Early Start Denver Model

1. Introduction

Version followed: Rogers & Dawson (2010) Early Start Denver Model for Young Children with Autism (1st ed. manual) and its 13-item Teaching Fidelity Rating System, as reported in training slides and trial records; parent-delivered ESDM (P-ESDM) as described in Rogers, Vismara & Dawson (2021) Coaching Parents of Young Children with Autism and trial protocols. The 2nd edition (Rogers & Dawson, 2025, Early Start Denver Model for Young Autistic Children) adds chapters on responding to concerning progress, partnering with families and cross-cultural implementation, revised decision trees, more on AAC and a neurodiversity-affirming framing; its text is not drawn on, so where it may differ this guide is marked [uncertain]. [source: Guilford 2nd-ed. page; Utah ESDM summary; PSU training slides]

What it is. ESDM is a comprehensive, manualised naturalistic developmental behavioural intervention (NDBI) for autistic children, or children showing early signs, aged roughly 12–48 months. It is a programme delivered by an interdisciplinary team (typically psychology/behaviour analysis, speech-language therapy, occupational therapy, early childhood education), not a talking therapy. It can run as 1:1 therapist sessions at home or clinic, in small groups in preschool/childcare (G-ESDM), or through parent coaching (P-ESDM). A psychotherapist would typically act as team lead, parent coach or behaviour consultant after ESDM-specific training, not deliver it alone without that training. [source: Wikipedia ESDM; Vivanti PSU slides] [synthesis: role note]

How change happens. Autism is understood to reduce the young child's social orientation and the social reward of interaction, so the child gets fewer of the everyday social learning experiences that build imitation, joint attention, communication and play. ESDM rebuilds this "social learning infrastructure" by making interaction with people highly rewarding (positive affect, shared control, child-chosen activities), then embedding many behavioural teaching episodes (antecedent–behaviour–consequence, prompting, shaping, fading) inside those enjoyable play and care routines, guided by a developmental curriculum and frequent data. Lineage: the Denver play-school model (Rogers), Piagetian and interpersonal developmental theory, pivotal response training and ABA. [source: Vivanti PSU slides; Wikipedia ESDM; Utah ESDM summary]

2. Framework

ESDM is organised in 12-week treatment cycles, not fixed phases. [source: Wikipedia ESDM; PSU Weber & Crawford slides; Utah ESDM summary]

Cycle structure

Step A — Assessment (week 0, then every 12 weeks). Play-based administration of the ESDM Curriculum Checklist (about 1–1.5 hours), plus parent report for skills not seen in session. Each item scored pass / inconsistent / fail. The Checklist is criterion-referenced, about 480 items in 4 levels (Level 1 ≈ 12–18 months, Level 2 ≈ 18–24, Level 3 ≈ 24–36, Level 4 ≈ 36–48 months) across domains: receptive communication, expressive communication, joint attention, social skills, imitation, cognition, play, fine motor, gross motor, behaviour, personal independence (self-care). [source: PSU slides (both); Utah summary] Goal: find the child's learning edge in every domain (the point where passes give way to inconsistent/fails).
Step B — Objective writing. Two to three functional objectives per domain (often around 20 in total) for the next 12 weeks, drawn from Checklist data, parent priorities and other professionals' input. Each objective names the antecedent, an observable behaviour, a mastery criterion and a generalisation criterion (people, settings, materials). [source: PSU Weber & Crawford; Utah summary]
Step C — Task analysis into learning steps. Each objective is broken into a sequence of steps from the child's current level to mastery; these go on the Daily Data Sheet. [source: Utah summary]
Step D — Daily teaching. Sessions alternate object-based joint activity routines and sensory social routines, each a few minutes, with many objectives targeted in each. [source: Utah summary; Vivanti slides]
Step E — Data and adjustment. Data are recorded about every 15 minutes during a pause; progress is reviewed against an expected rate and the decision tree is applied when progress stalls. [source: Utah summary; PSU Weber & Crawford]
Step F — 12-week review. Team reassesses with the Checklist, revises objectives with parents. [source: Wikipedia ESDM]

Typical dose and format

Therapist-delivered 1:1: sessions often about 1–2 hours; in the original RCT about 20 hours/week therapist delivery plus parent use at home, over 2 years; community programmes often 15–20 hours/week. Start ages 12–48 months; end around age 4–5 or school entry. [source: Utah summary; Vivanti slides; Dawson et al. 2010]
P-ESDM (parent coaching): commonly 12 weekly sessions of 1–1.5 hours, child present; the early infant/toddler study used 1-hour clinic sessions for 12 weeks; enhanced versions add home visits and motivational interviewing. [source: Vivanti slides; Rogers et al. 2019 abstract; ANZCTR 12618000254291]
G-ESDM: small groups in preschool/childcare at about 1 adult : 3–4 children, typically 15+ hours/week, activities around 10 minutes, with an individual learning opportunity for each child roughly every 30 seconds. [source: Vivanti slides; Utah summary]

