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Some of the most common screen assessment tools are: the Denver Developmental Screening Test II, the Ages and Stages Questionnaire, the Early Screening Inventory-Revised (ESI-R), the Hawaii Early Learning Profile (HELP) and the Developmental Indicators for the Assessment of Learning (DIAL) 1 2. Screening tools are administered by trained personnel. Denver II adalah revisi utama dari standardisasi ulang dari Denver Development Screening Test (DDST) dan Revisied Denver Developmental Screening Test (DDST-R). Denver II digunakan sebagai metode penilaian perkembangan anak yang meliputi 4 hal yaitu: personal sosial, motorik kasar, bahasa, dan motorik halus.

What is the Early Start Denver Model?

The Early Start Denver Model (ESDM) is a behavioral therapy for children with autism between the ages of 12-48 months. It is based on the methods of applied behavior analysis (ABA).

Parents and therapists use play to build positive and fun relationships. Through play and joint activities, the child is encouraged to boost language, social and cognitive skills.

  • Based on understanding of normal toddler learning and development
  • Focused on building positive relationships
  • Teaching occurs during natural play and everyday activities
  • Uses play to encourage interaction and communication

ESDM therapy can be used in many settings, including at home, at a clinic, or in school. Therapy is provided in both group settings and one-on-one.

It has been found to be effective for children with a wide range of learning styles and abilities. ESDM can help children make progress in their social skills, language skills, and cognitive skills. Children who have significant learning challenges can benefit just as much as those without learning challenges.

Parent involvement is a key part of the ESDM program. Therapists should explain and model the strategies they use so that families can practice them at home.

Who provides Early Start Denver Model services?

An ESDM therapist may be any of the following:

  • Psychologist
  • Behavior specialist (BCBA)
  • Occupational therapist
  • Speech and language pathologist
  • Early intervention specialist
  • Developmental pediatrician

All therapists must have specific training and certification in EDSM. This process requires them to:

  • Attend a training workshop
  • Submit video showing them using ESDM techniques in therapy sessions
  • Demonstrate they can use these techniques correctly and reliably

This ensures that a certified professional has the knowledge and skills to successfully use the teaching strategies with children with autism.

Details on training qualifications and the certification process can be found here. You can also visit the Early Start Denver Model website to learn more.

What is the evidence that the Early Start Denver Model works?

Over a dozen studies have demonstrated the benefits of ESDM as an early intervention for autism among children as young as 18 months. These studies included children across a wide range of learning abilities.

Many of these studies looked at ESDM delivered by trained therapists in one-on-one sessions with the child. One looked at ESDM delivered to groups of children in childcare. Others looked at the benefits of training parents to deliver ESDM therapy at home.

Benefits include improved learning and language abilities and adaptive behavior and reduced symptoms of autism. Research using brain scans suggests that ESDM improves brain activity associated with social and communication skills.

Is Early Start Denver Model covered by insurance?

Sometimes. Many types of private health insurance are required to cover services for autism. This depends on what kind of insurance you have, and what state you live in.

Multiboxing. All Medicaid plans must cover treatments that are medically necessary for children under the age of 21. If a doctor recommends ESDM and says it is medically necessary for your child, Medicaid must cover the cost.

Some young children receive ESDM through their Early Intervention program. Early intervention is offered in each state to children under age 3 who are not growing and developing at the same rate as others. These services are free or low-cost based on your family income.

Please see our insurance resources for more information about insurance and coverage for autism services.

You can also contact the Autism Response Team if you have difficulty obtaining coverage, or need additional help.

Where do I find Early Start Denver Model services?

Visit the Autism Speaks Directory to search for providers near you.

View a list of certified ESDM therapists provided by UC Davis Mind Institute.

What questions should I ask?

The following questions can help you learn more about ESDM before you begin. It can also help you learn whether a particular therapist is a good fit for your family:

  1. Who will be working with my child?
  2. What training will you offer to parents?
  3. Where do you hold therapy sessions?
  4. How do you determine program goals?
  5. Are you trained to offer ESDM therapy?
  6. Can parents participate in therapy sessions?
  7. Will sessions be one-on-one, or held in a group?
  8. How do you handle challenging behavior?
  9. How do you measure progress?
  10. What type of progress should we expect?

For more information

Early Start Denver Model training manual for parents: An Early Start for Your Child with Autism

This book provides useful tips and hands-on strategies that parents can use in their daily activities and play. Parents can even use this information while waiting for your child to be enrolled in therapy.

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Two-year Child Development Check

In this article

As part of the Healthy Child Programme (HCP) in the UK, children have a health and development review at the age of 2-2.5 years[1]. This is carried out by the health visitor. It may be done in the child's home, the baby clinic, the children's centre or the child's nursery.

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This may now be an integrated review, combining what was previously an Early Years Foundation Stage (EYFS) 2-year progress review (carried out by childcare providers), with the 2.5-year HCP review[2].

