. If we
can put these in place before the behavior happens, then we're managing at the beginning of the behavior.
Here are the rules. For avoidance, at the first sign of his negative response, when he was fussing, when he
started to whine, long before the head bang, they were giving the child choices. “Would you like to do this or
this?” That was one option.
A second way of managing this was to prompt him for the words he needed to say no. If he was fussing, “It's
time to sit in your chair” and he whines; “You're not hungry?” “You don't want to sit down?” He would say,
“don't want to.” “Fine, you don't have to sit down.” So now, the words reinforce not sitting instead of the head
banging. Once he spoke those words, we can reward his use of speech by not making him sit down. Once he
used those words, we can reward his use of them by supporting the avoidance function. “You don't have to sit
down.” That's his goal. He doesn't want to sit right now. So, we use the reward we knew that was behind the
avoidance behavior to support the new avoidance behavior we were trying to establish.
Let's look at how it worked for the attention function. For the attention function, he also had little behaviors that
led up to the head banging. He would whine, fuss and pull on his parents when they were on the phone. When
they were busy, he would start to shriek. The parents learned at the very first sign of those little attention bids,
they would prompt for words. “Want to play?” “Want momma?” “Need a hug?” The child would then follow
through. They would often use a cue. “Want a hug?” “Come play.” He would echo those words and they would
immediately follow through. Now he was using speech to make those requests and there was no reason for
him to escalate into head banging.
You might be thinking, how can any parent stop everything they're doing any second the child wants attention?
That would be exhausting. It is exhausting to do that every single time and we do not want children who have
to be rewarded at the very first request for attention every single moment. But we do need to reward all of
those new behaviors at the start to build that habit in. Another skill he's going to need is to understand “Just a
minute”, “As soon as I'm done with the phone”, “When the timer dings”, those kinds of waiting cues. But that's
another lesson and it will come at another time. Right now we've got to get the speech and language to take
over the function of requesting attention.
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We have an antecedent management plan in place. That's going to allow us to build in the substitute behavior
as his new way of asking to be finished or asking for attention. But we do have to do something with those
head banging behaviors when they occur, we have to have a plan. Parents need to know exactly what to do so
they aren't inadvertently reinforcing them.
For this little boy, the first rule of thumb was safety. We needed to move him away from any hard surface. If he
was on the sidewalk, he needed to be moved to the grass. If he was on the hardwood floor, he needed to be
moved to a piece of carpeting. Once he was in a safe place and there was no risk of injury, then we needed to
make sure that he did not receive attention for this behavior. Then we needed to help the parents learn how to
turn their backs and take a few steps walking away from him and become engaged in something else, like
looking at their phone, or writing on a piece of paper, or even just pretending to write on their hands. Anything
that made it look like they were not paying attention, all the time monitoring safety.
They would continue to be engaged in this way, monitoring his safety but providing absolutely no attention, not
even looking until he got quiet. Once he was quiet and the head banging stopped and he moved away from his
head banging position, then they wanted to turn around, call him, talk to him and go on with life as usual.
Social attention is now paired with not being on the floor, not banging his head and not being engaged in big
problem behaviors. As soon as this episode was done, parents needed to record the data. We needed to know
when these incidents occurred.
Now we have a full, positive behavior support plan, we know the substitute behaviors we want to put in place
and we're going to use reinforcement strategies for putting those in place. That's why this is called the positive
behavior support plan, we're building in positive behaviors through reinforcement strategies that will replace
the unwanted behavior. You can see there's no real punishment procedure here. There is simply no allowance
for reinforcement. It's a small extinction procedure followed by rewards for appropriate social behavior.
We need another piece for this boy, we need a crisis management plan. This is a child that can really create
injury both to himself and others. The parents identified that his bedroom situation provided a completely safe
place for him. He had a net around his bed, he could not get out and there was no hard surface he could hurt
himself on. The plan was that they would use a time out in his bed for safety management. If they cannot find a
way to keep him safe, they would put him in his bed, leave the room and then they would call or text their
therapist for support.
Slide 10: Parent Daily Behavior Data Sheet
What kind of a data plan did the parents need for this little boy? We tried a couple of versions. First we tried
keeping track of every single head banging incident. The parents found it impossible, there were far too many
to record. So we moved to a simpler system. We moved to this kind of a system, the one you see in front of
you. They kept track of four behaviors, two big problem behaviors, head banging and screaming, and our two
substitute behaviors, speech and gesture to request or speech and gesture to avoid. They used a Likert-based
system at the end of the day to record how the day seemed to them.
Were there no episodes of those behaviors? Were there no episodes in that day? Then they would code a one.
If it occurred once, they would code a two. If it happened a few times, they would code a three. If it seemed to
happen many times but not as much as every hour, they would count a four. If it was happening at least every
hour, they counted a five. If it happened multiple times per hour, it was scored a six. Notice that they were
keeping track of both problem behaviors but also the substitute behaviors. We wanted to see those substitute
behaviors occurring many times every hour.
It took a long time for head banging to get significantly reduced on this chart. This is a child who is head
banging 50-60 times an hour. It did reduce and the substitute behaviors quickly increased in number. As the
substitute behaviors increased, the head banging episodes decreased, they were no longer needed for him to
gain his functions. This ended up being a very successful plan for this child in all of the behaviors targeted.
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Slide 11: Video 2
Let's look for a minute at the video of the little girl again that you saw at the beginning. This is just two or three
sessions later but the mother is using a positive behavior support plan as you'll see. Making sure that she
reinforces any instruction well, that she's following child leads and that the child gets far more attention for
complying and interacting with people than she does for problem behaviors.
Slide 12: Video Explanation
We're going to end with two videos. You've seen a bit of this one before but you haven't seen the whole
segment which involves the problem behaviors these parents are dealing with on a very frequent basis. I want
you to watch how, in the space of a few minutes, this therapist goes from observing the child and a lot of
problem behaviors, a child who doesn't want to interact with her at all, and by reinforcement strategies, play
partner strategies and very, very few demands, she weaves this into the beautiful interactive episode that you
saw when we used this as an example of play partners. Seeing the backstory of this video makes it much
richer.
Slide 13: Video 3
It's really remarkable to watch the change in this little boy over the course of the few minutes of this episode,
isn't it? This is what skillful interaction and skillful reading of child behavior functions can accomplish.
Slide 14: Video 4/Conclusion
Now I bet you'd like to see him again. We have a video of him at age six to seven talking with the evaluator in
an assessment situation. He's talking about Halloween and the costume he's going to wear. Watch and see
how much progress he's made. It's fascinating to watch how in just a few years these children grow up and
acquire so much language, so many social skills.
We've just completed the section on managing problem behavior. Now you have all the pieces in place to put
together the whole treatment package. That's the topic of our next lesson.
See you soon.
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Slide 1: Teaching Practices
It's good to see you again. In this lesson we're going to be reviewing all of the teaching practices that we've
covered in terms of how to put them together into a piece of work and how to rate yourself and monitor your
use of these practices as they are integrated in particular interactions with children.
Slide 2: What You Need
For this lesson you're going to need Appendix B of the Treatment Manual in front of you. That's the teaching
fidelity rating system. So if you'll please open the fidelity score sheet and take a look at the behaviors along the
left you will see the teaching behaviors that we rate on this fidelity score sheet.
Slide 3: Fidelity Code Sheet
Many of these we've talked about and others of these you've seen very well demonstrated in the videos you've
watched this far. Managing child attention, the first behavior, you've seen that illustrated in every video you've
seen. Therapists in front of children managing the environment so there are no distracters. The ABC format is
talking about antecedent behavior consequence chains in terms of the teacher's ability to give an instruction or
model, make sure that the behavior is demonstrated with whatever prompting techniques are needed and then
making sure that the consequence of the child's behavior is appropriate for the child's performance.
Instructional techniques talks about those ways of eliciting a child's behavior, prompting and prompt fading,
shaping and chaining. Modulating child affect and arousal; is the child lively? Are they attentive? Are they
interested in what's happening? Is the child in an optimum state of arousal for learning?
Managing unwanted behaviors; we just talked about that in the lesson before this one. The quality of dyadic
(10) engagement we talked about when we were talking about becoming a play partner and balanced
interactions. The use of positive affect we've talked about throughout in terms of the reinforcing quality of the
environment and the activities. The teachers are pleasant with the children. They're enjoying themselves and
we're trying to create situations that are enjoyable for the children, too.
We've talked previously about providing multiple and varied communication opportunities, making sure that
we're giving children opportunities to do more than request. Children need to be able to protest to say, "I don't
want to," to greet people, to share emotion. All the many ways a toddler communicates before they ever have
their first words, that's what we have to make sure we're providing inside the opportunities for little children with
autism as well. The language level of the therapist refers to the therapist keeping their language just slightly
more complex than the child's. That's the one word up rule that's talked about in the manual.
Joint activity and transitions, that we covered under the joint activity structure lesson. We talked about the four-
part joint activity and the importance of smooth transitions, out of one activity and into another so that the
number of learning opportunities is maximized and the amount of time that children are not attending in
interacting with the adult is minimized. The full definition of each of these behaviors is in this appendix.
The last two items are adult optimizes child and adult sensitivity and responsivity. When adults are motivating
children to participate, they’re using several difference techniques. They’re interspersing maintenance trials
and acquisition trials. They’re making sure that children are getting strong reinforcers and they’re reinforcing
child attempts as well as child successes. They’re making sure children have preferred activities, that children
get to make choices, and that the adults are following children’s lead as much as they are leading. They’re
making sure that the activities are interesting, they’re introducing variation and novelty to keep children curious.
And finally, they’re reading cues about when to end the activity.
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Slide 4: Practice Rating
Now I want you to practice rating fidelity on some video examples. This will give you a chance to really read
through the definitions and experience applying them to videos of therapists that you see in front of you. If you
look at the score sheet you'll see that the behaviors are on the left and number of different activities are in
columns to the right. You're going to fill out one activity column for each complete joint activity that last more
than say 20 or 30 seconds. The rules for what to score are spelled out in the materials that lead into the fidelity
item. Please read all of the instructions before you start to do this.
Once you start, start the video and watch an activity all the way through to the end. Then stop the video, open
the fidelity item descriptions and start to read them one by one and assign a score one through five in the
column. If you need to watch it again you're allowed to watch it one more time but no slow motion and no
repeated examples. You want to be able to hold on to this in your head and you're really rating from a first
impression. That's because that's how you'll use this for yourself and that's how you'll rate other people live as
well. So that's how we want to practice this.
Now the videos that you're going to see are not perfect videos. You wouldn't get to practice all the code if they