Moving between steps / criteria

A learning step is passed when performed to criterion across three consecutive sessions; then the next step is targeted. [source: Utah summary]
Expected progress: visible change on data sheets about every 3–5 days for children receiving 20+ hours/week, or every 1–2 weeks at lower intensity; if not, apply the decision tree (Section 4, intervention 4). [source: Utah summary]
An objective is mastered when the behaviour meets its accuracy criterion and generalises across the specified people, settings and materials (example in training: imitates a modelled action within 5 seconds on 4 of 5 opportunities, across 3 activities and 2 people, on 3 consecutive sessions). [source: PSU Weber & Crawford]
Therapist fidelity: the 13-item Fidelity Rating System, each item scored 1–5; scores of 4–5 indicate the strategy is used usually/consistently. A commonly cited competence threshold is about 85% of the maximum with no item below 3. [source: van Noorden et al. 2022 for scoring] [uncertain: the 85% criterion and certification steps are not verified]
P-ESDM parent fidelity is scored with the same 13-item scale applied to parent–child play; coaching focus moves to the next strategy once a parent uses the current one at fidelity. [source: ANZCTR 12618000254291; van Noorden et al. 2022]

3. Guiding principles

[source: Vivanti PSU slides; PSU Weber & Crawford fidelity list; Utah summary; Rogers, Vismara & Dawson 2021 sample chapter] Each principle with its practical meaning:

Interpersonal engagement is the core target. Every activity is judged first by whether the child is engaged with you, not with the toy alone.
Learning is embedded in play and daily routines. Teach during play, meals, bath, dressing, not at a table drill.
Follow the child's interests and motivation. Start from what the child reaches for or looks at; build the teaching into that.
Shared control. Neither adult nor child runs the activity alone; you alternate turns and leadership.
Positive affect throughout. Your animated face, voice and enthusiasm are the main reward and must be visible and genuine.
Optimal arousal. Adjust your energy up or down so the child is alert, calm and available for learning.
Intrinsic and natural reinforcement. The reward is the activity itself or social fun; extrinsic rewards only when the decision tree calls for them.
Developmental curriculum. Targets follow typical developmental sequences and the Checklist level, across all domains at once.
Behavioural teaching precision. Every teaching episode has a clear antecedent, a target behaviour and a contingent consequence, with prompting, shaping and fading.
Imitation as a keystone skill. Teach imitation early, then use it to teach everything else.
Social-pragmatic view of language. Words are taught as tools for real communicative purposes within interaction, with nonverbal communication taught alongside.
Many, varied communicative opportunities. Each minute should contain several chances for the child to communicate.
Language pitched to the child's level. Keep your utterances short and just above the child's own.
Multiple objectives per activity. A single routine targets objectives from several domains.
Data-based decisions. Record frequently; change teaching when data stall, following the decision tree.
Positive behaviour support. Prevent and replace unwanted behaviour; no punishment-based consequences.
Parent partnership. Parents choose goals with you and are coached to use the strategies in daily life.
Interdisciplinary team. One lead, but goals across communication, motor, behaviour and self-care are planned jointly.
Fidelity-monitored delivery. You are rated on the 13 fidelity items; use them as your self-check.
(2nd ed.) Neurodiversity-affirming stance. Support development while respecting autistic ways of being. [uncertain: framing named on publisher page; practical content not drawn on]

4. Intervention inventory

Grouped as: A. assessment and planning; B. the teaching framework (mapped to the 13 fidelity items); C. domain teaching; D. behaviour; E. delivery formats (P-ESDM, G-ESDM, team). All example language is illustrative unless quoted. The Curriculum Checklist, data sheets and fidelity forms are copyrighted; use the published originals, not reconstructions. [source: Utah summary; PSU Weber & Crawford; Vivanti slides]

A1. Curriculum Checklist assessment

Purpose / when: Establish the child's skill profile in every domain at intake and every 12 weeks.
Steps: (1) Gather parent priorities and a description of a typical day. (2) Set up a play space with age-appropriate toys and snacks; run the assessment as a sequence of play activities, not item-by-item testing, with a parent present. (3) Score each item observed as pass, inconsistent or fail; ask the parent about items not observable (self-care, behaviour at home). (4) In each domain, identify the zone where passes turn to inconsistent/fail — the target zone for objectives. (5) Integrate other team members' observations. [source: Utah summary; PSU slides]
Example language (illustrative): "I'm going to play with her and see what she shows me; tell me if anything looks different from home."
Watch for: Under-scoring a tired or anxious child; confirm with parent report or a second probe. Working: the profile shows a clear learning edge in each domain.

