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Dolphin-Assisted Therapy: Claims versus Evidence

Dolphin-Assisted Therapy: Claims versus Evidence Hindawi Publishing Corporation Autism Research and Treatment Volume 2012, Article ID 839792, 7 pages doi:10.1155/2012/839792 Review Article 1 1 2 Britta L. Fiksdal, Daniel Houlihan, and Aaron C. Barnes Psychology Department AH23, Minnesota State University, Mankato, MN 56001, USA School of Education, University of Wisconsin Stout Menomonie, WI 54751, USA Correspondence should be addressed to Britta L. Fiksdal, britta.fiksdal@mnsu.edu Received 23 March 2012; Accepted 24 June 2012 Academic Editor: Bennett L. Leventhal Copyright © 2012 Britta L. Fiksdal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The purpose of this paper is to review and critique studies that have been conducted on dolphin-assisted therapy for children with various disorders. Studies have been released claiming swimming with dolphins is therapeutic and beneficial for children with autism, attention deficit hyperactivity disorder, physical disabilities, and other psychological disorders. The majority of the studies conducted supporting the effectiveness of dolphin-assisted therapy have been found to have major methodological concerns making it impossible to draw valid conclusions. Readers will be informed of the history of, theory behind, and variations of dolphin-assisted therapy along with a review and critique of studies published which purportedly support its use. 1. Dolphin-Assisted Therapy: As notedbyMorrison[4], for more than 12,000 years, animals and humans have been in therapeutic relationships Claims versus Evidence together. Dogs are generally the most common therapeutic Along with other pervasive conditions, those identified as animal, but the literature and historic record suggests that having autism spectrum disorders (ASD) have often been cats, guinea pigs, cockatoos, African grays, horses, chickens, subject to questionable or controversial treatments [1]. As pot-bellied pigs, llamas, goats, and donkeys have all been defined by Simpson, a controversial treatment is any method utilized with therapeutic aims [4]. Therateofanimal- or strategy that has not been validated by scientific support. facilitated therapy has increased dramatically over the past Such treatments may be of special concern when seemingly few years; however, the number of empirical research studies extraordinary results are guaranteed. Such concerns may be showing the efficacy of this therapy has not. Betsy Johnson confounded when physicians fail to anticipate or understand was among the first to discover using dolphins as a ther- the feelings of desperation that accompany some parents of apeutic agent with individuals suffering from neurological children with ASD when they come into the office [2]. The impairments [5]. The grace and beauty of dolphins along combination of desperation and a lack of effective treatment with their responsiveness to humans have led therapists options provided by the physician may lead parents to pursue and researchers to assess potential therapeutic benefits. This treatments with little or no empirical support. The number interest, however, has taken a reckless turn and has led to the of diagnosed cases of ASD has increased ten times in the past evolution of a treatment known as dolphin-assisted therapy 20 years with the current rate of one in every 166 children (DAT) [6]. born being diagnosed [3]. It was estimated that in 2005 the Dolphin-assisted therapies are primarily advertised National Institutes of Health spent $99 million on autism through popular media such as television, informational research. This number makes a stark increase compared to movies, and the internet [7]. According to Marino and the $22 million spent in 1997 [3]. Taken together, there exist Lilienfeld [8], the claims made supporting DAT by the many opportunities for the eager pursuit of a wide range facilities themselves have not been empirically supported, of treatments. Among those sharing relatively heightened neither has there been an increase in peer-reviewed papers interest and relatively little empirical support are animal- published on the topic from the 1970s to 2007. Researchers based treatments. and practitioners of DAT as well as parents with children 2 Autism Research and Treatment diagnosed with an ASD should be aware that support for In one example of a treatment plan, children first go this type of treatment has not been empirically validated. through an on-dock orientation that consists of the therapist Studies that have been held up as supporting DAT have and child sitting on the edge of a 2-3-inch raised dock serious methodological flaws rendering their results weak while the trainer is in the water manipulating the dolphin’s and meaningless [7–9]. Recent voices in the mainstream movement. Children are typically able to touch, play, or media have called for an aid in finding and selecting effective give simple hand commands to the dolphins during this treatments, with the hope of reducing the number of parents orientation to get them acquainted and comfortable with chasing down the latest “fashionable” trends in intervention, the dolphin. Once the child has completed the orientation and instead to base their decisions on valid data [3]. Unfor- stage, they start a series of therapeutic sessions. During these tunately, organizations that have in the past been trusted for therapeutic sessions, children are allowed to play with the guidance, have had trouble avoiding affiliations with special dolphins for a short time either from the dock or by going in interests [10]. Alternative treatments have sprung up, many the water with them after emitting a correct motor, language, with associated risk, with no empirical support and little or cognitive response. During the “play” time the children documentation. However, many of these unconventional can touch or kiss the dolphin, dance in a circle with the methods have the backing of major organizations supporting dolphin, or ride on the dolphin by holding onto the dorsal families with special needs children. fin [15]. This paper is an effort to navigate the often-spurious Humphries [15] found the cost of DAT varies depending claims in the literature and popular media, and to increase on the length and location of therapy as well as the therapy the likelihood that those seeking effective treatment will be package chosen. There are currently DAT programs all over successful. The purpose of this paper is to provide a detailed the world including Europe, the Middle East, Asia, USA, the description of DAT, review the studies published supporting Caribbean, Mexico, Israel, Russia, Japan, China, Bahamas, DAT, review the studies that have debunked this particular and South America [7, 14]. The typical price for five 40- treatment, and summarize the overall lack of empirical minute sessions is about $2,600. Typical travel, food, and support for its use. lodging costs can raise the price to $5,200 over two weeks. One notable example quoted in 2006, Nathanson’s Dolphin 2. Overview of DAT Human Therapy, costs $7,800 for two weeks or $11,800 for three weeks not including travel, food, and lodging [15]. Dolphin assisted therapy has been used with the aim of It is worth noting that these sums of money are being treating individuals identified as having mental and physical exchanged for activities that are often nearly indistinguish- disabilities for over 25 years [11]. DAT is a type of animal- able from swim-with-dolphin programs typically frequented assisted therapy that claims to help those who are physically by tourists [7–9]. and mentally ill and disabled as well as adults and children with various psychopathologies. Therapy generally involves the patient swimming and playing with dolphins in captivity- 3. DAT Claims and Indicated Treatments over several sessions while working on tasks such as hand- eye coordination or various verbal response targets. It is a Nathanson [13] reported the two-week Dolphin Human highly attractive form of therapy due to the dolphins being Therapy program significantly increases language, speech, well-liked, exotic animals [7, 8]. According to Nathanson gross motor, and fine motor functioning among children et al. [12], the primary purpose of his DAT program with various disabilities when compared to the more con- is to increase engagement and target behaviors based on ventional speech or physical therapy programs that last a the child’s individualized program by using dolphins to minimum of six months. DAT has been targeted for children compliment or assist other, more traditional, treatments. and adults of all ages, all genders, and all ethnicities [4]. The program focuses on increasing the frequency of target Supporters and therapists of DAT claim it is effective in behaviors by using basic-behavior modification principles in treating people with clinical disorders as well as conditions a relatively short-term intensive therapy [13]. including autism, epilepsy, Angelman syndrome, Down syn- There are many different variations of dolphin-assisted drome, dyslexia, Rett syndrome, Tay-Sachs disease, Tourette therapy ranging from the client simply looking at or taking syndrome, William syndrome, cancer, and AIDS [5, 7]. Other care of a dolphin, touching the dolphin, to entering the purported benefits of DAT include increased stimulation, water and swimming with the dolphin. Different therapists better memory, increased motor skills, accelerated healing, have different theories on how humans and dolphins interact and an increase in a person’s well-being [5] as well as reduced as well as the particular kind of therapy that should stress, pain, and depression, increasing relaxation, enhancing be employed for a specific patient [14]. The length and the production of infection fighting t cells, endorphins, frequency