Piloting the Early Start Denver Model in South Africa

Background: Specialised paediatric clinical services are scarce in low- and middle-income countries such as South Africa. Those that do exist are greatly overburdened. Children with autism spectrum disorders (ASD) may have access to services (such as speech and language therapy and occupational therapy) as infrequently as once every 4-6 weeks. Clearly, there is great need for further intervention, but given the lack of resources, such interventions may be best implemented if families can be trained to deliver at least some elements of those therapies themselves.
The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) addresses both general development and the specific impairments associated with autism, and, importantly, promotes parental involvement. ESDM is thus appropriate for South Africa as it targets multiple developmental domains simultaneously, hence increasing cost-effectiveness by (a) reducing the number of specialists a child needs to see, and (b) promoting family-delivered intervention.

Objectives: Any intervention implemented in South Africa must be effective and acceptable for a variety of language, cultural, and socioeconomic groups. Before introducing parent-delivery we wished to test the effectiveness and appropriateness of ESDM in a South African sample.

Methods: Our pilot study included 12 culturally diverse families (average participant age = 47.5 months, ADOS autism severity rating = 8.6, developmental quotient = 48.8) to test the feasibility of a one-hour-a-week therapist-delivered ESDM programme. Families were referred from the non-profit agency Autism Western Cape. The intervention was run over 12 weeks, with each child seen individually once a week. Children were assessed on the Autism Diagnostic Observation Schedule (ADOS), the Griffiths Mental Development Scales – Extended Revised edition (GMDS-ER), and the Vineland Adaptive Behaviour Scales second edition (VABS-II), before and after the intervention. Parents completed the Social Communication Questionnaire (SCQ) and the Measure of Processes of Care – South African edition (MPOC -8 [SA]), a measure of satisfaction with service delivery.

Results: Preliminary results suggest that parents noted improvement in multiple domains (including language, socialization, and behaviour), and indicated that their behaviour towards their child had changed as result of the intervention (e.g., they spent more time talking and playing). Formal measures of development partially supported the parent reports. Anecdotally, therapists also felt that working with families in their home language was more beneficial to the child.
Attendance at intervention sessions ranged from 20-100%. Unsurprisingly, regular attendance was associated with greater improvement and greater satisfaction with the intervention. Family structure and income significantly predicted attendance: Non-attendance was mainly due to financial difficulties (specifically, parents could not afford to take time off work, or could not afford the cost of taking public transport to the session), particularly for single parents.

Conclusions: This pilot study suggests that ESDM, when delivered by a trained therapist, can be effective in the South African context. The main barriers to delivery were language and non-attendance due to financial constraints. We advise using an easily-accessible community centre to host intervention sessions. We also suggest either training therapists from various language groups or requiring that therapists attend a language bridging course.