A2. Writing 12-week objectives

Purpose / when: Turn the profile into a teachable plan after each assessment.
Steps: (1) Pick 2–3 items per domain from the learning edge, prioritising what parents want and what is functional in daily life. (2) Write each as: antecedent (what the adult does/situation), observable child behaviour, mastery criterion (e.g., proportion of opportunities, latency), generalisation criterion (people, settings, materials). (3) Agree with parents; check objectives cover imitation, joint attention, communication, play and social domains, which are priority targets. [source: PSU Weber & Crawford; Utah summary; Wikipedia ESDM]
Example language (illustrative, to parent): "Of everything on this list, what would make the biggest difference to your mornings?"
Watch for: Objectives that are vague ("improve communication") or that only a therapist could elicit. Working: any team member or parent could tell from the wording whether the child did it.

A3. Task analysis into learning steps

Purpose / when: Make progress visible and teaching precise; done for every objective.
Steps: (1) Write the child's current baseline as step 1 and the mastery criterion as the last step. (2) Fill intermediate steps by increasing independence (less prompt), complexity, frequency, or generalisation (new people/materials). (3) Enter steps on the Daily Data Sheet with start dates and passed dates. [source: Utah summary; PSU Weber & Crawford]
Watch for: Steps too large (child stuck for weeks) or too small (passes every session). Working: steps are passed at roughly the expected rate.

A4. Daily data collection and the decision tree

Purpose / when: Monitor learning continuously; change teaching when progress stalls.
Steps: (1) About every 15 minutes, pause while the child plays independently and record the current step performance for objectives targeted (blank = not probed). (2) Code the child's overall behaviour for the session. (3) Summarise across sessions. (4) Compare with the expected rate: change every 3–5 days at 20+ hours/week or every 1–2 weeks at lower intensity. (5) If progress is inadequate, escalate in order: first reinforcement (increase social reinforcement; then pair with a more powerful reinforcer, including an extrinsic one, or follow a low-interest task with a highly preferred activity); then structure (more frequent probes, fewer materials and activities, more repeated opportunities, moving towards more adult-directed teaching); then visual supports (schedules, templates, video modelling), treated as a later step because the aim is natural, unsupported performance. Re-check after each change. [source: Utah summary; Vivanti slides] The 2nd edition has new and revised decision trees and a chapter on concerning progress. [uncertain: their content]
Example language (illustrative, to team): "Three weeks flat on the pointing objective — let's try a stronger reinforcer for that step before we add structure."
Watch for: Data taken from memory at the end of a session (unreliable). Working: changes in teaching are followed by renewed movement on data sheets.

B1. Managing the child's attention (fidelity item 1)

Purpose / when: Before any teaching episode; whenever the child's attention drifts.
Steps: (1) Position yourself face-to-face at the child's eye level (on the floor, child on a small chair or bean bag). (2) Remove or limit competing materials; keep toys in view but out of reach, in clear containers or on a shelf. (3) Join what the child is already looking at rather than pulling them to your choice. (4) Make yourself interesting: animated face, voice, movement. (5) Deliver the antecedent only once the child is attending to you or the shared material. [source: PSU fidelity list; Buckendorf handout citing Rogers, Dawson & Vismara 2012; Utah summary]
Example language (illustrative): "Oh! Cars!" (moving into the child's line of sight, holding the car near your face)
Watch for: Child seeing only your back or hands; talking at a child who is turned away. Working: the child looks at your face during the activity and returns to you spontaneously.

B2. Modulating affect and arousal; using positive affect (items 4 and 8)

Purpose / when: Keep the child in an alert, calm, available state; make you rewarding.
Steps: (1) Read arousal: under-aroused (passive, slumped, wandering) vs over-aroused (giggling to escalation, crashing, distress). (2) For low arousal: livelier voice, bigger movement, faster pace, physical games. (3) For high arousal: slower and quieter voice, rhythmic calm activities, deep-pressure or calm sensory routines, fewer materials. (4) Keep genuine, matched positive affect throughout — smile, delighted voice — tuned to what this child enjoys (some prefer quieter warmth). [source: PSU fidelity list; Buckendorf handout]
Example language (illustrative): (quietly) "Slooow... swing... and stop."
Watch for: Over-entertaining that tips the child into dysregulation. Working: the child stays engaged, can attend and respond, and seeks you out.

B3. Optimising motivation (item 7)

Purpose / when: Throughout; especially for children with narrow interests.
Steps: (1) Offer choices between two or more preferred materials; let the child choose. (2) Use the reinforcer that is natural to the response (asking for a ball gets the ball). (3) Reinforce attempts, not only perfect responses. (4) Intersperse easy maintenance tasks with new acquisition tasks. (5) Vary materials and end activities before interest is exhausted. [source: PSU fidelity list; Vivanti slides] [uncertain: interspersal of maintenance and acquisition tasks]
Example language (illustrative): "Bubbles or the drum?" (holding both up)
Watch for: Activities chosen by the adult that the child tolerates but does not enjoy. Working: the child approaches, reaches and initiates.

