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Effects of the Early Start Denver Model on emotional dysregulation and behavior problems in children with Autism spectrum disorder

Effects of the early start Denver model on emotional dysregulation and behavior problems in Chinese children with Autism spectrum disorder

BMC Pediatrics volume 25, Article number: 19 (2025) Cite this article

Abstract

Background

Most previous studies have focused on the clinical efficacy after intervention of ESDM, particularly in core symptoms. However, only a few have paid attention to the effectiveness of ESDM on emotional dysregulation and behavior problems in children with ASD. This study aimed to explore the effect of the ESDM on addressing emotional dysregulation and behavior problems in children with ASD in China, as well as its correlation with core symptoms of ASD.

Methods

A total of 319 children aged 1.5 to 5 years were included in this study and received treatment based on the ESDM intervention program Baseline assessment (T0) was conducted before intervention, including Children Behavior Checklist (CBCL), Autism Behavior Checklist (ABC) and Childhood Autism Rating Scale (CARS). All children with ASD were examined in the assessment (T1) after 12 weeks of treatment. Emotional dysregulation and behavior problems in children with ASD were measured using CBCL, while ABC and CARS were used to evaluate the core symptoms.

Results

In the T1 assessment, the core symptoms of children with ASD in ABC and CARS showed significant differences. Subscale scores of ABC and the severity of CARS, including senses, relationships, stereotypes objects to use, self-help and social also exhibited significant differences. The children showed significant differences in both total score and subscale scores of CBCL(P < 0.05), which included emotionally/reactive, anxious/depressed, somatic complaints, withdrawal, sleep problems, attention problems, aggressive behavior, internalization and externalization. The children demonstrated significant differences in scores of CBCL-AAA (P < 0.05), taking into account the combined total of attention, aggression and anxious/depressed CBCL T scores. In addition, a consistent positive correlation was observed between the overall scores of CBCL and the core symptoms of children with ASD as indicated by ABC and CARS in both T0 and T1(P < 0.01). In T0, the CBCL-AAA scores were positively associated with the core symptoms of children with ASD as reflected by CARS(P < 0.01), as well as senses of ABC( P < 0.05). During T1, a noteworthy significant positive correlation was observed between the CBCL-AAA scores and the core symptoms of children with ASD as indicated by both ABC and CARS assessment (P < 0.05).

Conclusions

Children with ASD benefit from ESDM, not only in terms of improving their core symptoms, but also in terms of improving their emotional dysregulation and behavior problems, and ESDM could be considered as one of the early treatment options for overall psychological promotion. The core symptoms of children with ASD are significantly associated with emotional dysregulation and behavior problems in young children, both cross-sectionally and prospectively for the short term over time. Emotional dysregulation and behavior problems represent an important comorbidity, and could be considered as potential treatment targets for treatment for improving emotional stability in ASD.

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Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that begins in early childhood and characterized by deficits in communication and social interaction, as well as repetitive and stereotyped behaviors [1]. The prevalence of ASD has risen to 1 in 36(2.76%), and it has gradually become a neurodevelopmental disorder in children that has been widely concerned and studied [2]. In addition to the core symptoms above, many children with ASD suffer from common emotional problems, such as aggression, self-injury, hyperactivity and so on [3]. Children with ASD are at increased risk of experiencing emotional dysregulation (ED) and behavioral problems [4, 5]. ED is defined as deficits in the valence, intensity, and expression of emotions monitoring and modulation, and is a significant contributor to dysfunction and clinical referral. The prevalence of ED is higher in children with ASD [6], which has a wide range of adverse impairments on children’s daily life, peer relationships, family life, adaptive behaviors, school readiness, academic achievement, and even throughout the life cycle [7, 8], and also increases parents’ parenting stress and financial burden [9]. Both the core symptoms of ASD and ED are not transient but persist over time [10], many individuals with ASD require continuous medical and social support throughout their lives, and effective intervention strategies for children with ASD at an early stage of life are urgently needed [11]. Few studies have been conducted specifically on the intervention for ED in children with ASD.