were. So read carefully. Don't assume that because these are experienced therapists that you've seen before
they're going to automatically be demonstrating the best example of every behavior. As you'll see even the
best therapists can't pull off every single activity at high levels of fidelity. We don't have complete control of the
situation. The child's a person, too.
You'll see in several wordings that it will say, "The therapist has done everything you could think of to manage
this well." We know that we only have so much control in any particular activity. So go ahead and try your hand
at rating these. The coding standards are also included so you can compare your scores to the ones that were
assigned.
Remember that an agreement on a score gives you a one point latitude. A four and a five are in agreement. A
three and a two are in agreement. Calculate your percentage of agreement. Let's see if you can get
somewhere up in the 70s or 80s in your first time through. This is a tool you'll be able to use for yourself on
your videos of your own work and that is an excellent way to start practicing ESDM.
Slide 5: Conclusion
I've just indicated that you can practice ESDM after the intro workshop. You don't have to get certification to try
to use these techniques. There are many therapists who make a big change in their practice after going
through this course and they find it's been very helpful. We want you to try your hand at writing lesson plans
this way, try your hand at using these techniques, look at your own skills around joint activity routines and see
how those go for you. Many therapists find that just the things they learn in this workshop alone – practicing all
the practice places like the one we just did and taking these examples and materials into their own practice –
can really be a help.
If you want to incorporate some of these teaching procedures into your own practice I would encourage you to
tackle that task with a colleague. Set up a little peer supervision group or a peer support group and start using
the materials sharing with your colleagues your struggles, your successes, sharing some videos, scoring
fidelity together. A peer support group can bring themselves a surprisingly long way towards incorporating
ESDM practices into your every day work with children.
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Slide 1: It’s Not Working!
Hi. We're here for the last lesson in the treatment module. This lesson addresses what to do if you are doing all
the things we've talked about and the child is not progressing.
Slide 2: Data Sheet
By not progressing we mean their minuses are not changing to plus minuses and pluses on your daily data
sheets. Of course you know this because you are taking data several times in every session and summarizing
the data. We've already talked about how to do that.
Slide 3: Decision Tree (RTI)
So what happens if you are in a therapy situation and you look at several weeks of data and say, "Oh no, it's
not working; what do we do now?" Don't worry. We have a number of steps to walk you through this situation.
We're going to be talking about using the decision tree. This is a response to intervention strategy and it is on
page 131 of your manual. So you can follow this along.
It's very well described in that chapter. We start by asking ourselves this question, "Does the skill I'm trying to
teach provide an intrinsic reinforce? Is there something about this activity or doing this action that the child can
enjoy?" If the answer is yes then we're going to begin with naturalistic teaching, the kind of teaching we've
been talking about so far all the way through these lessons. You're going to embed that skill in various joint
activity routines that the child initiates or chooses. The child's own goals in the materials or the activities
becomes the main reinforce as does your playful interaction and you're going to continue using those
techniques in those activities while you take data on the behavior you're trying to teach.
Is there measureable progress after three days or three sessions in terms of seeing those minuses turn into
plus minuses and plusses? If there is you are on the right track and you're going to continue that teaching
approach. We expect to see changes pretty quickly on every objective that you're teaching because you're
teaching at such a small step.
What happens if the answer is no, there is not measureable progress after three sessions or three to five
days? Well then we're up on this right hand side of the chart. We're also here is the skill that we're talking
about does not provide any intrinsic reinforcement. Skills like dressing skills or hand washing, things that don't
by themselves have a pleasurable component. What do we do to try to increase children's learning rates if they
are not progressing after three days and what do we try to do to motivate children if there is no intrinsic
reinforcer for the activity?
There are three different variables we're going to focus on and we're going to manipulate them independently
while trying to keep the teaching procedures as natural as possible.
Slide 4: Adapting Teaching Approaches to Ensure Success
What are those three variables? The first is reinforcement strength. The second is the structure of the learning
situation. The third is the use of visual supports.
Let's start with reinforcement. This is where you would start as you start problem solving around increasing
children's learning rates. We want to make sure that the child is experiencing the reinforcer as a strong
reinforcement. They are motivated for this reinforce. So we start with a natural or the intrinsic reinforcement of
the activity and the materials combined with the social reinforcers and supports that you're providing as the
therapist of the parent's providing. But if that isn't strong enough then we need to start adding strength to the
reinforcer and adding other reinforcers. The next thing we might try would be to add an extrinsic reinforcer,
something outside of just operating the activity but related to the activity as well as the social activity.
Step two; add some reinforcer strength when we need it, when step one doesn't seem motivating enough. In
step two, we're adding an extrinsic reinforcer, something outside the activity and the social praise alone. We
start by trying to find something that's related to the activity. For instance, if you're doing a music activity,
rhythm band for an imitation task you might end by turning on a tape of the child's favorite music. It's still
related to the task. It's music. But it serves as a reinforcer.
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If that doesn't get you enough reinforcer strength then we move to the use of toys that the child really prefers.
We use those to follow the child's performance. A toy still gives you something to do and something to teach in
with. You can be a play partner inside a child's favorite toy.
If the child's not motivated by either social praise or by toys and play then we start to need to bring in whatever
those special things are that this child enjoys and finds reinforcing. They may be electronic toys which as you
know we tend not to use in our normal teaching procedures. They may be food or drink if those are the only
things that motivate a child. We have got to get a strong reinforcer behind the behavior that we're trying to
teach so that the child starts to – we've got to get a strong reinforcer to follow the behavior we're trying to teach
in order for the child to build this skill into their repertoire.
But maybe the problem isn't reinforcer strength. The child may be highly motivated to do this activity but they're
still not learning it. In that case we are going to move towards manipulating the structure of the activity. As you
know we start with just embedding learning inside naturalistic child preferred play activities or interactive
activities with an adult and we rely on the child's desire to repeat alone to get the repetitions in.
The first manipulation we would make in this structure aspect of play is to count the opportunities and to make
sure that child is having five to ten opportunities to practice inside every hour. If it's a very high frequency
behavior in a typical child's development then we'd want even more practices. So now we need to start
counting learning opportunities interspersed with other kinds of behaviors.
The third manipulation involves reducing the variance in the child's experience of practicing this particular
behavior. We can reduce the variability of the child's experience in several ways. We can have the child seated
rather than in different locations in the room. We can use the same toy again and again and again until it's
learned in one toy before we start mixing materials. We can use it inside a single kind of an activity with that
toy rather than varied use of the toy.
Again, if we're doing these we want to continue to make sure they're getting ample opportunities to practice.
The final level of manipulation would be not interspersing that behavior with others but instead having the child
practice that desired behavior many times in a row. Now we're talking about mass trial learning of five to ten
opportunities without varying the materials when the child is seated and quite focused before you move on to
another activity.
Most of the time varying reinforcer strength and structure in the teaching situation will result in more rapid
learning. But occasionally it doesn't and then we bring in the third level of manipulation. We add visual
supports. Now there's no hierarchy to these. Any visual support that you think will help the child learn this
behavior in the presence in this antecedent can be used. What are the visual supports we might use? There
are many.
We might use visual antecedents like a picture schedule. We might use an ABC schedule for a set of chained
events. We might use visual cues like pictures or drawings or templates. We might use sorting boxes. We've
already talked about the use of a timer. We might use PECS, the Picture Exchange System or signs from
American Sign Language. Any visual support that you think will help the child can be used.
Across all of these if you've chosen the skill correctly you should see some progress. If not I would put that
objective aside for now. We do not want the child continuing to experience failure. If you do see some progress
with a variation you're going to maintain the variation on that teaching skill all the way through all the teaching
steps. You are not going to take away the supports that you needed until the child has mastered that behavior.
However you are not going to add these supports to other objectives that are going well. This is a specific
intervention for a specific learning target that is not preceding.
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Slide 5: Strategies
Do you maintain this kind of new teaching in this domain forever with the child? No, you don't. At the next 12
weeks when you start again with a new set of objectives you go back to the typical way of using ESDM, the
default strategies that are laid out in the manual and you start to use those unless you find a point at which the
child is not progressing again.
Here and there there's a student that needs far more support in terms of stronger reinforcement strength and
more structure for all learning. We're going to look at a video like that in a minute. That does not mean you're
not using Early Start Denver Model. This is all a part of Early Start Denver Model. ESDM is not a play based
approach. It's a graded approach that allows you to apply the empirically supported teaching strategies you
need to help a young child progress in the target areas you've identified through the assessment. We start with
the default strategy of naturalistic developmental and behavioral teaching but we vary it as needed to make
sure children progress. This really is a comprehensive treatment that allows you to use the full range of
empirically based supports and teaching strategies.
Slide 6: Decision Tree: Alternative Communication
Now we're often asked, "Do I use these same variants when the child's not progressing on their expressive
language objectives especially their speech objectives?" We've actually tailored this a little bit when the
problem is specifically moving into speech. The decision tree for speech difficulties is on page 180. Turn that
now and let's walk through it. So now we're talking about how to proceed with expressive communication when
the child is not making progress into speech. We always begin by building up the child's use of voice and
gesture to deliver an intentional communication to send a message to a partner that they want something,
don't want something, enjoy something, don't enjoy something or want to comment on something.
We are hoping to see a child produce 5 to 20 spoken word approximations within 3 to 6 months of their
treatment. That's one to two quarters. We're going to use the typical ESDM strategies to move from voice to
speech for the first six months for a young child. So we're going to stay in the normal teaching procedure for
three to six months counting the number of vocal expressions and word approximations the child's making
every couple of weeks. For a child who has learned a number of gestural imitations like motions to songs –
"Happy and You Know It," "Eensy Weensy Spider," like that.
We're going to follow the box on the right. We're going to do two main manipulations. We're going to introduce
a few signs to the child's repertoire using adapted ASL signs like baby signs. We're going to choose signs that
are easily within the child's repertoire and we're going to associate them with things that the child requests
frequently. Typical first signs are more, cookie, drink or whatever favorite toys the child has.
You're going to adapt those signs to make them easy for the child to do and you're going to teach them by
using the child's non-verbal requesting mode to model and say the word and the sign and then to prompt the
child to make the sign while you say the word handing the object over immediately. You're going to find many,
many opportunities to practice with the child so you can quickly fade your prompts and build in that
spontaneous gesture. Don't be too perfectionistic about how perfectly that sign is made.
