Dogs can make a difference: Research overview and results by Professor Daniel Mills, Professor of...

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PROF DANIEL S. MILLS BVSC PHD CBIOL FSBIOL FHEA CCAB

DIP ECAWBM(BM) MRCVS EUROPEAN & RCVS RECOGNISED SPECIALIST IN

VETERINARY BEHAVIOURAL MEDICINE DR HANNAH WRIGHT BSC (HONS) PHD

SCHOOL OF L IFE SCIENCES UNI VERSI TY OF L INCOLN

RI SEHOLME PARK L INCOLN LN2 2LG

Pet Dogs for Children with Autism Research

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Overview

Autism Spectrum Disorder and its impactMeeting current needs

Identifying effective interventionsDog related interventions for ASD

Assistance Dogs vs the PAWS programmeInitial results from PAWS research programme

Can a pet dog enhance the quality of life for families with a child with autism?

What aspects of the dog’s behaviour trigger desirable behaviour and interactions with autistic children?

Is greater benefit obtained in populations with certain demographic characteristics?

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ASD in society

Estimated prevalence 1 in 100 children, UKLifetime cost to the state estimated at £3m /

child Care Lost income Effect on contacts

Parents Siblings Wider family Local community

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Effect on family

Family organisation/planning (Heiman & Berger, 2008)

Family resilience, coping strategies (Bayat, 2007; Hastings et al, 2005)

Family cohesion (Estes et al, 2009)

Parental & siblings quality of life (Mungo et al, 2007)

Parental stress/psychological illness > stress proliferation (Bouma & Schweitzer, 1990; Hoffman et al, 2008)

Sibling relationship quality (Orsmond et al, 2009)

Parents marital relationship (Brobst et al, 2009)

Expressed Emotion (Hastings & Lloyd, 2007)

Friendship & social support (Dyson, 1997)

Employment (Montes & Halterman, 2008)

Outside access (Fox et al, 2002)

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Meeting the current need

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Interventions:Treatments, Therapies & Services

Over 800 listed by Research AutismMost lack scientific supportTreatment

PKU Comorbid conditions

Requirements Individualised Persistent Structured

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Intervention challenges

Family variationAutism Spectrum Disorders

Variability - number, presentation and severity of symptomsEffect every child (& family) differently

"If you've met one child with Autism….. you've met one child with Autism"

Families affected in different waysoNeed to fit into family way of being

What is the treatment goal?The process of establishing an evidence base

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Establishing an evidence base

Focus on goals that are easy to measure Focus on short term effectsPrefer homogeneous interventionsLimitation of RCTs

Focus on single treatment variables Population matching given heterogeneity

Poor quality models vs personalised medicine

Mesibov and Shea 2010

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Dog related interventions for ASD

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Autism Assistance Dog

Full public access.Children 3 - 10 years

old. Part of a team, with

the parent and child. Child wears a discreet

belt Attached to the assistance

dog and also holds on to a harness.

Commands and directions are given to the dog by the parent

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Autism Assistance Dogs

Dogs socialised and trained to remain calm in busy environments Calming focus Increase access and engagement with activities previously

impossible. Preventing tantrums through calming effect

A constant focus for child in unfamiliar environments Safer environment for the child, increased security Increased child and parent independence Introduced routines & structure Reducing bolting behaviour Interrupting repetitive behaviours & tantrums Providing a companion who does not make demands on the child Public perception At home

Dog is used to help develop social and emotional learning

Cost ~£20k/dog

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Assistance Dog numbers in the UK

GDBAHearing Dogs Dogs for the Disabled AssociationCanine Partners for IndependenceSupport DogsDog Aid

4500900250

150

15020

~30 for autism

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Autism Assistance dogs

Many apparent benefits not related to the specific training distracting away from meltdown behaviour building language skills a more general effect of having a dog in the family

1300 enquiries in 6 months Unable to meet demand

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PAWS (Parents Autism Workshops and Support)

• Parents attend a series of three, one day workshops,

• Project workers with a background in Child Development and Dog Welfare & Training, give parents an insight into potential benefits of dog ownership for their child, as well as the practical and theoretical skills into positive dog ownership.

o After the series of workshops, parents use the support of the PAWS team through an online forum, telephone or email, or through follow-up workshops to reach their individual goals.