B4. Sensory social routines (SSRs)

Purpose / when: Build engagement, shared smiles, eye contact, communication and imitation when the child is not interested in objects, is between activities, or needs arousal adjusted. The focus is on the partner rather than an object. [source: Utah summary; Buckendorf handout citing Rogers, Dawson & Vismara 2012]
Steps: (1) Find a game the child enjoys that uses your body, voice or a simple sensory prop (songs with actions, peekaboo, tickles, chase, swinging, bubbles, balloons, lotion). (2) Face the child; set a predictable rhythm and repeat 2–3 times. (3) Pause just before the climax with an expectant look and wait. (4) Continue as soon as the child signals (eye contact, gesture, sound, word, body movement); shape signals towards more mature forms over time. (5) Give the routine a name; keep your turn short so the child has a role. (6) Add variations (new verse, sound, step, person) once the routine is established. (7) End when interest drops. [source: Buckendorf handout; Vanderbilt TRIAD SSR tipsheet (secondary)]
Example language (illustrative): "Ready... set..." (pause, wait for look) "...GO!"
Watch for: Child passive while adult performs; over-arousal. Working: the child initiates or requests the routine, smiles at you, fills pauses.

B5. Joint activity routines (JARs) (item 12)

Purpose / when: The main teaching vehicle for object-based play and daily activities; each lasts about 2–4 minutes in 1:1 work and targets several objectives.
Steps: (1) Set-up: follow the child's choice of material; establish a shared focus. (2) Theme: take turns doing the basic activity (e.g., stacking blocks), embedding objectives (requesting, imitation). (3) Elaboration / variation: add new actions, materials or roles to increase complexity, target objectives from other domains (counting, colours, fine motor, pretend), and build flexibility. (4) Closing / transition: tidy up together and move to the next activity. [source: Vivanti slides; PSU Weber & Crawford]
Example language (illustrative): Set-up "Blocks! Build?" Theme "My turn... your turn." Variation "Uh-oh, crash! Big tower now." Closing "All done blocks. Put in."
Watch for: Stuck on theme repetition with no variation; parallel play without exchange. Working: several objectives probed per routine; the child tolerates and adds variations.

B6. ABC teaching episodes (item 2)

Purpose / when: Each targeted learning opportunity inside SSRs and JARs.
Steps: (1) Make sure the child is attending. (2) Give a clear antecedent fitted to the target (a model, an instruction, a pause, an offered choice). (3) Wait for the child's response. (4) Deliver a contingent, immediate consequence: the natural reinforcer plus social praise for a correct or improved attempt; a prompt for no or incorrect response, then reinforce the prompted response. (5) Record performance at the next data pause. [source: Vivanti slides; PSU fidelity list; Utah summary]
Example language (illustrative): Antecedent: holding a car out of reach and pausing. Child reaches and vocalises. Consequence: "Car!" (handing it over immediately)
Watch for: Unclear antecedents, reinforcing without a response, delayed reinforcement. Working: high frequency of clean episodes; increasing independent correct responses.

B7. Prompting and prompt fading (item 3, instructional techniques)

Purpose / when: Help the child succeed on a new skill, then remove help so the skill becomes independent.
Steps: (1) Choose the least intrusive prompt likely to work: full physical, partial physical, model, gesture/point, positional, verbal. (2) Give the prompt right after (or with) the antecedent when the child is unlikely to respond alone; reinforce the prompted response. (3) Record prompt level (full, partial, minimal) on the data sheet. (4) Fade systematically across opportunities (lighter touch, delay before prompting, smaller gestures). (5) Avoid repeated identical verbal instructions. [source: Utah summary; Vivanti slides; PSU Weber & Crawford] [uncertain: the specific prompt-type list is standard ABA practice; the manual's exact hierarchy is not drawn on]
Example language (illustrative): Model "Clap!" (you clap), wait 2–3 seconds, then gently guide the child's hands, then "Yay, clapping!"
Watch for: Prompt dependence (child waits for the prompt). Working: prompt level recorded is falling across sessions.

B8. Shaping (item 3)

Purpose / when: Build a behaviour the child cannot yet produce by reinforcing successive approximations (e.g., reach → reach with eye gaze → reach with vocalisation → word approximation).
Steps: (1) Identify the child's current best approximation. (2) Reinforce it consistently until reliable. (3) Raise the requirement one small step; reinforce only responses at the new level (or prompt them). (4) Drop back a step if the child stops responding. [source: Utah summary names shaping; procedure is standard behavioural method] [synthesis: step wording]
Watch for: Raising criteria too fast (frustration) or too slow (stalled). Working: approximations grow towards target on the learning steps.

