J. ChitdPsychd. Psychtat., Vol. 20, pp. 255-260.

Pergamon Preas Ltd 1979. Printed in Great Britain. 0OI2-9680/79/0701-O255$02.0O/O

Association for Child Psychology and Psychiatry.

TREATMENT OF SEVERE DOG PHOBIA IN CHILDHOOD

BY FLOODING. A CASE REPORT
UMA SREENIVASAN,* S. N . MANOCHA and V. K. JAIN

INTRODUCTION
PHOBIAS have been observed in every age group in man except shortly after birth.
Extensive studies during this century have not resulted in a universally effective
technique, instrument or drug. Techniques developed over the last 50 years include
interpretation, abreaction, modeling, systematic desensitization, implosion, operant
re-inforcement, drugs, etc. (Marks, 1975). The term "fiooding" was first used by
Polin (1959) and implies confrontation ofthe subject with the stimulus or situation
which causes distress until tolerance develops. The rationale is that maladaptive
avoidance behaviour is most effectively extinguished by preventing escape or
avoidance tendencies during treatment sessions (Wilson and Davison, 1971).
Experimental and clinical findings in fiooding are less consistent than in sys-
tematic desensitization. Barrett (1%9) found that flooding was as effective and more
efiicient than systematic desensitization in reducing snake phobias, while DeMoore
(1970) found the two techniques equally effective in decreasing morbid fear of
insects. However, at the 6-month follow-up both studies indicated that systematic
desensitization seemed to produce more stable improvement than fiooding, which
was associated with several relapses. Marks et al. (1971) have reported considerable
success using fiooding in severely phobic patients. Compared to systematic de-
sensitization they found that only fiooding produced significant decrease in physio-
logical arousal elicited by the stimulus. Yule, Sacks and Hersov (1974) provide one
of the few case reports in the literature of the use of fiooding in childhood. Our
report concerns a case of severe dog phobia treated by fiooding, after desensitization
faUed.

CASE HISTORY
Eleven-year-old Colleen and her 10-year-old sister Sharon were jointly referred
to the Department of Child Psychiatry at the Janeway Children's Hospital by their
pediatrician in February 1977 for "excessive fear of dogs". The only children of a
young couple, the two girls had been extremely fearful of dogs for about 5 years. No
precipitating events were recalled. An increase in the number of dogs in the neigh-
bourhood during the last year had led to the children becoming almost house-
bound. On Sunday evenings both would become apprehensive about running
into dogs on the way to the bus stop next morning. School refusal was not a problem
•Requests for reprints to: Dr. Uma Sreenivasan, Director of Child Psychiatry, Dr. C. A. Janeway
Child Health Centre, St. John's, Newfoimdland, AlA 1R8, Canada.
Accepted manuscript received 30 December 1978

255
256 UMA SREENIVASAN, S. N. MANOCHA AND V. K. JAIN

with Colleen, who was consistently above average in her studies. The teacher's
report stated that Colleen appeared to be on edge this year and unable to concen-
trate. She ruminated in the classroom about the various dogs that could conceivably
accost her on the way home. She was less anxious if her friend Cindy was in school
as they went home together, and she worried every morning about Cindy's attend-
ance. Colleen's sister Sharon aggravated Colleen's anxiety by becoming "hys-
terical" on sight of dogs. On the way home the presence of dogs on the street and
false alarms by teasing neighbours sent them running home in a panic, screaming
and crying. On family outings they stuck to adults or refused to leave the car if they
saw any dog.
In the first interview Colleen was extremely anxious with sweaty palms, and
restless, fidgety hands. She had several facial tics and grimaces, constantly licked
her lips, blinked rapidly (30-40 times a minute) and snaked her arms around each
other. Yet she was friendly, warm and able to express her feelings. Hearing about
dogs made her feel afraid and seeing a dog made her apprehensive that the dog
would jump on her and bite. She named many friends but she could not play out-
doors or visit them as they had dogs. Her younger sister Sharon was fidgety and
was worried about possible hospitalization but did not appear as tense, although
mother felt she was a bar to spontaneous recovery in Colleen. The latter insisted
that Sharon was more afraid than herself, and caused her embarrassment.
Colleen's parents were in their early thirties and very unlike each other. Father
was a skilled worker, very outgoing and belonged to sports teams. Mother was a
severely compulsive housewife. She had been treated for an anxiety state with
agoraphobia after the birth of the children when the attention they required con-
fiicted with completing her self-imposed drudgery. The only family history of
animal phobia was in a maternal aunt who was afraid of dogs and cats. Parents had
been advised by friends to get a pup and were looking for one.

Systematic desensitization
Out-patient treatment by systematic desensitization was started with the sisters
together. There were no difficulties in relaxing, imagery and accepting graduated
external stimuli not involving live dogs. At the end of 3 weeks, parents acquired a
small puppy which won approval from Sharon at once and she became less fearful
of other dogs. Colleen was unable to progress beyond furry toy dogs, and was in a
constant turmoil at home due to the pup, which had to be confined to the kitchen.
Parents became alarmed at her condition and 2 months after the initial contact
Colleen was admitted to the in-patient psychiatric unit in the hospital. The acute
manifestations of anxiety settled quickly and she shone in the hospital school. She
attributed her improvement to the absence of dogs (not permitted in the hospital),
and continued to panic in outdoor activities if dogs were sighted. She refused week-
ends home because ofthe pup. The impasse with in vivo confrontation remained.

Flooding
At this point, a trial of fiooding appeared to be justified. The parents and Colleen
were told that we would try to have Colleen remain in the same room as a live dog
with hospitjd staff present to ensure safety. Parents had no misgivings about the
 TREATMENT OF SEVERE DOG PHOBIA IN CHILDHOOD BY FLOODING 257

procedure but expressed total pessimism. Colleen agreed very reluctantly. It was
hoped to use the family's pup, but due to distance (15 miles) and difficulties with the
car mother would not commit herself.
A member of the staff (psychiatric nursing instructor) volunteered to bring her
2-yr-old white female cocker spaniel, known to be passive and friendly. Due to
hospital regulations about dogs, a trailer parked close to the psychiatric ward, and
used by the patients for play was chosen. Colleen and the therapists went to the
trailer shortly before the dog arrived. Six sessions of fiooding lasting about an hour
were spread over 10 days. After arrival in the room the dog was taken off the leash.
Clinical assessments of anxiety were completed before and after each session and
at the 3- and 6-month follow-up. Colleen's self reports of anxiety and the therapist's
ratings were recorded on a five point scale, following the method used by Gelder
and Marks (1968).

RESULTS
Figure 1 presents the therapist's ratings of Colleen's anxiety levels during treat-
ment and at the 3- and 6-month reviews.
Oburvcr

Floo«ng tMdsns Folkm-up

ovw 10 day period inwMks

FIG. 1. Therapist's rating of the patient's anxiety levels during the six treatment sessions, and at the
follow-up sessions at 12 and 24 weeks' interval.

Figure 2 shows the anxiety ratings for the first, third and sixth fiooding sessions
by the therapist and by the patient.
For the first session. Colleen was apprehensive for severid hours before. On arrival
in the treatment room she was anxiously scanning the area for the dog. When the
dc^ was led in she froze, visibly paled and her pupils were dilated. Staff talked
reassuringly to Colleen, but when the dog was freed she jumped on a chair. She
cried and pleaded that the dog should be placed on its leash. Gradually she relaxed
slightly but stayed on the chair, becoming anxious and entreating if the dog moved
towards the chair. Two of the staff played table tennis and tried unsuccessfully to
persuade Colleen to join them. In the second session she was equally anxious but
would get down from the chair or table she stood on for a few seconds but was never
at ease. Prior to the third session Colleen appeared excited, although she expressed
fear and dislike of the sessions. She managed to take part in the table tennis game
for brief periods, sitting on the table if the dog ambled towards the table. In the
258 UMA SREENIVASAN, S. N. MANOCHA AND V. K. JAIN

Observer Subjective

Flooding session # 1

Flooding session ^ 3

Before During i'ter Before After

Flooding session - # 6

FIG. 2. Levels of anxiety in the 1st, 3rd and 6th fiooding sessions as rated hy the therapist and the
patient.

fourth session she could pat the dog if it was not facing her. In the sixth session she
tolerated the dog in her lap, and then took the dog for a walk holding the leash to
the amazement of her parents who happened to arrive. After this, she was able to
take the family pet for a walk and then to go for a drive with the puppy in the car.
She spent a weekend at home without the puppy having to be isolated and was
discharged from the inpatient unit at the end of May, 1977, 7 weeks after admission.

FOLLOW-UP
In the first month following discharge Colleen was seen three times to assess
progress. She was fairly reljixed, her grimaces and fidgeting were not seen but she
still blinked often. Her school was surprised that she passed end of year exams with
ease. While there was no panic, some tensing was noticed by mother when Colleen
passed large dogs on the street. A slight fear of cats which had not been considered
a problem had disappeared. Mother complained that Colleen was not as compliant
as she used to be. Colleen was seen again at 3 and 6 months after fiooding, and took
 TREATMENT OF SEVERE DOG PHOBIA IN CHILDHOOD BY FLOODING 259

part in a videotaped interview which was shown to local psychiatrists at a case

conference. All the improvement was maintained at this time. Mother declined
further outpatient appointments, claiming that there were no problems. In Decem-
ber 1978, 19 months after fiooding, a home visit was undertaken. Colleen was now
attending a large high school and doing very well academically. Mother described
her as "completely recovered" and emphasized how independent she was now.
Colleen herself appeared quite care-free. She was friendly with all the dogs in the
neighbourhood, playing outdoors and visiting friends almost daily. No blinking
was seen, but was said to occur if she was very excited. Colleen's well-being ap-
peared to have generalised to her mother, who acknowledged a great relief from
the tension caused by her daughter's previous custom of arriving from school
"screeching and bawling" daily. Questioned about her ruminations Colleen had
difficulty recalling the thoughts of being attacked by dogs that used to pre-occupy
her. She felt that the ruminations had not recurred from the time that fiooding had
been completed.

DISCUSSION
The research literature remains confiicting with regard to desensitization as well
as fiooding. Hatzenbuehler and Schroeder (1978), in an illuminating review of
desensitization procedures in childhood, divide them into passive and active par-
ticipation methods. Speculating from the evidence the authors suggest that passive
association techniques would be more effective for severe avoidance and that active
participation procedures would vitiate the course of therapy by inciting a panic
reaction. At the same time, the authors hypothesize that active participation follow-
ing an initial passive association would be more effective in severe phobia by provid-
ing opportunity for actual rehearsal of new coping behaviours. The case described
here appears to follow this route with failure to progress when active participation
reached the point of confrontation with an unfettered dog.
In retrospect, the long standing severe avoidance behavior, panic reactions even
to teasing references to dogs and symptoms of a chronic tension state in our patient
are suggestive that desensitization alone would not be successful. Treatment by fiooding
caused considerable distress to the child in spite of prior desensitization therapy, and
could not have been sustained to its conclusion had she been an out-patient. Ad-
ditionally, her sister who was thought by the family to be more phobic responded to
desensitization alone. In the present state of our knowledge it is felt that desen-
sitization should precede fiooding.

SUMMARY
An 11-yr-old girl with a five year history of severe phobia of dogs was treated
with fiooding after desensitization failed. The procedure used is described and
theoretical implications are briefiy discussed. Nineteen months after fiooding the
girl is free of the phobia and symptoms of a tension state. Generalisation effects
include loss of a mild fear of cats, disappearance of ruminations about dogs attacking
her and enhanced social life and academic achievements.
260 UMA SREENIVASAN, S. N. MANOCHA AND V. K. JAIN

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