Introduction

Specific phobias are common in people with autism spectrum disorders (ASD). In a study of lifetime prevalence, Leyfer et al. (Reference Leyfer, Folstein, Bacalman, Davis, Dinh, Morgan, Tager-Flusberg and Lainhart2006) found that about half of children and young people with ASD surveyed were found to meet criteria for a specific phobia compared with less than 5% in typically developing children and young people. Phobias in young people with ASD can lead to risky behaviours and impede their access to the wider community (Ricciardi et al., Reference Ricciardi, Luiselli and Camare2006; see also Table 1 for specific behaviours of the study participants). Dogs are a common focus of specific animal phobia (Mannuzza and Klein, Reference Mannuzza and Klein1993) and reduce access to the community even for people with no other difficulties. Reviews of the evidence on treatment of anxiety disorders in typically developing young people have concluded that cognitive behavioural therapy (CBT) is effective (Reynolds et al., Reference Reynolds, Wilson, Austin and Hooper2012). Adapted forms of CBT have been extended to populations of young people with ASD and comorbid anxiety disorders (Wood et al., Reference Wood, Drahota, Sze, Har, Chiu and Langer2009). The methods used include psychoeducation and behavioural components such as systematic desensitization aimed at reducing the anxiety response. Young people with ASD and intellectual disabilities (ID) are typically excluded from trials of CBT because they have social and communication issues that may include difficulties accessing thoughts, emotions and feelings, as well as information processing problems. In addition, those who have both ASD and ID may have additional communication needs. Many of the components of CBT (e.g. coping self-talk, verbally mediated coping, affective labelling) rely on verbal concepts before discussion with the therapist (Rosen et al., Reference Rosen, Connell and Kerns2016), thus rendering traditional CBT inappropriate for most individuals with ASD and ID.

Table 1.

Table of participant characteristics and number of sessions provided

A number of further issues should be considered when designing an intervention for young people with ASD and ID. First, young people with ASD and ID often have little spoken language and use alternative or augmentative communication (AAC) methods such as the Picture Exchange Communication System. Activities need to be explained by pictures alone and presented as a sequence to assist anticipation and learning. However, these methods are often unable to convey complex information (cf. problems with use of CBT referenced in the previous paragraph). Second, the use of long sessions (one hour or more typical of CBT) can be difficult for young people with ASD and ID due to attention problems. Third, it is unclear how far the cognitive components can be addressed. The final consideration in designing an intervention for animal phobia requires that the feared animal takes part in at least some sessions, particularly at the end of treatment. Some people with phobias do not escape (‘flight’) but will attack the animal instead (‘fight’), which might endanger the welfare of the animal taking part (Williams, Reference Williams, Beinart, Kennedy and Llewelyn2009). Therefore, the therapist has to take account not only of the person with the phobia, but also any animal involved. Protection for the animal might involve some form of barrier to prevent the animal being injured.

Potential solutions include the use of the behavioural components of CBT such as ‘in vivo exposure and participant modelling, with the goal being a graduated, systematic, and prolonged exposure to feared stimuli. . .’ (Zlomke and Davis, Reference Zlomke and Davis2008), which have demonstrable efficacy for dog phobias in adults with ID (e.g. Dansey and Peshawaria, Reference Dansey and Peshawaria2009). Systematic desensitization can be delivered without the use of language as it is designed to extinguish the link between a feared stimulus and the fight/flight response by (1) providing an alternative response (often relaxation), (2) development of a fear hierarchy from least to most frightening situations, and (3) work up the hierarchy learning not to respond negatively to the feared stimulus. In the case of the participants in this study, we developed the hierarchy based on observations of their responses to stimuli such as pictures, soft toy dogs, videos of dogs and exposure to dogs at a distance within the school site (see also May et al., Reference May, Rudy, Davis and Matson2013). Coping behaviours can also be modelled by other participants in the session to demonstrate effective ways of managing the situation, and the skills taught can be generalized to other dogs and other environments. In planning interventions, goals of treatment have to be carefully considered. It may not be appropriate to abolish avoidance completely, so the goal might be to recognize potentially dangerous situations (e.g. guard dogs) while being able to encounter dogs in the community. Adapted CBT interventions could therefore be used to treat animal phobias for young people with ID and ASD.

In the school where the authors work, reviews of pupil progress had shown that a number of pupils were unable to access the community due to their phobic reactions to dogs. The psychology department agreed to devise a method for overcoming the phobias, so as to improve the possibilities of community activities. This paper describes a series of cases in which the authors establish a flexible protocol for the treatment of dog phobia in young people with ASD spectrum disorder and intellectual disability and severe communication impairments. The intervention was designed following the recognition that dog phobia was hindering the inclusion of young people with ASD and severe ID in community-based activities. The basis of the method is systematic desensitization using a range of stimuli from drawings, to photographs and live animals, together with modelling of coping behaviours.