B9. Chaining and behaviour bundles

Purpose / when: Teach multi-step routines (handwashing, toothbrushing, dressing, tidying).
Steps: (1) Task-analyse the routine. (2) Decide forward chaining (teach the first step, adult completes the rest) or backward chaining (adult does all but the last step; child completes the final step and gets the natural end-reward). (3) Prompt and fade each step; add the next once mastered. (4) For behaviour bundles (behaviours that occur together without fixed order, e.g., the components of a play scheme), teach components individually and in varied order. [source: Utah summary]
Example language (illustrative): "Last one — you turn the water off!" (backward chaining)
Watch for: Prompting every step at the same level. Working: more steps completed independently.

B10. Dyadic engagement and turn-taking (item 6)

Purpose / when: Make every activity a two-person exchange.
Steps: (1) Take a role in the activity (hand a piece, add a block). (2) Use short turns: "my turn", act or model briefly, then "your turn" and return the object. (3) Keep the child involved during your turn (narrate, invite them to watch). (4) Balance control: the child leads sometimes, you lead sometimes. [source: Utah summary; PSU fidelity list; Buckendorf handout]
Example language (illustrative): "My turn... (rolls ball) ...your turn!"
Watch for: Long adult turns causing the child to leave; grabbing and distress. Working: smooth back-and-forth exchanges sustained over minutes.

B11. Sensitivity and responsivity to child cues (item 9)

Purpose / when: Always; treat every child behaviour as potentially communicative.
Steps: (1) Watch for gaze, reaches, vocalisations, body orientation, moving away. (2) Respond quickly and meaningfully (give, comment, continue, stop). (3) Interpret and model the more mature form (child reaches → you say the word). (4) Respect protest and "all done" signals. [source: PSU fidelity list; Buckendorf handout]
Example language (illustrative): Child pushes the puzzle away. "All done puzzle." (removing it)
Watch for: Missing subtle signals in low-verbal children. Working: the child's signals become clearer and more frequent.

B12. Multiple and varied communicative opportunities (item 10)

Purpose / when: Ensure many chances per minute to request, protest, comment, greet, ask for help or share.
Steps: (1) Hold desired items in view but out of reach and wait (incidental teaching). (2) Offer choices. (3) Give small portions so requests recur. (4) Pause in familiar routines. (5) Create "needs help" situations (closed containers, wind-up toys). (6) Vary functions, not only requesting: comments, greetings, "no", showing. [source: Utah summary; Buckendorf handout; PSU fidelity list]
Example language (illustrative): (holding the jar lid tight, expectant look) ... "Open? Help!"
Watch for: Withholding becoming frustrating; only requests targeted. Working: varied communicative acts each minute.

B13. Adult language at the child's level (item 11)

Purpose / when: Always.
Steps: (1) Gauge the child's typical utterance length. (2) Speak mostly in utterances slightly longer than the child's (e.g., single words for a non-verbal child, two words for a single-word user). (3) Use the same words for the same things; name actions and objects as they happen. (4) Reduce questions and commands; narrate and comment. [source: PSU fidelity list; Buckendorf handout] [uncertain: the "one-up" rule is widely taught with ESDM but not confirmed]
Example language (illustrative): Child says "car"; you: "Fast car!"
Watch for: Long sentences, many questions. Working: the child imitates your words and phrases.

B14. Transitions between activities (item 13)

Purpose / when: Between every JAR or SSR.
Steps: (1) Close the activity clearly (tidy up together, "all done"). (2) Offer a choice of the next activity, or let the child's next interest lead. (3) Use transitions as teaching opportunities (carry, put away, walk together). (4) Keep transitions brief so engagement is not lost. [source: PSU fidelity list; Vivanti slides]
Example language (illustrative): "Blocks all done. In the box... Now? Ball or bubbles?"
Watch for: Dead time, protest at endings. Working: smooth, quick changes without behaviour problems.

C1. Imitation teaching

Purpose / when: Early and continuously; imitation is treated as a keystone skill later used to teach other skills.
Steps: (1) Start by imitating the child (actions, sounds) to build awareness of being imitated. (2) Use duplicate toy sets so you can model actions alongside the child. (3) Model actions on objects the child already likes, then novel actions; wait; prompt if needed; reinforce. (4) Progress: object imitation → gesture imitation (clap, wave) → oral-facial movements → vocal/word imitation; prompt and fade for gestures. (5) Imitate the child, then add a variation for the child to copy back. [source: Utah summary (citing Rogers & Pennington 1991); Buckendorf handout]
Example language (illustrative): You bang the drum twice: "Boom boom!" ... wait ... child bangs → "Boom boom! You did it!"
Watch for: Imitation only with physical prompts; imitation of only one action. Working: spontaneous imitation of novel actions and words across people.

C2. Nonverbal communication and joint attention

Purpose / when: Teach gaze coordination, gestures (reach, point, give, show, head shake/nod), following another's point and gaze, and sharing interest.
Steps: (1) Shape goal-directed reaches into points (prompt the point at the moment of reaching, then fade). (2) Teach giving to request help (hold out hand for a container the child can't open). (3) For responding to joint attention: point to nearby interesting items, then farther ones, prompting the child to look. (4) For initiating joint attention: create surprising events and respond with delight when the child shows or looks between object and you. (5) Pair gestures with words. [source: Utah summary (Level 1–2 examples); Vivanti slides] [uncertain: detailed joint attention procedures in the manual are not drawn on; the step order here is synthesis]
Example language (illustrative): (pointing to the bubbles) "Look! Bubbles!"
Watch for: Child points only with prompts or never checks your face. Working: spontaneous showing, pointing to share, looking where you point.

C3. Verbal communication (and AAC)

Purpose / when: Once nonverbal communication and vocal imitation are developing; AAC to be considered where speech is slow (2nd ed. emphasis).
Steps: (1) Increase vocalisations through sound play and imitation in SSRs. (2) Shape vocalisations into word approximations at pause points. (3) Model single words in context; then word combinations. (4) Expand the child's utterances by one element. (5) Teach receptive language within routines (following one-step instructions with gestures, then without). (6) Where speech is not emerging, add signs, picture exchange or speech-generating devices per team speech-language therapist. [source: Utah summary; Guilford 2nd-ed. page (AAC emphasis)] [uncertain: specific AAC procedures in the 2nd ed.]
Example language (illustrative): "More..." (pause) child: "muh" → "More! More bubbles!"
Watch for: Echolalia without function; demanding words before the child can imitate sounds. Working: increase in spontaneous, purposeful words across settings.

C4. Play teaching (functional, constructive, symbolic)

Purpose / when: Expand the cognitive aspects of play inside JARs.
Steps: (1) Start from the child's current play level (exploring, cause–effect, functional use). (2) Model the next level within the JAR variation phase (functional → constructive building → simple pretend with realistic props → pretend sequences → object substitution and role play). (3) Prompt imitation of new play acts, then fade. (4) Connect play schemes into sequences (feed the doll, then put to bed). [source: Wikipedia ESDM (cognitive play in dyadic routines); Rogers, Vismara & Dawson 2021 topics 8–9] [synthesis: level sequence]
Example language (illustrative): "Teddy hungry. Spoon... yum!"
Watch for: Repetitive lining up only; pretend imposed before functional play. Working: new play acts appear spontaneously and in other settings.

C5. Self-care and daily routines

Purpose / when: Personal independence objectives (eating with utensils, dressing, handwashing, toileting readiness); also as natural communicative contexts.
Steps: (1) Task-analyse the routine. (2) Teach via chaining with natural reinforcers (finishing handwashing → snack). (3) Embed communication and imitation targets (requesting, choosing, naming). (4) Coach parents to use the same steps at home. [source: Utah summary; Rogers, Vismara & Dawson 2021 (routines)]
Watch for: Rushing and doing it for the child. Working: increased independent steps at home.

D1. Managing unwanted behaviour (item 5; positive behaviour support)

Purpose / when: Whenever behaviour interferes with learning or safety (throwing, mouthing, tantrums, aggression, self-injury, persistent stereotypy that blocks engagement).
Steps: (1) Prevent: arrange the environment and materials to reduce opportunities (fewer items out, unbreakable materials, predictable structure). (2) For misuse of an object: take it, model the correct use, give it back and reinforce imitation of the correct use; if it continues, remove the object from the play space. (3) Teach a replacement behaviour serving the same purpose (e.g., signing "all done" instead of throwing to end an activity). (4) Do not use punishment-based consequences; keep high levels of positive attention for appropriate behaviour. (5) For severe, dangerous or persistent behaviour, a behaviour analyst conducts a functional assessment/analysis, identifies the function and builds a plan with replacement skills. [source: Utah summary; PSU fidelity list]
Example language (illustrative): Child throws a block. You hold it calmly: "Blocks go on top," (stack it) "your turn," (hand back) "on top — yes!"
Watch for: Inadvertently reinforcing (escaping demands, attention escalation). Working: lower frequency of the behaviour and use of the replacement.