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Research on dogs and ASD children

Children showed fewer autistic behaviours and more socially appropriate ones when a dog was introduced into therapy sessions (Redefer & Goodman, 1989) Effect was not lasting

Children were more playful, focused, and more aware of their social environments when in the presence of a calm dog, when compared to a toy or stuffed dog (Farnum, 2002)

Cortisol Awakening Response (CAR), but not basal cortisol, was significantly reduced in children with ASD following the introduction of a service dog, and subsequently increased after dogs were removed from the families (Viau et al, 2010)

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“Pet Dogs for Children with Autism”

Funded by the Big Lottery Fund

Collaboration between: Dogs for Disabled (DFD) National Autistic Society (NAS)– Research Autism University of Lincoln – Biological Sciences

3 year project 2010-2013

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The three research questions

Q1. Can a pet dog enhance the quality of life for families with a child with autism?

Q2. What aspects of the dog’s behaviour trigger desirable behaviour and interactions with autistic children?

Q3. Is greater benefit obtained in populations with certain demographic characteristics?

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Methods

Combination of qualitative and quantitative methods Thematic analysis of interviews (n=2*20) Longitudinal cohort study (93 +33)

Time control group (33) Field observations (20) Population survey (641/483 /347)

Development of new assessment scales to use alongside established scales

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Scales used

The Parental Stress Index-Short Form 36 items derived from the PSI

Three subscales: Parental Distress, Difficult Child Characteristics, Dysfunctional Parent-Child Interaction

The Family Assessment Measure -III Three components:

General Scale - overall family health; Dyadic Relationship Scale - how a family member views his

or her relationship with another Self-Rating Scale – self rating of own functioning within the

family

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Scales used

Spence Children’s Anxiety Scale (Pre-school, Parent Report)28 frequency rated anxiety items 6 subscales

Panic attack / agoraphobiaGeneralized anxietySocial anxietyObsessive compulsive disorderPhysical injury fears Separation anxiety

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Scales Used: PAWSs

PAWS 1 Family Normalcy Scale developed by Richard Mills 10 items:

child behaviour, self care, supervision, enjoyment of life, mobility, financial, general impact, social relations, community relations, coping

Comprehension analysis Reliability analysis – Time control group

PAWS 2 32 Behaviours and activities of importance identified

from interviews : child independence, social interactions, imagination,

walking, enjoyment, empathy, tantrums, repetitive behaviour, bolting, impacts on family, response to dogs

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Q1. Can a pet dog enhance the quality of life for families with a child with autism?

Pre/post intervention + follow up study Treatment Group – mainly families on PAWS

workshops Time Control Group – Dr Annette Hames

Clinical scales PSI Short Form FAM-III General Scale (Family Functioning) Spence Children’s Anxiety Scale PAWS#1: Child Provisional Normalcy Rating Scale PAWS#2 items

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Intervention study

Treatment group: n=93 families contacted 5 moved to the control group after the baseline interview 22 families dropped out before second interview

66 with two interviews (n=45 with all three interviews)

(10 rehomed dogs = 15% of those acquiring a dog)

Control group: n=33 families recruited n=5 drop outs (n=28 all three interviews)

BASELINE (PRE) FOLLOW UP

(25-35 WEEKS PI)

POST-INTERVENTION

(4-10 WEEKS PI)

MINIMUM 20 WEEK INTERVALMAX 6 MONTHS

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Matching of treatment and control groups :

Interview timings:Baseline-Post-intervention

Treatment: 4-36w (mean=12)Control: 7-24w (mean=11)

Post-int -Follow-up

21-35w (mean=27)7-30w (mean=26)

Baseline-Follow-up

25-49 (mean=38)22-40 (mean=37)

Gender of interviewee (parent):

Treatment ControlMale 7% 7%Female 93% 93%

Gender of child:

Treatment ControlMale 75% 82%Female 25% 18%

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Child Age:

Speech level:Treatment Control

Full Sentences 29 52% 16 57%

Simple phrases/sentences 11 20% 2 7%

Single words/gestures 8 14% 7 25%

Non-Verbal 5 9% 3 11%

Unknown 4 5% 0

Treatment Control

Average age and range 8.5 3-15 8.5 2-16

2 years and under 0 0% 1 3%

3-6 years 16 29% 7 25%

7–10 years 27 48% 12 43%

11-14 years 12 21% 5 18%

15+ 1 2% 3 11%

Matching of treatment and control groups :