Babies who use signs start with very immature productions. We'll use shaping techniques to clean it up later.
We want independence as quickly as possible. If the child is holding out their hands for you to manipulate them
you know you've been using too much physical prompting. Move back to their elbows, back to their shoulders
and pull those prompts away.
The second manipulation we're going to use is to have our speech therapist start using the prompt approach to
therapy with the child. We have had very good success using prompt therapy for children who are having
difficulty becoming verbal. I believe that it is our use of prompt plus signs or other strategies that have resulted
in the vast majority of the children that we serve being verbal before the age of four. So you're going to use
signs.
The speech therapist is going to bring in prompt. It's a speech therapy technique. You will continue to require
and build the child's attempted vocalizations to build speech productions. If there is no speech progress within
12 weeks with this approach then you're going to add PECS, the Picture Exchange Communication System
and move into PECS.
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We just covered the steps for a child who has developed some gestural communication. Now let's talk about
the child who has not developed much gestural communication in this three to six months. If we have a child
who is not imitating very many motions at all in songs then we're going to continue to work on motor imitation
and we're going to introduce PECS, the Picture Exchange Communication System as it's described in the
manual. We are also going to begin prompt therapy delivered by a speech therapist to try to build the child's
oral motor, speech motor, vocal control and help then progress to speech. We are going to continue to support
that child's intentional use of their voice. We're going to continue to reward vocalizations whenever they occur.
That's the package for children who do not have much gestural imitation.
With these techniques we have found that 90 percent or more of our children proceed into speech by the time
they're four. You may not have heard of prompt therapy. It's well-known among speech therapists and their
training's widely available both in the U.S. and in other systems. The prompt techniques were developed first in
Canada by a speech therapist named Deborah Hayden. It's widely taught throughout the U.S., Canada and
other areas. You'll find it on the Web. We found it extremely helpful. I think it's largely as a result of this whole
package that 90 percent of more of the children we've treated in our studies go on to speech, useful,
spontaneous, communicative phrase speech by the age of four.
Slide 7: Video
You're now going to watch a young child who's had many of these variants put in place in our program. I want
you to have the decision tree in front of you as you watch this piece of teaching and I want you to try to identify
every variant that you see that's in place. I want you to look carefully at how the therapist is using these
variants. Then I want you to pull out the fidelity measure and look at how many of the basic teaching strategies
that make up ESDM are still in place in this piece of teaching even though the therapist is using a number of
different kinds of teaching techniques other than following child's lead and using play based teaching.
You'll still see many of the characteristics that have been the hallmark of ESDM teaching all the way through
this, the positive affect that the therapist shares, the child's ability to make choices, the back and forth between
adult and child, the child's pleasure and comfort in doing the learning tasks. You may get some ideas from this
piece of video but I want you to remember that this was not all put in place at once, that this therapist went
down the decision tree and made step-by-step adjustments until she found the right combination of teaching
strategies that helped this child move forward. You're going to see examples of all three of the variables;
reinforcer strength, structure and visual supports.
Slide 8: Conclusion
We've now reached the end of this module on treatment techniques. We've been through all of the aspects that
make ESDM what it is. In the next two modules we're going to talk about how to use the ESDM approach when
we're working with parents and how to use it in group settings. See you back soon.
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Slide 1: Parent ESDM
Here we are in our last module. In this module we're going to be talking about using ESDM with parents and
using ESDM in groups
Slide 2: Parents in ESDM
Both of these approaches have research bases behind them we and this is the first time we've really been able
to share both of them. As you know from reading the therapist manual, parents are very involved in Early Start
Denver Model treatment. They're present throughout assessments, they're often present in treatment sessions
and we provide parent coaching both at home and in the clinic for children in all of our studies. You know that
determining parent goals is the first part of our assessment process and that it's quite important to us to help
parents integrate ESDM techniques into everyday life routines with their children at home.
Working with parents is critical because of the need to increase children's learning opportunities, you
remember that from the very first lecture. Home is the place where most learning opportunities exist for young
children with ASD and every other young child.
We don't require any particular level of performance from parents in our own work. We don't set number of
hours that they have to use it. We don't necessarily ask them to produce any data although sometimes it's
helpful particularly when we're doing parent management plans. Some parents want to do more, some parents
want to just learn how to work with the techniques and the routines themselves. We try to provide each parent
with what it is the parent's going to find most useful from us.
I think you can hear us following the lead of the parents. I know that's a very important part of early childhood
work in general.
Slide 3: Quote
There's a wonderful quote by Nicholas Hobb, from long ago, that I find helpful to keep on my desk at all times.
It's sat on my desk for 30 years. "Parents have to be recognized as special educators, the true experts on their
children and professional people, teachers, pediatricians, psychologists and others have to learn to be
consultants to parents.” That's what we're going to talk about in this hour, how to be consultants to parents in
their use of ESDM techniques at home.
Slide 4: ESDM Teaching Techniques--Book
You probably know that we've provided a self-help book for parents called An Early Start for your Child with
Autism which walks parents who don't have much access to autism intervention through the basic ESDM
techniques. It's written in a friendly way; gives lots of examples from children and parents at home and it turns
the teaching techniques that we're been talking about on the fidelity tool into kind of a more lay person's
language. There are 13 chapters and they involve capturing children's attention, finding their smiles in their
sensory social routines, learning how to do dyadic play in the Take Two to Tango chapter, teaching imitation –
do what I do – teaching parents about the principles of how children learn, the antecedents, behaviors and
consequence, or the ABCs of learning
We talk about joint attention behaviors as completing the triangle. We talk about non-verbal communication as
talking bodies. We talk about how children use play to learn and how play becomes more and more complex
over time and particularly the importance of pretend play for young children with autism. We end with the
chapter about developing speech and language.
The order of the chapters in the book does not dictate the order in which you're going to use them. Teaching
the first three chapters, I think, is very helpful, it gives parents the basics. As we've said before, having these
basic interaction strategies often is all you need to get children really learning and performing quite differently.
But occasionally a child is having so many behavioral difficulties that we can't do much with these first topics
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until we start to get some good behavior plans in place and that's a situation in which parents need to learn
about the ABCs, how children learn.
Sometimes parents are very skilled in a lot of these techniques and you want to target the ones that have
difficulty for them. More and more I'm finding myself teaching some of the principles of the developing speech
chapter very early in the process. So, it's fine to use the chapters as it seems to fit the parents' needs and
requests best as well as your observations of their strengths and needs.
Slide 5: Parent Coaching Process
How do we impart ESDM practices to parents? We found the coaching process has been very helpful to us.
You probably have heard about the application of parent coaching inside early childhood special education
work. There's been some excellent work done by colleagues who are now at the University of North Carolina.
Hanft, Rush and Shelden wrote a very important book called Coaching Families and Colleagues in Early
Childhood and they've recently followed it up with a newer edition, The Early Childhood Coaching Handbook.
They also have a very active website and all of their materials are available to the public for free. Our coaching
techniques are based on what we've learned from them and I'm very grateful for the work that they've put into
creating the materials that we're all using.
Slide 6: How We Wish It Worked
When we think about coaching parents, we often think, at first, that we're going to be helping parents learn
some techniques, the parent's going to be transmitting them to the child and there's going to be a pretty
straight-forward process in which our interventions lead to child change. I wish it worked like that.
Slide 7: The Reality
The reality is a much more complicated process, especially when we're working at homes, there are often
other people around in addition to the professional, the parent and the child.
But even if it's just the three of us in a coaching room there are still interactions going on back and forth all the
time between the three people. It's not a linear process at all. One of the challenges of coaching is to make
some kind of order and organization from the interactions so the parent has a chance to focus on what they
want to accomplish, try some things out and have a chance to evaluate the success of what they've tried.
Learning takes some time to process things cognitively and we've got to find a way to build in that opportunity
for intention, practice, reflection and evaluation into the coaching process if parents are going to have an
opportunity to learn.
Slide 8: Actions and Interactions Diagram
This diagram maps out the parent coaching process that we use in ESDM and it comes from the work of Hanft,
Rush and Shelden. In this diagram you see a large background circle that says Evaluation and that represents
the kind of framework that we're talking about; having goals, plans, actions and evaluatory framework in which
parents can think about what they're doing and the effect that they're creating in their children. Whenever we
have a goal we then need to initiate an action plan. So, you see at the left hand side of this diagram there is a
planning process that leads to an initiation by either the therapist or the parent, the initiation of an action with
the child. One adult is acting and the other adult is observing.
After that action sequence is completed then we see another set of circles, on the right now, that say
Reflection and Feedback. We need a chance to reflect together on the effect of the actions on the child's
behavior, vis-a-vis the goals that the actor had, and the person who is in the observation position needs to be
able to provide some feedback to the reflector. We see this process either moving to continuation as we
practice again and again because parents need to master some skills so that they can create them in the heat
of the moment at home in the ebb-and-flow of family life. Or we see a mastery arrow – this parent has
demonstrated this skill in many different kinds of activities, it's generalized from home and into the center.
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This is really a skill that's accomplished. They're ready to move on to something else. So, this is the framework
that we use and it allows for enough time to plan, do, reflect and plan again so the parent has a chance to have
practice lead to both a conscious activity and eventually kind of an automatic habit.
Slide 9: Video 1
In our parent coaching sessions the parents are extremely active. There's very little talking going on because,
as you probably know, in order to change behavior – and that's what's happening here, parents are changing
their own behavior, their own interactions with children – in order to change behavior we have to practice new
behaviors and talking does not get behavior change. Doing gets to behavior change. So, in our own sessions
parents are doing for probably 50 minutes of the 60 minute session.
Here's an example of the parent coaching moment in which the parents have come in saying, "We're losing
some of our skills around vocal communication. We want to work more on vocal communication. Give us a
brush-up session on this." So, you will see the parents have stated a goal and you'll see the coach letting them
start interjecting some questions, letting them find the answers and try again, try again. You'll see the parents
talking back and forth to each other and by the end of this episode you'll see each of them drastically increase
the amount of communication both verbal and non-verbal they're getting from their child.
Slide 10: Video Follow-up
Did you enjoy watching the parents shape their own behavior through this session? It might be interesting for
you to pull out your Fidelity Measure and rate each parent at the beginning of their episodes, their first
interactions with the child, and again in their last interactions with the child. Look at the change in their skills
across this short activity.
Slide 11: Parent-Implemented ESDM
