ARTICLES

Randomized, Controlled Trial of an Intervention for

Toddlers With Autism: The Early Start Denver Model
AUTHORS: Geraldine Dawson, PhD,a,b,c Sally Rogers,
PhD,d Jeffrey Munson, PhD,e,f Milani Smith, PhD,e Jamie
Winter, PhD,e Jessica Greenson, PhD,e Amy Donaldson,
PhD,g and Jennifer Varley, MSe
aAutism Speaks; bDepartment of Psychiatry, University of North
Carolina, Chapel Hill, North Carolina; cDepartment of Psychology,
eUniversity of Washington Autism Center, Center on Human
Development and Disability, and fDepartment of Psychiatry and
Behavioral Sciences, University of Washington, Seattle,
Washington; dMIND Institute, Department of Psychiatry,
University of California Davis, Sacramento, California; and
gDepartment of Speech and Hearing Science, Portland State
University, Portland, Oregon

KEY WORDS
autism, behavioral intervention, cognitive function,
developmental outcomes, early intervention
ABBREVIATIONS
ASDautism spectrum disorder
ESDMEarly Start Denver Model
ABAapplied behavior analysis
A/Massess and monitor
PDDpervasive developmental disorder
NOSnot otherwise specied
MSELMullen Scales of Early Learning
ADOSAutism Diagnostic Observation Schedule
VABSVineland Adaptive Behavior Scales
RBSRepetitive Behavior Scale

WHATS KNOWN ON THIS SUBJECT: Previous studies on the

efcacy of early behavioral intervention for improving outcomes
for preschool-aged children with autism have yielded promising
results. However, no randomized clinical trials of early
developmental behavioral intervention designed for toddlers with
autism have been conducted to date.
WHAT THIS STUDY ADDS: This study assessed the efcacy of the
Early Start Denver Model, a comprehensive developmental
behavioral intervention, for improving outcomes of toddlers with
ASD. The intervention, which was initiated when children were
less than 212 years, resulted in signicant improvements in IQ,
language, adaptive behavior, and autism diagnosis.

abstract
OBJECTIVE: To conduct a randomized, controlled trial to evaluate the
efcacy of the Early Start Denver Model (ESDM), a comprehensive developmental behavioral intervention, for improving outcomes of toddlers diagnosed with autism spectrum disorder (ASD).

This trial has been registered at www.clinicaltrials.gov

(identier NCT00090415).
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0958
doi:10.1542/peds.2009-0958
Accepted for publication Jul 17, 2009
Address correspondence to Geraldine Dawson, PhD, Autism
Speaks, 4120 Bioinformatics Building, University of North
Carolina, Chapel Hill, North Carolina. E-mail: gdawson@
autismspeaks.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Sally Rogers and Geraldine Dawson
are authors of Early Start Denver Model for Young Children with
Autism from which they receive royalties.

METHODS: Forty-eight children diagnosed with ASD between 18 and 30

months of age were randomly assigned to 1 of 2 groups: (1) ESDM intervention, which is based on developmental and applied behavioral analytic
principles and delivered by trained therapists and parents for 2 years; or
(2) referral to community providers for intervention commonly available in
the community.
RESULTS: Compared with children who received community-intervention,
children who received ESDM showed signicant improvements in IQ, adaptive behavior, and autism diagnosis. Two years after entering intervention,
the ESDM group on average improved 17.6 standard score points (1 SD: 15
points) compared with 7.0 points in the comparison group relative to baseline scores. The ESDM group maintained its rate of growth in adaptive behavior compared with a normative sample of typically developing children. In contrast, over the 2-year span, the comparison group showed greater delays in
adaptive behavior. Children who received ESDM also were more likely to experience a change in diagnosis from autism to pervasive developmental disorder, not otherwise specied, than the comparison group.
CONCLUSIONS: This is the rst randomized, controlled trial to demonstrate the efcacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive
behavior and reducing severity of ASD diagnosis. Results of this study
underscore the importance of early detection of and intervention in
autism. Pediatrics 2010;125:e17e23

PEDIATRICS Volume 125, Number 1, January 2010

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e17

Autism spectrum disorder (ASD) is

characterized by impairments in social reciprocity and communication,
and stereotyped and repetitive behaviors, with onset during early childhood. Intellectual disability is present
in a large proportion of individuals.1
With a prevalence of 1 per 150,2 autism
costs the United States $35 billion per
year.3 The lifetime per-capita societal
cost of autism is $3.2 million, with lost
productivity and adult care among the
largest costs.4 Thus, early-intervention
methods that can improve outcome
for individuals with ASD are of high
importance.
The 1987 report by Lovaas5 of an early
behavioral intervention that resulted
in 49% of children in the study being
mainstreamed into regular classrooms and showing signicant IQ
gains created a groundswell of interest among parents and professionals
in early intervention and raised questions about early plasticity in children
with autism.6 Although subsequent intervention studies, including a randomized, controlled trial,7 have documented improvements in IQ for a
subgroup of children, questions regarding the efcacy of early intervention have remained. Many of the studies lacked methodologic rigor. Authors
of a recent meta-analysis of the efcacy of early behavioral intervention
argued that stronger evidence that
early behavioral intervention results
in better outcomes than standard care
is still needed.8
Our study was a randomized, controlled trial of early intensive behavioral intervention for young children
with ASD that was funded by the National Institute of Mental Health (Dr
Dawson, principal investigator). It was
hypothesized that the early intervention would result in signicant improvements in cognitive abilities of
young children with ASD. The study differed from previous ones in several
e18

DAWSON et al

ways. First, we maintained a high level

of methodologic rigor, including goldstandard diagnostic criteria, randomization, comprehensive outcome measures conducted by naive examiners,
high retention rates, and measures of
delity of implementation of a manualized intervention.
Second, to our knowledge, our study is
the rst randomized, controlled trial of
intervention for toddlers with autism;
all children were younger than 30
months at entry. Given the recent recommendation by the American Academy of Pediatrics that 18-month-old
children be screened for ASD,9 it is imperative that the efcacy of earlyintervention models appropriate for
toddlers with ASD be demonstrated.
Third, the intervention, the Early Start
Denver Model (ESDM),10 is a comprehensive early behavioral intervention for infants to preschool-aged children with
ASD that integrates applied behavior
analysis (ABA) with developmental and
relationship-based approaches. The
ESDM was designed to address the
needs of toddlers with ASD as young as
12 months. The intervention is provided
in a toddlers natural environment (the
home) and is delivered by trained therapists and parents. In our study, children
received structured intervention at high
intensity, consistent with the National
Research Councils recommendation.11

PATIENTS AND METHODS

Study Procedures
Forty-eight children between 18 and 30
months of age diagnosed with autistic
disorder or pervasive developmental
disorder (PDD), not otherwise specied (NOS), were randomly assigned to
1 of 2 groups: (1) the ESDM group received yearly assessments, 20 hours/
week of the ESDM intervention from
University of Washington clinicians,
parent training, and parent delivery
for 5 or more hours/week of ESDM, in
addition to whatever community ser-

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vices the parents chose; and (2) the

assess-and-monitor (A/M) group received yearly assessments with intervention recommendations and referrals for intervention from commonly
available community providers in the
greater Seattle region.
Children were evaluated by experienced examiners naive to intervention
status at baseline (preintervention), 1
year after onset of the intervention,
and at either 2 years after onset of the
intervention or at 48 months of age,
whichever yielded a longer time frame.
Participants
Participants were recruited through
pediatric practices, Birth to Three centers, preschools, hospitals, and state
and local autism organizations. Exclusion criteria included (1) a neurodevelopmental disorder of known etiology
(eg, fragile X syndrome), (2) signicant
sensory or motor impairment, (3) major physical problems such as a
chronic serious health condition, (4)
seizures at time of entry, (5) use of psychoactive medications, (6) history of a
serious head injury and/or neurologic
disease, (7) alcohol or drug exposure
during the prenatal period, and (8) ratio IQ below 35 as measured by mean
age equivalence score/chronological
age on the visual reception and ne
motor subscales of the Mullen Scales
of Early Learning (MSEL).12 Children
who developed seizures during the
course of the study were not excluded.
Inclusion criteria included age below
30 months at entry, meeting criteria
for autistic disorder on the Toddler Autism Diagnostic Interview,13 meeting
criteria for autism or ASD on the Autism Diagnostic Observation Schedule,14 and a clinical diagnosis based on
Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition
(DSM-IV) criteria15 using all available
information, residing within 30 minutes of the University of Washington,

