Autism in Asia: Early Start Denver Model in Taiwan

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that causes atypical development in children’s social communication and social interaction. More than 30% of children with ASD are incapable of communicating through speech, struggle to comprehend language and may never acquire functional speech.

The typical symptoms of ASD include:

Having restricted and repetitive behavioural patterns.
Sensory issues.
Engaging in stereotypical behaviour (stimming).

They may even resort to violent tantrums and damaging or even self-harming behaviours.

The symptoms of ASD are often noticeable in early childhood, which causes a host of practical issues for families of children with ASD. For example, they may display food selectivity when they have restricted food acceptance, making mealtimes an uphill challenge.

ASD in Taiwan

The prevalence of ASD in Taiwan is about 1 out of every 130 children. Although under the National Health Insurance Program, every child with a confirmed diagnosis or is at high risk of ASD can access early intervention services at affordable rates, the waiting list for early intervention services is very long.

In Taiwan, the Early Intervention reporting and referral centres (EIRRCs) provide early intervention services in community-based hospitals. The centre’s multidisciplinary team includes speech pathologists, occupational therapists, child clinical psychologists, physical therapists, and social workers, working with psychiatrists, general physiatrists, and paediatricians.

To provide as many families with early intervention services as possible, the EIRRC offer them at low intensity, using varied approaches resulting in inconsistent quality.

The Early Start Denver Model

The Early Start Denver Model (ESDM) is a play-based behavioural therapy for children between the ages of 12 and 48 months with ASD. Based on the principles of Applied Behavioural Analysis (ABA) methods, the evidence-based program helps improve the social, emotional, cognitive, and language abilities of children with ASD during natural play and daily routines.

ESDM therapy is usable in various contexts, including the home, clinic, or educational institution. Therapy sessions can be group-based and in a one-on-one setting. Being designed based on an interdisciplinary and generalist model, the EDSM can be provided by professionals from various disciplines like psychology, occupational therapy, speech pathology, early childhood special education, and paraprofessionals. Even parents can carry out the intervention after training.

Since the quality of the parent-child relationship impacts the learning of infant toddlers, parents must be highly involved. Besides working with the child, the therapists will also teach parents how to apply sensitive and responsive tactics to enhance a child’s learning during regular times.

The ESDM uses play and fun to build positive relationships and boost children’s interest in things and other people. In play, children with ASD can learn that social interaction is beneficial. Play and fun also encourage children to communicate and express themselves.

Studies of ESDM report improved language and learning skills, adaptive behaviour, and decreased occurrence of ASD symptoms. Brain imaging studies also indicate that ESDM increases brain activity in the social and communication domains.

However, the ESDM has primarily been the subject of Western-based studies, and studies on non-Western cultures and nations are few and far between. For this reason, Chiang et al. evaluated the effectiveness of ESDM, with modifications such as a lower intensity and shorter duration, with delivery in local general hospitals in Northern Taiwan (2022).

Efficacy of the Adapted Early Start Denver Model

EDSM, being an interdisciplinary approach, is compatible with Taiwan’s multidisciplinary early intervention service system. Additionally, ESDM is a type of Naturalistic Developmental Behavioral Intervention (NDBI) which addresses the social communication issues of children with ASD in their natural settings. Furthermore, various studies from China, Italy, and Taiwan have reported the improvement of ASD symptoms, improved cognitive functioning, and reduced severity in communication abilities, pointing to the possible effectiveness of this adapted, low-intensity ESDM model.

Short-Term and Low-Intensity Early Start Denver Program in Taiwan

A multidisciplinary team of psychiatrists, clinical psychologists, occupational therapists, and speech-language pathologists was put together to deliver the ESDM for this study. Before starting the intervention, all therapists received training to meet the ESDM fidelity requirements.

The researchers put children with ASD into the ESDM and the control group. For over six months, children in the ESDM group would receive three sessions of one-on-one intervention and one session of three-hour intervention (nine hours in total). The children saw three different therapists for each one-hour session in different therapy rooms, which were switched every six weeks.

Two therapists led a one-hour group-based education session for parents twice a week. These parent education sessions included brief lectures on ESDM techniques and discussed their 5-minute parent-child interaction videos that parents recorded at home. Parents observed firsthand how the therapists applied the strategies in the therapy room with their children.

The professionals created 20–25 unique learning objectives focused on verbal and nonverbal communication, joint attention, social engagement, imitation, play, cognition, and motor and adaptive abilities. Behavioural information was gathered throughout each intervention session to track children’s progress against all the learning objectives.

As for children in the control group, they received early intervention services provided by community service providers, like the general hospital, clinics, and developmental centres. They received a range of interventions, such as physical therapy, occupational therapy, speech and language therapy, psychological therapy, special education, and other therapies. The therapists provided advice and consultation to the parents in the control group at baseline and at the other two time points.

Outcomes of the Short-Term and Low-Intensity Early Start Denver Program in Taiwan

In the context of Chinese culture, the results from the ESDM group considerably outperformed the standard community treatment control group after the six months intervention. Improvements were seen in their overall and nonverbal abilities. Similar significant improvements were reported by Colombi et al. in their study of low-intensity treatment in Italy (2016).

However, the positive results of the Taiwan study were not sustained six months after the intervention ended. These results contradict another study that reported improvements in overall intellectual capacity, adaptive behaviours, the severity of symptoms, and challenging behaviours that the ESDM group maintained for the 2-year follow-up period.

Upon investigating the differences, the researchers learnt that the age of the children and the number of hours of intervention they received per week affected post-study effectiveness. Children between 18-30 months displayed more and longer improvements than the older 2-4 years old in this Taiwan study. More than eight to nine-hour weekly interventions were needed to sustain post-study progress.

This study aims to understand the efficacy of low-intensity and short-term ESDM interventions to support the long wait list in the EIRRC and provide consistent services. Although there is uncertainty about the optimal duration and intensity to ensure sustained progress, the findings can help stakeholders and policymakers in Taiwan and other countries with similar cultures to make informed decisions about early intervention services for children with ASD.

Understand more about Children with ASD and Autism in Asia: