A therapeutic approach for ASD: method and outcome of the DERBBI – Developmental, Emotional Regulation and Body-Based Intervention

Abstract

Autism spectrum disorder (ASD) is a neurodevelopmental disorder displaying individual impairments in social interaction, communication skills, interest and behaviours. In the last decade several studies have been published on the approaches that can be used with ASD children. This study illustrated the therapeutic approach of the DERBBI method, defined as a relational and body based intervention. The research described the symptoms and emotional development outcomes of ASD children aged 21–66 months, after 2 of the 4 years of planned therapy; the study group included both children who had received a diagnosis of autism and children (under 30 months) who had a risk of developing symptoms. Approximately 78% of the children with a more severe ASD symptomatology after two years of therapy maintained this diagnosis, instead, among children with a less severe ASD symptomatology, about the 67% after two years of therapy no longer fulfilled the ADOS-2 criteria for autism. Among the children who were at risk of developing the autistic symptomatology, about the 42% no longer showed this risk after 2 years of therapy. The improvements that the children showed in their ability to understand the intentions of others and to contact the emotions of others were also investigated. The findings of this study have underlined the importance of early positive indicators which, among the Autisms, could be defined a specific subpopulation that get better benefits from such a type of intervention.

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A therapeutic approach for ASD: method and outcome of the DERBBI –
Developmental, Emotional Regulation and Body-Based Intervention
Magda Di Renzo1, Elena Vanadia1, Massimiliano Petrillo1, Davide Trapolino1,
Lidia Racinaro1, Monica Rea1-2 , Federico Bianchi di Castelbianco
1
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental disorder displaying individual impairments in
social interaction, communication skills, interest and behaviours. In the last decade several studies have
been published on the approaches that can be used with ASD children.
This study illustrated the therapeutic approach of the DERBBI method, defined as a relational and body
based intervention. The research described the symptoms and emotional development outcomes of ASD
children aged 21–66 months, after 2 of the 4 years of planned therapy; the study group included both
children who had received a diagnosis of autism and children (under 30 months) who had a risk of
developing symptoms.
Approximately 78% of the children with a more severe ASD symptomatology after two years of therapy
maintained this diagnosis, instead, among children with a less severe ASD symptomatology, about the
67% after two years of therapy no longer fulfilled the ADOS-2 criteria for autism. Among the children
who were at risk of developing the autistic symptomatology, about the 42% no longer showed this risk
after 2 years of therapy. The improvements that the children showed in their ability to understand the
intentions of others and to contact the emotions of others were also investigated. The findings of this study
have underlined the importance of early positive indicators which, among the Autisms, could be defined
a specific subpopulation that get better benefits from such a type of intervention.
Key words: Autism spectrum disorder, therapeutic approach, ADOS-2, Understanding intention, emotional
contagion.
1
Institute of Ortofonologia (IdO), Via Tagliamento 25, 00198 - Rome, Italy.
2 Department of Dynamic and Clinic Psychology, Sapienza University of Rome, Italy

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Introduction
Autism spectrum disorder (ASD) is a
neurodevelopmental disorder characterized
by individual impairments in social
interaction, communication skills, interests
and behaviors. Recent studies have reported
specific motor patterns in children with ASD
(Chelini et al., 2018; Khalil, Tindle, Boraud,
Moustafa, & Karim, 2018; Shafer, Newell,
Lewis, & Bodfish, 2017). Examples have
included early asymmetries of the supine
posture and walking, early abnormalities on
the intersubjective and mimetic-imitative
level, and atypical organization and
regulation of sensory and motor information
(Esposito & Venuti, 2008; Donnellan, Hill, &
Leary, 2010; Wales, 2014). In the last two
decades there has been a significant interest in
the relationship between emotion and
cognition and their inseparability during each
phase of development (Damasio, 2010;
Panksep & Biven, 2012).
Recent data, borrowed from neuroscience,
suggests human beings are aware of others’
state of mind by understanding their motor
purpose through emotional attunement (Stern,
2010; Gallese, 2006; Braten, 2009). In this
context, a developmental atypia of the first
affective attunement in children with autism
spectrum disorder could be related to
alterations of that functional mechanism of
our brain that allows us to understand the
sense of motor behavior of others, using our
own states or mental process, that is the
embodied simulation (Gallese, 2006). The
difficulty of giving an experiential content to
others' emotions and in developing imitative
processes represent central elements in the
autistic organization and consequently should
be considered primary targets of therapy (Di
Renzo, 2017).
Smith (2009) suggested the presence of an
imbalance between cognitive and emotional
strategies, consequently, the child with ASD
may experience an emotional overload when
managing internal states. Therefore, sufficient
flexibility in regulation, differentiation, and
coping strategies are absent. A study showed
that 2-year-old children with autism show
significantly lower levels of emotional
contagion (understood as automatic reactions
to the emotional expressions manifested by
another person who experiences the emotion
directly), than children of the same age with
typical development or with intellectual
disabilities (Scambler, Hepburn, Rutherford,
Wehner, & Rogers, 2007). Another study
analyzed the responses of autistic children in
situations where positive and negative
reactions were elicited, such that, the
experimenter either opened a gift or pretended
to get hurt, and the child’s response in the first
10 seconds was recorded. The authors noted
that low levels of emotional contagion in
children with ASD was also related to the
degree of impairment of their social-
communicative skills (Hepburn, Philofsky,
Fidler, & Rogers, 2008). Similarly, at 5 and 8
years of age, children with autism are
described as not being able to show
appropriate emotions to environmental
stimuli. Even in older children (8-13 years),
emotional contagion alterations were
identified towards specific emotional
expressions, such as anger and joy (Beall,
Moody, McIntosh, Hepburn, & Reed, 2008).
Furthermore, children with autism spectrum
disorder may show adequate cognitive
understanding of the function of the object,
but may show compromised social and
emotional skills, with difficulties in joint
attention and in the understanding of the
mental states of others (Baron-Cohen, 1991;
Rogers, & Dawson, 2010; Tomasello,
Carpenter, Call, Behne, & Moll, 2005).
These difficulties are often present and can be
found in the child's ability to interpret and
understand the emotions of others. This
difficulty could be due to the complexity of
the perceptive, introspective and
communicative capacity, but above all, due to
the difficulty in tolerating an intense
cognitive-emotional state, and difficulties in
differentiating the emotion of others from
their own (Trevarthen & Delafield-Butt,
2013). In addition, some authors argue that
the difficulties of individuals with autism
spectrum disorder could be traced to a deficit

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in movement and perception development, as
well as in body awareness. These sensory-
motor reactions become instruments in
enabling one to connect with others, and in
developing intentional and shared
communication in socio-emotional
reciprocity (Trevarthen & Delafield-Butt,
2013; Piaget, 1951).
In a recent meta-analysis by West (2018), it
was found that motor skills in children
diagnosed with ASD differed in a statistically
significant way from those of typically
developing children; furthermore, among
children with ASD, a relationship between
motor and communication abilities emerged.
Research by Holloway, Long and Biasini
(2018) showed that in a sample of 21 children
with ASD, the children's social skills were
predicted by specific motor impairments in
stability, motor accuracy, and object
manipulation. Choi, Leech, Tager-Flusberg,
and Nelson (2018) compared a sample of 71
high risk children without an ASD diagnosis,
30 high risk children diagnosed with ASD,
and 69 children with low risk without an ASD
diagnosis. They found that the development
of fine motor skills at 6 months of age
predicted expressive language at 3 years of
age in children at high and low risk of an ASD
diagnosis. Another study compared a sample
of 20 children with a high functioning ASD
diagnosis, and a sample of 21 typically
developing children aged between 8 and 14
years. Results showed worst levels of
coordination in children in the ASD sample,
and showed a relationship between
coordination and social skills (Kostrubiec,
Huys, Jas, & Kruck, 2018).
Previous longitudinal studies have confirmed
a relationship between early sensory seeking
with early social engagement and later social
difficulties, with assessments administered at
18, 24 and 36 months of age, suggesting the
importance of giving particular attention to
these aspects in the diagnosis and treatment of
children with ASD, both in the short and long-
term (Baranek et al., 2017; Baranek et al.,
2019; Damiano-Goodwin et al., 2018).
ASD and Developmental Therapeutic
Models
Developmental therapeutic models are
focused on the importance of first
attunements and of the imitative mechanisms,
of the processes of sensory and social
integration, of the support to the intentionality
and to the communication - even preverbal -
of the affective development as a foundation
on which cognitive abilities are developed.
Among these, the Early Start Denver Model
(ESDM) is a program of intervention intended
for preschool-aged children with autism
between 12 and 48 months of age, it
encourages initiative, motivation, and
participation (Dawson et al., 2010; Rogers &
Dawson, 2010). This intervention places
emphasis on the improvement of social
interaction as the main deficit that
characterizes an autism disorder. It considers
a hypothetical deficit in the imitative ability
due to an underlying praxic disorder or in the
ability to program sequences of movement.
This deficit would prevent the early
establishment of synchrony and coordination
at the level of the body, and would initiate
progressive difficulties in the area of
intersubjectivity. Therefore, according to the
Denver Model, the context in which the
interactions between the child and the adult
take place should be characterized by social
involvement, reciprocity, alternation of shifts
and shared affection.
Greenspan and Wieder (1997) described
another developmental model, the
Developmental Individual difference
Relationship based (DIR), which emphasizes
the encounter with the child in an integrated
approach that takes into account their
developmental level, the emotional tone and
the motivations. Assuming that social
relationships guide the development of
cognitive abilities, the proposed treatment is
Floortime, its first aim is to overcome the
sensory difficulties in order to re-establish the
interpersonal affective contact, as in the
absence of social relationships one’s self-
esteem, ability to take initiative, and creativity
do not develop.

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The Exchange and Development Therapy
(TED, Therapie d’echange et developpment)
is essentially based on the exchange between
the child and the operators (the environment)
to favor socialization and communication
skills (Lelord, Barthelemy-Gault, Sauvage, &
Ariot, 1978; Barthélémy et al., 1995). This
model aims to foster children's functional
abilities by encouraging their initiatives in an
atmosphere of tranquility, availability, and
serenity, terms that are not only a generic
approach to transversal treatments but play a
specific role on the neurophysiological side.
Finally, the term “functional rehabilitation” is
determined through the integration and
modulation of different neurophysiological
processes.
Among the developmental models, the
DERBBI- Turtle Project (Developmental,
Emotional Regulation and Body-Based
Intervention for children with autism
spectrum disorders) is the one being
proposed. DERBBI represents an interactive
developmental model with body mediation
that integrates the theoretical aspects
described in clinical activity that involves
caregivers, and supports social development
since the early years of life (Di Renzo et al.,
2016a; Di Renzo et al., 2016b). This
intervention is aimed at constructing
communicative modes, it is mediated by the
therapist and the caregiver who help the child
to regulate their own reactions when
confronted with external or internal stimuli
that can be perceived as disturbing or harmful.
The intervention also stimulates the child’s
understanding of the world around them
through a bottom-up process that starts from
the body and works upwards towards the
mind. The therapy aims to stimulate cognitive
and communicative abilities, although it does
not provide an exclusively structured
cognitive treatment before the age of 6, rather,
it does so by integrating support for the
mental and cognitive development within
bodily and relational mediated activities (Di
Renzo et al, 2016a).
Therefore, in light of what has been illustrated
thus far, the purpose of this study is to define
theoretical-scientific and methodological
assumptions of the DERBBI model while
monitoring the development of the core
symptomatology of autism. Additionally, the
ability to understand the intentions of others
and emotional contagion will be monitored as
indicators of future mentalization ability and
empathy in preschool-aged children
diagnosed with ASD, this was included in the
early bodily-mediated intervention program,
Turtle Project. Specifically, the research
objectives include:
1) Verify the symptomatic course in clinical
terms, in reference to the scores on the
ADOS-2 measure. Specifically, to verify the
reduction of repetitive behaviors scores and
the improvement of social affect scores
halfway through treatment (after 2 years),
controlling for the chronological age and
cognitive level of the child;
2) Verify the increase in scores of emotional
contagion and the ability to understand the
intentions of others, at 2 years from the start
of therapeutic treatment.
Materials and Methods
Participants
A group of 32 children was assessed at intake
(T0) and re-tested after 1 year (T1) and 2
years (T2), which is the halfway point of the
course of treatment. All children were
evaluated for ASD symptoms: 18 children
aged between 31 and 60 months received the
a diagnosis of autism; among these, 9 children
(28,1%) assessed with the ADOS-2 Module 1
fell in the Autism category (ASD, Autism)
and 9 children (28,1%) fell in the Spectrum
category (Autism Spectrum).
14 children aged between 21 and 30 months
were assessed with the ADOS-2 Toddler
Module; among these, 9 children (28,1%) fell
in High Risk category, 4 children (12,5%) fell
in the Medium Risk category and 1 child
(3,1%) fell in the Mild Risk category.
The mean age of the children in the ASD
group (5 females and 13 males) was 42.3
months (SD = 10.3) at T0. The mean age of
the children in the RISK group (3 females and
11 males) was 26.6 months (SD = 2.1) at T0.

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DERBBI- Turtle Method
For many years, The Institute of
Ortofonologia (IdO) has based its diagnostic
and therapeutic processes for children with
ASD, or at specific risk, on an integrated,
multi-professional, developmental-
relationship-body mediated approach which
is represented by the DERBBI method and
Turtle Project (Di Renzo et al, 2016a; Di
Renzo, 2017). This approach considers both
of the interrelated cognitive and affective
components (Alvarez, 2012; Bion, 1967;
Freud, 1965; Stern, 2004; Winnicott, 1989).
The Turtle Project is aimed at children aged
between 2 to 5 years old, diagnosed with
autism spectrum disorder. It involves
therapeutic interventions that consider the
child’s individual profile, defines the areas of
deficit, and enhances the emotional-relational
and cognitive potential (Schore, 2003, 2012;
Stern, 2004). The therapeutic project for this
developmental stage is centered on bodily
dimensions and on the adequate attunement of
the mother-child dyad (Anzieu et al., 1987; Di
Renzo et al., 2017; Trevarthen, 2001).
The difference between this intervention in
relation to other developmental models, both
interactive and behavioral (i.e., DIR, TED,
ESDM), is the use of the therapist's body as a
communication tool. The therapist is not only
a facilitator of parents' insightfulness but also
acts as a model to favor communication
protocols and to enrich an emotional
exchange in the dyad. Through his ability to
emotionally attune with the needs of the child,
the therapist introduces the mother, utilizing
play and body mirroring, to new
communication and relational methods. The
therapist, creating a therapeutic context as
natural as possible, participates in the
proposed play to activate the child's interest
and promotes joint attention. It is through
shared play that the child begins to
intentionally imitate the gestures of the other,
who begins to foresee it, expanding their
verbal protoform repertoire and creating the
premise for communicative reciprocity and
possible mentalization. This therapeutic
course has been implemented through
individual interventions with the child, which
is mediated by the parents (the therapist with
the parent/child dyad), and through group
interventions (groups of dyads and groups of
children).
Phases of the Turtle Project for children from
2 to 5 years of age: duration of 4 years, 10
hours per week, as showed in Table 1.
Instruments
ADOS-2 – Autism Diagnostic Observation
Schedule – Second Edition. The ADOS-2 is a
semi-structured, standardized assessment of
social affect (SA), repetitive and restricted
behavior (RRB), play and imaginative use of
objects, in relation to a diagnosis of ASD
(Lord et al., 2012). It consists of five modules,
each of which are appropriate for children and
adults of differing developmental and
language levels, ranging from nonverbal to
verbally fluent. The Toddler Module is
utilized for children between 12 and 30
months of age who do not consistently use
phrase speech, algorithms yield "ranges of
concern" rather than cutoff or classification
scores, this allows the administrators to form
clinical impressions, and to avoid a formal
classification which may not be appropriate at
such a young age. The Comparison Score
(CS) allows comparisons of a child's overall
level of autism spectrum-related symptoms to
that of children diagnosed with ASD who are
the same age and have similar language skills.
Emotional Contagion Test (TCE). The TCE-
Emotional Contagion Test, which was
standardized on a group of 120 children with
autism, allows for the identification of an
empathy precursor, emotional contagion,
through the administration of pre-verbal
stimuli (vocal signals, facial expressions,
gestures, proxemic and haptic systems), pre-
cognitive stimuli of basic emotions and the
encoding of their expressions in child's body,
emotions that can not be named because they
are not yet conscious (Di Renzo & Stinà 2011;
Di Renzo et al., 2016d; Inzani, Cazzaniga,

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Martelli, & Salina, 2004). The whole TCE
evaluation procedure was videorecorded.
Understanding of Other's Intention (UOI). To
assess the ability to understand others’
intentions, tasks were administered, which
were similar to Meltzoff's Intention condition
of Behavioral Enhancement Procedures (Di
Renzo et al., 2016c; Meltzoff, 1995). This
evaluation is defined as U.O.I.,
Understanding of Others' Intention.
The test allows researchers to detect the
child’s ability levels in understanding the
intentions of others, scores range from 0
(Absence of capacity) to 4 (Excellent
capacity). The whole UOI evaluation
procedure is videorecorded.
Leiter-R. The Leiter International
Performance Scale–Revised (Leiter-R) is
designed for the evaluation of intellectual
functions of nonverbal children and
adolescents aged between 2 and 20 years old
(Roid & Miller, 2002).
Procedure
The participants were recruited in the Institute
of Ortofonologia (IdO). The Institute is
accredited by the National Health System and
follows the procedures for taking care of
children and their families, and procedures for
monitoring the therapeutic project established
by the Public Health System. Starting in 2016,
the children were evaluated for a suspected
diagnosis of ASD. The diagnosis was
performed by a team of qualified clinicians
(with extensive experience in the field of
autism, with at least 5-10 years of expertise),
formed by psychologists /psychotherapists,
pediatric neurologists, child
neuropsychiatrists, and rehabilitation
therapists.
The diagnosis of autism was based on The
Diagnostic and Statistical Manual of Mental
Disorders, Fifth edition (DSM-5) criteria, in
addition to clinical observations, the children
were evaluated with the ADOS-2 measure,
and with parent interviews through the use of
questionnaires and rating scales (American
Psychiatric Association, 2013; Lord et al.,
2012). Experts evaluating the child and
administering ADOS-2 were not the same as
those who were involved in the child’s
therapy. Informed consent was granted from
all parents (Declaration of Helsinki). This
research met the ethical guidelines and the
legal requirements of the country in which it
was conducted. The research also complied
with the ethical standards of the American
Psychiatric Association (APA). After
receiving the diagnostic classification, all
children were included in the therapeutic
project. All the children in the study group at
Time 0 had been given the ADOS-2 measure
for the evaluation of autistic symptomatology,
as well as the TCE, UOI, and Leiter-R
measures.
At Time 1, the Leiter-R cognitive evaluation
and the measurement of related skills, such as
the ability to understand the intentions of the
others (UOI), were readministered.
At time 2 the ADOS-2 was readministered for
the evaluation of autistic symptomatology.
The TCE, UOI, and Leiter-R were also
readministered. The measurement of the
empathic capacity and of emotional contagion
was carried out at T2 because, as per protocol,
it is proposed in conjunction with the
evaluation with the ADOS-2.
Statistics
Most scores met the assumptions of normality
required for parametric statistical analyses,
therefore, parametric analyses were used. A
multivariate analysis for repeated measures
(MANOVA) was conducted to evaluate the
changes in the scores that the children
obtained during the two years of therapy. The
size of the effect was calculated using the
partial eta squared; for which η2p = 0.02 is
considered a small effect, 0.13 a medium
effect, and 0.23 a great effect. To analyze
changes in the diagnostic categories before
and after the two years of therapy, a Chi
square analysis was conducted. The
significance level was at p <0.05. All
statistical analyzes were performed using the
software version 21.0 of SPSS.

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Results
Descriptive
Table 2 shows the characteristics of the study
sample (N=32) at the time of the first
diagnosis (T0). The study group is made of 75
% males (n = 24). The ratio (4:1) reflects the
gender ratio currently estimated in the wider
population of children with ASD (4.5:1)
(Center for Disease Control and Prevention,
2014). With respect to the initial ADOS-2
classification (T0), the study group consisted
of 56.2% of children diagnosed with ASD,
and 43.8% of children at risk for autism.
With respect to the I.Q. evaluation at T0,
40.6% of children fell into the Average I.Q
category, and 53.2% fell into the Intellectual
Disability category.
The child’s chronological age and I.Q. score
were entered as covariates in the subsequent
analysis.
Optimal Outcome after 2 years
Among the 9 children who were initially
diagnosed with ASD-s, 2 of them no longer
fell into the ADOS-2 criteria of an autism
disorder after 2 years. Among the 9 children
who were initially diagnosed with Moderate
Autism (ASD-m), 6 of them no longer fell
into the ADOS criteria of an autism disorder
after 2 years. Among the 14 children who
were initially diagnosed at RISK, 6 of them
no longer fell into the ADOS criteria of an
autism disorder after 2 years. The Chi-square
analysis revealed a significant difference in
the overall percentage of children who
showed improvements in the diagnostic
categories after 2 years (P < .02) (see Table
3).
Autistic Symptomatology
In the study group, overall symptom severity
was measured at T0 using the ADOS-2 Total
score, Social Affect scores, and Restricted
and Repetitive Behaviors scores.
The children in the study group exhibited
significantly milder symptom severity after 2
years in ADOS-2 Total score and in Social
Affect scores (see Table 4).
The ANOVA for repeated measure, with IQ
and CA as covariates, did not show a
significant effect of the CA variable, while a
significant effect of interaction Time X IQ
score was found for Total score (F = 5.12; p <
.05) and Social Affect (F = 5.15; p < .05):
scores were reduced after 2 years of therapy,
especially in children who had a higher IQ at
T0. There were no differences between T0
and T2 in the RRB scores, which remained
substantially stable throughout the two years
(3.1 vs 3.3).
The changes in RRB scores were analyzed in
the two subgroups of children, i.e., those who
showed improvements by transitioning from
an ADOS-2 diagnostic category (14 children
who transitioned from ASD-s, ASD-m, or at
Risk to No-Autism) and those who did not
show improvements in regard to the ADOS-2
diagnostic category (18 children from ASD-s
who remained ASD-s, or children from ASD-
m who remained ASD-m). Substantial
differences were observed, such that, children
who showed improvements significantly
reduced the RRB scores (average T0 = 2.1
versus average T2 = 1.3; F = 4.6; p < 05; η2p
= .26), while those who did not improve,
showed an increase in scores (average T0 =
3.9 versus average T2 = 5.0; F = 4.3; p < .05;
η2p = .21).
Ability to understand the intentions of
others and emotional contagion
The children in the study group were re-tested
in their ability to understand the intentions of
others (UOI), the assessment was
readministered at 1 year and 2 years after
therapy (see Table 5). There were statistically
significant improvements in the UOI scores,
indicating an increase in the percentage of
children who reached good levels in their
ability to understand the intentions of others
after two years of therapy. After only 1 year
of therapy, the tendency towards