ARTICLES

Measures
Autism Diagnostic InterviewRevised
The toddler version of the Autism Diagnostic InterviewRevised13 is a semistructured parent interview that assesses autism symptoms across 3
domains: social relatedness; communication; and repetitive, restricted
behaviors.
Autism Diagnostic Observation
Schedule
The Autism Diagnostic Observation
Schedule (ADOS), WPS version,14 is a
semistructured standardized observation that measures autism symptoms
in social relatedness, communication,
play, and repetitive behaviors. A standardized severity score based on
codes within these domains can be calculated to compare autism symptoms
across modules.16
Mullen Scales of Early Learning
(MSEL)
The MSEL12 are a standardized developmental test for children from birth to 68
months of age. Four of the 5 subscales
PEDIATRICS Volume 125, Number 1, January 2010

Allocation

Enrollment

Excluded (n = 45)
Did not meet diagnostic
criteria (n = 38)
Met diagnostic criteria but
declined to participate in
randomization because of
demands of intervention
(n = 7)
Randomly assigned (n = 51)

Excluded (n = 3)
Declined ESDM because of
intervention requirements
(n = 2)
Subsequently diagnosed
with Rett syndrome (n = 1)

Follow-up

Retention rates were 100% (1-year)

and 100% (2-year) for the ESDM group
and 96% (1-year) and 88% (2-year) for
the A/M group, which yielded a sample
size of 24 in the ESDM and 21 in the A/M
group at outcome. Figure 1 shows the
participant owchart.

Assessed for eligibility

(n = 96)

Analysis

and willingness to participate in a 2year intervention. At baseline, 18 children in the A/M group and 21 in the
ESDM group received a DSM-IV diagnosis of autistic disorder. Six children in
the A/M group and 3 in the ESDM group
received a diagnosis of PDD NOS. This
difference was not signicant (Fishers
exact test, P .231). The ethnicities
involved were Asian (12.5%), white
(72.9%), Latino (12.5%), and multiracial (14.6%). The male-to-female ratio
reected the expected ratio in ASD of
3.5:1.

Allocated to ESDM
group (n = 24)

Allocated to A/M
group (n = 24)

Time 1 assessment
(n = 24)
Followed (n = 24)
Lost to follow-up
(n = 0)

Time 1 assessment
(n = 23)
Followed (n = 23)
Lost to follow-up
(n = 1)

Time 2 assessment
(n = 24)
Followed (n = 24)
Lost to follow-up
(n = 0)

Time 2 assessment
(n = 21)
Followed (n = 21)
Lost to follow-up
(n = 3)

Analyzed (n = 24)

Analyzed (n = 21)

FIGURE 1
Participant owchart.

were administered: ne motor, visual reception, expressive language, and receptive language. T scores for subscales
have a mean of 50 (SD: 10). The earlylearning composite score is a standard
score with mean of 100 (SD: 15).
Vineland Adaptive Behavior Scales
The Vineland Adaptive Behavior Scales
(VABS)17 are a parent interview that assesses social, communication, motor,
and daily living skills. They provide ageequivalent and standard scores for
several subscales, including expressive and receptive language and social
adaptive functioning.
Repetitive Behavior Scale
The Repetitive Behavior Scale (RBS)18
is a parent questionnaire that characterizes the severity of repetitive behaviors, yielding 6 subdomain scores (eg,

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sameness, self-injurious behavior)

and a total score.
Randomization
Participants were stratied into 2
groups on the basis of composite IQ at
entry (55 and 55) and gender to ensure comparable IQ and gender ratios
between groups. Within each of these
strata, randomization was conducted
by using random permuted blocks of 4.
The intervention groups did not differ
at baseline in severity of autism symptoms based on ADOS scores, chronological age, IQ, gender, or adaptive behaviors (see Table 1).
Intervention Groups
ESDM Group
The ESDM group was provided with intervention by trained therapists for
e19

TABLE 1 Baseline Measures for ESDM and A/M Groups

A/M Group

Age at study entry, mo

MSEL
Early-learning compositea
Receptive languageb
Expressive languageb
Visual receptionb
Fine motorb
VABS
Adaptive behavior compositea
Communicationa
Socializationa
Daily living skillsa
Motor skillsa
ADOS severity score
RBS total

ESDM Group

MS

Mean

SD

Mean

SD

23.1

3.9

24

23.9

4.0

24

0.48

7.52

.490

59.4
21.2
26.0
30.8
30.6

8.6
3.8
8.6
8.9
10.7

24
24
24
24
24

61.0
21.1
24.5
33.2
33.9

9.2
4.7
7.2
11.0
11.9

24
24
24
24
24

0.40
0.01
0.48
0.70
1.02

31.69
0.19
30.08
70.08
130.02

.530
.920
.492
.406
.318

69.9
69.6
72.4
86.8
72.5
6.9
21.5

7.3
7.3
9.4
10.0
6.5
1.7
19.2

24
24
24
24
24
24
24

69.5
68.4
73.8
87.3
70.9
7.2
15.2

5.7
7.6
7.7
11.4
6.2
1.7
10.8

24
24
24
24
24
24
24

0.04
0.32
0.29
0.03
0.78
0.35
1.93

1.69
17.52
21.33
3.52
31.69
1.02
468.75

.844
.577
.594
.381
.862
.557
.171

No signicant differences among baseline measures were found (P .10 on all measures).
a Standard score (mean: 100 SD: 15).
b T score (mean: 50 SD: 10).

2-hour sessions, twice per day, 5 days/

week, for 2 years. A detailed intervention manual and curriculum were
used.19 One or both parents were provided with parent training from the primary therapist during semimonthly
meetings, during which the principles
and specic techniques of ESDM were
taught. Parents were asked to use
ESDM strategies during daily activities
and to keep track of the number of
hours during which they used these
strategies. ESDM uses teaching strategies that involve interpersonal exchange and positive affect, shared engagement with real-life materials and
activities, adult responsivity and sensitivity to child cues, and focus on verbal
and nonverbal communication, based
on a developmentally informed curriculum that addresses all developmental
domains. Teaching strategies are consistent with the principles of ABA, such
as the use of operant conditioning,
shaping, and chaining. Each childs
plan is individualized. There is a strong
parent-family role responsive to each
familys unique characteristics. Parents are taught the basic ESDM strategies and asked to use them during everyday activities such as feeding, bath
time, and play. Parents chose teaching
e20

DAWSON et al

objectives from the curriculum that

they viewed as high priority.
Intervention programs were supervised by a graduate-level, trained lead
therapist who had a minimum of 5
years experience providing early intervention to young children with autism, with ongoing consultation from a
clinical psychologist, speech-language
pathologist, and developmental behavioral pediatrician. An occupational
therapist provided consultation as
needed. Intervention objectives and
strategies were reviewed, and the intervention was observed at least biweekly by the lead therapist and every
3 months by the speech-language pathologist. Intervention was delivered
by therapists who typically held a baccalaureate degree, received 2 months
of training by the lead therapist, and
met weekly with the lead therapist.
Therapists were trained to competence, dened as completing coursework, passing tests, mastering the intervention, demonstrating delity of
85% of maximum scores on the delity
instrument, and maintaining ongoing
delity.20
ESDM intervention hours were systematically recorded. Although 20

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therapist-delivered intervention hours

per week were made available, the actual mean was 15.2 hours (SD: 1.4) because of illnesses, vacations, and so
on. Parents reported spending an average of 16.3 hours/week (SD: 6.2) using ESDM strategies. The ESDM group
reported an average of 5.2 hours/week
(SD: 2.1) in other therapies (eg, speech
therapy, developmental preschool)
over the study enrollment period.
Other therapies were documented by
using an intervention history interview
administered every 6 months.
A/M Group
Children who were randomly assigned
to the A/M group received comprehensive diagnostic evaluations, intervention recommendations, and community referrals at baseline and again at
each of the 2 follow-up assessments.
Families were given resource manuals
and reading materials at baseline and
twice yearly throughout the study. The
A/M group reported an average of 9.1
hours of individual therapy and an
average of 9.3 hours/week of group interventions (eg, developmental preschool) across the 2-year period during which the intervention study was
conducted. In the greater Seattle area,
there are a number of Birth to Three
centers that provide interventions,
speech and language therapy, and
occupational therapy. Developmental preschool programs vary but typically include special education and
related services. There are a number
of private ABA providers in the
community.
Data Analysis
The effect of ESDM intervention was assessed by using repeated-measures
analysis of variance, with a priori contrasts that compared baseline scores
with 1- and 2-year outcome scores. The
primary outcome measures were the
MSEL composite standard score and
the VABS composite standard score.

ARTICLES

TABLE 2 Child Outcomes After 1 and 2 Years of Study Participation

1-y Outcome
A/M (N 23)

Chronological age, mo
MSEL
Early-learning
composite
Receptive language
Expressive language
Visual reception
Fine motor
VABS
Communication
Socialization
Daily living skills
Motor skills
ADOS severity score
RBS total

2-y Outcome

ESDM (N 24)

A/M (N 21)

ESDM (N 24)

Group Time
(Baseline vs
1-y)

Mean

SD

Mean

SD

Mean

SD

Mean

SD

38.1

3.8

15.3

38.8

4.4

14.9

52.1

4.3

29.3

52.4

3.4

28.5

0.95

64.0

13.8

4.4

76.4

23.4

15.4

66.3

15.3

7.0

78.6

24.2

17.6

5.99

31.1
33.0
29.0
26.1
63.7
71.0
68.9
65.3
70.7
7.3
23.3

11.1
9.8
11.5
6.7
10.7 1.7
8.6 5.0
8.8 6.3
13.0
1.2
12.1 3.5
7.1 7.4
12.2 15.9
2.1
0.4
17.5
1.0

38.9
36.1
38.8
32.7
65.7
73.5
70.0
65.6
75.1
6.5
15.5

15.4
17.8
14.2
11.6
16.4
5.6
11.7 1.3
9.8 3.8
11.7
5.0
9.9 3.8
8.6 5.3
14.4 12.2
1.5 0.7
12.3
0.9

31.5
30.0
34.5
28.5
59.1
69.4
63.1
58.0
64.1
7.3
22.0

10.6
10.2
9.2
4.0
13.0
4.5
9.5 2.8
8.8 11.2
15.8 0.7
9.3 8.9
8.1 14.5
12.3 23.1
1.8
0.3
16.3 0.6

40.0
36.6
41.0
33.5
68.7
82.1
69.2
64.7
77.4
7.0
16.7

16.3
13.6
17.9
12.2
15.9
21.8
11.6
12.4
19.8
1.9
13.1

18.9
12.1
7.8
0.4
0.8
13.7
4.6
6.2
9.9
0.2
2.5

4.00
1.99
4.22
1.32
0.85
1.38
0.01
0.89
0.99
3.38
0.001

MS

Group Time
(Baseline vs 2-y)
P

2.18 .334 1.27

MS

6.91 .266

1416.90 .018 4.31 1264.38 .044

745.21
290.43
621.97
161.35
71.61
175.69
1.15
51.78
157.43
13.15
0.19

.051
.165
.046
.256
.360
.246
.934
.350
.326
.072
.976

4.14 843.56 .048

4.88 748.07 .033
0.63 126.23 .433
0.46
63.81 .503
7.05 1181.82 .011
6.38 2300.98 .015
1.29 204.57 .263
6.73 773.34 .013
7.40 1881.65 .009
0.66
3.29 .422
0.37
92.50 .545

indicates mean change from baseline.

