Les explications sont en anglais, mille excuses, si quelqu'un veut traduire, je suis preneuse !
Mais je tenais absolument à présenter ce modèle d'intervention qui va beaucoup, beaucoup, beaucoup faire parler de lui, un modèle à suivre... :-)
Young children learn as much and as fast as they do because their experiences in the world are “scaffolded” by the important people in their lives. Their attention is followed, joined, and shared by the people who interact with them, and in these ongoing social interactions children learn from others during play and natural interactive experiences that occur throughout every day. They learn how to communicate, what words mean, what objects do, what people do, what’s funny and sad and scary and fun. Children learn from adults how to fit their language, their actions and their attention with another person in shared activities across the day. This process occurs by children watching, listening, doing, and copying another person. Other people also “explain” the world to infants and toddlers through their words and actions in all the ordinary interactive experiences that typically occur for young children.
Autism impedes this process of child learning and adult scaffolding, in several ways. Children with autism are less attentive to other people and so miss many learning opportunities by watching. Young children with autism have impaired communication skills, so they have difficulty learning from the communications that adults provide. Young children with autism also have difficulty imitating others, and so miss opportunities to learn by copying what others do. Young children with autism may not be quite as flexible in their play skills as others, and may enjoy repeating favorite actions with objects, rather than generating new play ideas and learning through discovery, and this limits their learning. And finally, young children with autism may not find social experiences as inherently rewarding as other children, which can result in reduced time in interactions of all sorts. Since interactions are a primary learning opportunity for toddlers, fewer interactions mean fewer learning opportunities.
These effects of autism constrain the learning of young children with autism, who typically have a number of developmental delays in many areas by the time they reach the toddler period, and these are the targets of treatment in the Early Start Denver Model.
Main Goals of ESDM
There are three main goals of treatment for young children with autism in the Early Start Denver Model:
Bringing the child into coordinated, interactive social relations for most of their waking hours, so that social attention, imitation and communication can be developed and learning through social experiences can occur;
Increasing the reward value of social engagement with others by choosing materials, activities, and routines that are enjoyable and interesting for children, by reading children’s cues and following children’s interests as we choose activities, and by developing play routines that add meaning and predictability for children.
Developing play activities into joint activity routines designed to build skills and “fill in” current learning deficits. The main skills that we focus on include teaching imitation, developing awareness of social interactions and reciprocity, teaching the power of communication, teaching a symbolic communication system, teaching more flexible, conventional and creative play with toys, and making the social world as understandable as the world of objects. Just as the typically developing toddler and preschooler spend virtually all their waking hours engaged in the social milieu and learning from it, the young child with autism needs to be drawn into the social milieu - a carefully prepared and planned milieu that the child can understand, predict and participate in.
The Early Start Denver Model draws extensively from previous work in two well-known models, the Denver Model and Pivotal Response Training. Our approach to young children with autism is based on an empirically-validated set of beliefs and practices, described below.
Beliefs at the Core of the Denver Model
- Families should be at the helm of their children's treatment.
- Each child with autism and family is unique; goals, interventions and approaches must be individualized.
- Children with autism can be very successful learners. Lack of progress generally signals problems with the design and implementation of the educational activity, rather than the inability of the child to learn.
- Autism is at its core a social disorder; treatment for autism must focus on the social disability. This requires that relationships be at the core of treatment of children with autism and their families.
- Children are members of families and communities and need to have a role in family life and family and community activities.
- Children with autism have minds, opinions, preferences, choices, feelings; they have a right to self-expression and some control of their world.
- Autism is complex disorder affecting virtually all areas of functioning; interdisciplinary professional guidance is needed to address the wide range of challenges that autism presents.
- Children with autism are capable of becoming intentional, effective, symbolic communicators and most children with autism can have useful, communicative speech when provided with appropriate interventions of sufficient intensity during the preschool years.
- Systematic instruction is a powerful tool for young children with autism. It involves concrete, well written objectives that are accomplished through pre-planned instructional activities. Progress is measured through ongoing data collection on each targeted objective.
- Several intervention approaches for children with autism have demonstrated their effectiveness in certain instructional methodologies; a comprehensive, contemporary treatment approach must be able to draw from all the expertise available in the field.
- Play is one of the young child’s most powerful cognitive and social learning tools. Building play skills in young children with autism will maximize their capacity for independent learning.
- Successful intervention for young children with autism requires that most of their waking hours be spent in socially-oriented activities. Providing more than 20 hours per week of targeted intervention is necessary for optimum progress. However, optimal intervention can be delivered in various settings and by various people. There is no one best formula for all children. The ingredients for success are: (a) lots of opportunity for 1:1 intervention; (b) from people who are skillful at delivering interventions; (c) careful delivery of target objectives; and (d) use of progress data and ongoing assessment to adjust interventions in order to maximize rate of gain.