In England, the responsibility for these early reviews was transferred from NHS England to local authorities in 2015[3].

This article covers the HCP two-year development check in England. The review is identical in principle in the rest of the UK but the specifics and terminology are available as follows:

  • Northern Ireland: health and development review at 2-2.5 years, a home visit by health visitors as part of the Healthy Child, Healthy Future programme of 2010[4].
  • Scotland: 27- to 30-month child health review guidance 2012, as part of the Scottish Child Health Programme published in 2005[5, 6].
  • Wales: 27-month check as part of the Healthy Child Wales Programme (0-7 years) published in 2016[7].

Aims

The two-year review aims to optimise child development and emotional well-being and reduce inequalities in outcome - specifically[8]:

  • Improvement in emotional and social well-being.
  • Improvement in learning and speech and language development.
  • Early detection of, and action to address:
    • Developmental delay.
    • Ill health.
    • Growth impairment.
  • High immunisation rates and reduction in rates of preventable disease.
  • Prevention of obesity.
  • Promotion of health-enhancing behaviours such as active play and well-balanced diet.
  • Early detection of psychosocial issues and action to address them:
    • Poor parenting.
    • Disruptive family relationships and domestic violence.
    • Mental health issues.
    • Substance misuse.
  • Provide information and advice about:
    • Dental care.
    • Accident prevention.
    • Sleep management.
    • Toilet training.
    • Behavioural management.

The process[8]

It is crucial to engage the parent(s) or carers and to discuss their views and concerns. Parents who voice concerns about their child's development are usually right[9]. Parents or carers must feel the process is useful, that their concerns have been listened to and addressed and that advice they have received is relevant and helpful. Invitations to the two-week check can be sent by letter, email, text or birthday card. Communication should be culturally appropriate; both parents should be encouraged to be involved where relevant and possible. Appointment times and venues must be flexible to enable a high response rate. Agreement of a shared agenda at the start, prioritising discussion of parental concerns and open-ended questions may all be helpful at the start of the appointment.

It may be helpful to offer a validated parental questionnaire to elicit concerns in advance of the appointment, to be discussed at the check. Appropriate questionnaires to use are the Parental Evaluation of Development Status (PEDS) or the Ages and Stages Questionnaire (ASQ)[10, 11]. From April 2015, NHS England mandated use of a standard questionnaire and specified ASQ-3 should be used; in addition, from October 2016 the ASQ:SE-2 (ASQ for social and emotional development) should be used[2]. Resources for a British form of the questionnaire have been funded and made available for health visitors to use.

This health and development check is designed to be flexible and non-prescriptive so it can be adapted to the needs and priorities of the locality and individual.

Assessment of development[8, 11]

Under the EYFS monitoring, progress is assessed in the following areas at age 2 years by a childcare provider, and a written summary provided for the parent(s) and/or carers[12]:

  • Communication and language.
  • Physical development.
  • Personal, social and emotional development.
  • Literacy.
  • Numeracy.
  • Understanding the world.
  • Creativity (expressive art and design).

This overlaps with the review which forms part of the HCP delivered by the health visiting team. At the 2- to 2.5-year review, development is assessed by answers on the ASQ-3 and by health visitors' observations. There are different forms to correspond to the appropriate age at which the questionnaire is being applied. Assessment includes the following areas but will vary slightly with exact age.

Gross motor skills

  • Walking and running without falling.
  • Ability to walk up or down at least two steps.
  • Jumping.
  • Kicking a ball.

Fine motor skills

  • Ability to make a stack of seven or more blocks.
  • Ability to thread beads or pasta on a string.
  • Imitating a drawing of a line.
  • Ability to use a turning motion for doorknobs, lids, wind-up toys.
  • Ability to turn switches on and off.
  • Ability to turn pages in a book.

Problem solving

  • Pretend play.
  • Knowing where items are kept and putting them away in the right places.
  • Recognition of own image in mirror.
  • Ability to work out a way of getting something out of reach.
  • Ability to copy lining up four objects in a row.
  • Picture recognition.

Personal-social

  • Copying gestures.
  • Ability to use cutlery.
  • Appropriate play with common toys.
  • Ability to put on a coat without help.
  • Calling themselves 'I' or 'me'.

Communication

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  • Following instructions (eg, 'get your book' or 'close the door'.
  • Vocabulary: Ability to name items/animals in a picture or parts of the body. Words such as 'mine', 'you', 'me'.
  • Understanding instructions given without gestures/pointing.
  • Ability to make sentences of 3-4 words.
  • Intelligible to familiar adults.

Hearing and vision

  • Parental concerns.
  • Family history of problems.

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Priority topics[8]

The HCP identifies the following topics as priorities at the two-year check.