Different treatments, including pharmacological interventions for ED in ASD are being tested. A mate analysis found that antipsychotics, and overall, medications used for ADHD (stimulants plus nonstimulants) were significantly more efficacious than placebo for ED. Some pharmacological interventions (particularly risperidone and aripiprazole) have proven efficacy for short term treatment of ED in ASD [12]. However, unfortunately, one study found that the rate of non-response for aripiprazole and risperidone in ASD was about 50% [13]. In terms of side effects, more than half the patients with ASD taking risperidone had one or more adverse events [14]. When choosing agents, it is crucial to also consider the importance of tolerability and safety as additional factors. In addition, most studies evaluating ADHD medication focused on individuals with concomitant ADHD symptoms [15]. The evidence on the efficacy of opioid antagonists, diuretics, fatty acids, neuropeptides, and mood stabilizers for ED in ASD is currently insufficient, so more research would be needed before these interventions could be widely implemented into clinical practice [12].

Psychosocial approaches [16] might be considered prior to or in addition to the pharmacological interventions [17]. This may include cognitive-behavioral therapy(CBT) [18], mindfulness-based treatments, acceptance-based approaches [19], applied behavior analysis(ABA) based interventions [20] or parent-mediated behavioral interventions [21]. Research of an intervention based on CBT found that adolescents who participated in the program significantly reduced anxiety and anger [22]. Scarpa and Reyes also investigated an intervention designed to address emotion regulation skills in 5 to 7-year-olds by using of a cognitive-behavioral program to explore feelings for children with High-functioning Autism or Asperger’s Disorder. The CBT-based interventions focused on teaching children specific emotion regulation skills (e.g., relaxation, cognitive restructuring, social support) that they can use during times of negative emotions. When these children participated in the intervention, their parents rated them as having lower negative instability, better emotional regulation, and shorter outbursts. Importantly, this intervention had a positive parental component, and participating parents also reported increased confidence in their own and their child’s ability to manage emotional states such as anger and anxiety [14]. However, effective nonpharmacological interventions for non-high-functioning children with ASD are still being explored. Interventions for ED and behavior problems in children with ASD under 60 months have been under-developed in China, while evidence-based method of early intervention is urgently needed.

Early Start Denver Model [23](ESDM) is a naturalistic developmental behavioral intervention (NDBI) [24] based on the behavioral principles of ABA [25]. In ESDM, behavioral strategies are implemented in a naturalistic social setting in alignment with developmental principles (i.e. including children’s interests and choices, adults’ sensitivity and reactivity, children’s influence and arousal, and targeting the development of appropriate skill/behavioral sequences) [26, 27].

ESDM has been shown to be effective in improving the cognitive, adaptive behavior and social communication skills of young children with autism [28,29,30]. Both the combination of intensive training and parent training based on ESDM and ESDM intensive training alone can improve the core symptoms of children with ASD aged 2–5 years, as well as improve their abnormal behavior. However, the former is more effective in relieving parenting stress [31], while helping with ESDM training at home. During parent training, parents underwent training and guidance sessions with therapists, where they were instructed to intervene and record videos at home. The therapists analyze the videos to guide the parent-implemented P-ESDM at home, which helps parents master interaction skills and effective strategies to cope with corresponding behavioral problems [18] Over time, this process helps in cultivating a healthy parent-child relationship and getting more emotional feedback [14]. Therefore, we chose intensive training and parent training based on ESDM as the intervention in our study.

Most of the previous studies have focused on the clinical efficacy after intervention of ESDM, particularly in core symptoms. However, few studies were found to explore the effectiveness of ESDM in the Chinese population, especially many clinical trials have not been able to definitively determine its effectiveness for ED and behavioral problems [32]. This study aimed to explore the effect of the ESDM on the treatment outcome of emotional dysregulation and behavior problems in children with ASD. We hypothesized that ESDM intensive training combined with parent training can improve children’s emotional disorders and behavior problems through the enhancement of their cognitive and adaptive skills, as well as bolstering parental capacity to address behavioral issues. Therefore, this study conducted an intervention involving 319 children diagnosed with ASD at our hospital to explore the effectiveness of ESDM on children with ASD as well as its impact on emotional dysregulation and behavior problems. This study also examined the correlation between ED and behavioral problems and core symptoms of ASD.

Methods

Participants

319 children with ASD clinically diagnosed in the Department of Developmental and Behavioral Pediatrics of the First Hospital of Jilin University were recruited from January 2020 to May 2023. All children were required to fulfill the ASD diagnostic criteria based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5th) [33]. Inclusion criteria were (1) aged 18–60 months (2) In the Department of Developmental and Behavioral Pediatrics of our hospital to receive rehabilitation training, parents personally participate in the training and (3) signed ethical informed consent before enrollment, from parents. Exclusion criteria were:1) Retts Syndrome, fragile X syndrome, Angelman syndrome, Prader-Willi syndrome, and other syndromes caused by known genetic defects or inherited metabolic diseases;2) more than three consecutives did not provide home intervention videos in the program during 12 weeks and 3) children who did not complete both baseline and postintervention assessments after 12 weeks were excluded.

Children were followed up and reevaluated 12 to 13 weeks subsequent to the initial assessment. The study was approved by the research ethics boards at the participating sites, and the parents provided written informed consent.

Assessment tools

The child behavior checklist 1.5-5 (CBCL)

The Chinese version of Child Behavior Checklist 1.5-5 (CBCL) [34, 35], a 100-item checklist completed by primary caregivers, is used to assess emotional and behavioral problems in children aged 1.5 to 5 years. On the CBCL, behaviors are scored on a 3-point scale (0 not true, 1 somewhat/sometimes true, and 2 very/often true). Raw scores are converted into T-scores and eight syndromic scales (emotionally/reactive, anxious/depressed, somatic complaints, withdrawal, sleep problems, attention problems, aggressive behavior and other problems-delinquency), which contributed to two general dimensions (internalization and externalization) and a total score.

T-scores are computed for each scale score and total score. T scores between 65 and 70 are borderline, while those above 70 are clinically abnormal.

Emotional dysregulation (ED)

ED was measured using the Attention, Aggression, and Anxious/Depressed scales of the CBCL(CBCL-AAA), which consider the cognitive, behavioral and affective dimensions of ED. The CBCL-AAA construct was first used to define the Deficient Emotional Self-Regulation (DESR) with scores between 1 and 2 standard deviations (SD) above the mean [36], while an elevation above 2 SD characterizes the emotional dysregulation profile [37]. The CBCLAAA score is computed by the sum of the Attention, Aggression and Anxious/Depressed CBCL T scores [38, 39].

According to Biederman [40], ED was defined as positive if the sum of the CBCL “attention problems”, “aggressive behavior”, and “anxious-depressed” (CBCL-AAA) T scores was equal to or higher than 180. Moreover, it is possible to distinguish two different profiles: (1) CBCL-DESR (Deficient Emotional Self-Regulation) when T scores are between 180 and 210; (2) CBCL-SED (Severe Emotional Dysregulation) when T scores are higher than 210. When scores are lower than 180, no profile is developed (no-ED) [41].

Autism behavior checklist (ABC)[42]

This scale describes a range of typical autistic behaviors and is designed to assess the presence of these behaviors in a certain subject. The assessment form consists of 57 items, each corresponding to a single score relating to a single symptom area. Five areas are considered: senses, relationships, stereotypes and object use, language, self-help and social. The total score is obtained by adding scores in different areas. The 57 items are classified as follows: 9 items for sensory area, 12 for a relationship, 12 for stereotypes and object use, 13 for language and 11 for self-help and social. The score assigned in presence of the behavior described by the single item varies from 1 to 4.

Childhood Autism Rating Scale (CARS)[43]

CARS is a 15-item behavioral rating scale used to diagnose autism in combination with clinical judgment. In addition, it assesses the severity of the disorder. The items of the scale include: related to people; imitate; emotional response; body use; object use; adaptation to change; visual response; hearing response; taste, smell, touch; fear or nervousness; verbal communication; nonverbal communication; activity level; level and consistency of intellectual response and general impressions. Each item is scored from 1 (no pathology) to 4 (severe pathology). The total scores are then calculated as “raw scores” and severity is classified as follows: a total score of 15–29.5 is considered “non-autistic”, a score of 30–36.5 is considered “mild to moderate” autism and a score of 37–60 is considered “moderate to severe” autism.