Description of the ESDM
The Early Start Denver Model curriculum and teaching practices were developed by Sally Rogers and Geraldine Dawson and their colleagues and are targeted for children ages 14 months through 3 with autism spectrum disorders. It involves both specified teaching practices and a specified set of skills to be taught. It can be delivered in any setting, and by a wide number of people, including parents who have learned the teaching method. It results from a joining together of two intervention approaches, the Denver Model, and Pivotal Response Training (PRT). The Denver Model was developed to serve children with autism during the toddler and preschool years. Over the 25 years of the Denver Model, hundred of young children have received ongoing services through the center based preschool, center based and inclusive community preschools, and 1:1 treatment delivery through home teams.
The Treatment Team
The Early Start Denver Model is an interdisciplinary model, in which early childhood special education, developmental and clinical psychology, applied behavior analysis, speech/language pathology, and occupational therapy, have been core disciplines in developing the intervention. The program at the UC Davis MIND Institute is directed by Sally J. Rogers, Ph.D., a licensed psychologist, who developed the original Denver Model. The UCDavis team includes developmental, clinical, and educational psychology, speech and language pathology, behavioral analysts, occupational therapy, and graduate and postgraduate trainees. Developmental pediatrics and child psychiatry are also available for consultation. ESDM staff work closely with children’s primary care physicians.
The treatment team is responsible for working with the parents to develop the child’s intervention plan and implementation. In the first session, the child’s current developmental skills are assessed in order to develop a set of short- term learning objectives for the child, a set of teaching activities for the parent, and data collection systems. The parents are provided with all these materials in a curricular notebook. The team works directly with the parent each week to implement the identified objectives and monitors the child’s progress on a weekly basis. In order to meet each family’s needs, the team observes and individualizes the intervention each week. In addition, the team reviews the progress data brought by the parents from home each week in order to help problem-solve and provide parents with the skills needed to ensure that the intervention is proceeding appropriately and that the child is progressing as rapidly as possible.
In the Early Start Denver Model, the head of the team functions as a generalist, attending to all aspects of the child's development, seeking disciplinary help as needed, but carrying responsibility for the child's treatment and progress and orchestrating the various aspects of the child's treatment. Parents and the head of the team share responsibilities for all aspects of the team functioning.
Teaching within family routines
Intervention for toddlers happens during playtimes and caretaking times throughout the day. Each individual family assists in determining how their child's current treatment objectives can best be incorporated into family routines. Activities like meals, bathing, playtime, chores, and family outings can be core learning experiences when they become activities in which to embed children’s objectives. Our goal is for each child to be engaged in targeted joint activity routines involving play and caretaking for at least 20 hours or more each week. The team works with the parents to identify these targeted hours within the daily life of the child, as well as within the routine of the family.
Combining this intervention with others
The parent teaching model described here is meant to be an initial intervention and most families will add additional interventions for their children. The skills being taught in the Early Start Denver Model should help parents use their time at home with their child to maximum advantage. These skills are not meant to replace other kinds of treatment, but rather to accompany other treatments that families might choose for their children. The skills you will learn here use empirically based methods from applied behavior analysis, communication development, and early childhood development.
Main Aspects of the Intervention Approach
Design and implementation of the intervention plan
The intervention plan and curriculum for each young child with autism needs to be individually constructed. Children receiving Early Start Denver Model treatment have quarterly objectives that are very specific, cover all affected areas of development, including play, social relationships, and family routines, and can be the basis for treatment across all settings. Short term objectives are written, and teaching plans and activities are developed for each. This constitutes the child’s curriculum. The child's curriculum is packaged in a notebook that contains goals and objectives, weekly teaching points, and data collection systems.
Emphasis on Relationships, Shared Control, and Positive Emotion
Children learn from people with whom they have positive emotional relationships. Autism particularly affects children's ability to engage in social relationships. In the Early Start Denver Model, teaching is embedded in positive social relationships between adults and children with autism. Fostering warm, affectionate, playful relationships is part of day to day, moment to moment treatment. Development and maintenance of positive affect during teaching is a core part of the model (“Find the smile”).
Six content areas are addressed in each child’s individualized curriculum: communication, social interactions, play skills, fine and gross motor development, cognition, and personal independence and participation in family life routines. A developmental orientation underlies the curriculum. Chronologically important skills are also stressed, and task analysis is used to break down skills into small, easily mastered components, with shaping and chaining used to develop complex skill sequences. Using chronologically appropriate materials found in natural settings is stressed.
Communication and imitation are the means by which people carry out social relationships and pass on their culture and accumulated social knowledge to the next generation. There is nothing that is more important for a young child with autism than the development of intentional, spontaneous communication. All children need a useful communication system, and this need dominates the treatment. The Early Start Denver Model uses a multifaceted approach to development of communication that includes four separate teaching strands, each with its own sequential curriculum, that begin in the first treatment session and permeate all of the child's treatment.
These four areas of emphases include:
- Teaching the child to use and understand nonverbal intentional communicative gestures;
- Teaching imitation skills involving objects, actions, and sounds;
- Teaching the meaning and importance of speech; and
- Teaching symbolic representations
The Denver Model began with a focus on developing play skills. Play of all kinds: social, physical, constructive, symbolic, and independent - is built into the child's curriculum because of the crucial role it plays in normal development. Children with autism cannot benefit maximally from interactions with other children if they cannot engage in the core social and learning play activities that preschoolers use. Age-appropriate play skills are directly taught. Besides the inherent developmental value of play skills, the ability to engage in age-appropriate play helps the child with autism “fit in” to the group and reduces the risk of social isolation.
In the Early Start Denver model, the child's sensory system is viewed as a crucial regulator of attention, arousal, and affect. Sensory social activities are a primary means to optimize attention and positive affect in order to facilitate learning.
Personal independence and participation in family routines
In the Early Start Denver model, child spontaneity and independence are highly valued. Skill development in this area is developed by having choices, carrying out routines of daily living, independent play and independent, goal-directed tasks and chores that contribute to family life. This is often a potential area of strength for persons with autism, and developing these skills as fully as possible allows the person with autism to demonstrate their competence.
The ability to initiate, maintain, and appropriately terminate social interactions and to engage in a wide range of social activities is crucial for the interpersonal and communicative development of young children with autism. Social skills are carefully taught embedded in natural social exchanges: sensory social activities, joint activity routines with materials, and dyadic interactions that occur in all life routines. The entire communication curriculum is by nature a social curriculum as well, and teaching imitation skills, play skills, and nonverbal and verbal communicative behaviors, across preschool, structured teaching, and family life routines, are core social interventions.
The Denver Model understands that deficits in motor development, motor sequencing, and motor planning (dyspraxia) are often present in autism and can interfere greatly with social exchanges, play, independence in daily living skills, and preschool participation. Interventions in this area are aimed at functional skill development for play and learning. Motor skill development targeted via systematic instruction with a variety of typical toddler activities and toys, adapted as needed. Gross motor play is taught as part of play and leisure skills activities, involving ball play including catching, throwing, and song and movement games.
Hand development is a particular focus of intervention across the preschool years, because later problems with dressing skills, handwriting, and other fine motor tasks are seen as resulting from both poor muscle tone and praxis, as well as the accumulating effects of lack of practice and challenge over the years. Initially, cause and effect and one step action toys are used to build hand and finger manipulation, hand strength, bilateral coordination and purposeful play. As the hands are developing through a developmental motor sequence, tool use is incorporated into toy play and eventually into writing, art activities, home activities, dressing skills, and other preschool activities.
The focus of the Early Start Denver Model is on optimizing relationships in the family and teaching new, adaptive skills that allow children greater control, autonomy, competence, and personal satisfaction within their social experiences. The tools of increasing positive interactions among child and family members, functional analysis, communication training, structured teaching of alternative, more conventional behaviors, redirection, and adding structure and visual cues to the physical environment provide the basis for teaching children with autism new behavioral strategies to achieve their goals.
Role of Families
Families are at the helm of their child's treatment; their styles, values, preferences, goals, and dreams guide their child's treatment plan. Parents are the primary teachers of all young children; parental teaching for young children with autism is crucial to the child's progress. However, autism is a complex disorder and parents may need guidance, support, and help in various aspects of designing and carrying out treatment for young children with autism.
Contributions from Pivotal Response Training (PRT)
There are two intervention models that have been joined together in the ESDM. Its ties to the Denver Model have already been discussed. The second model, Pivotal Response Training (PRT), is based on the principles of Applied Behavior Analysis. PRT incorporates specific variables associated with motivation within a systematic teaching approach to increase communication, language and play skills under natural conditions that more closely resemble the way typically developing children acquire developmentally appropriate skills (L.K. Koegel, Koegel, Harrower, & Carter, 1999; L.K. Koegel, Koegel, Shoshan, & McNerney, 1999). The motivational variables are delivered in 1:1 interactions consisting of turn taking, incorporating children’s interests and preferences within learning opportunities, varying the task sequencing and interspersing previously mastered tasks with new acquisition tasks, rewarding children’s for attempting new skills as well as performing them successfully, and incorporating natural rewards that are directly and inherently related to the child’s response. Research has shown that incorporating these motivational variables as a group into an intervention approach can lead to collateral improvements in nontargeted behaviors and generalized areas of responding. These areas include decreases in disruptive behaviors (R.L. Koegel, Koegel, & Surratt, 1992), improved child affect (R.L. Koegel, O’Dell, & Dunlap, 1988), improvements in speech intelligibility (R.L. Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998), improvements in academic learning (Kern, & Dunlap, 1998), decreases in stereotypic and restrictive behavior (Baker, 2000; Baker, Koegel, & Koegel, 1998), and improvements in social areas (L.K. Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998; L.K. Koegel, et al., 1999; Schreibman, Stahmer, & Pierce, 1996).