Secondary outcome measures were

the ADOS severity score,16 the RBS,18
MSEL, and VABS subscale scores, and
changes in diagnostic status (autistic
disorder, PDD NOS, and no diagnosis).

RESULTS
No serious adverse effects related to
the intervention were reported during
the 2-year period.
1-Year Outcome
Table 2 displays statistics for 1- and
2-year outcomes, change scores relative to baseline, and group comparisons for primary and secondary measures. Signicant intervention effects
were found for cognitive ability after 1
year on the MSEL composite standard
scores. The ESDM group demonstrated
an average IQ increase of 15.4 points
(1 SD) compared with an increase of
4.4 points in the A/M group. The visual
reception subscale was the only individual subscale on the MSEL on
which the groups signicantly differed at the 1-year outcome. The
ESDM group gained 5.6 T-score
points, whereas the A/M group declined 1.7 points. The ESDM group improved 17.8 points on receptive language compared with a 9.8-point
PEDIATRICS Volume 125, Number 1, January 2010

improvement in the A/M group, a difference that fell just short of statistical signicance.

the ESDM group, whereas the A/M

group improved 10.2 and 4.0 points,
respectively.

As a whole, children gained raw

score points in the daily living skills
subscale of the VABS; however,
progress was much slower in relation to the VABS normative sample
between baseline and 1 year. The
groups did not differ in terms of
adaptive behavior, measured by the
VABS composite standard score, after 1 year (the ESDM group showed a
3.8-point decline, and the A/M group
showed a 6.3-point decline). The
groups did not differ in terms of their
ADOS severity scores or RBS total
score after 1 year of intervention.

The ESDM and A/M groups signicantly differed in terms of their

adaptive behavior as measured by
the VABS composite standard scores
at the 2-year outcome (see Fig 2). The
ESDM group showed similar standard scores at the 1- and 2-year outcomes, indicating a steady rate of development, whereas the A/M group,
on average, showed an 11.2-point average decline. Thus, the A/M groups
delays in overall adaptive behavior
became greater when compared
with the normative sample. The A/M
group showed average declines in
standard scores that were twice as
great as those in the ESDM group in
the domains of socialization, daily living skills, and motor skills. The
groups did not differ in terms of their
ADOS severity scores or RBS total
score after 2 years of intervention.

2-Year Outcome
Two years after the baseline assessment, the ESDM group showed significantly improved cognitive ability,
measured by MSEL composite standard scores, which increased 17.6
points compared with 7.0 points in
the A/M group. The bulk of this
change seems to have been a result
of receptive and expressive language, which showed increases of
18.9 and 12.1 points, respectively, for

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Diagnosis
At baseline, the diagnoses in each
group were not signicantly different (Fishers exact test, P .461)
and were distributed as follows:
e21

FIGURE 2
Mean scores on the MSEL (left) and the VABS composite (right) for children in the ESDM and A/M
groups 1 and 2 years after entering study. Error bars indicate 1 SD.

ESDM, 21 with autistic disorder and 3

with PDD NOS; A/M, 18 with autistic
disorder and 6 with PDD NOS. At the
2-year outcome, 15 (62.5%) children
in the ESDM group had the same diagnosis (14 with autistic disorder, 1
with PDD NOS) and 15 (71.4%) children in the A/M group had the same
diagnosis (all 15 with autistic disorder). Diagnosis improved (baseline
autistic disorder to PDD NOS at year
2) for 7 (29.2%) children in the ESDM
group but for only 1 (4.8%) child in
the A/M group. However, the diagnosis changed from PDD NOS at baseline to autistic disorder at year 2 for
2 (8.3%) children in the ESDM group
and 5 (23.8%) children in the A/M
group. Thus, children who received
ESDM were signicantly more likely
to have improved diagnostic status
at the 2-year outcome compared with
children in the A/M group, as assessed by using Fishers exact test 2
(intervention groups) 2 (improved
versus worsened diagnosis) contingency table (P .041). Fishers exact
test for the 2 (intervention groups)
3 (diagnostic change: no change
versus improved versus worsened
diagnosis) contingency table was
just short of signicance (P .060).
e22