E1. P-ESDM parent coaching session

Purpose / when: To teach parents ESDM strategies so they embed learning opportunities in daily routines; as a stand-alone low-intensity intervention (often 12 weekly sessions) or alongside therapist delivery.
Steps (session routine as used in trials): (1) Greet; collect any home data. (2) Progress check: review last week's focus and the home practice. (3) Warm-up: parent plays with the child for a few minutes using last week's strategies while you observe (often video-recorded, ~10 minutes in some protocols). (4) Joint reflection on the warm-up: parent first, then you. (5) Topic: introduce or revisit a strategy (parent can choose); discuss with a handout and link it to the child's objectives; model briefly if useful. (6) Parent practises the strategy in an activity with in-the-moment coaching. (7) Reflect. (8) Practise again in a different activity (e.g., snack, bath, book, play) and reflect. (9) Plan the week: which routines, which strategy, how to note practice. [source: ANZCTR 12618000254291; van Noorden et al. 2022]
Topic sequence (P-ESDM coaching book, ch. 7): (1) getting the child's attention; (2) making interactions enjoyable for both; (3) back-and-forth turn-taking; (4) nonverbal communication; (5) imitation; (6) the ABCs of behaviour; (7) joint attention; (8) flexible, creative object play; (9) pretend play; (10) spoken language. Group formats compress these into four themes: capturing attention, structuring JARs, behavioural strategies for new skills, and teaching communication objectives. [source: Rogers, Vismara & Dawson 2021 Italian sample (contents); van Noorden et al. 2022] The parent book An Early Start for Your Child with Autism (2012) presents a parallel set for parents, including SSRs, imitation, joint attention, play, speech and "putting it together". [source: Buckendorf handout] [uncertain: exact chapter titles not verified]
Example language (illustrative): "What did you notice when you paused before 'go'?" ... "Which part of your day would be easiest to try that in this week?"
Watch for: Lecturing; too much new content; parent watching you rather than practising. Working: parent's fidelity scores (13-item scale on parent play) rise; the parent independently names and adapts strategies.

E2. Coaching techniques within P-ESDM

Purpose / when: The how of coaching across every session.
Steps: (1) Position as a partnership of two experts: you on development and teaching, parent on the child and family; set goals collaboratively from family priorities. (2) Use reflective questions and statements more than instruction; give didactic input mainly when the parent asks. (3) Give feedback focused on the goal and the child's response, non-judgementally; highlight what worked first. (4) Coach during real routines (snack, play, bath, dressing), positioning yourself so you support rather than replace the parent. (5) Coach siblings into play where appropriate. (6) Help the parent problem-solve and plan independently to build self-efficacy. (7) Enhanced P-ESDM adds motivational interviewing, multimodal learning materials and home visits. [source: Rogers, Vismara & Dawson 2021 sample ch. 1–2; PSU Weber & Crawford; Rogers et al. 2019 abstract]
Example language (illustrative): "You waited, and he looked right at you — what did you do next?"
Watch for: Parents feeling evaluated. Working: parent brings their own examples and solutions to sessions.

E3. Group parent coaching (tiered model)

Purpose / when: Lower-cost first tier; individual coaching for families who need more.
Steps: (1) Weekly 60–90 minute clinic group with children present, for about 9–10 weeks. (2) Parents reflect on goals and last week's practice. (3) Present one topic; group problem-solves linking it to each child's goals. (4) At least 10 minutes of each parent practising with their child with coach feedback; record a short parent–child video weekly. (5) Move families not reaching fidelity to 1:1 coaching focused on strategies not yet at fidelity. [source: van Noorden et al. 2022 (a research adaptation, not the founders' core protocol)]

E4. Group-based ESDM (G-ESDM) in preschool/childcare

Purpose / when: Delivering ESDM in inclusive or specialised early-years settings and preparing for school routines.
Steps: (1) Staff ratio about 1:3–1:4; individual objectives targeted inside group activities and activity centres. (2) Set up peer interaction: position children near each other, parallel play with duplicate toy sets, materials as "magnets" for interaction, circle games; adults act as background supports. (3) Teach peer goals: giving and taking materials, showing, asking for a turn or object, saying "no/mine/not yet", responding to greetings. (4) Add group skills: following shared routines, group participation, daily living and safety skills. [source: Vivanti PSU slides; Utah summary]
Watch for: Children waiting with no learning opportunities; adults over-mediating peer exchanges. Working: frequent individual opportunities per child and spontaneous peer exchanges.

E5. Interdisciplinary team and 12-week review

Purpose / when: Plan, supervise and revise each cycle.
Steps: (1) A team lead conducts the assessment and writes objectives with the parents and other disciplines. (2) Therapists deliver sessions and take data; lead supervises via data and fidelity ratings of video. (3) Review progress at least weekly via data; apply the decision tree. (4) Reassess and rewrite objectives every 12 weeks. [source: Wikipedia ESDM; PSU Weber & Crawford; Utah summary] [uncertain: supervision frequency not stated]

E6. Online caregiver modules (Help is in Your Hands)

Purpose / when: Free self-guided or provider-supported parent learning based on ESDM parent research, useful between sessions or where coaching is scarce.
Steps: Four modules: increasing attention to people; increasing communication; joint activity routines; ABCs of learning opportunities. Narrated video lessons with real families and follow-up activities; providers get a syllabus, webinars and handouts after registering. [source: UC Davis MIND Institute HIIYH flyer]

5. Handling problems

Source-based guidance is tagged; the rest is [synthesis].