Healthy lifestyle

This focuses on the prevention of obesity and on nutrition and active play. Nearly a third of children aged 2-15 years are obese currently, leading to huge potential health and economic costs later in life[13]. The two-year review is an excellent opportunity to discuss and establish lifelong healthy eating habits and encourage physical activity. This should be within the context of the whole family's eating and activity patterns. Parents and siblings are role models, and meals should ideally be taken within the family group. Specific information and advice about a healthy balanced diet should be shared and should be culturally appropriate and relevant. Vitamin drops containing vitamins A, C and D should be given to all children up to the age of 5 years.

Weight and height may be recorded on the growth charts in the child's 'red book'. Body mass index charts can be used for overweight or obese children. Referral for growth problems or interventions for obesity may be considered where appropriate.

Immunisation

Immunisation status is checked at the two-year review and followed up if not complete. Advice is given about the forthcoming schedule of further vaccination and its importance.

Personal, social and emotional development

This gives an opportunity for the parents to discuss temper tantrums and other behavioural problems, sleep issues and toilet training. By this age most toddlers are out of nappies in the daytime and using a potty or toilet. Issues such as parenting, involvement of the father, parental relationships and secure attachments can be discussed.

Speech, language and communication

Normall by this age a child can understand more complex instructions, has a range of 200 words or more, uses two- or three-word phrases, and can be understood by those who know them well. Where this is not the case referral to audiology or speech and language therapy may be appropriate.

Injury prevention

Most injuries at this age occur at home as a result of scalds, burns, falls or accidental poisoning, and this is an opportunity to raise awareness and prevent such incidents. Examples of areas to discuss include:

  • Locked cupboards for medicines, cleaning products. etc.
  • Stair-gates.
  • Covers for electric plugs.
  • Covers for sharp corners.
  • Smoke alarms.

Tools[8]

The Department of Health's 2009 guidance on the two-year review advises that if there are concerns, a formal assessment using validated tools should be used. Which is appropriate in each circumstance may vary between locality and individuals. The recommended tools are not needed in every child but support professional judgement where used. Validated recommended tools include:

  • UK World Health Organization (WHO) growth charts (to chart weight and height accurately in order not to miss problems such as obesity).
  • Ages and Stages Questionnaire (ASQ) (for general development).
  • Schedule of Growing Skills II (SOGS II) (for general development).
  • Parents' Evaluation of Developmental Status (PEDS) (for general development).
  • Sure Start Speech and Language Measure or the Communicative Development Inventory (CDI) (for speech and language assessment).
  • Social and Communication Questionnaire (SCQ) (autistic spectrum disorders).
  • The Modified Checklist for Autism in Toddlers (M-CHAT).
  • Ages and Stages Questionnaire: Social and Emotional (ASQ:SE).
  • Achenbach Child behaviour checklist.
  • Brief Infant Toddler Social Emotional Assessment (BITSEA).
  • Strengths and Difficulties Questionnaire.
  • HOME inventory (for parenting style observation).

Editor's note

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November 2017 - Dr Hayley Willacy recently read up-to-date guidance for first-line and second-line investigations for children with global developmental delay under the age of 5 years[14]. Global developmental delay (GDD) affects 1%-3% of the population of children under 5 years of age, making it one of the most common conditions presenting in paediatric clinics. Recent evidence shows that genetic testing for all children with unexplained GDD should be first line, if a cause is not already established. This review demonstrates that all patients, irrespective of severity of GDD, should have investigations for treatable conditions. The number of treatable conditions discovered this way is higher than previously thought and investigations for these metabolic conditions should be considered as first line. Additional second-line investigations can be led by history, examination and developmental trajectory.

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  • Ages and Stages Questionnaires and the 2 year review; e-Learning for Health Care

  1. Healthy Child Programme: pregnancy and the first five years of life; Dept of Health

  2. Fact Sheet: Developing a public health outcome measure for children aged 2-2.5 using ASQ-3; Dept of Health

  3. Services for children age 0-5: Transfer to local authorities; GOV.UK, Updated 12 Nov 2015

  4. Healthy Child, Healthy Future; NI GOV.UK

  5. The Scottish Child Health Programme: Guidance on the 27-30 month child health review; NHS Scotland

  6. Scottish Child Health Programme; ISD Scotland/NHS Scotland

  7. Healthy Child Wales Programme; Welsh Government

  8. Healthy Child Programme - The two year review; Dept of Health, 2009

  9. Bellman M, Byrne O, Sege R; Developmental assessment of children. BMJ. 2013 Jan 15346:e8687. doi: 10.1136/bmj.e8687.

  10. Early Years (under 5s) foundation stage framework (EYFS); GOV.UK, 29 July 2014

  11. Childhood obesity: a plan for action; GOV.UK, August 2016

  12. Mithyantha R, Kneen R, McCann E, et al; Current evidence-based recommendations on investigating children with global developmental delay. Arch Dis Child. 2017 Nov102(11):1071-1076. doi: 10.1136/archdischild-2016-311271.

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Am very concerned abt my child development. He is currently 2 years 3 month old and i feel he is lagging in basic development. He is very active physically like running. walking and claiming on table..

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