of sessions vary depending on the program. Some and hormones, and enhancing the recovery process [6]. In therapists run sessions for a week, two weeks, or a month. summary, Nathanson et al. [12] claim that DAT increases Some programs have even tried single sessions that last a attention span, motivation, and language skills more rapidly couple of hours instead of the typical 10–30 minutes [12]. and cost effectively than other more conventional therapies Humphries [15] found that, in five of the six studies she and the treatment effects are maintained over an extended evaluated, sessions lasted on average 30 minutes each and each study consisted of approximately 16 sessions total. period of time. Autism Research and Treatment 3 4. History of Dolphin-Assisted Therapy backing these claims appears to be purely anecdotal [6]. Dolphins produce sounds, often described as clicks, and What would come to be known as dolphin-assisted therapy below the blowhole as part of a technique called echolocation dates back to the work of John Lilly in the 1950s [6]. His work dolphins can emit a rate of 300 clicks per second, using was extended during the 1970s when dolphin researchers echolocation to navigate, find food, and communicate with started studying interactions between dolphins and children other dolphins [6]. Simply put, a human interacting with with neurological impairments [15]. An educational anthro- dolphins differs from the current standards of medical pologist at Florida International University, Betsy Smith, practice for therapeutic ultrasound, which call for repeated is credited with conducting the first line of research in application at a specific intensity and duration [11]. 1971 involving dolphins and children with neurological Other theorists propose that dolphins are sensitive to impairments [6, 7]. people with disabilities and that they seek to help them by Since 1982, there have been only a small number of publi- paying extra attention to them through playful expressions of cations involving dolphin-assisted therapy [11]. Nathanson’s concern [6]. This has been termed “secret language” by some first pilot studies on dolphin-assisted therapy took place DAT therapists. In the 70s, Dr. Smith theorized that dolphins at Ocean World in Ft. Lauderdale, FL, in 1978 and 1979. could communicate acoustically with body movements and Based on the pilot studies, DAT was altered to consist of one are attended to the body movements of others. This appeared session per day, two days per week with only one therapist to be especially true in the case of children with autism. It for the program at Dolphin Research Center in Grassy seemed to DAT’s supporters that the dolphins understood Key, FL, from 1988–1994 [13]. According to Nathanson, his their thoughts and actions [6]. Dolphin Human Therapy program began providing full- It has also been theorized that through DAT, human time therapy across the years of 1995 and 1996. Sessions contact with dolphins produces intense emotions and feel- were offered five days a week and multiple therapists were ings of reconnection and happiness which consequently employed at Dolphins Plus in Key Largo, FL. In 1997, a increases the well being of the participant [5]. Dolphins full-time, multiple therapist program opened in Miami, FL, have been reported to bring joy and happiness to people at the Miami Seaquarium on Virginia Key. Between 1988– through their playful behavior and constant “smile.” The 1997, children who entered dolphin-assisted therapy were joy, novelty of the situation, and extra attention are likely diagnosed with over 40 different diagnoses and came from components that enhance a person’s quality of life thus over 37 different states and 39 different countries. Many of increasing the motivation to learn [6]. It may be that the children were diagnosed with multiple disabilities. In dolphins become positive reinforcers for the patient emitting 1997, Nathanson and colleagues started scheduling almost a specific behavior or achieving a therapy goal [7]. For all of the children enrolled in Dolphin Human Therapy for some people, interacting with animals in general has a calm at least two weeks of sessions instead of one [12, 13]. and stress-reducing effect. Brensing et al. [11] found that dolphins have a relaxing influence on people based on the analysis of EEG scans. 5. Theories behind Dolphin-Assisted Therapy In addition to ultrasound-based theories, Nathanson based his dolphin-assisted therapy on the theory that, There have been numerous theories voiced regarding how dolphin-assisted therapy works. These theories are often as a result of swimming with dolphins, children will presented to the public in verbose and vague language, using increase their attention to stimuli in the environment [15]. Nathanson’s attention deficit hypothesis implies that people terms that sound technical but really have no significant meaning. When precise scientific terms are used, they are with mental retardation and other disorders are unable to often used incorrectly or without proper context. Such learn because of a deficit in physiological attention to the obfuscating language is typically applied by pseudoscience important details of the stimuli and not because they are practitioners with the purported aim of sounding more unable to process information. This contributes the overar- advanced, legitimate, and scientific [5]. Since the exact ching theory that animals increase attention for individuals, etiology of autism is unknown, advocates of DAT are able therefore leading to improved cognitive processes such as to create any explanation for the efficacy of the treatment. enhanced learning, motor skills, language, and memory [13]. McKinney et al. [6] report that simply being in water There are no limits or regulation on the number of erroneous claims that can be made [7]. The three most prominent has a relaxing therapeutic effect on people with various theories for DAT are echolocation, dolphins being attracted disabilities. Aquatic therapists claim that adding the calming to people with disabilities, and overall joy and relaxation. effects of animals such as dolphins to being in water will Other theories include simply being in the water and enhance the therapeutic effects. increasing attention in individuals with autism [6–9, 15]. Nathanson [13], Brensing et al. [11], McKinney et 6. Research behind Dolphin-Assisted Therapy al. [6], and other proponents of DAT have claimed that ultrasound emitted by dolphins through echolocation clicks There have been multiple claims made supporting dolphin- has a mechanical effect on human endocrine and neural assisted therapy. Lukina [16]aswellasServais [17]claim systems. These effects enhance healing by changing the that DAT improved language, cognitive processing, attention, individual’s body tissue and cell structure. This is one of the behavior, motivation to learn, and even some medical most popular theories behind DAT; however, the evidence conditions. Nathanson [13] and Nathanson et al. [12] 4 Autism Research and Treatment claim that dolphin human therapy has successfully increased DAT as an effective treatment for individuals with severe motivation, gross and fine motor skills, speech, language, and disabilities [12]. attention. They also claim that two weeks of therapy is just In 1998, Nathanson conducted another study examining as good if not better than six months of other traditional the long-term effects of DAT and found the increases in treatments. Humphries [15] evaluated six studies supporting functioning were maintained or improved at the one-year DAT [12, 13, 16–19] and found all of the studies were at followup. Nathanson sent out 137 questionnaires to assess risk for investigator bias, novelty of the therapy, and multiple the long-term effects of DAT, of which 71 were returned treatment interference. (52%). Following DAT, it was expected that children would return and continue with their conventional therapies such Morrison [4] found that there were several methodolog- as occupational, speech, and physical therapies, parent ical weaknesses consistently seen throughout DAT studies. follow ups, and special education services. According to the Some of these weaknesses included lack of consistent ran- questionnaires that were returned, following DAT clients domization of participants, small sample size, absence of increased the amount of time they participated in and control or typical care group, lack of reliability and validity benefited from their conventional therapies more than 50%. measurements, attrition rates, poor generalization, selection This study also found that two weeks of therapy were bias, and novelty effect. According to Marino and Lilienfeld significantly more effective than one week and that their [8], if these methodological weaknesses were accounted for, it model of DAT, Dolphin Human Therapy, showed beneficial would be shown that there is nothing unique or special about long-term effects for approximately 95% of the children dolphins per se in DAT. treated [13]. Dolphin-assisted therapy receives the majority of its Marino and Lilienfeld [9] found multiple reasons why advertisement, praise, and positive attention from the media both studies, Nathanson et al. [12] and Nathanson [13], (e.g., news programs, promotional films). Some reports should be interpreted with caution. After assessing both claim the success rates for physical and behavioral improve- articles, a minimum of 11 methodological weaknesses were ment through DAT is 90% [15]. Marino and Lilienfeld [7] found that undermined the scientific validity for both found one website that claimed, “The field of medicine studies. The main weaknesses consisted of the potential for has shown extraordinary results of the therapy (DAT) and placebo effect, history effects, and regression to the mean all breakthroughs in outcomes in relation to conventional meth- due to a lack of experimental control [7]. ods of treatments such as prescribed medication, human The study conducted by Nathanson and colleagues in therapy, and others.” The popularity for DAT continues to be 1997 appeared to have used a modification of a pre- substantial, while the research base continues to be meager at postdesign. The “pre-test,” or selection criteria, was the fact best [8, 15]. that children were only able to participate contingent on their In 2003, Dr. Betsy Smith, one of the first researchers inability to respond on their own to a physical or verbal to investigate and propose the possibility of DAT having task. After two weeks of DAT, each child was assessed (the therapeutic value, denounced its use. Describing it as an inef- posttest) for their ability to respond on their own to the same fective and exploitative practice, Dr. Smith voiced two main task as before. Changes in response from pre- to posttest concerns: (1) monetary gain was more involved with DAT’s were attributed solely to DAT. Nathanson claimed to have practice than was empirical evidence supporting its use, and used a single-subject design, however, he failed to report (2) it was undermined and detracted from valid therapy any individual subject’s data. Instead, he compiled all the programs [7]. Purveyors of DAT programs can expect to data from each subject into tables obscuring analysis at an gain a substantial amount of money from every family and individual level. Because of this aggregation of data, it is client who seeks their help. The potentially hazardous impact possible that some children did worse after therapy but the of time and money spent for DAT is compounded when data was embedded in a group of children who did show the same resources could be spent on empirically supported improvements [9, 15]. treatments (e.g., discrete-trial teaching). Currently, there are The most important and detrimental flaws to the study no studies that show DAT to be consistently effective [5]. conducted by Nathanson et al. in 1997 stem from a lack of Nathanson et al. [12] argued that compared to con- experimental control. Lack of experimental control makes ventional long-term therapies, Dolphin Human Therapy, a it impossible to attribute any changes to DAT alone. There form of DAT, achieved effective results more quickly and was no control group for which to compare the treatment at lower cost. Nathanson and colleagues compared two group, no dismantling strategy to expose subjects to the weeks of DAT to six months of speech and physical therapy different treatment components in a systematic manner, and with individuals with multiple disabilities. Each participant no counterbalancing between what they called the pre- and received six months of conventional therapy right before post- tests. Without a control group, it is impossible to rule DAT and had received 16 or 17 sessions throughout a two- out a placebo effect, regression to the mean, novelty effects, week DAT program. They claimed the administration of DAT history, the effect water could have had on the children’s to children with severe disabilities significantly increased performance, or other variables such as an increase in motivation, motor skills, attention, and language. Results interpersonal attention or interpersonal contact. Nathanson showed that prior to DAT 0% of the children were able to et al. appear to have changed the way the dependent variable was assessed at various points in the study. This suggests make the independent target response and after DAT 57– 71% were able to, therefore making an argument supporting that instrumentation might have been the cause of changes Autism Research and Treatment 5 that appeared to occur. Many of the participants came from without major diagnoses. Each child interacted with the different states or even different countries. Nathanson and dolphins by swimming with them for 10–15 minutes for 5– colleagues did not have a randomized control group to 10 sessions. The results indicated that the cardiac rhythms for assess for variables associated with these children being in a each group increased after having swum with the dolphins. different state and possibly even a different country. Lukina claimed that the results of the study supported the Another set of problems with the Nathanson et al. [12] fact that the redistribution of “psychoemotional” dominants study stems from how the children’s responses were recorded opens possibilities for psychotherapy and rehabilitation and measured. Experimenter expectancy could have had measures [16]. an effect on the behavior recorded since the observers One major flaw in the Lukina’s study was a lack of were aware of the outcome desired for the study. To add clear definition for “psychoemotional” dominants or how to the threat of experimenter expectancy, there was no they are related to changes in cardiac rhythms. Furthermore, operational criterion or definition differentiating between Lukina claimed that DAT reduced depression, night phobias, what was considered an independent response from one hysteria, and enuresis for the children in the “infantile that was assisted or guided. Having a strong interrater neurosis” group, however, there was no data reported reliability coefficient or a report on procedural integrity may showing this was the case. Lukina also failed to mention the have helped to minimize this methodological flaw; however, assessment instruments used to assess depression, night pho- the authors never explained how they get their inter-rater bias, hysteria, and enuresis for these children. Psychotherapy reliability coefficientof1.00orwhatitrepresented.Itcould was also a part of therapy, so attributing all the positive have been based on every trial from the entire study, it effects to DAT is impossible because the different treatment could have been a small sample of trials, or it could have components were never assessed independently. Although only included trials in which there was perfect inter-rater there was a comparison group of children without major reliability [9]. diagnoses, there was no control group of children who did The follow-up study conducted by Nathanson in 1998 fell not swim with dolphins. When you add to this the use of victim to many of the same methodological flaws as the 1997 a single A-B comparison design lacking experimental rigor, study (i.e., history, placebo effects, instrumentation, lack of there is clear reason to question the validity of the study control group, and regression to the mean). Nathanson’s [8, 15]. follow-up data were based solely on a questionnaire filled The study conducted by Servais [17]involvedtwo out by the parents of the children who underwent DAT experiments. The first experiment included two control the year before [9]. Nathanson concluded that the children groups (a classroom group and a computer group) and an maintained their skills one year later, two weeks of DAT was experimental group (dolphin group). Each group consisted better than one week, and there were no differences in long- of three children with autism. Children from each group were term effects of DAT due to the participant’s disorders(s) [13]. taught the same cognitive task in their respective settings. Nowhere in his paper did Nathanson attribute any of the The second experiment consisted of a dolphin group and a changes to the months of conventional therapy each child classroom group only. All groups in each experiment were had received in between the end of DAT and the follow-up given pre-tests first, followed by 10–15 “learning sessions” questionnaire as well as in between the pre- and post- test in which the cognitive tasks were taught in each of the measures [7–9]. groups, followed by each group being administered a post- Nathanson failed to control for demand characteristics, test. Results showed the children working with the dolphins including the tendency for participants to respond in a way responded correctly more often compared to the children in they feel is appropriate for what they think the researcher the control groups. Outcome measures of social-emotional wants to hear. Not only did he fail to control for it, he made status revealed increases of kindness, attentiveness, initiating it worse by beginning each item of the questionnaire with play, self-control, and eye contact were found with the a statement that attributes all success to dolphin-assisted children who participated in the DAT compared to the therapy. This made the hypothesis of the researcher evident control groups. to each parent as they were filling out the questionnaire. Servais [17] is also hindered by methodological and The questions in the questionnaire only asked about the practical flaws that call validity into question. At times during positive effects of DAT (mostly behaviors that were improved the study, in order to increase exposure to the dolphins, the or maintained) and did not assess or ask about behaviors that human subjects were provided with correct answers to the might have gotten worse or regressed. Of the 137 question- cognitive tasks [15]. According to Marino and Lilienfeld [8], naires sent out, 71 were returned, and the study incorporated Servais did not explicitly state whether the pre- and post-tests no pre- postmeasurement of parents’ perceptions of behavior were the same within or across groups making it impossible [9]. to rule out instrumentation effects. The children in the In another study, Lukina [16] assessed the effects of first dolphin group improved and performed significantly DAT on the psychoneurological functioning of children with better than those in the second dolphin group but no other various conditions compared to healthy children through the differences were reported between groups in the first exper- use of a single group pretest-posttest design. The participants iment. The children from the second dolphin group did not included 30 children with infantile neurosis, 25 children appear to have improved or performed significantly better with mental retardation and autism, 35 children with other than the control group from the second experiment. Other unspecified diseases, and a comparison group of 57 children threats to the validity of the study include experimenter 6 Autism Research and Treatment expectancy and demand characteristics because the author making it impossible to rule out demand characteristics was the only person who coded the behavioral outcomes. [7–9, 18]. Second, there was nothing done to control for It is unclear whether other components of therapy, (e.g., possible placebo or novelty effects of interacting with an swimming outdoors, etc.) might have contributed to a child’s exotic animal. Third, because the study relied on self- improvement. report measures and the participants were not blind to the Likura et al. [19] looked at the effects of DAT on patients condition, informant bias is impossible to rule out [7–9]. with atopic dermatitis (skin condition). There were two Fourth, no follow-up study was conducted meaning that the groups of patients, one group included swimming with differences between the control and experimental groups can dolphins in the seawater therapy, and the other group only be explained by the different conditions at the time of received only seawater therapy. For six days the patients the test [7–9, 18]. Fifth, nothing was done to control for swam with dolphins in seawater, which is typically painful “resentful demoralization” which refers to when a participant for individuals suffering from atopic dermatitis. Dramatic realizes they are receiving a less beneficial treatment and skin changes have been reported after contact with seawater, becomes resentful, thus potentially threatening construct however, patients typically complain of pain or stress making validity [7–9]. According to Antonioli and Reveley they it difficult to stay in the water for prolonged periods. The controlled for “resentful demoralization” by allowing the purpose of the dolphins in this study was to minimize the participants in the control group to swim with the dolphins stress and pain felt by the patients, thus distracting them after the final evaluation. However, since it occurred after and helping them to relax. Each DAT session lasted 90 the final evaluation there is no reason to believe “resentful minutes and each participant had two sessions per day for 6 demoralization” was not a threat [7–9]. days. Skin conditions for patients in both groups improved; however, the psychological well-being (level of pain and 7. Summary and Recommendations stress experienced) of the group that swam with dolphins was significantly better than the group without dolphins [8, 19]. In general, DAT is subject to criticisms regarding novelty The main criticism of the study conducted by Likura and due to the fact that dolphins are charismatic, exotic animals colleagues [19] is the lack of details given regarding what that most people will not regularly encounter in their daily seawater therapy for patients with atopic dermatitis is. Along lives. Future research should focus on reducing the novelty of with a lack of details about the therapy, methodological dolphins by incorporating exposure to build familiarity prior components of the study were missing as well. It is impossible to intervention or by using a comparison group that interacts to attribute the positive effects on the stress and pain with some other exotic, charismatic animal. Construct levels of the patients to swimming with dolphins when no validity is consistently threatened when researchers fail to information is given informing the reader what the non-DAT recognize that there are multiple components to a specific therapy entailed. The conclusions made by the authors are treatment. In the case of DAT, swimming in the water, subjective and vague at best [8]. being somewhere warmer, being in a different country or A study conducted by Antonioli and Reveley [18] somewhere new, and sleeping and living in novel settings assessed the effects of swimming with dolphins on the (e.g., hotel) are all potentially confounding variables that levels of depression and anxiety among individuals with need to be controlled for in order to attribute changes solely mild to moderate depression. A control group consisting to DAT. Construct confounding is generally controlled for of individuals with mild to moderate depression was used by taking apart the treatment and testing each component to compare the effects of DAT on the experimental group. separately through use of extended, multiple phase designs All subjects were required to quit taking any medications and control groups [8]. (antidepressants) or receiving psychotherapy four weeks Despite these persistent threats to validity and the lack before starting the study. A modified version of the Hamilton of empirical support for DAT, it is not surprising that many Rating Scale for Depression, the Beck Depression Inventory, health professionals have continued to offer such treatment and the Zung Self-Rating Anxiety Scale were used as as an option. Likewise it is not surprising that those seeking behavioral and psychological measures during baseline and treatment continue to heed the recommendations of both at the end of treatment. Results showed that individuals health professionals and the media to employ purveyors of who were able to swim with the dolphins in the water DAT. McWilliam [20] found multiple reasons why people reported significant improvement in the depression scores adopt unproven practices, including the following; many compared to the control group who swam in the water proven practices are more difficult to implement than without dolphins. unproven therapies, unproven practices sometimes reinforce According to Marino and Lilienfeld [8], the study the specialization of a professional, professionals tend to conducted by Antonioli and Reveley [18] controlled for believe what other professionals tell them without investigat- more extraneous variables when compared to any of the ing for themselves, people often tend to believe the results other studies conducted on DAT. Researchers randomly and research that support their established values and beliefs, assigned individuals to control and experimental groups, many professionals do not have time to keep up reading the they utilized pre- and post-tests with blind raters, and literature available on all relevant topics and research, and incorporated validated assessment instruments. Despite this, parents have ample motivation to serve as a source of hope Marino and Lilienfeld found many limitations to the study. and optimism in the face of the challenges their children First, the participants were not blind to the condition are facing. Unproven therapies often claim to provide rapid Autism Research and Treatment 7 results that are all encompassing (e.g., promising to return a [14] DolphinTherapy(n.d.), 2009, http://www.researchautism.net/ interventionitem.ikml?print&ra=64&infolevel=4. child with autism back to their “normal” self) [1]. [15] T. L. 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DAT indicated for several conditions, including ASD, is zootherapy: the case of the Autidolfijn project,” Anthrozoos, an excellent example of the urgent need for clear, verifiable, vol. 12, no. 1, pp. 5–15, 1999. and repeatable evidence within psychology supporting ther- [18] C. Antonioli and M. A. Reveley, “Randomised controlled trial of animal facilitated therapy with dolphins in the treatment apies. Specifications regarding cost effectiveness and efficacy of depression,” British Medical Journal, vol. 331, no. 7527, pp. of the treatment should be required before therapies are 1231–1234, 2005. endorsed or supported. Overall, research studies need to be [19] Y. Iikura, Y. Sakamoto, T. Imai et al., “Dolphin-assisted sea- better designed and threats to validity must be addressed water therapy for severe atopic dermatitis: an immunological before we deem DAT as an effective intervention for any and psychological study,” International Archives of Allergy and population [15]. Immunology, vol. 124, no. 1–3, pp. 389–390, 2001. [20] R. A. McWilliam, “Controversial practices: the need for a reacculturation of early intervention fields,” Topics in Early References Childhood Special Education, vol. 19, no. 3, pp. 177–188, 1999. [21] J. Turk, “The developmental psychiatry manifesto,” Clinical [1] R. L. Simpson, “Evidence-based practices and students with autism spectrum disorders,” Focus on Autism and Other Child Psychology and Psychiatry, vol. 10, no. 4, pp. 617–621, Developmental Disabilities, vol. 20, pp. 110–119, 2005. 2005. [2] J. W. Harrington, P. A. Patrick, K. S. Edwards, and D. A. Brand, “Parental beliefs about autism: implications for the treating physician,” Autism, vol. 10, no. 5, pp. 452–462, 2006. [3] C. Kalb, “When does autism start?” Newsweek, vol. 145, no. 9, pp. 44–53, 2005. [4] M. L. Morrison, “Health benefits of animal-assisted interven- tions,” Complementary Health Practice Review, vol. 12, pp. 51– 62, 2007. [5] Marine Connection: Protecting Dolphins and Whales World- wide. (n.d.), “Truth about dolphin assistedtherapy,” 2009, http://www.marineconnection.org/campaigns/captivity dat2006.html. [6] A. McKinney, D. Dustin, and R. Wolff,“Thepromise of dolphin-assisted therapy,” Parks and Recreation, vol. 36, pp. 46–50, 2001. [7] L. Marino and S. O. Lilienfeld, “Dolphin-assisted therapy for autism and other developmental disorders: a dangerous fad,” American Psychological Association, vol. 33, pp. 2–3, 2007. [8] L. Marino and S. O. Lilienfeld, “Dolphin-assisted therapy: more flawed data and more flawed conclusions,” Anthrozoos, vol. 20, no. 3, pp. 239–249, 2007. [9] L. Marino and S. O. Lilienfeld, “Dophin-assisted therapy: flawed data, flawed conclusions,” Anthrozoos, vol. 11, pp. 194– 200, 1998. [10] Tribune Watchdog Dubious Medicine, “NovAutism treat- ments: Risky alternative therapies have little basis in science,” 2009, http://www.chicagotribune.com/health/chi- autism-treatments-nov22.0.1396079.story. [11] K. Brensing, K. Linke, and D. Todt, “Can dolphins heal by ultrasound?” Journal of Theoretical Biology, vol. 225, no. 1, pp. 99–105, 2003. [12] D. E. Nathanson, D. de Castro,H.Friend, andM.McMahon, “Effectiveness of short-term dolphin-assisted therapy for children with severe disabilities,” Anthrozoos, vol. 10, no. 2-3, pp. 90–100, 1997. [13] D. E. Nathanson, “Long-term effectiveness of dolphin-assisted therapy for children with severe disabilities,” Anthrozoos, vol. 11, no. 1, pp. 22–32, 1998. 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Dolphin-Assisted Therapy: Claims versus Evidence

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Copyright © 2012 Britta L. Fiksdal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Autism Research and Treatment Volume 2012, Article ID 839792, 7 pages doi:10.1155/2012/839792 Review Article 1 1 2 Britta L. Fiksdal, Daniel Houlihan, and Aaron C. Barnes Psychology Department AH23, Minnesota State University, Mankato, MN 56001, USA School of Education, University of Wisconsin Stout Menomonie, WI 54751, USA Correspondence should be addressed to Britta L. Fiksdal, britta.fiksdal@mnsu.edu Received 23 March 2012; Accepted 24 June 2012 Academic Editor: Bennett L. Leventhal Copyright © 2012 Britta L. Fiksdal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The purpose of this paper is to review and critique studies that have been conducted on dolphin-assisted therapy for children with various disorders. Studies have been released claiming swimming with dolphins is therapeutic and beneficial for children with autism, attention deficit hyperactivity disorder, physical disabilities, and other psychological disorders. The majority of the studies conducted supporting the effectiveness of dolphin-assisted therapy have been found to have major methodological concerns making it impossible to draw valid conclusions. Readers will be informed of the history of, theory behind, and variations of dolphin-assisted therapy along with a review and critique of studies published which purportedly support its use. 1. Dolphin-Assisted Therapy: As notedbyMorrison[4], for more than 12,000 years, animals and humans have been in therapeutic relationships Claims versus Evidence together. Dogs are generally the most common therapeutic Along with other pervasive conditions, those identified as animal, but the literature and historic record suggests that having autism spectrum disorders (ASD) have often been cats, guinea pigs, cockatoos, African grays, horses, chickens, subject to questionable or controversial treatments [1]. As pot-bellied pigs, llamas, goats, and donkeys have all been defined by Simpson, a controversial treatment is any method utilized with therapeutic aims [4]. Therateofanimal- or strategy that has not been validated by scientific support. facilitated therapy has increased dramatically over the past Such treatments may be of special concern when seemingly few years; however, the number of empirical research studies extraordinary results are guaranteed. Such concerns may be showing the efficacy of this therapy has not. Betsy Johnson confounded when physicians fail to anticipate or understand was among the first to discover using dolphins as a ther- the feelings of desperation that accompany some parents of apeutic agent with individuals suffering from neurological children with ASD when they come into the office [2]. The impairments [5]. The grace and beauty of dolphins along combination of desperation and a lack of effective treatment with their responsiveness to humans have led therapists options provided by the physician may lead parents to pursue and researchers to assess potential therapeutic benefits. This treatments with little or no empirical support. The number interest, however, has taken a reckless turn and has led to the of diagnosed cases of ASD has increased ten times in the past evolution of a treatment known as dolphin-assisted therapy 20 years with the current rate of one in every 166 children (DAT) [6]. born being diagnosed [3]. It was estimated that in 2005 the Dolphin-assisted therapies are primarily advertised National Institutes of Health spent $99 million on autism through popular media such as television, informational research. This number makes a stark increase compared to movies, and the internet [7]. According to Marino and the $22 million spent in 1997 [3]. Taken together, there exist Lilienfeld [8], the claims made supporting DAT by the many opportunities for the eager pursuit of a wide range facilities themselves have not been empirically supported, of treatments. Among those sharing relatively heightened neither has there been an increase in peer-reviewed papers interest and relatively little empirical support are animal- published on the topic from the 1970s to 2007. Researchers based treatments. and practitioners of DAT as well as parents with children 2 Autism Research and Treatment diagnosed with an ASD should be aware that support for In one example of a treatment plan, children first go this type of treatment has not been empirically validated. through an on-dock orientation that consists of the therapist Studies that have been held up as supporting DAT have and child sitting on the edge of a 2-3-inch raised dock serious methodological flaws rendering their results weak while the trainer is in the water manipulating the dolphin’s and meaningless [7–9]. Recent voices in the mainstream movement. Children are typically able to touch, play, or media have called for an aid in finding and selecting effective give simple hand commands to the dolphins during this treatments, with the hope of reducing the number of parents orientation to get them acquainted and comfortable with chasing down the latest “fashionable” trends in intervention, the dolphin. Once the child has completed the orientation and instead to base their decisions on valid data [3]. Unfor- stage, they start a series of therapeutic sessions. During these tunately, organizations that have in the past been trusted for therapeutic sessions, children are allowed to play with the guidance, have had trouble avoiding affiliations with special dolphins for a short time either from the dock or by going in interests [10]. Alternative treatments have sprung up, many the water with them after emitting a correct motor, language, with associated risk, with no empirical support and little or cognitive response. During the “play” time the children documentation. However, many of these unconventional can touch or kiss the dolphin, dance in a circle with the methods have the backing of major organizations supporting dolphin, or ride on the dolphin by holding onto the dorsal families with special needs children. fin [15]. This paper is an effort to navigate the often-spurious Humphries [15] found the cost of DAT varies depending claims in the literature and popular media, and to increase on the length and location of therapy as well as the therapy the likelihood that those seeking effective treatment will be package chosen. There are currently DAT programs all over successful. The purpose of this paper is to provide a detailed the world including Europe, the Middle East, Asia, USA, the description of DAT, review the studies published supporting Caribbean, Mexico, Israel, Russia, Japan, China, Bahamas, DAT, review the studies that have debunked this particular and South America [7, 14]. The typical price for five 40- treatment, and summarize the overall lack of empirical minute sessions is about $2,600. Typical travel, food, and support for its use. lodging costs can raise the price to $5,200 over two weeks. One notable example quoted in 2006, Nathanson’s Dolphin 2. Overview of DAT Human Therapy, costs $7,800 for two weeks or $11,800 for three weeks not including travel, food, and lodging [15]. Dolphin assisted therapy has been used with the aim of It is worth noting that these sums of money are being treating individuals identified as having mental and physical exchanged for activities that are often nearly indistinguish- disabilities for over 25 years [11]. DAT is a type of animal- able from swim-with-dolphin programs typically frequented assisted therapy that claims to help those who are physically by tourists [7–9]. and mentally ill and disabled as well as adults and children with various psychopathologies. Therapy generally involves the patient swimming and playing with dolphins in captivity- 3. DAT Claims and Indicated Treatments over several sessions while working on tasks such as hand- eye coordination or various verbal response targets. It is a Nathanson [13] reported the two-week Dolphin Human highly attractive form of therapy due to the dolphins being Therapy program significantly increases language, speech, well-liked, exotic animals [7, 8]. According to Nathanson gross motor, and fine motor functioning among children et al. [12], the primary purpose of his DAT program with various disabilities when compared to the more con- is to increase engagement and target behaviors based on ventional speech or physical therapy programs that last a the child’s individualized program by using dolphins to minimum of six months. DAT has been targeted for children compliment or assist other, more traditional, treatments. and adults of all ages, all genders, and all ethnicities [4]. The program focuses on increasing the frequency of target Supporters and therapists of DAT claim it is effective in behaviors by using basic-behavior modification principles in treating people with clinical disorders as well as conditions a relatively short-term intensive therapy [13]. including autism, epilepsy, Angelman syndrome, Down syn- There are many different variations of dolphin-assisted drome, dyslexia, Rett syndrome, Tay-Sachs disease, Tourette therapy ranging from the client simply looking at or taking syndrome, William syndrome, cancer, and AIDS [5, 7]. Other care of a dolphin, touching the dolphin, to entering the purported benefits of DAT include increased stimulation, water and swimming with the dolphin. Different therapists better memory, increased motor skills, accelerated healing, have different theories on how humans and dolphins interact and an increase in a person’s well-being [5] as well as reduced as well as the particular kind of therapy that should stress, pain, and depression, increasing relaxation, enhancing be employed for a specific patient [14]. The length and the production of infection fighting t cells, endorphins, frequency of sessions vary depending on the program. Some and hormones, and enhancing the recovery process [6]. In therapists run sessions for a week, two weeks, or a month. summary, Nathanson et al. [12] claim that DAT increases Some programs have even tried single sessions that last a attention span, motivation, and language skills more rapidly couple of hours instead of the typical 10–30 minutes [12]. and cost effectively than other more conventional therapies Humphries [15] found that, in five of the six studies she and the treatment effects are maintained over an extended evaluated, sessions lasted on average 30 minutes each and each study consisted of approximately 16 sessions total. period of time. Autism Research and Treatment 3 4. History of Dolphin-Assisted Therapy backing these claims appears to be purely anecdotal [6]. Dolphins produce sounds, often described as clicks, and What would come to be known as dolphin-assisted therapy below the blowhole as part of a technique called echolocation dates back to the work of John Lilly in the 1950s [6]. His work dolphins can emit a rate of 300 clicks per second, using was extended during the 1970s when dolphin researchers echolocation to navigate, find food, and communicate with started studying interactions between dolphins and children other dolphins [6]. Simply put, a human interacting with with neurological impairments [15]. An educational anthro- dolphins differs from the current standards of medical pologist at Florida International University, Betsy Smith, practice for therapeutic ultrasound, which call for repeated is credited with conducting the first line of research in application at a specific intensity and duration [11]. 1971 involving dolphins and children with neurological Other theorists propose that dolphins are sensitive to impairments [6, 7]. people with disabilities and that they seek to help them by Since 1982, there have been only a small number of publi- paying extra attention to them through playful expressions of cations involving dolphin-assisted therapy [11]. Nathanson’s concern [6]. This has been termed “secret language” by some first pilot studies on dolphin-assisted therapy took place DAT therapists. In the 70s, Dr. Smith theorized that dolphins at Ocean World in Ft. Lauderdale, FL, in 1978 and 1979. could communicate acoustically with body movements and Based on the pilot studies, DAT was altered to consist of one are attended to the body movements of others. This appeared session per day, two days per week with only one therapist to be especially true in the case of children with autism. It for the program at Dolphin Research Center in Grassy seemed to DAT’s supporters that the dolphins understood Key, FL, from 1988–1994 [13]. According to Nathanson, his their thoughts and actions [6]. Dolphin Human Therapy program began providing full- It has also been theorized that through DAT, human time therapy across the years of 1995 and 1996. Sessions contact with dolphins produces intense emotions and feel- were offered five days a week and multiple therapists were ings of reconnection and happiness which consequently employed at Dolphins Plus in Key Largo, FL. In 1997, a increases the well being of the participant [5]. Dolphins full-time, multiple therapist program opened in Miami, FL, have been reported to bring joy and happiness to people at the Miami Seaquarium on Virginia Key. Between 1988– through their playful behavior and constant “smile.” The 1997, children who entered dolphin-assisted therapy were joy, novelty of the situation, and extra attention are likely diagnosed with over 40 different diagnoses and came from components that enhance a person’s quality of life thus over 37 different states and 39 different countries. Many of increasing the motivation to learn [6]. It may be that the children were diagnosed with multiple disabilities. In dolphins become positive reinforcers for the patient emitting 1997, Nathanson and colleagues started scheduling almost a specific behavior or achieving a therapy goal [7]. For all of the children enrolled in Dolphin Human Therapy for some people, interacting with animals in general has a calm at least two weeks of sessions instead of one [12, 13]. and stress-reducing effect. Brensing et al. [11] found that dolphins have a relaxing influence on people based on the analysis of EEG scans. 5. Theories behind Dolphin-Assisted Therapy In addition to ultrasound-based theories, Nathanson based his dolphin-assisted therapy on the theory that, There have been numerous theories voiced regarding how dolphin-assisted therapy works. These theories are often as a result of swimming with dolphins, children will presented to the public in verbose and vague language, using increase their attention to stimuli in the environment [15]. Nathanson’s attention deficit hypothesis implies that people terms that sound technical but really have no significant meaning. When precise scientific terms are used, they are with mental retardation and other disorders are unable to often used incorrectly or without proper context. Such learn because of a deficit in physiological attention to the obfuscating language is typically applied by pseudoscience important details of the stimuli and not because they are practitioners with the purported aim of sounding more unable to process information. This contributes the overar- advanced, legitimate, and scientific [5]. Since the exact ching theory that animals increase attention for individuals, etiology of autism is unknown, advocates of DAT are able therefore leading to improved cognitive processes such as to create any explanation for the efficacy of the treatment. enhanced learning, motor skills, language, and memory [13]. McKinney et al. [6] report that simply being in water There are no limits or regulation on the number of erroneous claims that can be made [7]. The three most prominent has a relaxing therapeutic effect on people with various theories for DAT are echolocation, dolphins being attracted disabilities. Aquatic therapists claim that adding the calming to people with disabilities, and overall joy and relaxation. effects of animals such as dolphins to being in water will Other theories include simply being in the water and enhance the therapeutic effects. increasing attention in individuals with autism [6–9, 15]. Nathanson [13], Brensing et al. [11], McKinney et 6. Research behind Dolphin-Assisted Therapy al. [6], and other proponents of DAT have claimed that ultrasound emitted by dolphins through echolocation clicks There have been multiple claims made supporting dolphin- has a mechanical effect on human endocrine and neural assisted therapy. Lukina [16]aswellasServais [17]claim systems. These effects enhance healing by changing the that DAT improved language, cognitive processing, attention, individual’s body tissue and cell structure. This is one of the behavior, motivation to learn, and even some medical most popular theories behind DAT; however, the evidence conditions. Nathanson [13] and Nathanson et al. [12] 4 Autism Research and Treatment claim that dolphin human therapy has successfully increased DAT as an effective treatment for individuals with severe motivation, gross and fine motor skills, speech, language, and disabilities [12]. attention. They also claim that two weeks of therapy is just In 1998, Nathanson conducted another study examining as good if not better than six months of other traditional the long-term effects of DAT and found the increases in treatments. Humphries [15] evaluated six studies supporting functioning were maintained or improved at the one-year DAT [12, 13, 16–19] and found all of the studies were at followup. Nathanson sent out 137 questionnaires to assess risk for investigator bias, novelty of the therapy, and multiple the long-term effects of DAT, of which 71 were returned treatment interference. (52%). Following DAT, it was expected that children would return and continue with their conventional therapies such Morrison [4] found that there were several methodolog- as occupational, speech, and physical therapies, parent ical weaknesses consistently seen throughout DAT studies. follow ups, and special education services. According to the Some of these weaknesses included lack of consistent ran- questionnaires that were returned, following DAT clients domization of participants, small sample size, absence of increased the amount of time they participated in and control or typical care group, lack of reliability and validity benefited from their conventional therapies more than 50%. measurements, attrition rates, poor generalization, selection This study also found that two weeks of therapy were bias, and novelty effect. According to Marino and Lilienfeld significantly more effective than one week and that their [8], if these methodological weaknesses were accounted for, it model of DAT, Dolphin Human Therapy, showed beneficial would be shown that there is nothing unique or special about long-term effects for approximately 95% of the children dolphins per se in DAT. treated [13]. Dolphin-assisted therapy receives the majority of its Marino and Lilienfeld [9] found multiple reasons why advertisement, praise, and positive attention from the media both studies, Nathanson et al. [12] and Nathanson [13], (e.g., news programs, promotional films). Some reports should be interpreted with caution. After assessing both claim the success rates for physical and behavioral improve- articles, a minimum of 11 methodological weaknesses were ment through DAT is 90% [15]. Marino and Lilienfeld [7] found that undermined the scientific validity for both found one website that claimed, “The field of medicine studies. The main weaknesses consisted of the potential for has shown extraordinary results of the therapy (DAT) and placebo effect, history effects, and regression to the mean all breakthroughs in outcomes in relation to conventional meth- due to a lack of experimental control [7]. ods of treatments such as prescribed medication, human The study conducted by Nathanson and colleagues in therapy, and others.” The popularity for DAT continues to be 1997 appeared to have used a modification of a pre- substantial, while the research base continues to be meager at postdesign. The “pre-test,” or selection criteria, was the fact best [8, 15]. that children were only able to participate contingent on their In 2003, Dr. Betsy Smith, one of the first researchers inability to respond on their own to a physical or verbal to investigate and propose the possibility of DAT having task. After two weeks of DAT, each child was assessed (the therapeutic value, denounced its use. Describing it as an inef- posttest) for their ability to respond on their own to the same fective and exploitative practice, Dr. Smith voiced two main task as before. Changes in response from pre- to posttest concerns: (1) monetary gain was more involved with DAT’s were attributed solely to DAT. Nathanson claimed to have practice than was empirical evidence supporting its use, and used a single-subject design, however, he failed to report (2) it was undermined and detracted from valid therapy any individual subject’s data. Instead, he compiled all the programs [7]. Purveyors of DAT programs can expect to data from each subject into tables obscuring analysis at an gain a substantial amount of money from every family and individual level. Because of this aggregation of data, it is client who seeks their help. The potentially hazardous impact possible that some children did worse after therapy but the of time and money spent for DAT is compounded when data was embedded in a group of children who did show the same resources could be spent on empirically supported improvements [9, 15]. treatments (e.g., discrete-trial teaching). Currently, there are The most important and detrimental flaws to the study no studies that show DAT to be consistently effective [5]. conducted by Nathanson et al. in 1997 stem from a lack of Nathanson et al. [12] argued that compared to con- experimental control. Lack of experimental control makes ventional long-term therapies, Dolphin Human Therapy, a it impossible to attribute any changes to DAT alone. There form of DAT, achieved effective results more quickly and was no control group for which to compare the treatment at lower cost. Nathanson and colleagues compared two group, no dismantling strategy to expose subjects to the weeks of DAT to six months of speech and physical therapy different treatment components in a systematic manner, and with individuals with multiple disabilities. Each participant no counterbalancing between what they called the pre- and received six months of conventional therapy right before post- tests. Without a control group, it is impossible to rule DAT and had received 16 or 17 sessions throughout a two- out a placebo effect, regression to the mean, novelty effects, week DAT program. They claimed the administration of DAT history, the effect water could have had on the children’s to children with severe disabilities significantly increased performance, or other variables such as an increase in motivation, motor skills, attention, and language. Results interpersonal attention or interpersonal contact. Nathanson showed that prior to DAT 0% of the children were able to et al. appear to have changed the way the dependent variable was assessed at various points in the study. This suggests make the independent target response and after DAT 57– 71% were able to, therefore making an argument supporting that instrumentation might have been the cause of changes Autism Research and Treatment 5 that appeared to occur. Many of the participants came from without major diagnoses. Each child interacted with the different states or even different countries. Nathanson and dolphins by swimming with them for 10–15 minutes for 5– colleagues did not have a randomized control group to 10 sessions. The results indicated that the cardiac rhythms for assess for variables associated with these children being in a each group increased after having swum with the dolphins. different state and possibly even a different country. Lukina claimed that the results of the study supported the Another set of problems with the Nathanson et al. [12] fact that the redistribution of “psychoemotional” dominants study stems from how the children’s responses were recorded opens possibilities for psychotherapy and rehabilitation and measured. Experimenter expectancy could have had measures [16]. an effect on the behavior recorded since the observers One major flaw in the Lukina’s study was a lack of were aware of the outcome desired for the study. To add clear definition for “psychoemotional” dominants or how to the threat of experimenter expectancy, there was no they are related to changes in cardiac rhythms. Furthermore, operational criterion or definition differentiating between Lukina claimed that DAT reduced depression, night phobias, what was considered an independent response from one hysteria, and enuresis for the children in the “infantile that was assisted or guided. Having a strong interrater neurosis” group, however, there was no data reported reliability coefficient or a report on procedural integrity may showing this was the case. Lukina also failed to mention the have helped to minimize this methodological flaw; however, assessment instruments used to assess depression, night pho- the authors never explained how they get their inter-rater bias, hysteria, and enuresis for these children. Psychotherapy reliability coefficientof1.00orwhatitrepresented.Itcould was also a part of therapy, so attributing all the positive have been based on every trial from the entire study, it effects to DAT is impossible because the different treatment could have been a small sample of trials, or it could have components were never assessed independently. Although only included trials in which there was perfect inter-rater there was a comparison group of children without major reliability [9]. diagnoses, there was no control group of children who did The follow-up study conducted by Nathanson in 1998 fell not swim with dolphins. When you add to this the use of victim to many of the same methodological flaws as the 1997 a single A-B comparison design lacking experimental rigor, study (i.e., history, placebo effects, instrumentation, lack of there is clear reason to question the validity of the study control group, and regression to the mean). Nathanson’s [8, 15]. follow-up data were based solely on a questionnaire filled The study conducted by Servais [17]involvedtwo out by the parents of the children who underwent DAT experiments. The first experiment included two control the year before [9]. Nathanson concluded that the children groups (a classroom group and a computer group) and an maintained their skills one year later, two weeks of DAT was experimental group (dolphin group). Each group consisted better than one week, and there were no differences in long- of three children with autism. Children from each group were term effects of DAT due to the participant’s disorders(s) [13]. taught the same cognitive task in their respective settings. Nowhere in his paper did Nathanson attribute any of the The second experiment consisted of a dolphin group and a changes to the months of conventional therapy each child classroom group only. All groups in each experiment were had received in between the end of DAT and the follow-up given pre-tests first, followed by 10–15 “learning sessions” questionnaire as well as in between the pre- and post- test in which the cognitive tasks were taught in each of the measures [7–9]. groups, followed by each group being administered a post- Nathanson failed to control for demand characteristics, test. Results showed the children working with the dolphins including the tendency for participants to respond in a way responded correctly more often compared to the children in they feel is appropriate for what they think the researcher the control groups. Outcome measures of social-emotional wants to hear. Not only did he fail to control for it, he made status revealed increases of kindness, attentiveness, initiating it worse by beginning each item of the questionnaire with play, self-control, and eye contact were found with the a statement that attributes all success to dolphin-assisted children who participated in the DAT compared to the therapy. This made the hypothesis of the researcher evident control groups. to each parent as they were filling out the questionnaire. Servais [17] is also hindered by methodological and The questions in the questionnaire only asked about the practical flaws that call validity into question. At times during positive effects of DAT (mostly behaviors that were improved the study, in order to increase exposure to the dolphins, the or maintained) and did not assess or ask about behaviors that human subjects were provided with correct answers to the might have gotten worse or regressed. Of the 137 question- cognitive tasks [15]. According to Marino and Lilienfeld [8], naires sent out, 71 were returned, and the study incorporated Servais did not explicitly state whether the pre- and post-tests no pre- postmeasurement of parents’ perceptions of behavior were the same within or across groups making it impossible [9]. to rule out instrumentation effects. The children in the In another study, Lukina [16] assessed the effects of first dolphin group improved and performed significantly DAT on the psychoneurological functioning of children with better than those in the second dolphin group but no other various conditions compared to healthy children through the differences were reported between groups in the first exper- use of a single group pretest-posttest design. The participants iment. The children from the second dolphin group did not included 30 children with infantile neurosis, 25 children appear to have improved or performed significantly better with mental retardation and autism, 35 children with other than the control group from the second experiment. Other unspecified diseases, and a comparison group of 57 children threats to the validity of the study include experimenter 6 Autism Research and Treatment expectancy and demand characteristics because the author making it impossible to rule out demand characteristics was the only person who coded the behavioral outcomes. [7–9, 18]. Second, there was nothing done to control for It is unclear whether other components of therapy, (e.g., possible placebo or novelty effects of interacting with an swimming outdoors, etc.) might have contributed to a child’s exotic animal. Third, because the study relied on self- improvement. report measures and the participants were not blind to the Likura et al. [19] looked at the effects of DAT on patients condition, informant bias is impossible to rule out [7–9]. with atopic dermatitis (skin condition). There were two Fourth, no follow-up study was conducted meaning that the groups of patients, one group included swimming with differences between the control and experimental groups can dolphins in the seawater therapy, and the other group only be explained by the different conditions at the time of received only seawater therapy. For six days the patients the test [7–9, 18]. Fifth, nothing was done to control for swam with dolphins in seawater, which is typically painful “resentful demoralization” which refers to when a participant for individuals suffering from atopic dermatitis. Dramatic realizes they are receiving a less beneficial treatment and skin changes have been reported after contact with seawater, becomes resentful, thus potentially threatening construct however, patients typically complain of pain or stress making validity [7–9]. According to Antonioli and Reveley they it difficult to stay in the water for prolonged periods. The controlled for “resentful demoralization” by allowing the purpose of the dolphins in this study was to minimize the participants in the control group to swim with the dolphins stress and pain felt by the patients, thus distracting them after the final evaluation. However, since it occurred after and helping them to relax. Each DAT session lasted 90 the final evaluation there is no reason to believe “resentful minutes and each participant had two sessions per day for 6 demoralization” was not a threat [7–9]. days. Skin conditions for patients in both groups improved; however, the psychological well-being (level of pain and 7. Summary and Recommendations stress experienced) of the group that swam with dolphins was significantly better than the group without dolphins [8, 19]. In general, DAT is subject to criticisms regarding novelty The main criticism of the study conducted by Likura and due to the fact that dolphins are charismatic, exotic animals colleagues [19] is the lack of details given regarding what that most people will not regularly encounter in their daily seawater therapy for patients with atopic dermatitis is. Along lives. Future research should focus on reducing the novelty of with a lack of details about the therapy, methodological dolphins by incorporating exposure to build familiarity prior components of the study were missing as well. It is impossible to intervention or by using a comparison group that interacts to attribute the positive effects on the stress and pain with some other exotic, charismatic animal. Construct levels of the patients to swimming with dolphins when no validity is consistently threatened when researchers fail to information is given informing the reader what the non-DAT recognize that there are multiple components to a specific therapy entailed. The conclusions made by the authors are treatment. In the case of DAT, swimming in the water, subjective and vague at best [8]. being somewhere warmer, being in a different country or A study conducted by Antonioli and Reveley [18] somewhere new, and sleeping and living in novel settings assessed the effects of swimming with dolphins on the (e.g., hotel) are all potentially confounding variables that levels of depression and anxiety among individuals with need to be controlled for in order to attribute changes solely mild to moderate depression. A control group consisting to DAT. Construct confounding is generally controlled for of individuals with mild to moderate depression was used by taking apart the treatment and testing each component to compare the effects of DAT on the experimental group. separately through use of extended, multiple phase designs All subjects were required to quit taking any medications and control groups [8]. (antidepressants) or receiving psychotherapy four weeks Despite these persistent threats to validity and the lack before starting the study. A modified version of the Hamilton of empirical support for DAT, it is not surprising that many Rating Scale for Depression, the Beck Depression Inventory, health professionals have continued to offer such treatment and the Zung Self-Rating Anxiety Scale were used as as an option. Likewise it is not surprising that those seeking behavioral and psychological measures during baseline and treatment continue to heed the recommendations of both at the end of treatment. Results showed that individuals health professionals and the media to employ purveyors of who were able to swim with the dolphins in the water DAT. McWilliam [20] found multiple reasons why people reported significant improvement in the depression scores adopt unproven practices, including the following; many compared to the control group who swam in the water proven practices are more difficult to implement than without dolphins. unproven therapies, unproven practices sometimes reinforce According to Marino and Lilienfeld [8], the study the specialization of a professional, professionals tend to conducted by Antonioli and Reveley [18] controlled for believe what other professionals tell them without investigat- more extraneous variables when compared to any of the ing for themselves, people often tend to believe the results other studies conducted on DAT. Researchers randomly and research that support their established values and beliefs, assigned individuals to control and experimental groups, many professionals do not have time to keep up reading the they utilized pre- and post-tests with blind raters, and literature available on all relevant topics and research, and incorporated validated assessment instruments. Despite this, parents have ample motivation to serve as a source of hope Marino and Lilienfeld found many limitations to the study. and optimism in the face of the challenges their children First, the participants were not blind to the condition are facing. Unproven therapies often claim to provide rapid Autism Research and Treatment 7 results that are all encompassing (e.g., promising to return a [14] DolphinTherapy(n.d.), 2009, http://www.researchautism.net/ interventionitem.ikml?print&ra=64&infolevel=4. child with autism back to their “normal” self) [1]. [15] T. L. Humphries, “Effectiveness of dolphin-assisted therapy as It is becoming more evident that reliance and unre- a behavioral intervention for young children with disabilities,” stricted use of unproven therapies for children with autism Bridge, vol. 1, pp. 1–9, 2003. are hindering the field of ASD treatment and research. A [16] L. N. Lukina, “The effect of dolphin-assisted therapy sessions pattern of reliance on suspect therapies has led to unhealthy on the functional status of children with psychoneurological and unrealistic expectations for progress and improvement disease symptoms,” Fiziologiia Cheloveka,vol. 25, no.6,pp. for children with ASD. Turk [21] calls for therapies to be held 56–60, 1999. responsible for providing solid, empirical evidence for their [17] V. Servais, “Some comments on context embodiment in use. DAT indicated for several conditions, including ASD, is zootherapy: the case of the Autidolfijn project,” Anthrozoos, an excellent example of the urgent need for clear, verifiable, vol. 12, no. 1, pp. 5–15, 1999. and repeatable evidence within psychology supporting ther- [18] C. Antonioli and M. A. Reveley, “Randomised controlled trial of animal facilitated therapy with dolphins in the treatment apies. Specifications regarding cost effectiveness and efficacy of depression,” British Medical Journal, vol. 331, no. 7527, pp. of the treatment should be required before therapies are 1231–1234, 2005. endorsed or supported. Overall, research studies need to be [19] Y. Iikura, Y. Sakamoto, T. Imai et al., “Dolphin-assisted sea- better designed and threats to validity must be addressed water therapy for severe atopic dermatitis: an immunological before we deem DAT as an effective intervention for any and psychological study,” International Archives of Allergy and population [15]. 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