Child not progressing on data. Apply the decision tree in order: strengthen reinforcement (more social reinforcement, then pair with a stronger or extrinsic reinforcer, or follow a low-interest task with a preferred one) → add structure (more frequent opportunities, fewer materials, more adult-directed teaching) → add visual supports. Also check that steps are small enough and the objective is within the child's learning edge. [source: Utah summary] The 2nd edition revises the decision trees and adds a chapter on concerning progress. [uncertain] Before escalating, rule out hearing, vision, sleep, illness, seizures or a change at home with the family and paediatrician. [synthesis]
Child avoids people or shows little interest in social games. Lead with sensory social routines using the child's preferred sensations; keep your turn short; pause and wait; reinforce any signal. Join solitary play by imitating the child rather than redirecting. [source: Utah summary; Buckendorf handout] [synthesis: start with imitation of the child]
Narrow interests / low motivation for toys. Build JARs around the special interest (letters, spinning items) and use it as the theme while adding variations; offer choices; use natural reinforcers. [synthesis grounded in follow-the-child's-interest principle]
Overwhelm, over-arousal, meltdowns. Lower your intensity, reduce materials and noise, shift to calming rhythmic routines; stop demands until the child is regulated; then restart with an easy, preferred activity. Track triggers on the data sheet's behaviour code. [source: PSU fidelity list (arousal item)] [synthesis: specific steps]
Unwanted behaviour persists or is dangerous. Move from in-session redirection and replacement teaching to a functional assessment led by a behaviour analyst and a written positive behaviour support plan. [source: Utah summary] If self-injury causes tissue damage or there are safety concerns at home, involve the medical team and follow local safeguarding processes. [synthesis]
Adult over-directing (common with therapists trained in discrete trials). Self-rate on the shared control, motivation and responsivity fidelity items using video; practise waiting and following. [synthesis using the 13 fidelity items]
Prompt dependence. Use the least intrusive prompt, insert a short wait before prompting, fade systematically, and record prompt level each probe. [source: Utah summary (prompt level recording)] [synthesis]
Parent non-adherence to home practice. Shrink the plan to one strategy in one or two existing routines (bath, snack); ask the parent to pick them; review barriers without judgement in the progress check; consider motivational interviewing as in enhanced P-ESDM. [source: Rogers et al. 2019 abstract (MI enhancement); Rogers, Vismara & Dawson 2021 (collaborative goals)] [synthesis: specific steps]
Parent stress, low mood or feeling judged. Start each reflection with what the parent did well; keep coaching non-evaluative; ask about family wellbeing; refer for parental mental-health support when needed (a psychotherapist-coach can screen but should not turn coaching sessions into the parent's therapy). [source: Rogers, Vismara & Dawson 2021 sample (non-judgemental, goal-focused feedback)] [synthesis: referral advice]
Rupture in the coaching relationship (parent disagrees with goals, feels criticised, misses sessions). Name it, invite the parent's view, return to their priorities and revise objectives together; repair before teaching more content. [synthesis]
Family concerns that ESDM is ABA or not neurodiversity-affirming. Explain how ESDM uses ABA learning principles inside child-led, play-based, relationship-focused interaction without punishment, and that goals are chosen with the family; respect choices about which goals to pursue; treat stereotypy as a target only when it blocks learning or causes harm. The founders now frame the 2nd edition as neurodiversity-affirming, and whether ESDM counts as ABA is debated in the literature. [source: Vivanti PSU slides; Guilford 2nd-ed. page; Vivanti & Stahmer 2021 cited via Wikipedia] [synthesis: conversation content]
Limited hours / cannot fund intensive delivery. Use P-ESDM coaching (12 weekly sessions) and the free online modules to multiply learning opportunities in daily routines. [source: Vivanti slides; HIIYH flyer] [synthesis]
Culture and language. Choose routines, games and songs that fit the family's daily life and home language; let parents lead goal priorities. The 2nd edition has a chapter on implementing ESDM across countries and cultures. [source: Guilford 2nd-ed. page] [uncertain: chapter content]
Child is minimally verbal at the end of a cycle. Increase nonverbal and vocal imitation work and involve the speech-language therapist about AAC early rather than waiting. [source: Guilford 2nd-ed. page (AAC emphasis)] [synthesis]
Child ages out or moves to school. In the final cycles, target group skills (shared routines, peers, waiting) via G-ESDM-style activities and hand over objectives and strategies to the school team. [source: Vivanti slides (next learning environment)] [synthesis]
Telehealth delivery. Coach parents live via video with the parent and child in their own routines; keep the session routine (warm-up, reflection, topic, practice, plan). [synthesis; remote ESDM-informed coaching is being trialled (NCT05417607)] [uncertain]
Therapist fidelity drift. Periodic video fidelity ratings by a certified rater; target items scoring below 4. [source: van Noorden et al. 2022 (scoring); Zitter et al. 2023 (fidelity linked to child learning)]

Training note. Delivering or coaching ESDM is expected to follow formal ESDM training (introductory and advanced workshops, then video-based fidelity certification through the developers' training organisation; P-ESDM coaching certification is separate). [uncertain: details should be checked with the ESDM training organisation]

Sources

Sources: