A Comparison of Approaches to Delivery of the Early Start Denver Model (ESDM) for the Reduction of Stress in Parents and the Acceleration of Developmental Progress in Preschoolers with Autism

Interventions are various approaches to delivery of Early Start Denver Model (ESDM; Rogers & Dawson, 2010), all implemented within the context of the Victorian Autism Specific Early Learning and Care Centre (ASELCC), in Melbourne, Australia. Intervention Phase A: Enrolment Groups with non-random assignment (occurring between Baseline [BL] and 10-month End-Point [10m EP] assessment) 1. ASELCC Playroom Children enrolled in ASELCC Playrooms will receive ESDM delivered in group- and centre-based format, as developed and recently manualised by the Victorian ASELCC team (i.e., G-ESDM; Vivanti et al., 2017). The ASELCC Playrooms are situated within the La Trobe University Community Children’s Centre, a long day care program operating from 8.15am to 6.15pm. Within the ASELCC Playrooms, G-ESDM intervention hours are focused between 9.30am and 2.30pm with families encouraged to ensure their child attends during this period. Enrolment in ASELCC Playrooms is offered across one calendar year (approx. Feb-Dec) with most children attending 3 days per week (i.e., few children offered alternative placements to fill rooms to capacity). G-ESDM intervention delivery is by a core classroom staff of early childhood educators, with a maximum ratio of 1 adult to 4 children. At least one educator per room is ESDM Certified. All staff participate in annual ESDM training workshops and receive ongoing coaching and support from an on-site allied health team (psychologist/s, speech pathologist/s, occupational therapist/s) which include additional ESDM Certified Therapists. ESDM Trainers are also employed at the centre to oversee staff training needs and ongoing quality assurance of G-ESDM delivery. Each child undergoes an ESDM Curriculum Checklist assessment by an ESDM Certified Therapist at the start of their enrolment year, and quarterly thereafter. Intervention goals are written from this assessment and parent priorities, and these are targeted in the playroom across the rest of the quarter. Where child progress is behind what is expected, staff use an ESDM decision tree to determine changes that can be made to the teaching to better support the child's learning. ASELCC Playroom staff (who are not already ESDM Certified) receive initial/annual training followed by regular supervision and coaching across the calendar year by Senior ESDM Certified Therapists. Training will center around one-to-one ESDM implementation (across various children and activity contexts; Rogers & Dawson, 2010) and also G-ESDM practices (i.e., small-group and whole-of-classroom implementation; Vivanti et al., 2017). Formal fidelity checks will be conducted across the calendar year using the ESDM Fidelity Tool, with % fidelity computed. 2. Autism Playmates Children enrolled into Autism Playmates will receive ESDM delivered by Therapy Assistants in individual- and home/community-based format. This approach has been developed by the Victorian ASELCC team to provide an alternative and potentially more affordable option to the group/centre-based ASELCC Playroom model. Autism Playmates mirrors the one-to-one approach manualised by Rogers and Dawson (2010) but is adapted for delivery by trained paraprofessional staff (Therapy Assistants) under the supervision of an ESDM Certified Therapist and with consultation from the Victorian ASELCC allied health team. Autism Playmates is offered across approximately one year (i.e., 10-12 month period), comprising three or four cycles of A) assessment and goal planning, followed by B) 12 weeks of targeted delivery. Therapy Assistants (often undergraduate students of an allied health discipline) work directly with the child, for at least 10 hours per week, either in the family home and/or at the child’s local educational/care setting. Each child undergoes an ESDM Curriculum Checklist assessment by an ESDM Certified Therapist at the start of their enrolment year, and at the start of each quarterly cycle. An ESDM Trainer provides initial training to the Therapy Assistants, following which they begin to work with the child. The supervising ESDM Certified Therapist reviews and provides feedback to the Therapy Assistants on two videotaped submissions of their work with the child, soon after their initial training. Within each 12-week intervention delivery period, the supervising ESDM Certified Therapist meets three times with the Therapy Assistant/s and once with the child’s family to A) review delivery of ESDM and provide coaching as required, and B) review the child’s progress. Autism Playmates Therapy Assistants will receive initial training followed by regular supervision and coaching across the calendar year by Senior ESDM Certified Therapists. Training will center around one-to-one Training implementation with the specific child who the Therapy Assistant is working with, across various activity contexts. Following initial training, Therapy Assistants will submit video footage from two therapy sessions for a formal fidelity check by the supervising ESDM Certified Therapist. Over the course of the child’s program, the ESDM Certified Therapist will conduct further formal fidelity checks with each Therapy Assistant twice per 12-weekly therapy/goal cycle and provide coaching as required. These fidelity checks will be conducted via live observation against the ESDM Fidelity Tool with % fidelity computed. Intervention Phase B: Randomisation Group (occurring between 5-month Mid-Point [5m MP] and 10-month End-Point [10m EP] assessment) 1. Parent Coaching Half of families enrolled in this trial will be selected at random for Parent Coaching ESDM (P-ESDM). P-ESDM will be delivered by ESDM Certified Therapists who have completed subsequent training in P-ESDM Parent Coaching, and achieved fidelity prior to the commencement of work with trial families. Session content will follow Rogers, Dawson and Vismara (2012) and families will be provided with a copy of this book, on loan, for the duration of their P-ESDM intervention period. P-ESDM will comprise 13 x 1 hour clinic-based sessions, with the Parent Coach and participating parent and child in attendance. The series will comprise an initial goal planning session and 12 core sessions at weekly intervals. The initial P-ESDM session provides an opportunity for the Parent Coach to assess the child using the ESDM Curriculum Checklist and agree on child learning objectives with the parent. The parent and coach will also talk about the parent’s own goals for themselves. Subsequent sessions provide opportunities for the parent to receive hands-on practice with coaching in the implementation of the ESDM techniques and learning objectives with their child. The Parent Coach and parents will engage in discussion and reflection about the use of the techniques to support the child’s learning and engagement. Sessions are individualised to meet individual parents’ needs and learning styles and focus on supporting the transfer of techniques into everyday home routines. P-ESDM sessions will be conducted at a La Trobe University clinic space. The intention will be for the 15 P-ESDM sessions to be completed within the 5-month period following the child’s 5m MP assessment. Where delays to the planned scheduling occur (i.e., due to illness, public holidays, etc), therapists will attempt to complete as many as possible of the 13 sessions P-ESDM within the 5-month period (e.g., by reducing the time between booster sessions). However, any sessions outstanding beyond the 10m EP assessment will not be completed, with a shorter ‘dose’ of sessions noted. Parent Coaching staff will all be ESDM Certified Therapists who have subsequently participated in a training workshop on P-ESDM, completed coaching sessions with one or more practice families, and achieved fidelity prior to commencing work with trial families. P-ESDM staff will conduct monthly peer supervision sessions across the course of the trial. All Parent Coaching sessions with trial families will be video recorded for review during peer supervision, and to permit scrutiny of a proportion of tapes by independent raters against fidelity criteria using the ESDM Fidelity Tool with % fidelity computed.