Marino, L., & Lilienfeld, S. O. (2021). Third time’s the charm or three strikes you’re out? An updated review of the efficacy of dolphin‐assisted therapy for autism and developmental disabilities. Journal of Clinical Psychology, 77(6), 1265-1279. https://doi.org/10.1002/jclp.23110

Reviewed by Sunita Chhatwani, MEd, and Vincent Winterling, EdD
Association for Science in Autism Treatment

Why research this topic?

Research Synopses - Psuchological, Educational and Therapeutic InterventionsDolphin Assisted Therapy (DAT), a form of Animal Assisted Intervention (AAI) is used with individuals with autism spectrum disorder (ASD) and other developmental disabilities. In this form of therapy, the clients swim and interact with dolphins (in captivity) with the aim of improving attention, motivation, communication, and social skills. Challenges in social and communication skills are a core feature in individuals with ASD, and therefore DAT has been a choice of treatment for many individuals with autism. The increased prevalence of autism has led to a greater need for selecting only evidence-based treatments to better support individuals with autism. In the current review, Marino and Lilienfeld systematically reviewed all the available DAT literature since 2007 to determine if DAT may be termed an effective therapy for autism with confidence. The authors have previously published two reviews, in 1998 and 2007, about the efficacy of the DAT. The growing body of literature around DAT highlights the need for scientific evidence of the treatment, according to the authors.

What did the researchers do?

In this, their third review of the DAT literature, Marino and Lilienfeld, revisited the peer reviewed literature on DAT since 2007 with the aim to offer an update on the methodological status of DAT, which was reported to be flawed by them in their earlier two reviews published in 1998 and 2007.

The authors conducted a comprehensive search for relevant literature. They conducted a systematic review of the DAT literature published since 2007 using a variety of search strategies. Of the available literature they found, only six studies, out of eleven that were originally identified, were selected for final review based on the inclusion criteria of using live dolphin interactions and measurable clinically relevant outcomes in the study that were related to autism. Studies using virtual reality (VR) that employed images of dolphins were eliminated from the review. Another study, the only one of its kind reporting no evidence for improvement in autism with DAT, was also excluded due to serious methodological errors.

Each of the remaining six studies were later reviewed in detail. The authors focused their review on participant characteristics, hypotheses, treatment implications, measurement tools, assessment methods employed, and the outcome measures of the study to thoroughly analyze whether sufficient measures were implemented to control for the variety of validity issues that may confound these types of outcome-based research studies.

What are the limitations and strengths of the study?

One of the major strengths of Marino and Lilienfeld’s review is the continuing comprehensive search of the DAT literature which minimizes chances of omission of any meaningful DAT study and provides confidence that the existing literature was analyzed. Formulation of inclusion and exclusion criteria for the studies adds to the assurance the reader may employ in trying to evaluate the claims of the authors.

An additional strength of this review is the careful delineation of the many threats to internal and construct validity that pervade this research area. For those with an interest in research methodology this is an important discussion (e.g., failure to account for internal validity and construct validity issues including nonspecific effects, construct confounding, demand characteristics, experimenter’s expectancy effect, history, maturation, multiple intervention interference, informant retrospective bias and differential attrition). A specific, and unique threat to validity associated with DAT highlighted by the authors was the excitement of interacting with an exotic animal in a water (new environment). Any of these threats to validity in a study can immediately limit whatever successful findings that are reported. Although authors identified few studies (included in the review) employing appropriate measures to control some aspects of validity, i.e., (Breitenbach et al., 2009), who employed control for the effects of an aquatic environment or (Griffioen & Enders‐Siegers, 2014), who included a control for novelty effects, none of a single study reviewed could be termed as methodologically strong.

Based on DAT literature review the authors suggest that future DAT studies need to be better designed to control the threats to validity (multiple) before it can be deemed as therapeutic for any population. The authors point out that presence of even one major threat to validity can render a study’s findings difficult, or in some cases impossible, to interpret. Hence, they provide suggestions to control validity threats found in each study for future DAT research. The continued efforts on the parts of the authors to systematically review DAT literature as an ASD intervention needs to be applauded.

What did the researchers find?

The author’s findings fall into two major categories: those pertaining to research methodology and those addressing safety concerns.

With respect to research methodology the authors found that the DAT research is still lacking in the necessary experimental controls to establish DAT as an effective intervention. As they did in previous reviews, the authors continue to note significant limitations to the research methods that make evidence-based conclusions inappropriate. Thus, the authors concluded that nearly a decade after their initial review, there remains no compelling evidence that DAT is a legitimate therapy for autism or any other developmental disorders.

Another important point reported by authors was that in most of the studies included in the recent review, the researchers too acknowledged the similar threats to validity as reported by them and these findings make it more compelling for these threats to be addressed.

Apart from methodological concerns, the authors suggest caution when considering DAT. For example, the authors also highlighted some important revelations: that DAT was renounced by the original developer and by the International Association of Human-Animal Interaction Organizations (IAHAIO). There also remains a concern about the soundness of the theoretical rationales for DAT treatment and why participating in activities with a dolphin might have a therapeutic impact on children with autism. While participating in dolphin therapy can indeed bring you benefits, there is no evidence that what is beneficial is the dolphin and not the other factors associated with the therapy.

What do the results mean?

The results of the review indicate that due to the lack of adequate scientific evidence on DAT it can’t be regarded as evidence-based intervention for ASD or any other condition. The authors, therefore, strongly discourage the parents/families and professionals from using it as an intervention for people with autism or any other specified condition. Some safety and ethical issues associated with DAT were also highlighted by the authors. Since wild animals (dolphins) are used in captivity for therapy sessions the risk for clients as well as animals can’t be ruled out. The fact that DAT is conducted by therapists at the dolphinariums/dolphin parks which are not regulated by any official body enhances the possibility of exploitation of animals, clients and involved parents is always present. In addition, DAT is reportedly quite expensive while producing no verifiable results for the children involved. There is also no evidence that dolphin therapy is more effective than therapy with other animals, which are much cheaper and easier to access. Keeping in mind the safety and ethical reasons the authors warn parents, practitioners, patient advocacy groups, particularly in the autism community to take special care in recommending and promoting DAT for ASD and other disorders.

References:

Breitenbach, E., Stumpf, E., Fersen, L. V., & Ebert, H. V. (2009). Dolphin‐assisted therapy: Changes in interaction and communication between children with severe disabilities and their caregivers. Anthrozoös, 22(3), 277-289. https://doi.org/10.2752/175303709X457612

Dilts, R., Trompisch, N., & Bergquist, T. M. (2011). Dolphin‐assisted therapy for children with special needs: A pilot study. Journal of Creativity in Mental Health, 6(1), 56-68. https://doi.org/10.1080/15401383.2011.557309

Griffioen, R., van der Steen, S., Cox, R. F. A., Verheggen, T., & Enders‐Slegers, M. J. (2019). Verbal interactional synchronization between therapist and children with autism spectrum disorder during dolphin assisted therapy: Five case studies. Animals, 9(10), Article 716. https://doi.org/10.3390/ani9100716

Griffioen, R. E., & Enders‐Slegers, M. J. (2014). The effect of dolphin‐assisted therapy on the cognitive and social development of children with Down syndrome. Anthrozoös, 27(4), 569-580. https://doi.org/10.2752/089279314X14072268687961580

Kohn, N., & Oerter, R. (2013). Dolphin assisted therapy works: Scientific findings from Eilat and Florida. International Journal of Clinical Psychiatry, 1(1), 1-16.

Marino, L., & Lilienfeld, S. O. (1998). Dolphin‐assisted therapy: Flawed data, flawed conclusions. Anthrozoos, 11(4), 194-200. https://doi.org/10.2752/089279398787000517

Marino, L., & Lilienfeld, S. O. (2007). Dolphin-assisted therapy: More flawed data and more flawed conclusions. Anthrozoös, 20(3), 239-249. http://dx.doi.org/10.2752/089279307X224782

MdYusof, M. S. B., & Chia, N. K. H. (2012). Dolphin encounter for special children (DESC) program: Effectiveness of dolphin‐assisted therapy for children with autism. International Journal of Special Education, 27(3), 54-67.

Citation for this article:

Chhatwani, S., & Winterling, V. (2021). Research synopsis: Third time’s the charm or three strikes you’re out? An updated review of the efficacy of dolphin‐assisted therapy for autism and developmental disabilities. Science in Autism Treatment, 18(9).

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