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improvement did not reach statistical
significance.
The children in the study group were also re-
tested for emotional contagion (TCE) after 2
years (see Table 5). It was found that after 2
years of treatment, the number of children
who reached the level of empathy rose from
9.3 to 43.7.
Discussion
The data presented in this study illustrates the
results of implementing the DERBBI
intervention, specifically, the Turtle Project
for preschool-aged children diagnosed with
autism spectrum disorder. The evolution of
the autistic symptomatology of 32 children
was monitored and described following 2
years of therapy, midway through the course
of this project. At the time of intake, the
children had been diagnosed with autism or,
if under 30 months of age, presented with a
risk of developing symptoms.
The results indicated that severe levels of
symptomatology at the time of intake was less
correlated with an optimal outcome following
2 years of therapy. Additionally, being at risk
for ASD before the age of 30 months seems
to be a fairly reliable indicator of the
evolution of symptoms in successive years. In
fact, children who presented with a severe
diagnosis maintained the same diagnosis in
78% of cases following 2 years of therapy.
Conversely, among the children who
presented with a moderate diagnosis,
approximately 67% no longer met the ADOS-
2 criteria for autism after 2 years of therapy.
Among the children who were at risk for
developing autistic symptoms, approximately
42% no longer met criteria for an autism
spectrum diagnosis after 2 years of therapy.
The data presented seems to be more
encouraging than data from previous studies
that have reported lifetime prevalence rates of
80-90% for pediatric ASD cases (Charman,
Howlin, Berry, & Prince, 2004; Woolfenden,
Sarkozy, Ridley, & Williams, 2012).
Nonetheless, results are in accordance with
other studies that have reported estimates
ranging from 3-25% of children who no
longer met criteria for an ASD diagnosis (Helt
et al., 2008; Sutera et al., 2007).
Overall, the greatest increase in skills was
shown to have occurred on the Social Affect
sphere, regardless of the children’s age. The
improvements in overall symptomatology
were more evident in children who at the time
of the first assessment, presented with higher,
or at minimum measurable, cognitive skills.
Similar results have been reported by other
authors who have described higher cognitive
levels and motor skills at the time of
diagnosis, for groups of children who no
longer fell into the ASD diagnostic category
after therapeutic intervention (Sutera et al.,
2007; Turner, & Stone, 2007).
The data presented in this study demonstrate
a marked improvement in the manifestation of
restricted and repetitive behaviors in children
who no longer met the ADOS-2 general
criteria for autism after 2 years, when
compared to children who transitioned from a
severe autism category to a moderate autism
category. In contrast, repetitive and
stereotypical behaviors increased in intensity
in children who did not demonstrate a change
in diagnostic category. In support of what had
been initially expected, important
improvements were observed in the study
group, including the children’s ability to
understand the intentions of the adults they
were facing. Similarly, results showed
children were better able to manifest coherent
emotional responses when faced with a
stimulus proposed by the TCE.
Conclusion
In accordance with the recent evidence on the
treatment of pediatric ASD, the data presented
in this study suggests that in order to have a
positive impact on the developmental
trajectory of children diagnosed with ASD,
who have been placed in a therapeutic course
that provides active parental involvement, it is
necessary for one to: Identify the child’s
socio-communicative impairments from their
first year of life; Define the child’s individual
characteristics through careful clinical
observation and through standardized,

