Integrating the Early Start Denver Model (ESDM) in ASD Preschools in Israel – Results of a Matched Controlled Study

Background:

The Early Start Denver Model was previously shown to be effective as an intensive home- and group based intervention (Dawson et al., 2010; Vivanti et al., 2014). However, there is currently no evidence for the effectiveness of the ESDM integration into existing community preschool-services. In Israel, this setting is the main provider of intervention services for young children with ASD. It is therefore important to assess the effectiveness of the ESDM when applied in this setting.

Objectives:

To conduct a controlled trial, comparing an implementation of the ESDM in ASD community preschools, to the eclectic program commonly applied in such preschools in Israel. The model has been adapted to the community preschool settings through: (1) translation of relevant training materials (2) A workshop on ESDM principles and teaching techniques conducted for preschool educational and clinical staff (3) weekly individual and group play activities conducted together by preschool aids and ESDM therapists.

Methods:

Fifty-eight children, aged 35-57 months, from eight ASD preschools, participated in the current study. Thirty-three (7 girls) attended preschools in which ESDM was integrated, and twenty-five (3 girls) attended eclectic preschools. Groups were matched on age and developmental level. Both groups received 30 hours per-week of educational intervention and 10 treatment hours per-week by a multidisciplinary team (psychologist/psychotherapist, occupational therapist, speech and language pathologist, physiotherapist, behavior analyst). The implementation of the ESDM included the use of the model’s curriculum and treatment practices, and therapists’ adherence to the ESDM fidelity rating system. Educational staff incorporated ESDM principles and objectives into the daily preschool routine. In addition, in the ESDM-based program, parents attended weekly parent-child therapy sessions.

Changes in children's cognitive ability (MSEL) and adaptive behaviors (teacher and parent reported VABS-II) as well as parent reported sense of stress (PSI-SF) and competence (P-SOC) were measured pre- and post- 8 months of intervention.

Results:

Both groups showed significant gains in MSEL visual reception, fine motor, receptive and expressive language age-equivalent scores. However, the ESDM-based intervention group showed significantly higher increases in receptive and expressive language, and in fine-motor age-equivalent scores, compared to the eclectic intervention group.

Both groups showed significant gains in all teacher and parent-reported VABS-II subscales. However, the ESDM-based group showed significantly higher gains in the teacher-reported receptive and expressive language, domestic and coping skills subdomains, and in parent-reported play and domestic skills. Parent-reported sense of competence increased in both groups. Additionally, in the eclectic group, parents’ perceived stress decreased at post-intervention, while no such decrease was observed in the ESDM-based group.

Conclusions:

The current study’s results indicate that the ESDM is cross-culturally valid in Israel, and that it can be integrated into existing community preschools, with positive child outcomes. Cultural and logistical barriers and adaptations introduced to overcome such barriers will be discussed. Additionally, parental involvement in the intervention improves parental competence, but maintains parental stress in the ESDM group, possibly due to the intensive parental involvement and commitment required in the current program, as well as the time-consuming and emotionally charged nature of the treatment process.