We've been studying our parent coaching method for many years now. I want to share some of the evidence
with you that demonstrates the parent delivered ESDM, or P-ESDM, has some positive effects on parents and
children. Thus far we have published three single subject designs and two randomized controlled trials
including three tele-health studies that have examined the effects of our parent coaching process on parent
change and child change. We've worked with over 100 children ages 6 months to 36 months and their parents
across all of these studies and we've worked in several sites.
In general we have worked in 12 week sessions delivering an hour a week, sometimes two hours a week either
in clinic or at home with some follow-up maintenance sessions and we've taken measures of the parent use of
techniques throughout the coaching period, the child changes in language, play and gesture use.
Slide 12: Parent Master Approach Graph
One of the consistent findings we've had across this study is the rate of parent learning of the techniques. This
particular graph shows you 45 different parents across 12 weeks of intervention. It shows you the mean rating
on the fidelity instrument, which you are already familiar with, before their therapy session started and then
week by week across the 12 weeks. What you'll see is that almost no parent is at fidelity at the start of
intervention. Fidelity is marked at the 4.0 level.
But what you'll see is that from their first session on virtually every parent shows an increase in scores from
session to session. If you will look at week eight you'll see that almost every parent, except for three, is
clustered at or above the fidelity point. In eight hours of work with their coach the parents are demonstrating
therapist-level fidelity on this tool. As they continue through treatment their scores gets better and better and
more consolidated.
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We've also found that in the maintenance period, which you don't see here, after treatment has ended at week
12 parents continue to maintain and increase their skills even without further coaching. The vast majority of
parents take well to this intervention, they like using it. We've found no difference in parents who have more
education compared to parents who have less education, parents who have higher socioeconomic status
versus parents who have lower socioeconomic status. We've even found that parents who do not read the
materials but instead rely on coaching and videos achieve fidelity at the same rate as other parents.
Slide 13: ESDM Supports Working Alliances with Families Graph
Parents working with an ESDM coach report feeling strong alliances with their therapists. In a randomized
controlled trial, published by Annette Estes in 2013, we found out that parents who are receiving their therapy
from an ESDM parent coach reported significantly stronger working alliances than parents who were receiving
their therapy from therapists from other traditions.
Slide 14: Representative Data from Parent-ESDM from a Distance: Effects on Child
Communication
Here are representative data from one of our single subject designs, this one carried out and published by
Laurie Vismara in 2013. In the chart labeled Words you see the results of 12 weeks of ESDM coaching on 9
children's vocabulary development.
In the first column on the left we see these nine individual children's number of spontaneous words spoken in
ten minutes of play with their parents and we see that for the children across several weeks without treatment.
Some children speak almost no words. A few children have a few words but they don't use them very often.
The average of these children is less than five words spoken in ten minutes.
The next column shows you what happens when the parents start to use ESDM techniques being coached
once a week by their therapist. We see an immediate increase in the number of words children are speaking in
ten minutes. These are not echoed words, these are spontaneous words. What this shows you is that even in
the very first week ESDM techniques bring out more child speech. But you will also see that over the weeks in
that column the number of words each child is speaking goes up. There's an acceleration in virtually every
child's rate and that's shown by that horizontal line across the top. That's the mean number of words across all
nine children each week. So they are extending their vocabularies week by week by week. That's due to the
effect of the ESDM teaching techniques on children learning new words.
The final column shows the ability of the parents and the child to maintain this higher use of language. Even
after therapy ends we see the children continuing to use a high rate of speech. That means that the parents
themselves without further support from their therapists are able to maintain and teach new words to their
children using the techniques they've learned.
The graph labeled imitation shows you the same kinds of data for child imitations inside play. We've talked
earlier about how critical imitating other people is for a young child's learning and how much autism affects
child imitation. Here you see even more clearly than in the word data these children are not imitating their
parents in their natural play. In the first column the rate of imitation is almost at zero.
Again, in the middle column we see the rapid effects of P-SDM techniques on child's immediate imitation. The
children are showing more imitation in the very first treatment session and it grows over time. There's an
acceleration of imitation across the 12 weeks and in the last column a maintenance of higher imitation after
therapy ends.
Thus we see very rapid responses of children to the parents' addition of ESDM techniques in their daily home
experiences. This shows you how quickly we can see and measure the effects of ESDM changes on children's
behavior and on parents' behavior.
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Slide 15: Both Groups (48 in each) Make Significant Gains; No Effect of Group
You may be aware of a randomized controlled study that I published in 2012 comparing children getting P-
ESDM treatment to children getting community treatment. If you know that paper you know that both groups of
children show significant gains in a number of areas: they increase their developmental rates, they increase
their language usage, they increase their adaptive behavior skills and they decrease the number of autism
symptoms they showed. That's true of both groups of children.
We did not find a specific effect of P-ESDM in this study. Why is that? We don't know the answer to that. We
do know that it was effective in changing child behavior. We also know that the children in the comparison
groups were getting three to four times as much therapy as were the children getting P-ESDM, whose only
treatment was a one-hour a week parent coaching session.
There were a number of other complicating variables in this data set which makes it hard to interpret the data.
Personally, I feel the number of single subject designs, in which we look at each child's response to the
treatment separately, is a better reflection of the effect of this treatment than is the randomized control trials.
But all these data are published and you can make the decisions as you wish.
Slide 16: Video 2
Now you're going to see a couple of videos of a parent using ESDM techniques. The first video you'll see
presents a little boy who's just turning two. He's not received any treatment before. He already has a diagnosis
of autism and his parents are in their first session in which we ask them to show us how they typically play with
him so we can see their techniques and his responses. I want you to watch the video and I want you to pay
particular attention to how many initiations each parent makes to the child, how appropriate those initiations
are and what the child's response to the parent is like.
I also want you to watch the frequency of the parent initiations over the time the video runs. Okay? Keep a little
chart on what I asked you. We'll talk about it at the end.
Slide 17: Video 2 Follow-up
What did you see in that video? You may want to share it on the community forum. What I see are parents who
are both making appropriate initiations to try to play inside the activities the child has picked. I see the child
ignoring or actively avoiding the parent initiations. I also see the rate of parent initiations dropping over time.
We talked about this concept in the very first lecture, the fact that the child's own autism and their lack of social
responses have an effect on parent behavior. When children don't reward their parents' efforts by responding
parents often think they're on the wrong track, that their techniques aren't appropriate and they stop trying.
When parents stop trying children stop learning and that's a basic reason for the principles and the techniques
that we use.
Slide 18: Video 3
In front of you is another video of this same child and his dad taken about four weeks later. I want to give you a
little background here. The mother is the parent who's been coming to the parent coaching sessions, the
father's been away at work. The parents get together the evening after each parent coaching session and after
their children go to bed the mother has taught the dad through the activities. They've shared the information in
the manual and the mother's demonstrated some things so that the father knows what's going on. But we
haven't seen the father since that very first video that you saw. But on this particular day Mother was ill so Dad
brought the child in. He has not been coached by either one of us.
Let's watch how he carries out this activity. You may want to get the Fidelity Measure in front of you and take
some ratings of Dad's behavior. You can do that in the first video too so that you could look at changes and
stable traits in the dad's behavior.
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Slide 19: Video 3 Follow-up
This is a remarkable degree of change in father/child play behaviors in a few short weeks that's been
transmitted from parent-to-parent. The father knows how to position himself and materials to get his child's
attention, he knows how to follow his child in and to create such a motivating activity that the child wants to
follow. The child's learned quite a bit, too. He's learned about the set-up, theme, variation and closing routines.
So, we see him naturally clean up the first toys when he realizes he doesn't want to play with those and bring a
new box to initiate another routine with his dad. Both partners are initiating and both partners are responding.
We also see that principle of play partner. The two of them are in very balanced interactions, back and forth.
The father is scaffolding this interaction very well. We see the child talking in this episode, not only talking but
signing, imitating his father's speech, combining a sign and a word and spontaneously requesting and naming
and commenting on objects and colors. We see both of them with a similar goal and we see the excitement
grow as the goal is reached and the tower gets higher and higher and higher. And we see great shared
pleasure as they anticipate the falling down of this tall, tall tower.
I hope you also noticed how the child's fussiness drops away as the game becomes more interesting and the
goal of building the tallest tower possible overrides the child's initial goal of having the colors alternate in a very
specific way. It's a great example of how just setting up a great activity overrides negative behavior and it
drops away all on its own. The father doesn't reinforce it, he doesn't draw any attention to it. Instead the
positive behaviors which are being reinforced greatly override any fussiness.
Slide 20: Closing
In this lesson we've talked about basic parent coaching strategies. We teach this in workshops and in
certification processes. We also have created a parent coaching manual which may eventually be on the
market. We've gone over the parent coaching methods that we've developed inside ESDM to transmit these
techniques to parents. We've gone over with you all the main principles that we use and we've given you some
references for parent coaching techniques and manuals that are available to you specifically focused on early
childhood work. I hope you try this with your parents. We've found a great deal of success and a great deal of
pleasure for ourselves as we watch parents become more and more confident and competent in their
interactions with their children.
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Slide 1: ESDM in a Group Environment, G-ESDM
Hi, I’m Cynthia Zierhurt and I am a licensed clinical and developmental psychologist. I am here to share with you
our work in the Early Start Denver Model in a group environment. And as you recall, Dr. Sally Rogers started the
Denver Model, the precursor to the ESDM, in Denver in a preschool and she was able to utilize Denver Model
principles successfully to help children develop and grow in a number of areas. She also took that preschool
implementation and disseminated it in community-based preschools in Denver.
So, we have a strong foundation for work in a group or preschool environment for the ESDM. The Early Start
Denver Model was applied in a group environment in a childcare center in Melbourne Australia, with our
colleagues Dr. Cheryl Dissanayake and Dr. Giacomo Vivante. At that childcare center, we were able to pilot and
practice how the Early Start Denver Model would look and be implemented in a group environment.
So, it is my pleasure to share this work with you as well is talk about adaptations from a childcare or daycare
environment to maybe a clinic or group environment that isn’t a preschool. So, the idea is that the Early Start Denver
Model can be adapted to a number of different types of group environments.
What does a group environment mean? It could include a child with autism spectrum disorder and other children,
also, who have ASD or could be a child with ASD, and typically developing children that serve as peer models in
activities or even throughout the day. So, I hope you enjoy this lesson on the Early Start Denver Model in a group
environment.
One of the things I think about when we’re implementing the Early Start Denver Model in group is the questions
you might get from parents or other professionals. Does this mean the Early Start Denver Model is diluted in a
group environment? Can you implement ESDM in a group and also have one-to-one sessions? I hope to answer
those questions as we have learned that the ESDM in a group environment can facilitate lots of different learning
activities for children that may or may not be assessable in a one-to-one therapeutic setting.
Slide 2: G-ESDM Child Goals
For example, children learn cooperative play with other children. They learn how to read the social cues of other
children and teachers in facilitating transitions from one activity to another. These are skills that help the child
transition to mainstream school environments.
How does the ESDM fit in preschool settings? Well, in our experience, the fact that the Early Start Denver Model
is both naturalistic and developmental affords a unique opportunity to place it into preschools that often
emphasize those very things. So, the opportunities for children to play with real-life play materials, toys and
games, and the developmental curriculum is often valued by teachers and staff who desire to follow a child’s
progress along with the understanding of developmental sequences.
So, what are our goals for the children who participate in group ESDM (G-ESDM)? Well, generally, we hope that
children will learn to participate independently in a variety of group opportunities. I will begin to share with you
different types of group activities, very small activities to large group activities. We hope that children will learn to
communicate, both with adults, such as staff, but more importantly, with peers, communicating expressively using
speech and language as well as nonverbal gestures. We encourage children to manipulate objects appropriately,
to build the foundation for appropriate play skills, to play both alone, independently, but also with others children
with the items that are available in the environment.
We want for children to be independent around their own materials, their own belongings. We want to develop
personal independence skills. The preschool or group environment allows for children to practice taking coats off,
hanging them up on a hook, having a lunchbox and placing it in a cubby, taking that lunchbox out and securing a
space at a table and having lunch with their own items.
We want for children to interact spontaneously with their friends, to initiate interactions and have opportunities to
create rich play themes, whether it’s playing in the dramatic play area or playing with a puzzle. As we would
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expect in the one-to-one facilitation of the Early Start Denver Model, we expect in the group delivery that children
will have accelerated progress in all domains of development. And we want them ready for that next learning
environment.
Slide 3: Classroom
So, let’s start with the classroom. One of the quotes from the manual written by Dr. Sally Rogers and Dr.
Geraldine Dawson is that the environment, or the classroom, does not look or feel different from any other well-
designed and well-structured toddler or preschool classroom or environment. This helped us frame our
conceptualization about how the structure, or the space, should look in a classroom. As you are passing by a
classroom for the G-ESDM, it really should not look any different than any other preschool environment or group
environment for young children.
Slide 4: Classroom
We want for children to be able to operate in this classroom or in this space independently. So, therefore, we want
the spaces in the boundaries to be defined well visually so it’s very clear for children how they might move from
one space to another.
Obviously, for all children, we want to reduce distractions. Classrooms are busy spaces. They are noisy. They
have lots of movement in it. So, we want to have as much visual clarity as possible. We want the paths to be
clear so that children understand how to move from outside to inside, from center to center. And everything that is
available should be accessible for children and also should define the function or the play space.
So, like any preschool, you’d expect a dramatic area and a craft table. These are just some examples of materials
that are provided for children that help them to understand what they are to do in that space.
One of the questions we often get asked, often by teachers, is, “Are visual schedules appropriate in the G-ESDM
classroom?” They can be, for specific children who need them. We don’t apply them to every child in the
classroom. Some children are able to take the normal, social cues of other children or teachers saying, “It’s time
to go to group,” and transition successfully. And for those children, we would not like them reliant on a visual
schedule. But for some children who aren’t yet ready to take those cues and move from one space to another, we
might help them with the visual schedule. We have a decision tree just like we had in the ESDM that helps guide
you in making decisions around what alternative communication devices we might need for children.
Slide 5: Daily Plan
As important as a classroom and spaces for children and staff, so is a plan. Each day must be carefully planned
out for children to learn as much as they can in that time that you have them. So, for our staff, or therapists,
implementing the G-ESDM, we want to make sure that they have a guide map for each part of the day so, that
each part of the day, they know where they are supposed to be and are assigned a place and a role for each
activity in transition. This helps them to prepare the facilitation of learning for those children in those activities.
We also need a plan for the children so that they have a wide variety of activities to learn in. They need a
schedule that includes small, small group activities and large activities, activities outside, activities inside, and
activities that are going to target the many objectives that they have. So, each child has their own individual
schedule as well as a classroom schedule that we would follow.
A consistent schedule or plan of activities for children is very important, both for the staff but certainly for the child
as well, so that they can learn all the different types of activities that they are going to be participating in and they
have that sense of predictability that helps facilitate comfort in a group environment. We also want to make sure
that all of our activities are balanced out to modulate the arousal or leaning state of the child. Just like in the
ESDM, we carefully think through activities that are very focused, such as art activities or puzzles, things that are
at the table, with sensory social routines or big group motor activities to optimize the learning state of the child
throughout the group time.
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Slide 6: G-ESDM Sample Daily Routine
Here’s a typical preschool daily routine. And what I’d like to share with you is how we may target different
objectives through each of these activities. So, children arrive in the morning. This is a prime opportunity to greet
them, work on greetings, and also help them with personal independence skills, such as taking their coat off,
hanging it up on a hook, putting their belongings in a cubby. Children might then transition to the various play
centers that you’ve carefully planned out that target a number of domains. That could be fine motor, such as an
art activity. It could be a dramatic play theme with teddy bears in a tea set.
In outside play, we have the opportunity to work on gross motor skills and also participation in social gains, such
as Duck, Duck Goose. In group time, we might select specific children to comprise a small group activity where we
might very clearly and specifically target specific objectives that each of the children need to work on. I’ll show you
some examples very soon.
Mealtimes offer us the opportunity, once again, to return to those personal independence skills around utilizing
utensils but also social skills, such as passing items from one person to another and having small conversations
at the table during meals.
We found quiet activities and rest time to be a really nice opportunity to teach children how to play independently
and quietly so that other children could rest and/or engage in activities such as reading or just simply playing with
a toy in a more reserved fashion.
If you are able to offer play centers more than once in a given period of time, like the sample schedule shows,
that allows children to return to activities they may or may not have had an opportunity to play in. So, we can
track how children move from center to center such that they don’t avoid specific centers that they maybe don’t
enjoy or are not as well skilled in.
In this sample schedule, snack time and outside play repeat. I’d like to highlight the idea of group time. Group
time often refers to larger group activities, so different from the small group activities I was discussing before
where we select specific children. This group time — all children are invited to attend. When they’re ready to sit in
a large group and listen to the teacher read a book, we have a great opportunity to work on those skills that are
required for kindergarten large group activities.
Slide 7: “Lead” Role
Next, I’d like to talk about the idea of the lead. We found that it is very important for parents and other staff to
have a primary caregiver model so that there is maybe one or maybe two staff members, at most, that are
thinking about the child in the family in a larger group environment. So, that lead might be the person who
assesses the child every three months and writes objectives and is generally concerned with tracking the
progress of the child.
It helps for families to know whom they should talk to if they have concerns about their child’s development, their
progress, or even behavioral issues. And that person is able to coordinate with all of the staff and other programs
that the child may be participating in. We find it also is key for transitional times, such as when a child is entering
a group environment or moving on to the next environment, that there’s one or one-to-two people who really
know the child in the family.
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Slide 8: Lead Designs Child’s Plan
The G-ESDM, like the ESDM, implements the curriculum every three months. That assessment is key to
understanding how the child is progressing. The curriculum checklist has many columns and one of the columns
allows us to observe a child in a preschool environment. So, the lead might be able to do some observations in
the regular day-to-day class with a child. But it’s still important that that lead take the time to interact with the child
one-to-one and assess.
Then the lead will write the objective steps and create a data sheet, the full treatment package for the child for the
quarter. It’s important that that lead make sure that all the staff working with the children have an opportunity to
read over those objectives, understand where the child is headed in terms of their next quarter goals. And,
obviously, the league will also be the main person monitoring the progress for the child over the quarter in
throughout as much time as the child is participating in a group environment.
Slide 9: Small Group Activities
Small group activities are those activities referred to earlier, when we select specific children to comprise a small
group. They are often led by a few staff. One person is leading that activity but there’s also what we call invisible
support, which supports the facilitation of skills for particular children who might need it. These can be really short
activities. The emphasis is that learning opportunity should be provided every 30 to 60 seconds. Many times
that’s the adult but sometimes it’s the facilitation between a peer interaction. These group activities should be fun
and motivating for children, carefully planned out so that children enjoy these learning opportunities. And multiple
objectives can be targeted in these activities.
Slide 10: Small Group (Clock)
Next, you have an opportunity to watch a very skillful therapist and invisible support in Australia in our group
program at the La Trobe Autism Specific Early Learning and Care Center. Pay attention to these various
principles or suggestions that we’ve made about small group activities
Slide 11: Small Group (Clock)
So, having just watched that video, I’d like to highlight a few ESDM teaching strategies that you’ve just observed.
I’d also like to talk through a few objectives that the teacher was working on with the children as well as focus on
some G-ESDM teaching strategies.
So, first for the Early Start Denver Model, it’s very important that the teacher or the staff person or therapist is
providing clear antecedent behavior consequence chains. And this skillful therapist is doing just that. Each child
knows what is being expected of them and she’s consequating their behaviors with praise, natural praise. She’s
helping children utilizing the least-to-most prompting hierarchy. She’s focusing on turn taking, which is very
important in the ESDM.
And children are learning lots of things in the small group activity. They are learning not only to wait their turn, but
to observe what other children are doing with this object. They are also learning how to imitate gestures, that twisting
motion that she modeled many times during that activity, as well as counting.
In terms of the G-ESDM strategies, I’d like just to highlight two. First off, child attention. Here, in this activity, the
therapist is less concerned about the child attending to her as much as she wants the children to watch each
other and attend to one another as well as initiate with one another. And there’s a very clear opportunity that the
therapist and the invisible support have to work together to support a child’s learning in a particular moment. And
during that moment, what happens is the therapist and the invisible support engage in some nonverbal
communication themselves to determine when to provide that support for the child.
You may want to go back to the video and look at the strategies now that I have highlighted them for you.
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Slide 12: After Group Activity (Playdough)
Here’s another small group activity video for you to watch.