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quantitative and qualitative methods; Provide
early intervention (Hamadneh, Alazzam,
Kassab, & Barahmeh, 2019; Zwaigenbaum et
al., 2015).
Specifically, the DERBBI approach aims to
promote the emergence or stabilization of
social skills such as joint attention, imitation,
reciprocal interaction, and other general
functional adaptive skills. It is necessary to
include interventions mediated by the child’s
parents to enable the therapist to work on
attunement. The developmental models are
characterized by work on the sensory and
social integration processes, support for
intentionality and communication, and the
affective development of children diagnosed
with ASD (Zwaigenbaum et al., 2015). In
continuation of this model, the therapeutic
activities for different age groups provided by
the Turtle Project aim to encourage imitation
and learning in an emotionally shared context
e aims to promote affective attunement as the
basis of subsequent social development, and
behavioral and cognitive development. The
DERBBI model presented in this study favors
diadic therapy, or rather, a setting with
parental mediation, especially in the child’s
early years. This is done to allow for an
understanding of the atypical functioning and
needs of the child, on which to build a new
form of relationship that will help the child
and mother to connect in an authentic and
individualized way, and to motivate them to
learn new communication patterns. The
therapist utilizing the Turtle developmental
model is distinct from those utilizing other
diadic therapy approaches due to their active
interaction in therapy (Alvarez, 2012). In this
way, the therapist stands as a support to the
relationship and a facilitator of
communication. By actively participating in
the exchange and by including the mother-
child dyad in the same cognitive context and
in a single affective climate, the therapist
promotes the expansion of the dyadic state of
consciousness (Tronick et al., 1998).
In fact, it is through the use of new forms of
syntonization, dysregulation, and
reattunement that the pre-verbal
psychobiological matrix can contribute to the
formation of the first nucleus of the implicit
self (Schore, 1994).
In addition to these objectives, what
characterizes the DERBBI model is the bodily
dimension, which is seen as a mode of
communication and learning, and as a tool for
achieving a greater awareness of body and
space perception, of organization and motor
fluidity, and of sensory and perceptual
regulation. It also allows the child to be led in
an intimate relational hook which will
promote a reduction in defensive states, the
regulation of activity levels, and an increase
in the awareness of others and self. Moreover,
the therapy works on the anticipation of
actions through the construction of a sensible
response to signals, which are predominantly
motor (Nadel, 2006; Solomon, Holland, &
Middleton, 2012). This is done while
simultaneously respecting the child’ s
inclinations and presentation, as the already
exposed emotional construct is preceded by
the cognitive construct, and because in
childhood, play and the body represent a
favored channel of communication and
relationships (Di Renzo et al., 2016a).
Consciously attuning to the motor acts of the
child with ASD, while recognizing the
affective and intentionality content of the
interactions, is a technique that not only
provides the child with an interactive pattern
of actions that is temporally defined, thus,
offering perspective, it also compensates for
the feelings of anxiety and anguish that are
related to the motor dysregulation exhibited
by the child (Hardy & Blythe La Gasse,
2013). From this perspective, the motor
stereotypy must also be interpreted as a
defensive response resulting from
overstimulation, which can therefore be
regulated and modified. Moreover, the
attunement promotes regulation and produces
meaning, which allows for the channeling of
motor activity in more functional and
adaptive ways.
In conclusion, the Turtle Project – according
to the DERBBI model – aims to be defined as
an “approach model” as opposed to an
“universal method or technique”, and it is
modular and flexible in respect to context and

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the individual child. Moreover, the child’s
developmental course can be modified by
preventing symptoms from becoming fixed
and solidified, otherwise, symptoms may
become pervasive and may dramatically
interfere with the quality of life of the entire
family system.
Limitations
The main limitation of this study is the
absence of a control group, as the children
were immediately evaluated in a diagnostic
examination and were placed into therapeutic
care upon arrival. Thus, researchers were not
able to place any participants from the waiting
list in a control group. Moreover, although
there was a delay of a few months in initiating
therapeutic treatment, the evaluations used in
this study provided the first follow-up after 1
year of starting treatment. It would be an
ethical violation for a group of children to
begin therapy 1 year after their diagnosis was
confirmed.
Table 1. DERBBI phases
PHASE 1
First year of therapy: children of 2 years of age. Duration: 10 hour for
week. Therapy team: neuropsychiatrists, psychotherapists, psychologists,
psychomotricists, osteopaths
Aim
To promote the emotional attunement between child and caregiver and to
stimulate the process of peer imitation. To transforme bodily experiences
into emotional ones.
Therapy
Mother -
Child
Dyad
The Mother-Child dyad is fundamental to rediscover the sense and the
pleasure of play; to share that favors affective attunement (mirroring). To
promote self-regulation perceptive-motor activities, supported by imitation
and mirroring, are proposed. The therapy includes a session in small group
with mother and child and a session in a small group of 4 children with 2
operators. Each session lasts about 2 hours.
AAT-
Animal
Assisted
Therapy
There is a weekly session with animal. The relationship with the animal
can facilitate sensory experiences and emotional regulation.
Parental
Counseling
The counseling includes individual or couple sessions every 15 days
concerning child's educational project. Monthly group sessions are
scheduled with 4/5 parental couples Sessions are scheduled twice per
month for fathers only.