DAWSON et al

DISCUSSION
Recommendations by the American
Academy of Pediatrics9 that all children be screened for autism at 18
months of age oblige the development of interventions that are appropriate for toddlers with ASD. To our
knowledge, this study is the rst to
demonstrate the efcacy of an intensive intervention designed for toddlers with ASD as young as 12
months of age. After 2 years of intervention, children provided with the
ESDM19 showed signicant improvements in IQ, adaptive behavior, and
diagnostic status compared with
children who received community interventions. Consistent evidence of
improvement in communicative abilities in the ESDM group was found, as
demonstrated by gains in receptive
and expressive language scores on
the MSEL subscales and the VABS
communication subscale. Signicant
improvement for the ESDM group
was found for overall adaptive behavior, communication, daily living
skills, and motor skills. Specically,
the ESDM group, although still significantly delayed in adaptive behavior,
was able to keep pace with the rate
of change of the VABS normative

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sample, whereas the communitybased intervention group continued

to fall farther behind in adaptive behavior. Given the importance of
adaptive behavior for everyday functioning at home and school, the fact
that the ESDM group did not continue
to fall farther behind is likely to affect ability to function in lessrestrictive environments. This demonstrates that the ESDM intervention
accelerates overall development and
is generalizing to everyday life.
Whereas 71% of the children in the
group that received communitybased intervention retained their diagnosis of autistic disorder over the
2-year period, only 56% of children in
the ESDM group did so. The diagnosis
of 7 children (30%) in the ESDM
group changed from autistic disorder to PDD NOS, whereas this
only occurred for 1 child (5%) in
the community-intervention group.
These diagnostic assessments were
conducted by experienced clinicians
who were naive with respect to
intervention-group status. However,
this change in diagnostic severity
was not reected in signicant differences in the ADOS severity scores.
This lack of correspondence between measures is difcult to interpret, because the childs performance in the ADOS contributes to
clinical diagnosis. However, other
behaviors, including parental report,
also contribute to overall clinical
diagnosis. The repetitive-behavior
scores also did not change over time
in either group.

CONCLUSIONS
The outcomes of this study, which involve an increase in IQ scores of 17
points (1 SD) and signicant gains in
language and adaptive behavior, compare favorably with other controlled
studies of intensive early intervention
(eg, Smith et al [2000],7 which delivered discrete trial intervention for 2

ARTICLES

years for 25 40 hours/week). The

group differences reported from our
study are larger than those produced
by other comparative trials of developmental behavioral approaches, which
were conducted for briefer periods of
time and with fewer hours of delivery
per week.21,22 Whether the children will
sustain their gains over a longer term
is an important question that will require follow-up study.

The results of this study suggest that

the ESDM model,19 an intervention approach that uses teaching strategies
of ABA that are delivered within an affectively rich, relationship-focused
context, can be effective for improving
outcomes of young children with autism. Parents use of these strategies
at home during their daily activities
likely was an important ingredient of
its success.

ACKNOWLEDGMENTS
This study was supported by National
Institute of Mental Health grant
U54MH066399 (to Dr Dawson).
We acknowledge the contributions of
the parents and children who took
part in this study and the support and
effort of numerous undergraduate and
graduate students and staff who are
part of the University of Washington
Autism Center.

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e23

Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The

Early Start Denver Model
Geraldine Dawson, Sally Rogers, Jeffrey Munson, Milani Smith, Jamie Winter,
Jessica Greenson, Amy Donaldson and Jennifer Varley
Pediatrics 2010;125;e17; originally published online November 30, 2009;
DOI: 10.1542/peds.2009-0958
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The

Early Start Denver Model
Geraldine Dawson, Sally Rogers, Jeffrey Munson, Milani Smith, Jamie Winter,
Jessica Greenson, Amy Donaldson and Jennifer Varley
Pediatrics 2010;125;e17; originally published online November 30, 2009;
DOI: 10.1542/peds.2009-0958

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/125/1/e17.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on March 8, 2016