Slide 13: Staff Roles During Group Time
In that last video, you were able to see a lot of tremendous learning going on for the children in that video. They
were sharing experiences. They were playing and engaged in a dramatic play theme. They were motivated. It
was a really nice activity. And I’d like to break it down a little bit right now from the perspective of what was the
staff doing during those activities.
So, in the G-ESDM, we are thinking about three particular roles in each group. The opener starts activity with the
children and they remain in the activity throughout the duration of that theme. They also close that activity. There
is a staff member who is assigned the bridge. And the bridge is somebody whose job it is to make sure that all of
the children transition to the activity from another activity.
So, there’s a moment in that video when you see another child wander, sort of wonder and move around, take a
look at what is happening with the children that are focused on the Play-Doh. That child is being followed by a
bridge. That child will not be left alone to just wander aimlessly in the environment. That bridge is going to make
sure all of the children that are supposed to be in an activity and engaged in fact remain in that activity. It’s okay if
they need a little break and have a little bit of a wander, but they’re going to come back into purposeful, functional
play or activity. So, this lead, or opener, bridge, and closer role is very important for the successive children
learning in these various activities.
Also, the invisible support role, which can be the bridge role, is really important to facilitate that children are in
fact engaged in activities at the level that they can offer. So, for example, if a child needs prompting, that invisible
support is the person who might help a child with those physical supports. But that invisible support is also
engaged in activities when they’re not needed in that role.
So, in that Play-Doh activity, you see two adults engaged in play with the children. Most of the time, the invisible
support is sitting silently behind the children. But in this video, you see the invisible support near the children and
engaging in the activity as the children don’t need much physical prompting in this activity.
Slide 14: Each Activity
One of the challenges of the group environment when we’re thinking about multiple children is how do we keep
track of multiple children with multiple objectives in multiple domains? And it is a challenge. And so, we have
learned some tips and suggestions that I am going to offer.
It’s really important as we are planning activities that we create cheat sheets or smaller, condensed versions of
our data sheets to keep the staff on target for the child learning in those activities. So, if I were doing an activity on
art, I might take the fine motor skills for each of the children and have them near the table or on the table that I
was working with those art activities. The idea is to keep the consistent group schedule so that we know what
children will be learning each day or each week and can monitor progress as are going through those various
activities.
Slide 15: Planning Transitions
As I’ve been sharing with you, group ESDM requires a lot of careful planning. And one of the areas that we plan
for is transitions. We hear a lot that parents are concerned that children really have difficulty moving from one
activity to another. And so, we want to make sure that we have thought through for each child how to successfully
move and engage in activities. We want children to independently move from, say, a play center to outside time
and use the normal, social cues that the teacher or staff or other children are providing.
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But they have to know where they’re going. So I’d like to show you this next video on how this staff member
transitions children from outside to inside.
Slide 16: Transitions Bells
So, in this video, you can see that the therapist is outside with the items that she’s going to use in the next
activity. They’re like transitional objects and she holds them up and shakes them as she is offering the children to
come inside and play in this small group activity. And she continues to offer them as a visual reminder of what
they’re going to be doing when they enter into the classroom and have a very clearly defined place to sit. And
they sit down in this activity and then she offers a choice, another key ESDM teaching strategy.
Slide 17: Meals are Planned Activities
If you have the opportunity to have meals or snack in your group ESDM sessions, this offers the children multiple
opportunities to engage in both the appropriate functional behaviors of eating with various utensils, but also to
engage in social interactions. Therefore, it is very key that your staff or the therapists are engaged with the
children at the table during meals. Often times, we have our staff sit at the end of the table and eat their lunch
with the children, talking with them and engaging them, modeling how to have conversations and how to pass
items, say, the salt from one person to another. Children should be face-to-face to encourage conversations and
interactions. And all of the principles of a small group activity, including data taking, are incorporated during a
meal.
Slide 18: Peer Interactions
One of the most joyful and encouraging aspects of working in a group environment is watching children with
autism spectrum disorder develop friendships. That is facilitated by supported peer interactions. Children can
grow from learning how to just imitate their peers to sharing interests with their peers. It’s really important that the
therapists are thinking through and planning for peer interactions, supporting peer interactions in every activity
that is offered.
Some of those strategies include face-to-face positioning. And in the ESDM, we are often thinking about how
children are looking at us, whereas in the group ESDM, we are thinking about how children are looking at each
other.
For some children, objects are the motivating factor. It’s not yet the peer. So, having objects and multiple objects
can help those peer interactions. Whenever children are engaging in some interactive experience, we want to
manage the distractors and provide opportunities for those interactions to be sustained. Our role as adults is to
facilitate that interaction and not intrude so much that it takes over for that child or set of children.
Slide 19: What Helps?
As I just said, multiple objects can facilitate peer interactions. Objects that are interesting and motivating for the
children and double sets of objects can often foster imitation for children. So, having multiple sets of hats and
sunglasses and various items, musical instruments and such, help children to watch their peers and what they
are doing with these objects and begin to develop the spontaneous imitation skills that we know encourage
learning.
Slide 20: G-ESDM New Fidelity Items
So, because peer interaction is so key to the G-ESDM, it’s been added as its own individual fidelity item in the G-
ESDM Fidelity Tool. As Dr. Rogers explained, fidelity of implementation is important to ensure that we are
utilizing the strategies that support children in the ESDM and G-ESDM.
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Slide 21: Daily Data for Each Child
I’d like to conclude this learning module on the G-ESDM on a very important topic: data taking. It is important that
we remember that no matter how many children we have in a group activity; we must take accurate data for each
child in each activity. What gets measured improves. And we want these children just like in the individual ESDM
to make rapid progress in all of the developmental domains targeted.
So, it’s important that we take daily data or session data and it’s important that we summarize the data so that we
can review the progress and make any implementation changes as necessary.
Thank you for the opportunity to share our work with the G-ESDM in a preschool environment. This has been our
very rich experience in learning from children and families about how to make this adaptation possible. As I
mentioned, our adaptation was in the context of a long day care or preschool setting. But we certainly believe that
the group environment could be utilized in a clinical format for shorter months of time with the same principles.
I hope that this is been a valuable learning experience for you.
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Slide 1: The Neuroscience Behind ESDM
I’m Dr. Geri Dawson, Professor at Duke University and one of the co-developers of ESDM. As a clinician and a
neuroscientist, I’ve always been interested in early development of the brain and its relationship to both typical
and atypical development. Now that you understand the principles and theory behind ESDM, I am going to
explain the neuroscience behind it. Over the last several years, scientists have gain a lot of knowledge about
early brain development and its role in children’s early learning. This has helped us understand the important
role of the environment in shaping children’s brain and behavioral development.
Slide 2: Duke Center for Autism and Brain Development Duke University
The work I’ll be telling you about during today’s session was conducted at the University of Washington when I
was a professor there. I now direct the Duke Center for Autism and Brain Development, one of the ESDM
training sites.
Slide 3: Experiences Build Brain Architecture
We all inherit genes from our parents and those genes influence all aspects of our development from our hair
color to our cognitive abilities. Human beings have about 25,000 genes.
We know that autism is a condition that is affected by genetics. Genes likely account for why one child with
autism develops language easily and others struggle throughout life. Genes set the stage for development but
it is early experiences that actually shape the circuits in the brain.
The brain processes information by forming connections and networks between nerve cells, called neurons.
The connections between neurons are called synapses.
A child’s brain actually has about twice as many synapses as it will have in adulthood. Between birth and age
three, synapses are formed at a faster rate than at any other time. This surplus of synapses is gradually
pruned. Repeated use strengthens a synapse. Those that are rarely used are eliminated.
In this way, early experiences shape the circuits of the brain. Interestingly, research suggests that autism is
associated with having too many synapses. This early pruning process appears to have been disrupted.
Slide 4: Human Brain Development
Recall that I said that the brain is rapidly forming synapses during early development. Note that the rate of
synapse formation is about 700 per second in the early years! This graph illustrates when certain functions of
the brain develop and when they are most influenced by experience.
Environment has an impact on the development of the sensory symptoms shortly after birth. It has its impact
on language and social communication from birth to 6 years. Thus, this is an important period for early
intervention for young children with autism.
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Slide 5: Brain Development in Autism
Let me explain this illustration to you. We know quite a bit about how autism develops during early life. We
have learned this by watching home videotapes made of infants who later developed autism and by
prospectively following infants at risk for autism by virtue of the fact that they have an older sibling with autism.
We’ve learned that before 6 months of age, infants who later develop autism don’t show many symptoms. If
symptoms are there they are subtle they are not obvious. Thus, the baby is interacting with the world in a
relatively normal way and the brain is getting the type of experience it expects to get during this time.
However, between 6-12 months, the infant with autism begins to pay less attention to people, babbles less,
and doesn’t imitate others. In other words the baby is not socially engaged with others. This lack of social
engagement means that the infant is not learning about faces, voices, gestures, and other aspects of the social
world during this early developmental period.
The brain is wired to expect that social and language stimulation should occur during this period. However, for
an infant with autism, the parts of the brain that are important for social and language development, such as
the prefrontal and temporal cortices, are not getting the expected amount of stimulation. Synapses in those
areas are not being strengthened.
Instead, the infant is focusing on objects or sometimes unusual details in the environment. Areas of the brain
that specialize in object-related activities, such as patterns, are being stimulated. Thus, the synapses in those
areas are being strengthened.
Fortunately, early intervention based on ESDM can change this pattern of development.
Slide 6: Four Ways ESDM Promotes Brain Development
In the next part of the lecture, I am going to explain how ESDM is designed to promote brain development and
address the specific differences in brain development associated with autism.
The first way ESDM promotes brain development is by teaching skills during the period when the brain usually
acquires those skills and is most plastic. Recall that I said that between birth and 6 years of age, the brain is
forming synapses and experience has its biggest impact on social and language development. The brain is
primed to develop social and language skills during this time. This is the concept of neural readiness.
When you teach skills when the brain normally expects to acquire those skills, the ability to respond is more
rapid and stronger. The synapses in the regions of the brain responsible for language and social skills have not
been eliminated because of lack of use. They are there and ready to be strengthened.
This is why outcomes for children with autism are better the earlier intervention begins and why it takes more
effort and longer when the same intervention is delivered when a child is older.
I do want to make a point here though: Although it is true that the brain is more plastic and responsive early in
development, the window for plasticity in early childhood is still relatively large. Also, we are learning that, even
throughout adulthood, the brain is still able to form new synapses.
So, intervention at any point in development is still important and helpful. But, earlier is better.
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The second way that ESDM promotes brain development is by redirecting the child’s focus of attention back to
people. These are clips from home videotapes taken during first birthday parties of infants. This is the moment
when the cake is given to the baby and the family is singing “Happy Birthday.” The typical 1 year old – on the
right – is looking at the people around him and smiling.
But notice what the baby with autism is doing. That baby is more interested in the plate. Autism is associated
with deficits in social attention.
Researchers have used eye tracking devices to show that infants with autism pay attention to different things in
the environment compared to typical infants. Typical infants naturally focus their attention toward people,
especially their eyes. From 2 months onward, infants with autism show less and less attention to the eyes of
other people.
Slide 8: What the Child pays Attention to Shapes Brain Circuitry
What a child pays attention to shapes brain circuitry. We demonstrated this in a research study where we
observed how children with autism responded when another person became upset. In this photo, one of my
former graduate students, Jamie McPartland, has just hit his finger with the play hammer and he is pretending
to cry. Most often, typical kids will stop playing and look up at the adult who has hurt himself. The typical focus
of attention is on the face of the person who is crying.
Slide 9: What the Child pays Attention to Shapes Brain Circuitry
The little boy with autism – shown in the picture – is continuing to focus on the object and doesn’t pay attention
to the crying adult. We measured how often and how quickly the children paid attention to the adult who was
crying. Then, on a separate day, we measured their brains’ responses to emotional stimuli using EEG. We
found a strong correlation between the children’s brain responses and their tendency to pay attention to the
distressed adult. Children who did not pay attention showed a much slower and weaker brain response to
emotional stimuli.
When you learn ESDM, you will learn strategies that naturally draw the child’s attention toward you and others.
You will learn how to be in the child’s spotlight of attention and use the child’s natural preferences and interests
to draw the child’s attention toward your face. Eventually, the child will spontaneously look at you. The child
will come to realize that people are both interesting and fun. They are worth paying attention to.
Once the child’s attention is gained, learning about the social world including play, gesture, and language can
occur. This social platform also sets the stage for cognitive development which occurs through object and other
types of play.
To summarize, ESDM promotes brain development by addressing deficits in social attention.

It teaches strategies that will increase attention to others.
This provides more opportunities to learn about faces, facial expressions, gestures, and spoken language.
It stimulates social brain circuitry and sets the stage for further learning.
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The third way that ESDM promotes brain development is by facilitating affective or emotional engagement.
Many studies have shown that children with autism have deficits in affective engagement. For example,
children with autism show fewer “social smiles” – that is, smiles combined with eye contact. Affective
engagement means being mutually emotionally engaged with each other during a communicative act.
It turns out that affective engagement doesn’t just promote emotional development and relationships, it also is
important for cognitive and language development. This was demonstrated by a landmark study by Dr. Pat
Kuhl.
Dr. Kuhl has spent her career understanding how infants learn language. Studies have shown that when
babies are born, they are capable of perceiving all of the sounds – the phonemic contrasts – of all the
languages in the world. However, over time, infants lose this ability. They only retain the ability to perceive the
phonemes associated with the language to which they are exposed when they are a baby. This is one reason
we have an accent when we try to learn a new language as adults. We actually don’t perceive some of the
phonemes of the new language.
Dr. Kuhl was interested in whether infants exposed to a foreign language would be able to retain their ability to
perceive the phonemes associated with that language. So, she decided to expose infants in the US to
Mandarin Chinese and those in China to the sounds of English. She did this in two ways: In one group, the
female speakers directly engaged with the infants while they spoke to them. In the second group, she showed
the exact same female speaker doing the same thing but on a videotape. The infants actually heard exactly the
same thing but in one condition they were interacting with a live person. She found that only the infants
interacting with the live female were able to retain the phonemes of the foreign language.
This study shows that it is not only what we see or hear but also the degree of emotional engagement that is
important in shaping how our brains develop and how much we learn from the environment around us.
Slide 12: Key Role of Affect in Learning
This illustration shows some of the brain regions involved in attention, memory, and emotion.
The prefrontal cortex and anterior cingulate cortex are important for directing attention to a stimulus. However,
it is the amygdala that attaches emotional significance to the stimulus. The degree to which a stimulus is
deemed to be emotionally significant will influence whether you remember it later. The hippocampus is
responsible for memory functions.
For example, imagine you are at a party and you are introduced to someone new. At that moment, you will be
paying attention to the person. However, whether you recall that person’s name later will be influenced by how
emotionally invested you are in that person. Similarly, when a child pays attention and is emotionally engaged
during learning, the child is more likely to retain that information.
Affect also guides attention. We look at things that we find rewarding. Children with autism initially don’t find
social stimuli as rewarding as a typical child does. Autism may disrupt brain circuits responsible for sensitivity
to social reward.
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In summary, the third way that ESDM promotes brain development is by facilitating affective engagement.
ESDM uses strategies that are designed to make social interactions more rewarding and fun. We call this
“Finding the Smile.”
The purpose of sensory social routines, a strategy used in ESDM, is to find activities that are fun and involve
sharing positive affect between the child and adult.
These types of activities stimulate social reward brain circuitry and set the stage for further learning.
Slide 14: ESDM in Action
Here’s an example of a child engaged with his parent in therapy while Jamie Winter, an ESDM therapist,
coaches.
Notice how the parent sits directly across from the child so she is in the child’s spotlight of attention. Notice
how she is using an object that the child is interested in to bring his attention to her face and see how they are
both smiling about this interaction.
You will learn many strategies that promote social attention and affective engagement.
Finally, the fourth way that ESDM promotes brain development is through multi-model and multi-domain
teaching. This is designed to facilitate neural connectivity between different parts of the brain.
Many studies using different brain imaging techniques have shown that autism is associated with reduced
neural connections between different parts of the brain. This has been shown by functional MRI where we can
see that the amygdala, which is responsible for attaching emotional significance to a stimulus, is not well
connected to parts of the brain that are responsible for processing information from the face.
Dr. Mike Murias, an Assistant Professor at Duke, and I conducted a study where we measured functional
connectivity between different brain regions using EEG. The picture on the left shows connections between the
frontal part of the brain and the temporal and occipital lobes. The blue lines are ones where the individuals with
autism showed weaker connections than typical individuals.
Slide 16: Why is Neural Connectivity Important?
Why is neural connectivity important?
Complex behaviors such as social interaction and language require precise coordination among many different
brain regions. When I am speaking with another person, I am using my auditory cortex to process the language
while I use the region around the superior temporal sulcus to interpret the person’s facial expressions. At the
same time, I am monitoring the emotional significance using my amygdala. I need to use my prefrontal cortex
to hold the information on line over time and prepare my response.
If people with autism have weak long range connections between different brain regions, this helps us
understand why language and social skills are so difficult for them.
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Let’s return to the parent who is interacting with her child using ESDM strategies. Rather than focusing on only
one skill such as eye contact which might stimulate one area of the brain, she is simultaneously teaching many
skills. She has multiple teaching objectives. Take a moment and write down all of the skills that the parent
might be targeting in this teaching episode.
This teaching episode offers many teaching opportunities, including targeting: Eye contact, joint attention,
affective engagement, receptive language, expressive language, shapes, colors, fine motor skills, and others.
Slide 19: Data Evidence
The last part of this teaching module will review the evidence that ESDM can influence brain activity. After all,
theory is one thing. Data is another!
In 2010, my colleagues and I at the University of Washington conducted a randomized clinical trial testing the
effects of ESDM on toddlers with autism. In this study, 48 children who were 30 months or younger were
randomized to receive two years of ESDM by trained therapists or treatment as usual in the community.
Parents in the ESDM group were taught to use ESDM at home. The two groups actually ended up receiving
similar number of hours of intervention overall.
Outcome measures included assessments of children’s behavior as well as brain activity which we measured
with EEG. We found significant improvements in IQ, language, and adaptive and social behavior.
We measured children’s EEG activity while they viewed photos of women’s faces and photos of toys.
In previous research in our lab, we had found typical children show stronger brain responses when viewing
faces than objects, but toddlers and preschool age children with autism show the reverse pattern. They show
greater brain activity when viewing objects than people.
In the ESDM clinical trial, we compared three groups of children at the end of the trial when children were 4
years old: Typical children, children who had received two years of ESDM and children who received treatment
as usual in the community.
We measured two brain wave frequency bands: Alpha and theta. When the brain is more engaged and
attentive, alpha power is reduced and theta power is increased. You can see in the graph the typical children
and children who received ESDM showed essentially identical patterns of brain activity. Their brains were more
engaged when they are viewing faces than objects. The children in the community group showed the opposite
pattern: More engaged when viewing objects than faces.
This was the first demonstration that early intensive intervention based on ESDM not only influences children’s
behavioral outcomes; it also positively affects their brain development. It normalizes the atypical patterns we
associate with autism.
This is really good news. The brain is plastic in children with autism.
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Children with autism who made greater improvements in social behavior showed more normal patterns of brain
activity. We were very pleased when TIME Magazine recognized our work showing that ESDM can normalize
children’s brain activity as one of the top 10 medical breakthroughs of 2012.
The goal of ESDM is to alter the trajectory of brain and behavioral development so that it is closer to that of a
typical child. Each child is different and the degree to which the gap is closed will differ. But the trajectory of
brain and behavioral development will be changed for every child who receives early intervention and this will
help every child reach his or her full potential.
Thanks for listening and this opportunity to tell you about the neuroscience behind ESDM.
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UC Davis MIND Institute