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Contacts
with
educational
context.
Every month an operator observes the child in the classroom during the
educational and socializing activities with the class group. Weekly
contacts with the school and 3 meetings a year with the school team.
PHASE 2
Second Year of Therapy: children of 3 years of age. Duration: 10 hour for
week. Therapy team: neuropsychiatrists, psychotherapists, psychologists,
psychomotricists, speech therapists, music therapists
Aim
To improve the level of emotional regulation; to stimulate the motor
initiative and the redefinition of a body schema; to support communication
strategies through play.
Therapy
2 weekly individual or group sessions lasting about two hours. The
therapy is centered on the body and on sensoriality, also through music
therapy sessions to encourage listening, useful for the prosodic aspects of
language.
AAT- Animal Assisted Therapy: See Phase 1
Parental Counseling: See Phase 1
Contacts
with
educational
context.
The project includes three meetings (Working Group for Handicap) in
which an operator meets the teachers. In addition, on a monthly basis, an
operator performs an observation in the classroom.
PHASE 3
Third Year of Therapy: children of 4 years of age. Duration: 10 hour for
week. Therapy team: neuropsychiatrists, psychotherapists, psychologists,
psychomotricists, speech therapists
Aim
To improve playing skills, linguistic, cognitive, behavioral and relational
skills; attention skilld, motivation and relationship with others. The
expressive drawing skills are also reinforced.

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Therapy
One session per week of a small group (4 children) with 2 operators and
an individual therapy session with child
AAT- Animal Assisted Therapy: See Phase 1
Parental Counseling: See Phase 1
Contacts with educational context: See Phase 2
PHASE 4
Fourth Year of Therapy: children of 5 years of age. Duration: 10 hour for
week. Therapy team: neuropsychiatrists, psychotherapists, psychologists,
psychomotricists, speech therapists
Aim
The therapy is centered on the cognitive, linguistic and personal autonomy
areas, to stimulate the school learning prerequisites, the attentive skills,
also through logical-narrative activities. The expressive drawing activities
are proposed to support spatial and temporal organization, but also
creativity
Therapy
There are 2 weekly sessions each one lasting about 2 hours: a group
session with children and 2 operators, and an individual session with child.
It is also proposed the technique of holophony, a technique of sound
reproduction that simulates the strategies of human listening by immersing
the listener in a three-dimensional auditory reality
AAT- Animal Assisted Therapy: See Phase 1
Parental Counseling: See Phase 1
Contacts with educational context: See Phase 2
Table 2. Frequency distributions and percentages of groups based on gender, intellectual
disability and ADOS-2 classifications
Legend. ASD-s = severe autism spectrum disorder; ASD-m = moderate autism spectrum
disorder; RISK = Risk Spectrum Disorder
After 2 years (T2)
No Spectrum
N (%)
Spectrum
N (%)
ASD
N (%)
P
Study Group
(N=32)
ASD-s (N=9)
2 (6.3)
0
7 (21.9)
.02
ASD-m (N=9)
6 (18.8)
2 (6.3)
1 (3.1)
Risk (N=14)
6 (18.6)
0
8 (25)
Tot (N=32)
14 (43.7)
2 (6.3)
16 (50)

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Table 3. Differences in the number (and percentages) of children in the different ADOS-2
categories, at the beginning and after 2 years of treatment
Legend. ASD-s = severe autism spectrum disorder; ASD-m = moderate autism spectrum
disorder; RISK = Risk Spectrum Disorder
Table 4. Differences between T0 and T2 scores obtained with ADOS and ADOS-2 in the study
group (N=32), with IQ and CA covariate
Legend. T0 = intake; T2 = after two years of treatment
Table 5. Differences with respect to the UOI (understanding of Other Intention) and to the TCE
(Emotional Conbtagion Test), observed in the study group at the beginning and after 1 and 2
years of treatment.
UOI, absent/low N (%)
UOI, moderate N (%)
UOI, good/excellent N (%)
10 (31.3)
4 (12.5)
18 (56.3)
8 (25)
4 (12.5)
20 (62.5)
.08
7 (21.9)
4 (12.5)
21 (65.6)
.05
Sample (N=32)
Gender (% males)
24 (75%)
Age in months T0, mean (sd; range)
35.4 (11.1; 21-66)
Classificazione ADOS e ADOS-2
% ASD-s
% ASD-m
% Risk
28.1%
28.1%
43.8%
IQ Classifications
N (%) Average
N (%) Borderline
N (%) Intellectual Disability
13 (40.6%)
2 (6.2%)
17 (53.2%)
ADOS-2, Mean (sd)
Total score
Social Affect
Restricted Repetitive Behaviors
16.2 (6.1)
13.1 (0.8)
3.1 (.3)
13.8 (8.8)
10.4 (1.1)
3.3 (.4)
.05
.05
.20
.15
.15
/

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TCE, absent/low N (%)
TCE, emotional contagion N (%)
TCE, empathy N (%)
15 (46.9)
14 (43.8)
3 (9.3)
/
/
8 (25)
10 (31.3)
14 (43.7)
.02
Legend. T0 = intake; T1 = after one year of treatment; T2 = after two years of treatment
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