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Dr. Raffaella Devescovi

The Early Start Denver Model intervention implemented in the Public Health System: an Italian experience. Dr. Raffaella Devescovi. Division of Child Neurology and Psychiatry Institute for Maternal and Child Health I.R.C.C.S. Burlo Garofolo Trieste.

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Dr. Raffaella Devescovi

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  1. The Early Start Denver Model intervention implemented in the Public Health System: an Italian experience Dr. Raffaella Devescovi Division of Child Neurology and Psychiatry Institute for Maternal and Child Health I.R.C.C.S. Burlo Garofolo Trieste

  2. The Early Start Denver Model (ESDM):An Intensive, Comprehensive, Early Intervention for Toddlers and Preschoolers with Autism Spectrum Disorders (ASD)

  3. ESDMis an extension of the first Denver model, developedas a group model in the 1980s in Denver by Prof. Sally Rogers and colleagues,aimed at children between 24 and 60 months of age with autism in preschool. • ESDMwasdevelopedat the UC Davis M.I.N.D.Institutefor children with autismstarting from 12 months up to 48-60 months. • ESDMderives from research on learningprocesses in youngchildren and on the effectsthatautismhas on earlydevelopment. • The goal of ESDMis to decrease the severity of autismsymptoms and accelerate development in alldomains (especially cognitive, socio-emotional and linguistic area).

  4. Comprehensivedevelopmental curriculum In a relationship-based approach With strong positive affective frame Emphasis on social development: communication and language, imitation and play Naturalistic teaching is preferred; increased structure as per needed Basic Elements of the Intervention Model

  5. Denver Model beliefs • Autism is a social disorder: Relationships must be at the heart of the intervention • Young children are socially engaged all day long: even children with autism need it • Families involvement is extremely important (“at the helm..”) • A single methodology is not enough; we need to draw from all the expertise available

  6. Teaching Practices PRT Principles ABA Principles Denver Model Principles Taking turns Giving choices Maintenance interspersed with acquisition Reinforcing the child attempts Activities are intrinsically reinforcing for thechild Communication In all activities Dyadic engagement Child spontaneity and initiative Modulating affect/arousal Combining objectives One word up Attention ABC Format Prompting, shaping chaining, fading Number of repetitions Management of unwanted behavior (Adapted from prof.C.Colombi)

  7. Manualized Intervention Curriculum Teaching practices Settings: individual, group, parent-mediated

  8. Three teaching settings 1:1 teaching Teaching in group preschool classes Teaching at home within family routines

  9. Social orientation & attention Affect sharing Imitation Joint attention Language Functional and symbolic play ESDM : Focus on the primary deficitsin early autism

  10. AUTISM AND DEVELOPMENT Major "social deprivation" due to the effects of autism Child is notinvolved soadequately in learningsocial skills Lack of social skills learning altersneurological and psychological development

  11. Bring the child into the social loop Teach the building blocks of social life: imitation emotionalcommunication sharing experiences language Goals of Denver Model treatment • Use intensive, systematically planned teaching to fill in the learning gaps that have already been accumulated

  12. Designing the intervention

  13. Receptive language Expressive language Joint attention Social interaction Fine motor skills Gross motor skills Imitation Cognition Play Personal independence Eating Dressing Grooming Chores Step 1: Curriculum Assessment Autism affects all domains of the development

  14. 12 week objectives developed with parents; 2-3 per each developmental area Objectives written in ABC format; measurable, targeting generalization and independent or spontaneous performance A: antecedent: what is the stimulus that elicits the behavior? B: What is the behavior, defined measurably? C: What is the criterion for mastery of this objective? Step 2: Writing Specific Treatment Objectives

  15. Each objective is broken down into 4-6 teaching steps First step represents baseline level of skill Last step represents mastery level of skill Intermediate steps define progress towards mastery Step 3: Developmental task analysis of each objective

  16. Step 4: Build the Data Sheet • Daily data sheet constructed from task analysis for each objective • Data collected at 15 minute intervals • Data used to adjust daily teaching practices • Goal: measurable progress within three instructional sessions

  17. RCT: 48 toddlers (18-30 months) assigned to ESDM intervention or control group with ABA/educational approach Equal intensity: 20 hours of treatment per week for 2 years; two step follow-up (cognitive, linguistic and adaptive skills): at 12 mths and 24 mths of treatment respectivelyResults: in the ESDM group more significant cognitive and linguistic improvements and reduced severity of ASD diagnosis, with stable adaptive functioning versus decline in the control group at 2 years of treatment

  18. MSEL: cognitive and linguistic development VABS: adaptive behavior

  19. Pilot experience gained in the Trieste and Gorizia area

  20. RetrospectiveStudy • Sample: 35children, 31 males and 4 females, aged 20-36 months at the time of diagnosis, evaluated at T0 and T1: average duration of treatment 15 mths. • Monitoredparameters: • Cognitive Development • Linguistic Development • Severity of autismsymptoms • We have compared these same parameters to the Age and to the Developmental Quotient at the baseline