100

102

104

106

108

110

112

114

116

118

1 2 3

TS

TS

BASELINE POST-INTERVENTION FOLLOW UP

Tota

l S

tres

s (T

S)

sco

re

High scores (>86)

Treatment

Control

•Significant reduction in treatment group (RM-ANOVA n=45, F=19.582, p<0.001)• BL-PI (post-hoc Bonferroni, p=0.014)

• BL-FU (post-hoc Bonferroni, p=0.009)

• No significant change PI-FU (post-hoc Bonferroni, p=0.859)

PSI – total scores

*Sig <0.0125 after correction for multiple tests

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43

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45

46

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1 2 3

DC

DC_C


High scores (>33)

Dif

ficu

lt C

hil

d (

DC

) s

ub

scal

e sc

ore

Treatment

Control

•Significant reduction in treatment group (RM-ANOVA n=45, F=12.967, p<0.001)• BL-PI (post-hoc Bonferroni, p<0.001)

• BL-FU (post-hoc Bonferroni, p<0.001)


•No significant changes in control group (RM-ANOVA n= 27, F=5.093, p=0.015)

PSI – Child characteristics


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27

29

31

33

35

37

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1 2 3

PCDI

PCDI_C


Treatment

Control

85th percentile

High scores

Par

ent-

Ch

ild

Dy

sfu

nct

ion

al I

nte

ract

ion

(P

-CD

) s

ub

scal

e sc

ore

Treatment

Control

PSI – Parent child interaction

• Significant reduction in treatment group (RM-ANOVA n=45, F=7.401, p=0.001)• BL-PI (post-hoc Bonferroni, p=0.009)



• No significant changes in control group (RM-ANOVA n= 27, F=0.376, p=0.689)


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27

29

31

33

35

37

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1 2 3

PD

PD_C


85th percentile

Normal range

High scores

Par

ent

Dis

tres

s (P

D)

sub

sca

le s

co

re

Treatment

Control

• Significant reduction in treatment group (RM-ANOVA n=45, F=13.762, p<0.001)• BL-PI (post-hoc Bonferroni, p<0.001)



• No significant changes in control group (RM-ANOVA n=27, F=2.093, p=0.134)

Parenting Stress Index (PSI) – Parent distress


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Parenting Stress Index Results

Although no significant difference between Treatment and Control groups in any of the subscales at the three time points.

Reductions seen in all areas Biggest effect on Parental Distress

This is of clinical relevance as this reduced from high to normal range.

All other subscales remain well within the high ranges.

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Benchmark: PSI data from ‘Early Bird’ study

Early Bird: Parent focused programme with information,

explanations and practical strategies aimed at increasing parent confidence in helping their child.

Eight 3.5 hour session over three months Recently diagnosed children

Follow up +3mo, +9mo Full version of PSI n=119 vs waiting list control n=24

Progressive reduction in three PSI measures over time (child, parent & total stress)

Control group n/s changes pre EB programme During 3mo tx improved PSI total, PSI parent, but not

PSI child

Shields & Simpson 2004

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FAM-III Family FunctioningTo

tal S

core

45

-55

= A

vera

ge

fu

nct

ion

ing

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45

46

47

48

49

50

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BL PI fU

tx

control

•No significant change in treatment group (RM-ANOVA n=43, F=1.321, p=0.272)

•No significant change in control group (RM-ANOVA n=27, F=2.095, p=0.133)

•No significant difference between groups at any time point (t-tests, p>0.05)

PAWS#1 Family Normalcy

•Significant change in treatment group (RM-ANOVA n=43, F=5.714, p=0.005)• BL-PI (post-hoc Bonferroni, p=0.031)



•No significant change in control group RM-ANOVA n=27, F=0.733, p=0.486

•No significant difference between groups at any time point (t-tests, p>0.05)

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33

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BL PI FU

To

tal

Sco

re

Treatment

Control

Treatment group (n=15) Control Group (n=26)S

core

(%

)

Repeated Measures ANOVA (sig< 0.007) Treatment Group Control Group

Panic Attack/Agoraphobia (♦) F=1.657, p=0.214 F=0.289, p=0.751

Separation Anxiety (■) F=6.064, p=0.006 F=0.479, p=0.662

Physical Injury Fears (▲) F=13.656, p=0.001 F=7.390, p=0.002

Social Phobia (x) F=5.637, p=0.009 F=0.460, p=0.581

Obsessive Compulsive Disorder (x) F=2.738, p=0.082 F=0.062, p=0.892

Generalised Anxiety Disorder (•) F=1.167, p=0.326 F=3.558, p=0.036

Total score (I) F=9.856, p=0.005 F=4.402, p=0.017


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Q2. What aspects of the dog’s behaviour trigger desirable behaviour and interactions with autistic

children?

Field studies – video child-dog interactions in the home

Three aspects of behaviour of interest:1. preceding behaviour (e.g. approach, orientation)2. dog’s response to child's action3. activity resulting in termination of interaction

Methods 3 different scenarios where dog a perceived benefit (with and

without the dog present) Talking to a non-familiar person (with/without dog present) Behaviour on a walk (with/without dog present) Interaction between child-parent (with/without dog present)

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Field study Scenario 1:Talking to a non-familiar person (with/without

dog present) Child head orientation Child body orientation Communication

Single words/short phrasesSentencesOther vocalisationsGesture (inc. pointing, signing)

Fidgeting

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Non-familiar person scenario preliminary results

n=13 ASD, n=11 (neurotypical controls age and gender matched)

No significant differences identified in any of the measures: Child head orientation, body orientation, Communication

Single words/short phrases, sentences other vocalisations, gesture (inc. pointing, signing)

Individuals responded in different ways

Rate of eye gaze towards stranger in ASD and neurotypical (NT) children

rate

/ m

in

dog no dog dog no dog

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Field study Scenario 2:Walking (with/without dog present)

Parent walking with child Researcher following with camera Two walks (one with/one without dog) Same route where possible

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Ethogram for walking scenario:

Proximity of child to parent <1m,1-3m,>3mChild contact with parent (e.g. holding hand)

Child position in relation to parentLevel, behind, in front

MotionWalking, running, still

Response to parent requestsCompliant, refusal

Activity directed towards environment (e.g. plucking leaves, stamping on bushes)

Pace of walk (parent, child)

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Walking with parent (with/without dog) Results

n=14 children with ASD: 10m/4f, age 5-16 (mean 9)Walks took significantly longer with the dog (same route) (t=3.245, p=0.006)No significant differences in any of the other measures:

Distance from parent Position in relation to parent Speed of movement (stopped/walking/running)

Effects very individual

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Q3. Is a greater benefit obtained from populations with certain demographic

characteristics?

The influence of a dog on child is unlikely to be uniform, so need large sizes to pick out these more variable effects and predictors of these

Use 28 items derived from initial interview responses concerning benefits and risks in order to try to identify significant predictors, e.g. Age, Breed, Sex, Source of dog, Child characteristics Family structure and Experiences

Survey of a large population (~500) with adog to establish prevalence of effects and significant predictive demographic features

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Survey

Mode =1 (Strongly Agree)

Mode=2 (Mainly Agree)

Mode=3 (Partly A/Partly D)

↑ child happier in self ↑ tolerate routine changes

↑ independence in self care

↓ conflict with siblings ↑ affection to family ↑ pay attention on tasks

↑ family able to get out

↓ afraid of dogs ↑ empathy for family

↑ willing to walk ↑ engaging with strangers

↑ imagination in social play

↑ independence in home

↓ likely to tantrum

↓ time tantrum recovery

↑ communicate needs

↓ family arguments ↓ Repetitive behaviours

↓ running off/bolting ↑ family flexible routines

↑ social with family

↑ willing in new activities

↑ communicate feelings

↑ parent time to self

↑ cooperation with family

↑ family enjoyment

↑ imagination in own play

↓ hesitant other dogs

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Grouping of benefits (n=347)

3 factor structure1. Tolerance to changes in routine, willingness to do something

new, willingness to go for a walk, independence in self care, independence within the home, happiness in self, affection to the family, fear of dogs, tendency to tantrum, recovery from tantrum, ability to pay attention, repetitive behaviours, empathy, imagination in social play, imagination in own play, parental time to self, enjoyableness of family activities – adaptability (34.5%v)

2. Communication of immediate needs, communication of feelings with family, flexibility in routine, social interactions with family, co-operation with family, hesitancy with other dogs – social skills (14.0%v)

3. Conflict with siblings, family arguments, family ability to get out of house, running off/bolting – conflict management (5.0%v)

Total v. explained : 53.5%

Mode =1 (Strongly Agree)

Mode=2 (Mainly Agree)

Mode=3 (Partly A/Partly D)

↑ child happier in self ↑ tolerate routine changes

↑ independence in self care

↑ willing to walk ↑ affection to family ↑ pay attention on tasks

↑ independence in home

↓ afraid of dogs ↑ empathy for family

↓ time tantrum recovery

↑ engaging with strangers

↑ imagination in social play

↓ family arguments ↓ likely to tantrum

↓ running off/bolting ↓ repetitive behaviours

↓ conflict with siblings ↑ family enjoyment

↑ family able to get out

↑ imagination in own play

↑ parent time to self

↑ willing in new activities

↑ communicate feelings

↑ communicate needs

↑ cooperation with family

↑ family flexible routines

↑ social with family

↓ hesitant other dogs

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Predicting effects

Significant factors retained & positive contribution Total score: (R2=11.6%) F1 - Adaptability: (R2=11.3%)

Language ability - greater language ability Number of parents in family - 1 parent (vs. 2) Regular contact with horses – yes Dog is a retriever type (vs other inc crosses & u/k) – yes Dog gender – female

F2 – Social Skills: (R2=1.6%) Unpaid support – yes

F3 – Conflict management: (R2=8.9%) Language ability - greater language ability Paid support – no Dog age – older dog

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Comparison between survey and intervention population

Mode =Strongly Agree

Mode=Mainly Agree Mode=Partly A/Partly D

↓ running off/bolting*s ↓ hesitant other dogs*s ↑ pay attention on tasks*s

↓ conflict with siblings*s ↑ tolerate routine changes*s ↑ independence in self care*

↑ child happier in self*s ↓ tantrum/meltdown*s ↑ empathy for family*

↓ time tantrum recover*s

↑ willing in new activities*s ↑ imagination in social play*

↑ willing to walk*s ↑ parent time to self*s

↑ family able to get out* ↑ cooperation with family*s

↓ family arguments* ↑ family enjoyment*s

↑ independence in home*

↓ repetitive behaviours*s

↑ imagination in own play*s

↑ engaging with strangers*s

↑ family flexible routines*

↑ social interaction w family*

↑ communicate feelings*

↑ communicate needs*

↑ affection to family*

↓ afraid of other dogs*

KeyGreen text = significant changes in intervention populationRed text = no significant changes in intervention population

*= also when child is without dog* = only when child is with dog

S = changes occur in short term & maintained

no changes in control group

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Summary

Consistent evidence that pet dogs can help families with an autistic child But specific effects often varied and often hard to

predictReductions in PSI measures

Total Stress (parenting) Parent-Child Dysfunctional Interaction Difficult Child Parental distress (clinically relevant)

Reduction in Child Anxiety Total anxiety Separation anxiety

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Summary

Impact of a dog seems to fall into three main domains Adaptability Social skills Conflict management

Strongest effect seems to be on conflict management skills, then social skills, adaptability is more variable

Effects are very individualistic Specific effects are difficult to predict in advance

Field observations to support the findings are ongoing

Although the PAWS programme does not enhance the benefits of having a dog, it provides essential preventive advice, and will in future include further information on realistic expectations

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What next

?

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Acknowledgements

First and foremost we would like to thank all the families who took the time to take part in one or more parts of this work, when you had so many other demands on your time

To our collaborators at Dogs for Disabled, National Autistic Society and colleagues at Lincoln, especially Dr Annette Hames and Jessica Hardiman

To our sponsors, especially the BIG lottery Fund for having the courage to invest in the first major study of its kind relating to this important condition

To you all for listening

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Thank you!

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Dogs can make a difference: Research overview and results by Professor Daniel Mills, Professor of...

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