Current Research Projects involving the Early Start Denver Model
The existing research base for the ESDM comes from a variety of studies carried out using pre-post group designs for a large number of preschools enrolled in a specialized Denver Model preschool program in Colorado (e.g. Rogers and Lewis, 1989) and a recent single subject study of the Denver Model (Rogers et al, 2006). A strong existing research base for PRT has been built up over the past several decades, generally using individual delivery of PRT or parent training studies, and described in numerous papers by Laura Schreibman, Robert and Lynn Koegel, Brooke Ingersoll, Aubyn Stahmer, and others. Research work on the ESDM is now underway in a variety of studies.
The ESDM was designed to be delivered in various ways, including individual therapy sessions by various clinicians, intensive early intervention programs delivered individually at home or in preschool by parents and trained staff for 25 or more hours per week, and in inclusive preschool programs where children with autism participate in group educational experiences with their individual teaching needs embedded into the classroom structure and delivered by trained personnel. For many preschoolers, their interventions across the week contain a mix of parent delivered ESDM in natural routines at home, delivery in some group programs, delivery during speech/language therapy and/or OT sessions, and additional 1:1 teaching at home or at preschool from trained personnel. Our research program on ESDM is examining several different applications of ESDM to determine its efficacy and effectiveness in various delivery formats.
One primary study is continuing at the University of Washington, initiated under the leadership of Dr. Geraldine Dawson and now under the direction of Dr. Annette Estes. The study, funded by the National Institute of Mental Health, NIMH STAART #U54 MH66399, involves a randomized controlled trial of ESDM compared to ongoing community interventions for 48 children with ASD. These children began the study by 30 months of age and participated for a 24 month period. The children randomized to the treatment receive 20 hours per week of ESDM in their homes delivered by project staff, and an additional 5 or more hours per week of ESDM from their parents.
A second research project now getting underway involves a multisite replication of the University of Washington study, involving three sites, Seattle (University of Washington, Dr. Annette Estes) , Ann Arbor, Michigan (University of Michigan, Dr. Catherine Lord), and Sacramento (University of Davis, the MIND Institute, Dr Sally Rogers). Similar in design to the previous UW study, this also involves a randomized design, with 108 children to be enrolled across the three sites, between the ages of 12 and 24 months. This project will examine predictors and mediators of treatment response, and will seek to replicate the efficacy of ESDM in minimizing developmental impairment and severity of ASD.
A third research study, currently in press in the journal Autism, was conducted by Dr. Laurie Vismara here at the MIND Institute and examined the use of ESDM by parents. Toddlers with ASD and their parents attended 12 one hour sessions shortly after initial diagnosis. During the sessions the parents were taught to carry out the ESDM teaching techniques, one topic per week, and asked to carry out the particular technique at home during natural caretaking and play routines. Weekly data gathered during each session demonstrated that all parents acquired the teaching techniques, generally within 6 weeks or so, and that over the course of the treatment period and the 3 month follow up, children demonstrated steady increases in their spontaneous use of words, imitation of play and language, and their attention to and initiations with their parents.
A final study currently underway, again led by Dr. Vismara, is examining the success of teaching others to carry out ESDM and use it in typical community intervention programs – a study of treatment effectiveness. This study involves teams at four different sites across the country – a public school setting, a university clinic, a children’s hospital, and a specialized autism intervention center. We are piloting the use of telecommunications technology to determine whether personnel can be trained to fidelity in the model at long distance, and whether children and parents show the kinds of gains that occur in our university based settings.
Training in ESDM
Professionals and parents who wish to learn the ESDM approach can take advantage of several different training venues. Each summer, the MIND Institute ESDM staff provides both introductory and in depth training in August of each year in association with the Summer Institute held at the MIND. Information about this Institute can be found on the MIND Institute website. Parents in the area may be able to enroll in one of the research studies in Washington, Michigan, and Sacramento. Clinicians trained in the Denver Model are practicing in Denver, Aspen, Reggio Emilia, Italy, Canada, and Seattle, among other sites. Intervention sites that are interested in adopting the ESDM at their own sites should contact staff at the MIND Institute or Seattle sites about possible additional training opportunities.
The next training at the MIND Institute will be held August 4-5, 2008 for an introductory workshop, and August 11-13, 2008, for an advanced workshop for those who have already participated in introductory training. See the MIND Institute website to enroll. For further information, contact Diane Larzelere, administrative assistant, at 916-703-0268.
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