Animal Assisted Therapy for Children With Pervasive Develomental Disorders

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2002 24: 657West J Nurs ResFrançois Martin and Jennifer Farnum

Animal-Assisted Therapy for Children with Pervasive Developmental Disorders

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Western Journal of Nursing ResearchOctober 2002, Vol. 24, No. 6

Animal-Assisted Therapyfor Children With PervasiveDevelopmental Disorders 1

François MartinJennifer Farnum

The present study quantitatively evaluated the effects of interaction with dogs on children withpervasive developmental disorders (PDD), disorders characterized by lack of social communi-cations and abilities.While interacting with a therapist, childrenwere exposed to three differentconditions: (a) a nonsocial toy (ball), (b) a stuffed dog, and (c) a live dog. Prosocial andnonsocial interactions were evaluated in terms of both behavioral and verbal dimensions.Results show that children exhibited a more playful mood, were more focused, and were moreaware of their social environments when in the presence of a therapy dog. These findings indi-cate that interaction with dogs may have specific benefits for this population and suggest thatanimal-assisted therapy (AAT) may be an appropriate form of therapy.

Animal-assisted therapy (AAT) has been theorized to be an effective formof treatment for childrenwith pervasive developmental disorders (PDD), dis-orders characterized by a severe impairment of social functioning and inter-actions (American Psychiatric Association, 1994). Animals may be one wayto increase attachment between children with PDD and their social environ-ments. Animals are believed to act as transitional objects, allowing childrento first establish bonds with them and then extend these bonds to humans(George, 1988; Katcher, 2000; Winnicott, 1986). Because forming socialbonds is difficult for children with PDD, AAT may be an effective method oftherapy for this population. To test this hypothesis, the current study evalu-ated the effects of supervised interaction with dogs on children with PDD,examiningbothbehavioral andverbal dimensions. This interactionwith dogswas compared to interactions in two other conditions: (a) a ball and (b) astuffed dog. To accurately assess differences between conditions, a

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Western Journal of Nursing Research, 2002, 24(6), 657-670

François Martin, Ph.D., College of Veterinary Medicine, Washington State University;Jennifer Farnum, M.A., College of Veterinary Medicine, Washington State University.

DOI: 10.1177/019394502236639© 2002 Sage Publications



predetermined research protocol was used throughout supervised sessions.In this way, true distinctions between conditions could be delineated. How-ever, because a strict research protocol was employed instead of a more ver-satile therapeutic agenda, the claimcannot bemade that the research involvedAAT per se but rather that it allows for increased insight into the processesunderlying AAT.

ANIMALS AS THERAPEUTIC AIDES FOR CHILDRENWITH PERVASIVE DEVELOPMENTAL DISORDERS

In the fields of nursing, medicine, and psychotherapy, AAT has beenreceiving growing attention as a legitimate means of aiding patients.Looking for alternative methods of treatment for a variety of ailments, manyexperts in these fields have suggested that AAT may be able to serve animportant role in a range of different settings. Such settings include hospitals(Cole & Gawlinski, 2000; Miller & Ingram, 2000), residential care facilities(Kogan, 2000; Taylor, Maser, Yee, & Gonzalez, 1993), rehabilitation facili-ties, and hospices (Conner & Miller, 2000). AAT may be appropriate in sucha wide range of settings because of its potential to influence a large numberof health-related problems. For example, research indicates that animalcompanionship may be associated with lowered heart rates (Friedmann,Katcher, Lynch, & Thomas, 1980) and blood pressure (Anderson, Reid, &Jennings, 1992; Friedmann et al., 1980), reduced anxiety (Barker &Dawson, 1998), alleviation of depression, and greater self-esteem (Walsh &Mertin, 1994). Animals, it appears, may have the ability to enhance bothphysiological and psychological well-being.

Existing literature also indicates that animals may be particularly wellsuited for children, suggesting that animals are crucial in children’s social(Triebenbacher, 2000) and cognitive development (Melson, 2000).Research has shown that interaction with animals may alleviate stress inchildren (Hansen, Messinger, Baun, & Megel, 1999), is associated with areduction of symptoms in children with severe attention deficit/hyperactiv-ity disorder and conduct disorders (Katcher & Wilkins, 1998), and increasedpositive behaviors of children with Down’s syndrome (Limond, Bradshaw,& Cormack, 1997). Other researchers have suggested that AAT may beappropriate for yet another genre of disorders—PDD (Law & Scott, 1995;Nathanson, 1998; Nathanson, de Castro, Friend, & McMahon, 1997;Redefer & Goodman, 1989). PDD includes autistic disorder, Rett’s, child-

658 Western Journal of Nursing Research



hood disintegrative disorder, Asperger’s, and PDD not otherwise specified(American Psychiatric Association, 1994). Differences in these disordersinclude their prevalence in males versus females, their age of onset, and thespecific deficits found in each disorder. Deficits common to all PDDsinclude a lack of social interactions and communication skills, as well as ste-reotyped behaviors (e.g., hand flapping). In general, these children aresocially withdrawn, lack appropriate social skills, and are disinterested anddisengaged from their social environments; traditional therapies have notproved particularly advantageous for this population. For instance, neitherpharmacological interventions (Aman & Langsworthy, 2000; Volkmar,2001) nor educational therapies (e.g., sensory-motor therapy, communica-tion therapy) (Dawson & Watling, 2000; Dempsey & Foreman, 2001;Goldstein, 2000) appear to effectively manage all symptoms associated withPDD. For this reason, a more effective treatment for PDD must be deter-mined. AAT may hold the potential to greatly benefit this population.

One reason that AAT may be beneficial for children with PDD involvesthe notion that animals can act as transitional objects. As transitional objects,children establish primary bonds with the animals; these bonds can then betransferred to humans (George, 1988; Katcher, 2000; Winnicott, 1986).Because children with PDD have difficulties forming such bonds, AAT maybe a good fit for this population. Preliminary research in the field does sup-port this assertion: In a study involving AAT and children with autistic dis-order, AAT was found to increase prosocial behaviors, decrease self-absorp-tion, and lessen stereotypical behaviors (Redefer & Goodman, 1989).

PURPOSE

Although there appears to be some initial evidence that AAT may beeffective for PDD, further investigation is necessary. In general, studiesevaluating the effectiveness of AAT share a common shortcoming: lack ofscientific control and rigor. Because much of the information availableabout AAT is qualitative or anecdotal (Law & Scott, 1995; Mallon, 1992;Voelker, 1995), there is a need to incorporate scientific protocol in AATstudies. Such protocol includes clear definition of the goals of the research,proper instruments of measurement and documentation, gathering of suffi-cient sample sizes, and the use of a control condition (Voelker, 1995). Incor-porating these criteria, the current study seeks to quantitatively measure thebehavioral and verbal interactions of children with PDD.

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PREDICTIONS

Children were expected to exhibit more frequent and longer durations ofprosocial behaviors when in the presence of a therapist with a dog versus (a)a therapist with a nonsocial toy (a ball) or (b) a therapist with a stuffed dog.Prosocial behaviors were those behaviors that indicated interest and engage-ment in the environment, for example, by giving treats to the dog, laughing,or talking to the experimental object (ball, stuffed dog, live dog). Interactionwith a dog was also expected to produce less frequent and shorter durationsof nonsocial behaviors than the two other conditions. Nonsocial behaviorsincluded such categories as “ignoring questions” and “hand flapping.”

DESIGN

This experiment used a completely within-participants repeated-mea-sures design, with all participants experiencing all three experimental condi-tions (i.e., the children served as their own control).

SAMPLE

Participants

Participants were 10 children ranging in age from 3 to 13 with develop-mental ages of 2.5 to 6.5. All 10 children had been diagnosed with someform of PDD; 7 were diagnosed with PDD not otherwise specified, 2 withAsperger’s, and 1 with autistic disorder. School psychologists or familyphysicians provided diagnostics. None were institutionalized, and all exceptthe youngest were attending public school. Two participants were female; 8were male. Participants were recruited via local physicians and school prin-cipals who related the nature of the study to the families of potentialparticipants.

METHOD

Research was conducted in accordance with the Institutional ReviewBoard’s specifications. After obtaining approval and parental consent, all




children were individually administered the Psychoeducational Profile–Revised (PEP-R) (Schopler, Reicher, & Renner, 1990), a widely used instru-ment possessing high validity and reliability (Muris, Steerneman, &Ratering, 1997; Van Berckelaer-Onnes, & Van Duijn, 1993). The PEP-Rassesses seven different areas of functioning including imitation, percep-tion, fine motor control, gross motor control, eye-hand coordination, cogni-tive performance, and cognitive verbal performance. The combined scoresof the PEP-R were used to determine developmental age.

Sessions

Each child participated in 45 research sessions, all of which were con-ducted one-on-one with the therapist. The sessions were held three times perweek for a total of 15 weeks, so that children experienced each of the threeconditions every week. In other words, children would experience the ball,stuffed dog, and live dog conditions all in 1 week and then the followingweek again experience all three conditions. Presentation of conditions wascounterbalanced across participants.

Sessions were videotaped for data-coding purposes and were held at theschool the child was attending. Sessions were conducted in a special room orarea that school administration had designated for this purpose. To resched-ule missed sessions (due to illness, holidays, etc.), meetings were occasion-ally held at a child’s home or the People-Pet Partnership (PPP) office. Acameraperson was in attendance during sessions and, at times, the child’sparent or parents or school aide. These people were asked to limit their con-tact with the children, interacting with them only when necessary.

Sessions lasted approximately 15 minutes, during which time a child waspresented with either a ball, a stuffed dog, or a live dog. Therapists consis-tently used a medium-sized, orange ball ideal for tossing and playing. Thestuffed dogs were selected based on their physical similarity to the live dogsthat were used in the experiment. Three live dogs were employed for thisstudy, although each child was only exposed to one of the dogs. Live dogsincluded a Clumber Spaniel, a Newfoundland, and a Border Collie/YellowLab cross. To increase generalizability, dogs differing in size and color wereselected; all were temperament tested by the PPP director and trained by PPPpersonnel, and all exhibited particularly social and friendly behaviors.

Therapists also received extensive training from PPP personnel. Becausepractical considerations necessitated the hiring of two people for this posi-tion, it was necessary to make instructions and guidelines as uniform as pos-sible. For example, both therapists followed the same research protocol and

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were instructed to behave and interact in similar manners. Although five ofthe children were seen by both therapists, statistical analysis did not find anysignificant trend in the behavior of the children as a function of the therapist.

During the research sessions, therapists followed a predeterminedresearch protocol designed to elicit prosocial behaviors. This protocol wasconstructed in accordance with the developmental and behavioral categoriesof the PEP-R. Having a consistent protocol also served to limit the influenceof therapist style and skill level. Examples of questions include the follow-ing: “What color is the ball?” “Can you toss the ball?” “Do you rememberthe name of this stuffed dog?” “Can you brush the dog?” and “Tell me astory about the dog.” According to the developmental age of the child, thetherapist would further elicit responses based on these questions.

Interactions

Children’s interactions were analyzed in terms of two categories: behav-ior and verbal. Within each of these categories, specific variables were eval-uated; these variables had been previously established during a pilot study.Frequency of interactions and their corresponding durations were coded.Durations were coded in terms of seconds per minute except in the case ofinteractions that were too brief (e.g., answering “yes” to a question). In addi-tion to the behaviors listed in Tables 1 and 2, other behaviors were coded.They are not presented in this article because of their very low occurrenceand/or because they were not significantly different across the experimentalconditions. These variables included touching the therapist, playing catch,answering a question from the therapist with “yes” or “no,” giving a nonver-bal answer (e.g., head nodding), ignoring a question, talking about one’sfamily, social agreement (e.g., “uh-huh”), agreeing to a request with anexplanation, complying with a request nonverbally, refusing to comply witha request by saying “no,” refusing to comply with a request nonverbally,echolalia, and crying.

Coding Data

A Horita TG-50 was used to insert time codes on the videotapes. Thisallowed coders to analyze the videotapes frame by frame. Four codersassessed the behavior of the children. From each 15-minute session, codersevaluated a total of 3 minutes: 1 minute from the first third, 1 from the




TABLE 1: Mean Occurrences of Behaviors in the Three Conditions

Ball Stuffed Dog Dog

Variable M SD M SD M SD F p

Hand flapping (f) .03a .23 .01a,c .12 .06c .35 4.92 .008Hand flapping (d) .09a .83 .02a,c .24 .13c .93 5.33 .005Touching experimental object (f) 2.41a,b 2.27 1.57a,c 1.45 1.37b,c 1.67 35.52 .000Touching experimental object (d) 19.25b 19.15 18.89c 20.1 8.31b,c 13.5 63.08 .000Giving treats (f) NA NA .07c .37 .35c 1.10 28.43 .000Laughing (f) .41a,b 1.06 .21a,c .64 .57b,c 1.18 20.09 .000Laughing (d) .93a,b 3.15 .50a,c 3.44 1.44b,c 4.29 6.48 .002Looking at therapist (f) 3.82a,b 2.89 3.43a,c 2.92 2.75b,c 2.92 26.42 .000Looking at therapist (d) 9.61a,b 9.85 7.27a 8.29 6.63b 8.24 16.87 .000Looking at object (f) 4.34a,b 3.35 3.85a,c 2.98 4.85b,c 2.69 18.03 .000Looking at object (d) 15.35b 13.12 16.98c 15.25 21.66b,c 14.95 27.14 .000Looking around the room (d) 33.92b 15.57 34.39c 15.35 29.97b,c 15.17 12.43 .000

NOTE: NA = not applicable; (d) = duration (in seconds per minute); (f) = frequencies.a. Indicates a difference (paired-samples t test, p < .05) between ball and stuffed-dog conditions.b. Indicates a difference between ball and dog conditions.c. Indicates a difference between stuffed-dog and dog conditions.

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TABLE 2: Mean Occurrences of Verbalizations in the Three Conditions

Ball Stuffed Dog Dog

Variable M SD M SD M SD F p

Respond to questions withdetailed explanations (f) .94b 1.22 .94c 1.17 .65b,c .92 12.99 .000

Talk about therapist (f) .27a,b .74 .13a .45 .09b .35 12.75 .000Talk about therapist (d) .71a,b 2.91 .29a 1.46 .25b 1.17 4.73 .009Talk about self (f) .37a,b .74 .2a .54 .26b .58 9.18 .000Talk about self (d) .97a 2.72 .46a,c 1.62 .75c 2.28 8.16 .000Talk about experimental object (f) .38a,b .84 .78a 1.44 .73b 1.27 18.61 .000Talk about experimental object (d) .87a,b 2.38 1.97a 4.33 1.94b 4.14 17.99 .000Talk to experimental object (f) .02a,b .16 .11a,c .43 .55b,c 1.21 46.95 .000Talk to experimental object (d) .06a,b .66 .19a,c .82 1.02b,c 2.62 28.59 .000Talk about unrelated topics (f) 1.21b 1.55 1.13c 1.43 .7b,c 1.1 27.51 .000Talk about unrelated topics (d) 3.46b 6.14 3.69c 6.82 2.18b,c 5.43 11.35 .000Answer a request “yes” (f) .05 .34 .04c .26 .09c .33 3.56 .029Ignoring a question followed by an

unrelated statement (f) .18a .57 .27a,c .64 .19c .52 3.38 .035

NOTE: (d) = duration (in seconds per minute); (f) = frequencies.a. Indicates a difference (paired-samples t test, p < .05) between ball and stuffed-dog conditions.b. Indicates a difference between ball and dog conditions.c. Indicates a difference between stuffed-dog and dog conditions.

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second third, and 1 from the last third. To determine which minutes would beevaluated, sessions were assigned a random-coding sequence.

To ensure that all coders were making similar judgments of the interac-tions, coders were instructed on proper procedures until they achieved 90%interrater reliability. Reliability was calculated by means of an Excel pro-gram specifically designed for this project. The program determined inter-rater reliability by calculating the overlap between coders’ assessments ofinteractions. Periodic checks of reliability were made throughout the codingprocess on 10% of the sessions. The overall reliability between codersremained high (91.3%).

ANALYSIS OF DATA

Repeated-measures analysis of variance tests (SPSS 10.0) (SPSS Inc.,1999) were used to evaluate differences in children’s interactions as a func-tion of the three conditions. Pairedt tests were employed to determine thelocation of differences in the model.

FINDINGS

Preliminary analyses suggested no clear trend in terms of developmentalage and therefore were not included in subsequent analyses. The limitednumber of females (N= 2) also prohibited analyses on possible effects ofgender.

In terms of behavior variables (Table 1), children were more likely to per-form hand flapping in the dog condition than in the stuffed-dog condition,t(449) = –2.81,p < .005; hand flapping lasted for a longer period of time,t(449) = –2.50,p < .01. Children were more likely to touch the ball than thedog, t(449) = 8.30,p < .001, as well as the stuffed dog more than the dog,t(449) = 2.14,p < .033. These touching behaviors lasted longer in the ballcondition, t(449) = 9.9,p < .001, and the stuffed-dog condition,t(449) =9.13,p< .01. Children looked at the therapist less frequently in the dog con-dition than in the ball condition,t(449) = 7.07,p< .001, or stuffed-dog con-dition, t(449) = 4.48,p< .001. Less time was spent looking at the therapist inthe dog condition than in the ball condition,t(449) = –7.17,p < .001.

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Children were more likely to give treats to the live dog than the stuffeddog,t(449) = –5.33,p< .001. They laughed more frequently in the dog con-dition than in the ball condition,t(449) = –2.36,p< .019, or the stuffed-dogcondition, t(449) = –6.12,p < .001; laughing lasted for longer durations,t(449) = –2.24,p < .025 (ball); t(449) = –3.60,p < .001 (stuffed dog).Children looked at the dog more often than they looked at the ball,t(449) =–2.39,p< .017, or the stuffed dog,t(449) = –6.07,p< .001, and spent longeramounts of time looking at the dog than the ball,t(449) = –7.09,p< .001, orthe stuffed dog,t(449) = –5.33,p < .001. Children spent less time lookingaround the room in the dog condition than in the ball condition,t(449) =4.01,p < .001, or the stuffed-dog condition,t(449) = 4.51,p < .001.

In terms of verbal interactions (Table 2), results indicate that childrenanswered questions with detailed explanations less often in the dog condi-tion than in the ball condition,t(449) = 4.24,p< .001, or the stuffed-dog con-dition, t(449) = 4.37,p< .001. They also talked about the therapist less in thedog condition than in the ball condition,t(449) = 5.02,p < .001, and forshorter amounts of time,t(449) = 3.12,p< .002. Children talked about them-selves less frequently in the dog condition than in the ball condition,t(449) =2.40,p < .017. They talked about themselves for longer amounts of time inthe dog condition than in the stuffed-dog condition,t(449) = –2.28,p< .023.

Results also show that children were more likely to talk about the dogthan the ball,t(449) = –5.07,p< .001, and for longer durations,t(449) =–4.91,p < .001. Children talked to the dog more frequently than to the ball,t(449) = –9.32,p < .001, or the stuffed dog,t(449) = –7.68,p < .001.Children spent a greater amount of time talking to the dog than to the ball,t(449) = –7.52,p< .001, or the stuffed dog,t(449) = –6.61,p< .001. Also, inthe dog condition, children were less likely to talk about topics unrelated tothe research protocol. (Unrelated topics were those that were not related tothe object, the therapist, or the child—for example, talking about a televisionprogram.) This finding was true compared to both the ball,t(449) = 6.37,p<.001, and stuffed-dog conditions,t(449) = 5.87,p < .001. Children talkedabout unrelated topics for shorter lengths of time in the dog condition,t(449)= 3.51.p < .001 (ball);t(449) = 4.33,p < .001 (stuffed dog). Children werealso more likely to comply with a request by saying “yes” when in the dogcondition than in the stuffed-dog condition,t(449) = –2.57,p< .01, and theywere less likely to ignore a question and follow with an unrelated statementin the dog condition than in the stuffed-dog condition,t(449) = 2.09,p < .038.




DISCUSSION

Although the sample size of this study prohibits extensive generalization,the results nonetheless provide some tentative support for the efficacy ofAAT for children with PDD. Behaviors of the children varied as a functionof experimental condition, and interaction with dogs appeared to have somepositive benefits. These findings support the work of Redefer and Goodman(1989) and lend merit to the assertion that AAT may be beneficial for thispopulation (Law & Scott, 1995; Nathanson et al., 1997).