Procedures

Baseline assessment (T0)

Before intervention, baseline demographic information was collected from parent questionnaire at the time of enrollment, including baseline age (the age at enrollment), gender. All children were evaluated in behavior problems and ED by CBCL. In addition, they were evaluated in core symptoms of ASD by ABC and CARS.

Post-intervention assessment after 12 weeks (T1).

Children with ASD received ABC, CARS, CBCL and ED assessment after the 12-week intervention.

Intervention process

Children with ASD(n = 319) received ESDM intervention training in the program by therapists, which lasted 1 h, once a day, 6 days a week for 12 weeks in the hospital. Parents received 10 training guidance sessions from therapists lasted 3.5 h once a week. Additionally, they were tasked with intervening and recording videos at home as part of the program. The therapists analyze the videos to guide the parent-implemented P-ESDM at home. By training, parents received training and mentoring to learn the basic method of ESDM from therapists during the intervention process, which could continue to exert the efficacy of ESDM. Finally, 319 children were included in statistical analysis.

Quality control

All children with ASD were diagnosed according to ASD criteria in DSM-5 by two qualified clinicians and also met ADOS diagnostic criteria to ensure diagnostic accuracy. All assessments were performed using uniform guidelines and following strict operating procedures by certified clinicians.

All therapists were required also to pass a standardized assessment before engaging in intervention training. Therapists met together weekly to provide peer supervision, to discuss the implementation of the intervention to various children, and the accuracy of ESDM implementation was reviewed by viewing, coding, and discussing video recordings of therapists’ sessions in the study.

Data analysis

Descriptive quantitative and qualitative analyses were performed, along with correlation analysis. SPSS 27.0 software was used for statistical analysis. A Mann–Whitney U test was used to compare data before and after intervention that were not normally distributed. Discrete-valued data were represented by frequency (%) or quartile, chi-square or non-parametric tests were used for comparison between male and female. P < 0.05 was considered as statistically significant.

Results

Comparison in baseline demographic characteristics

The main demographic characteristics of children are presented in Table 1. There were 319 children in our study, including 234 boys and 85 girls, median age 37.00 months at the time of baseline data. Among the samples, 54(16.93%) ASD children were clinically abnormal in total scores of CBCL, as well as 134 ASD children were diagnosed with ED, accounting for 42.01%.

Table 1 Comparison in baseline demographic characteristics
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Data in CBCL and CBCL-AAA in T0 assessment

No statistical differences were found in both total and subscale of CBCL and CBCL-AAA between male and female groups, including emotionally/reactive, anxious/depressed, somatic complaints, withdrawal, sleep problems, attention problems, aggressive behavior internalization and externalization (all P>0.05).The results showed that male and female groups had no significant differences in ED and behavior problems with ASD before intervention, which suggest that a high prevalence of these problems gender neutrally in children with ASD (Table 2).

Table 2 Comparison in CBCL and CBCL-AAA between male and female in T0
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Differences in ABC scores between T1 and T0 assessment

The total scores, stereotypes and object use, senses, self-help and social and relationships in ABC decreased significantly between T1 and T0(all P<0.05), whereas no significant decrease was found in language(P>0.05). After 12 weeks intervention, the core symptoms of children with ASD were improved, especially in object use, senses, self-help and social and relationships (Table 3).

Table 3 Comparison in scores of ABC over 12 weeks of ESDM intervention
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Differences in CARS scores between T1 and T0 assessment

The total score and severity of CARS decreased significantly between T1 and T0.

(all P<0.05). The core symptoms of children with ASD were improved in T1 compared with T0 (Table 4).

Table 4 Comparison in scores of CARS over 12 weeks ESDM intervention
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Differences in CBCL scores between T1 and T0 assessment

The total scores, withdrawal, anxious, sleep problems, somatic, aggression, emotionally/reactive, delinquent behavior, internalization and externalization in CBCL decreased significantly between T1 and T0 (all P<0.05),whereas no significant decrease was found in attention (P>0.05) (Table 5).

Table 5 Comparison in scores of CBCL over 12 weeks ESDM intervention
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Differences in CBCL-AAA scores between T1 and T0 assessment

The total scores, anxious and aggression in CBCL-AAA decreased significantly between T1 and T0 (all P<0.05), whereas no significant decrease was found in attention(P>0.05).After 12 weeks intervention, the ED of children with ASD was improved (Table 6).

Table 6 Comparison in the scores of CBCL-AAA
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Correlation analysis in behavior problems and ED associated with the core symptoms in T0

We performed a correlation analysis to explore behavior problems and ED associated with the core symptoms. As shown in Table 7, there was a positive correlation between the total scores of CBCL and the core symptoms of children with ASD as reflected by ABC and CARS in T0 (P < 0.01), as well as in stereotypes and object use and self-help and social (P < 0.05). The withdrawal of CBCL was positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.01), as well as in senses, self-help and social and relationships (P < 0.05). The sleep problems of CBCL were positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.05), as well as in stereotypes and objects, senses and self-help and social (P < 0.05). The aggression of CBCL was positively associated with the core symptoms of children with ASD as reflected by CARS (P < 0.05), as well as stereotypes and objects and self-help social of ABC (P < 0.05). The emotionally/reactive of CBCL was positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.05), as well as in relationships (P < 0.05). Both delinquent behavior and internalization of CBCL were positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.05), as well as in self-help and social, relationships (P < 0.05). The externalization of CBCL was positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.05), as well as in self-help and social (P < 0.01). The CBCL-AAA score was positively associated with the core symptoms of children with ASD as reflected by CARS (P < 0.01), as well as senses of ABC (P < 0.05).

Table 7 Behavior problems and ED associated with the core symptoms in T0 using correlation analysis
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Correlation analysis in behavior problems and ED associated with the core symptoms in T1

We performed a correlation analysis to explore behavior problems and ED associated with the core symptoms. As shown in Table 8, The total scores of CBCL, withdrawal, sleep problems, aggression, attention, delinquent behavior, internalization, externalization and CBCL-AAA were positively associated with the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.01), as well as in stereotypes and object use, senses, self-help and social and relationships (P < 0.05). There was a positive correlation between the anxious and the core symptoms of children with ASD as reflected by ABC and CARS in T1 (P < 0.01), as well as in senses and relationships (P < 0.05). There was a positive correlation between somatic of CBCL and the core symptoms of children with ASD as reflected by ABC, including stereotypes and object use, self-help and social and relationships (P < 0.01). There was a positive correlation between emotionally/reactive of CBCL and the core symptoms of children with ASD as reflected by ABC and CARS (P < 0.01), as well as in senses, self-help and social and relationships (P < 0.01).

Table 8 Behavior problems and ED associated with the core symptoms in T1 using correlation analysis
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Discussion

The present study provided a preliminary test to examine the effects of the ESDM on emotional dysregulation and behavior problems in Chinese children with ASD. We hypothesized that intensive training and parent training based on ESDM would improve ED and behavior problems in children with ASD. We analyzed the efficacy of ESDM intervention over 12 weeks. The results were consistent with the hypothesis, and some even included unexpected surprises.

Efficacy of ESDM intervention at 12 weeks

After 12 weeks of ESDM intervention, the results showed significant differences in core symptoms of children with ASD. Children with ASD especially improved greatly in stereotypes and object use, senses, self-help and social and relationships, except language. ESDM is an approach that integrates developmental science and applied behavior analysis, with focus on verbal development, joint attention, imitation, social development, game skill and cognitive ability [44], an appropriate intervention for children aged 1.5 to 5 years [45]. The above results were the concentrated embodiment of focus abilities in ESDM, which suggest that ESDM could effectively improve core symptoms of children with ASD after 12weeks of intervention, which were consistent with those of previous studies [46]. Xu et al. found that after 8 weeks of ESDM intervention, autistic symptoms were significantly reduced and severity classification was improved in Chinese ASD children [47]. In consideration of language, it might not be improved immediately after ESDM intervention, 12 week period might be not enough to exhibit the improvement of language of ABC, which could be gradually reflected over time [48]. In addition, children with ASD have no or limited use of gestures and language in communication, especially at a young age. After ESDM intervention, their language skills developed and they can speak more words and sentences, which may have more scores in language of ABC. Wang et al. [32] found that the speech and communication abilities of children with ASD were significantly improved after 6 months of ESDM intervention, and the cognitive ability and symptom severity of children were improved after 6 months of follow-up. It also indicates that language improvement in children with ASD may take longer, supporting our interpretation. In Wang’s study, ESDM has long-term effectiveness for Chinese children with ASD. However, there is no follow-up assessment a few months after finishing the intervention in our study to illustrate the sustained efficacy. In the future, multi-center and longer-term longitudinal studies should be conducted to further verify the effectiveness of ESDM in Chinese children with ASD, so as to promote the wide application of ESDM in China.

Among the samples, 54(16.93%) ASD children were clinically abnormal in total scores of CBCL, as well as 134 ASD children were diagnosed with ED, accounting for 42.01%. In T0, male and female groups had no significant differences in ED and behavior problems with ASD, which suggests that these problems do not differ by sex and are more likely to occur in children with ASD. The most common behavioral problem for both male and female was withdrawal. Our results showed that there were significant differences in behavior problems. Children with ASD especially improved greatly in withdrawal, anxious, sleep problems, somatic, aggression, emotionally/reactive, delinquent behavior, internalization and externalization, as well as in ED. These results demonstrated the efficacy of the combination of intensive training and parent training based on ESDM in behavior problems and ED in young children with ASD.

ESDM can improve the cognitive, social-emotional, and verbal abilities of children with ASD, and help them better understand the verbal and non-verbal information of others. It can improve the ability of ASD children to recognize, understand, express and process facial expressions, voice emotions, and action emotions during social interaction, in other words, it helps them gradually be able to evaluate, maintain, and modify their own and others’ emotions. After ESDM intervention, ASD children are aware of their emotions, develop emotion regulation skills, so ESDM may help to improve ED. Gao et al. found the combination of intensive training and parent training based on ESDM is more effective, which can improve the core symptoms of children with ASD, reduce the abnormal behaviors and relieve parenting stress [31]. Zhou’s [49] study also demonstrated that parent-implemented ESDM via coaching from professionals improved developmental outcomes, especially in the language domain, and social communicational behaviors of Chinese toddlers with ASD. However, none of them explored its effect on irritability or ED in children with ASD. Parent training can help parents better understand the condition and behavior characteristics of children with ASD and the basic method of ESDM, which may help parents in China provide effective early intervention to their children with ASD via improving their skills when they are still at a waiting list for services or lack access to intervention, and continue to exert the efficacy of ESDM. By training, parents have mastered the skills of coping with children’s behavior problems and ED, and applied them to daily family intervention training, which can increase parent-child interaction and emotional communication, improve parents’ confidence in implementing family intervention and the quantity and quality of family intervention, so as to help cope with children’s emotional and behavior problems. Based on these, we designed this study and preliminarily demonstrated that intensive training and parent training based on ESDM would improve ED and behavior problems in children with ASD.

The results were consistent with the hypothesis. The combination of intensive training and parent training based on ESDM uses one method to solve multiple problems, that is, to improve the core symptoms, ED and behavioral problems of children with ASD, which simplifies the rehabilitation training as much as possible while improving the treatment efficiency. At present, ESDM may be used as one of the programs to improve the ED and behavioral problems of children with ASD in the early stage, and it provides a direction for the prevention and treatment of emotional and behavioral problems in preschool children with ASD.

Behavior problems and ED are associated with the core symptoms in T0 and T1.

In this study, we performed a correlation analysis to explore behavior problems and ED associated with the core symptoms. Both in T0 and T1, at 12 weeks intervention, the behavior problems (CBCL) and ED (CBCL-AAA) correlated with the core symptoms of ASD (ABC, CARS), which showed the persistence of this association between behavior problems and ED associated with the core symptoms using a short prospective design. It suggested that behavior problems and ED may be persistent in ASD, as also reported by others [50, 51]. In addition to the core symptoms, children with ASD are also more likely to have social cognition, emotional cognitive impairment and emotional regulation problems [52]. Their ability to recognize and regulate emotions is insufficient, leading to ED and a series of secondary behavioral problems [7]. Because many individuals with ASD require continuous medical and social support throughout their lives, effective intervention strategies for children with ASD at an early stage of life are urgently needed. A large number of studies have shown that the earlier intervention, the better prognosis of children with ASD [53]. Consider the above correlation, we should focus on behavior problems and ED in children with ASD of early intervention.

ESDM is a successful model of intensive family intervention. However, the recommended intervention time is difficult to completely achieve in public hospitals, 20 h per week. A meta-analysis summarized that intervention time of ESDM by professional ranged from 4.6 to 20 h per week in 12 original researches [26], suggesting that most studies have not met the recommended time. In our study, although the intervention was low-intensity by therapists compare with the recommended intervention time, parents also were required to participate in the whole process and ESDM intervention for children was continued at home every-day. We were not given specific durations of the home intervention, but each parent actually conducted family intervention in different times every-day, which compensates for the lack of intervention time in hospitals. In longer longitudinal observation, however, cannot be evaluated in this study. Next, we will design control group to assess and define the possible impact of treatment interventions in the near further, as well as in longitudinal observation.

The present study suggests the positive effect of intensive training and parent training based on ESDM on ED and behavior problems in children with ASD. ESDM has a particular emphasis on reactive interaction and developmental orientation, which is based on evidence of normal social-communication development patterns. ESDM is an integration of a developmental model, the Denver model, a naturalistic applied behavior analysis (ABA) model and pivotal response training (PRT) [54]. Compared with other models, ESDM has a superiority in detailed behavioral teaching paradigms, focusing on the impact and quality of interpersonal relationship. ESDM is specifically designed for preschool children with ASD through interactive training which can be applied to every natural life scenario, promoting comprehensive development [55]. More and more evidences demonstrate that ESDM can alleviate social interaction deficits, cognition, language, and adaptive behavior in children with ASD [56]. Fuller et al. found that there were improvements in cognition and language, including 12 articles, whereas no significant effects were observed in autism symptomology, social communication, and repetitive behaviors for a short term [26]. Based on the above results, we speculate that children with ASD had significant progress in language and cognitive after ESDM intervention, which helped them understand and express emotions, identify and deal with ED and behavioral problems. At the same time, we also considered the length of treatment. It is recommended that the requirement for more than 20 h of therapy per week, however, it is difficult in Chinese public hospitals. In our study, parent training based on ESDM makes up for the shortcomings of the above intervention practice. The results strengthen the comprehensive efficacy of ESDM interventions [57]. In addition, it suggests that we should pay attention to the intensity of training and long-term efficacy of ESDM in children with ASD.

Strengths and limitations

The present study included several strengths. All assessments and intervention were strictly monitored. Additionally, we found a positive effect by analyzing the data before and after treatment before and after the intervention. However, there were still some limitations. Although the training was mainly conducted by the therapists for children in a strict process, uniformed and standardized training was lacking for theoretical guidance to parents. There is poor homogeneity between the intervention of the therapist to the children and the theoretical guidance to the parents. The preliminary trial was conducted only for preliminary analysis and no control group was set up. Long-term efficacy was not assessed. This was a single-center study, considering the lack of professional therapists and the imbalance of economic level in China, a multi-center and longer-term longitudinal study should be carried out to further test the effectiveness of ESDM on ED and behavioral problems in Chinese children with ASD.