  21. Methods Procedures • Referral to the Child Neurology and Psychiatry of "BurloGarofolo“ in Trieste directly from the pediatricians based on the positive screening (M-CHAT) or on reporting by nursery school educators • The diagnosis of ASD is formulated by a child neuropsychiatrist expert in autism based on the clinical judgment and results of ADOS • The children diagnosed were treated with ESDM, provided at the public community centers for the developmental age of the Trieste and Gorizia areas

  22. Methods Intervention • The intervention was provided according to the curriculum and principles of ESDM treatment • The average duration of treatment was 15 months • Intervention intensity was on average 3-5 hours per week of 1:1 treatment on the child's objectives, associated with approximately weekly parent-coaching sessions (implemented by the parent's direct observation of the session through the unidirectional mirror, or by a shared vision of the video recording the treatment sessions or sometimes through intervention at home). • Similarly, nursery school educators and kindergarten teachers shared the treatment objectives with monthly meetings with therapists and/or assisted directly at the sessions.

  23. Methods OutcomeMeasures • For cognitive and linguisticskillsthe scores of the following tests were used and compared: • BayleyScales of Infant and Toddler Development, Third Edition (Bayley-III), Cognitive and Language developmentScales, to all children at T0 and T1 up to 42 months. • Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPSSI-III) at T1, over 42 months. • For ASD diagnosis and autismsymptomsseverity: AutismDiagnosticObservation Schedule (ADOS-G e 2) - CalibratedSeverity Score (CSS, Gotham 2007)

  24. 120 120 100 100 80 80 60 60 cognitive, T0 cognitive, T1 40 Language,T0 LanguageT1 Results Pre and post-intervention comparison related to the whole sample Cognitive Domain Linguistic Domain Parametric test for paired data showed a significant improvement (p = 0.0016) Non-parametric test for paired data showed a significant improvement (p = 0.0125)

  25. 10 8 6 4 2 0 ados_pt_t0 ados_pt_t1 Results Severity autism symptoms A significant reduction in ADOS-CSS is observed (p: 0.0263).

  26. 0.<75 1.>=75 0.<75 1.>=75 120 120 100 100 80 80 60 60 40 Results Sample stratification based on the baseline QI score, if <75 or ≥ 75 Cognitive Domain Linguistic Domain Language,T0 LanguageT1 cognitive, T0 cognitive, T1 Both groups show a statistically significant improvement, but more marked in the first group (p=0.0190 vs p=0.0274) The group with the lowest cognitive level (<75) shows a statistically significant improvement to T1 (p=0.0048 vsp=0.4511)

  27. Analyzing the quantitative distribution of the data we observed that 13/19 children among those who were improved in the severity of the symptoms of autism, at the time of diagnosis had an age <27 months

  28. 0.20-26 1.27-36 10 8 6 4 2 0 ados_pt_t0 ados_pt_t1 Results The sample was divided into two groups based on age: <27 mths and ≥ 27 mths Applying multivariate logistics, we find a significant association between the early diagnosis and the improvement of autistic symptoms, regardless the starting cognitive and linguistic level (p:0,026).

  29. Conclusions • Even with the limits of low treatment intensity, it is possible to obtain a significant improvement in cognitive and linguistic development in children treated with the ESDM intervention model; • The lack of a control group treated differently or even untreated requires fair prudence in attributing these results also to the physiological maturation, as well as to the effectiveness of the ESDM treatment; • However we think that the basic factors were the precocity of the intervention and the active involvement of caregivers / educators, so that the children with the lowest cognitive level at diagnosis time seem to be the ones who benefit most from the early intervention with ESDM, in terms of cognitive and linguistic gain.

  30. Evaluation of the effectiveness of a regional program of Early Diagnosis and ESDM treatment for autism spectrum disorders (ASD): The S.F.I.D.A. project

  31. S.F.I.D.A. (=Challenge) Acronym: Screening, Friuli Venezia Giulia, Intervention, Diagnosis, Autism It is a research project, approved and funded with thecontributions for clinical, translational, basic, epidemiological and organizational research, of the regional law 17/2014 of FVG Region. The project sees as leader the IRCCS Burlo Garofolo and as parterns all the centers of child neuropsychiatry belonging to the regional public health system Duration: 3 years (March 2018 - February 2021).

  32. Where does S.F.I.D.A. come from? • From the approval of the «Regional Guidelines for the care pathway of autism spectrum disorders in developmental age» (DGR 434.13 / 03/2017); • From the approval of ESDM training in the FVG Regional Training Plan 2016-2018 (DGR 571/2017 with June 2017 integration), addressed to professionals operating in the Public Health Regional System.

  33. Aims • To evaluate the effectiveness and feasibility of a FVG Regional Program for Autism Spectrum Disorders (DSA) based on the early diagnosis and application of ESDM model, provided as part of the Public Regional Service; • To achieve uniformity of paths both in the diagnostic process of the ASD and in the intervention model by all the Public Structures involved.

  34. Stages of the project Recruitment and Follow-up Actions for Earlydiagnosis Statistical processing of collected data Presentation of results (2021)

  35. Thanks for attention !!! and see you in Trieste in 2021….

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