MIND THE GAP A framework for disseminating a sustainable early intervention model (Early Start Denver Model) for pre-school children with Autism. MIND THE GAP Elizabeth Aylward: : AUTISM IN EDUCATION CONFERENCE KU MB ASELCC UNIVERSITY OF NSW & SYDNEY SW AREA HEALTH

This process began with a story… Video MIND THE GAP Elizabeth Aylward

ESDM DISSEMINATION & SUSTAINABILITY MODEL INNOVATION CAMPUS In partnership with UNSW & Sydney South West Area Health Intervention program Practitioner and Parent Training Building workforce capacity Research informing practice Dissemination ASD REFERRALS M-ESDM Mainstream service staff & Famiies E CLINICS P-ESDM Rural and remote Two strands of training are used to cover all staff levels CLINICS ESDM Child therapy CLINICS P-ESDM Parent coaching MIND THE GAP Elizabeth Aylward

The Early Start Denver Model in the group setting MIND THE GAP Elizabeth Aylward

The Early Start Denver Model in the Clinic MIND THE GAP Elizabeth Aylward

The Early Start Denver Model in a mainstream setting MIND THE GAP Elizabeth Aylward

The Early Start Denver Model in the home MIND THE GAP Elizabeth Aylward

The Early Start Denver Model (ESDM) CURRICULUM SPECIFIC TEACHING PRINCIPLES MIND THE GAP Elizabeth Aylward

Teaching Principles PRT Principles ABA Principles Denver Model Principles PRT Principles ABA Principles Modulate arousal Dyadic engagement Quality of JA elaborated routines Combine objectives Communication in all activities, varied functions Emphasize NV communication One word up rule Follow child’s lead Give Choices Take turns Maintenance interspersed with acquisition Reinforces child attempts Direct response-R+ relationship Attention ABC Format Efficacious application of behavioral teaching techniques Number of repetitions Management of unwanted behavior Have audience refer to fidelity items as you review this. I mapped each practice onto th related fidelity item – it was a really good intro to the fidelity system and made this all make much more sense.

Current ESDM Study (8) 2009: KU Children’s Services, in partnership with UNSW, established the NSW Autism Specific Early Learning & Care Centre (ASELCC) one of 6 in Australia, funded by DSS 2016: embarking on a dissemination model and study to roll out our early intervention service to children with ASD attending mainstream early childhood services across NSW . Through a parent ESDM coaching model, we are also rolling out the ESDM into the homes of families in rural and remote areas of Australia.

Resource Implications and way forward… As effective as the ASELCCS have proven to be they are limited to one centre in each capital city of Australia. They are resource intense which led to the need for Translating this highly effective evidence based model to less resource intense methods of delivery & settings The implementation of this has required intensive training of multiple practitioners to a level of certification for those with degrees, or high levels of competency for those without degrees.

Two levels of ESDM Training for Staff Pilot study demonstrated the need for a second level of ESDM Training for Primary Contact Staff…those delivering ESDM in the group all day, who are supervised by Certified ESDM Therapists. It was not enough to train each of the Centre Directors to Certification in the model and send in two additional Certified therapists into the program. It seemed from the pilot study, that for the children with ASD, included in mainstream services to make the same rapid progress that their peers in the Specialist service were making, every staff member needed to be trained in the ESDM to a high level of competency. This led to the development of a second tier package. Discuss the process of Certified Therapists assess the child, develop their program and collate their data. They also mentor and coach Primary contact staff who deliver the program and collect data.

Tier Two ESDM Training Package FOR: Primary Contact Staff working with Children with ASD 10 MODULES X 2 HOURS SUITABLE FOR ECEs & DIPLOMA TRAINED STAFF GOING ONLINE JULY 2016

DISSEMINATION STUDY 60 Participants in this dissemination study consist of two groups of children, all with a diagnosis of ASD receiving ESDM early intervention 10 per site per year x 3 years = 30 from the NSW ASELCC and 10 per site per year x 3 years = 30 from the mainstream setting. Both settings will be using the same intervention (ESDM) and the two processes for staff-training to fidelity will be replicated, following pilot This model and study are the outcome of our already published Maladaptive Behaviour study. ESDM elsewhere in Australia right now:

Maladaptive Behaviours…a barrier to inclusion in mainstream settings Maladaptive behaviours lead to social difficulties disruption to children’s learning – is often the cause of transition difficulties and a hindrance to inclusion in mainstream early childhood settings. It is crucial that these are replaced with more socially acceptable behaviours. Our first maladaptive behaviour study found a significant reduction in behaviour problems, p< 0.001, effect size of Cohen’s d = -3.104. This demonstrated that ESDM is a powerful tool for the management of maladaptive behaviours

The ESDM significantly reduces this barrier to inclusion… The essence of the ESDM is to bring the child back into the social loop at every possible opportunity. promoting a child’s receptive and expressive communication particularly the child-led communicative functions of joint attention, social interaction and turn taking which are important ways of preventing and replacing maladaptive behaviours In addition, the modulation of child and adult arousal is a most powerful tool for preventing the maladaptive behaviours before they begin. This maladaptive behaviour study was the key to our dissemination model…

Training all receiving staff Managing behaviour in children with ASD Implications of the Maladaptive behaviour Study led to the need to build capacity by: Coaching all parents Training all receiving staff Managing behaviour in children with ASD Tier Two ESDM Training Package FOR: Primary Contact Staff working with Children with ASD

How does it work? Early interventions that enhance social attention may be critical in effecting change via brain plasticity At the heart of the ESDM is the empirical knowledge- base of infant-toddler learning and development and the effects of early autism. If we observe how typically developing infants do most of their early learning…observational learning and imitation Hence the ESDM draws on science of learning principles that cue the child’s attention to our faces, our voices and actions so we can provide very clear social communicative cues to elicit a response.

Brain plasticity & outcomes Autism spectrum is highly heritable but responds dramatically to intensive early behavioural intervention. Genetic variations associated with ASD involve activity-dependent regulation in the brain, or synapse development that depends on postnatal learning and experience. Intensive treatment therefore offers the opportunity to overcome the effects of these biological deficits if initiated early (12 months) when the plasticity is greatest and especially in the preschool years. Also early intervention may prevent domain –specific deficits cascading on a trajectory toward full expression of the disorder and instead direct it towards a typical developmental trajectory

Conclusion With a reported prevalence of >1% and the evidence base suggesting early identification/ intervention for better outcomes, costly and resource intensive clinic based interventions are unsustainable. Community dissemination of the ESDM early intervention within mainstream children’s services, family homes and other community settings might offer a sustainable solution with significant clinical, social and economic benefits in resource constrained environments in Australia and abroad