Children laughed more and gave treats more often in the dog condition,implying a happier, more playful mood and an increase in energy. Thisincrease in energy seems to have been appropriately channeled as evidencedby the fact that children’s attention was primarily centered on the dog andnot on distracters unrelated to the protocol. For instance, children were morelikely to keep their gaze focused on the dog than on the ball or the stuffeddog and they appeared to be less easily distracted in the dog condition, look-ing around the room less in this condition. Children were also more likely totalk to the dog, initiating numerous conversations and exchanges. They weremore likely to engage the therapist in discussions regarding the dog than dis-cussions regarding the ball.

Further support that dogs may aid in maintaining the interest and focus ofchildren with PDD is evidenced by the fact that children spoke less abouttopics unrelated to the therapeutic protocol in the dog condition than ineither of the other conditions. Compared to the stuffed-dog condition, chil-dren were also more apt to agree to a request from the therapist. They wereless inclined to disregard questions from the therapist by talking about unre-lated subjects (as compared to the stuffed-dog condition). For example, thetherapist asking, “What color is the ball?” and the child answering, “The rugis dirty” would be considered “ignoring a question followed by an unrelatedstatement” (see Table 2). This may be a particularly powerful finding, as thiscategory may best represent the typical interactions of children with PDD,interactions that are one-sided and which fail to integrate others’ communi-cations and perspectives. That children were less inclined to disregard thera-pist questions with irrelevant “answers”—combined with frequent talking tothe dog and less frequent discussions about topics unrelated to protocol—indicates that using a therapy dog may increase meaningful, focuseddiscussions.

Although these results are promising, some of the findings run counter tothe general hypothesis. For example, children responded to questions with

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detailed explanations less often in the dog condition. They were also lesslikely to initiate conversations about themselves or conversations about thetherapist. One explanation for this may be that children talked more aboutthe dog and to the dog, thus allowing less time to talk about other topics.Children looked at the therapist less often in the dog condition compared tothe two other conditions, perhaps because they looked at the dog more often.Children touched the dog less often than the ball or the stuffed dog. This maybe explained by the fact that the children would place the ball or the stuffeddog on their laps and “forget” about them—which would be impossible to dowith a live, active dog.

Another unexpected result was that children exhibited more hand flap-ping in the presence of the dog. Although hand flapping is usually consid-ered a stereotyped behavior and therefore viewed as undesirable, we believethat in this study, hand flapping was a mode of expressing excitement andexhilaration. In a therapeutic context, it could be the job of the therapist tohelp children moderate these undesirable behaviors and to transform thisexcitement into something more appropriate, but this task was beyond thescope of this research.

Although the results are certainly encouraging, this study does not evalu-ate AAT per se. Therapists used a research protocol, not a therapy protocol.They did not try to modify the behavior of the children; they only tried toelicit prosocial behaviors. The primary reason for using a research protocolwas to enable examination of differences between conditions or, in otherwords, to determine whether children may be more primed for therapy whenin the presence of a dog. We wanted to examine the foundation of AAT—thehuman-animal bond. In this way, extraneous variables were minimized,allowing us to focus on the fundamental interaction occurring—child andanimal.

With this research, we now have some quantitative indication that inter-action with dogs may have a positive effect on the behaviors of children withPDD. The next step is to see if and how it can be used in a clinical setting andto verify if these positive effects can be generalized to other spheres of thechildren’s lives. It is also important to know whether all of these effects—orany—would be maintained outside therapy sessions.

Taken together, this research provides some evidence that AAT may bean effective form of treatment for children with PDD and ameliorates ourprevious understanding of the potential benefits of AAT for this population.Perhaps the most important aspect of this research is that it is one of the firststudies to quantify the effects of interaction with dogs on this population in ascientific and controlled manner. With the knowledge obtained from this




study, it is possible to begin to further test the implications of the findings,particularly as they apply in clinical settings. By building on the results ofthis research, both researchers and clinicians can start to delineate the mosteffective methods of serving clients with PDD through AAT.

NOTE

1. This research was made possible in part by the Pet Care Trust Foundation, Washington,D.C. We wish to acknowledge the contributions of Daun Martin, Camille McElwain, WillowGormley, Tony Ezetta, Céline Cazorla, and Kristie Morse in this research.

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Animal Assisted Therapy for Children With Pervasive Develomental Disorders

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