Conclusion, ESDM can effectively improve ED and behavioral problems in children with ASD after a 12-week intervention. The core symptoms of children with ASD are significantly associated with emotional dysregulation and behavior problems in young children, both cross-sectionally and prospectively for short term over time. Emotional dysregulation and behavior problems represent an important comorbidity, and could be a potential treatment target for improving emotional stability in ASD. More importantly, it is worthwhile to further explore the efficacy of ESDM on the ED and behavior problems of children with ASD, so as to achieve the purpose of obtaining multiple effects by using just intervention method based on ESDM, improve the time and economic efficiency of treatment, and benefit the children, parents, families and society.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ASD:

Autism spectrum disorder

ESDM:

Early Start Denver Model

ABC:

Autism Behavior Checklist

CARS:

Childhood Autism Rating Scale

CBCL:

Children Behavior Checklist

CBCL-AAA:

attention, aggression and anxious/depressed CBCL

ED:

Emotional dysregulation

CBT:

cognitive-behavioral therapy

ABA:

Applied behavior analysis

EIBI:

Early intensive behavioral intervention

NDBI:

naturalistic developmental behavioral intervention

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Acknowledgements

We are grateful to all children and parents participating in the study.

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Non.

No financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.

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Authors and Affiliations

  1. Department of Developmental and Behavioral Pediatrics, Children’s Medical Center, The First Hospital of Jilin University, Changchun, China

    Wan-Xia Liu, Ling Shan, Chun-Li Li, Yu-Mo Liu, Yang Xue, Yu-Ling OuYang & Fei-Yong Jia

  2. School of Nursing, Jilin University, Changchun, China

    Wan-Xia Liu, Yu-Mo Liu, Yu-Ling OuYang & Fei-Yong Jia

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Contributions

WXL: drafting the article, and data analysis. LS, CLL: implementer of professional treatment. YML: implementer of professional treatment, and professional evaluation. YX: professional evaluation. YLOY: final approval of the version to be published, revising it critically for important intellectual content. FYJ: concept and design, acquisition and interpretation of data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Fei-Yong Jia.

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Ethical approval

This study was approved by the Department of Developmental and Behavioral Pediatrics of the First Hospital of Jilin University in Changchun (approval no: 20170107).

Consent for publication

All caregivers of toddlers with ASD were informed of the associated benefits and risks, and then voluntarily signed informed consent before intervention.

Competing interests

The authors declare no competing interests.

ASELCC: Autism specific early learning and care center; MSEL: Mullen scales of early learning; SCQ: Social communication questionnaire; VABS-II: Vineland adaptive behavior scales second edition; DQ: Developmental quotient..

Authors information

WXL, YML and YLOY and postgraduate students in the medical technology direction of the School of Nursing, Jilin University, studying and researching the diagnosis and treatment of pediatric common diseases and frequent-onset diseases. Especially the diagnosis and treatment of neurological diseases in children, such as autism, mental retardation, learning problems, children’s attention deficit hyperactivity disorder, tic disorder, and other diseases. LS and YX are pediatricians who specialize in the diagnosis and treatment of pediatric neurological diseases, such as cerebral palsy, autism, mental retardation, learning problems, attention deficit hyperactivity disorder, tic disorder and other diseases in children. CLL is a child rehabilitation therapist, specializing in the rehabilitation of children with neurodevelopmental disorders, especially good at ESDM. FYJ is the director of developmental behavioral Pediatrics, chief physician, professor, doctoral supervisor of the First Hospital of Jilin University, deputy leader of Developmental Behavioral Group of Pediatrics Branch of the Chinese Medical Association, member of the Children’s Rehabilitation Professional Committee of the Chinese Rehabilitation Medical Association, editorial board member of the international Journal of Pediatrics, skilled in the diagnosis and treatment of common pediatric diseases and frequent diseases. Especially good at the diagnosis and treatment of neurological diseases in children, cerebral palsy, autism, mental retardation, epilepsy, children’s psychology, learning problems, children’s attention deficit hyperactivity disorder, tic disorder, migraine, demyelination and other diseases have profound attests.

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Liu, WX., Shan, L., Li, CL. et al. Effects of the Early Start Denver Model on emotional dysregulation and behavior problems in children with Autism spectrum disorder. BMC Pediatr 25, 19 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12887-024-05299-5

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