ESDM Training Program

UCDE Online ESDM Introductory Course

Early Start Denver Model for Young Children with Autism

Sally J. Rogers and Geraldine Dawson

Sally J. Rogers and Geraldine Dawson

Find full information about this title online: www.guilford.com/p/rogers7

An Early Start for Your Child with Autism

Using Everyday Activities to Help Kids Connect, Communicate, and Learn

Sally J. Rogers, Geraldine Dawson, and Laurie A. Vismara

Find full information about this title online: www.guilford.com/p/rogers8

Lesson 1.1—ESDM Principles

• List of publications (links included)

Lesson 2.1 – Using the Curriculum Checklist

• Parent Goal Sheet

• Curriculum Checklist (part of required materials)

Lesson 2.2—Writing a Treatment Plan

Lesson 2.3—Baby Steps to Mastering the Data Sheet

• How to Write Objectives and Teaching Steps

• Sample Data Sheet

• Blank Data Sheet

Lesson 3.1—Deconstructing ESDM

• ESDM Fidelity Rating System

Lesson 3.3—Building Joint Activity Routines

• Ideas for Joint Activities & Sensory-Social Routines

• Joint Activity Routine elements

Lesson 3.4—Building a Treatment Hour

• Sample Data Sheet

• Blank Data Sheet

Lesson 3.5—How Do I Take Data and Play?

• Blank Data Sheet

• ESDM Model Objectives and Steps

• Flow Chart for Behavior Management

• Functional Behavior Support Plan

Lesson 3.7—Teaching Practices

• Appendix B of Treatment Manual (part of required materials)

• Fidelity Coding Sheet

Lesson 3.8-- It's Not Working!

• ESDM Play Partner Decision Tree (p131 of manual)

• Decision Tree—speech difficulties (p180 of manual)

ESDM Journal Publications

ROGERS, S . J. (2000) ‘Differential Diagnosis of Autism before Age 3’, International

P-ESDM Parent Goals for Intervention

Today’s Date: _____/____/____

Rogers & Vismara ©2012

Targeted Curriculum item (s):

Targeted Curriculum item (s):

Targeted Curriculum item (s):

Targeted Curriculum item (s):

1 Severe behavior (e.g. aggression, SIB, frequent/intense tantrums

In each 15 min period mark a + for completed consistently; -

Teaching Steps/Task Analysis:

□ Each objective is broken down into 4-6 teaching steps

ESDM Fidelity Rating System

another caregiver, or a paraprofessional using the techniques. Mastery level of performance

achieved over several consecutive activities.

therapists (or parents) conducting self-review. Ongoing monitoring of fidelity is also an

for periodic coding.

inter-rater reliability studies of the live coding system.

Today’s Date: _//

Parent__ Rater and Date_