Complementary Therapies in Clinical Practice 21 (2015) 42e46
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
The use of Animal-Assisted Therapy in adolescents with acute mental disorders: A randomized controlled study* M.C. Stefanini a, *, A. Martino a, P. Allori a, F. Galeotti b, F. Tani c a
Neurofarba Department, Child's Health Unit, University of Florence, Italy Nurse and Therapist AAT, Meyer Pediatric Hospital, Florence, Italy c Department of Health Sciences, Psychology and Psychiatry Unit, University of Florence, Italy b
a b s t r a c t Keywords: Animal-Assisted Therapy in pediatric hospital Acute psychiatric disorders in children/ adolescents Methodology of AAT Randomized controlled study
Objectives: The aim of this study was to compare the effects of Animal-Assisted Therapy (AAT) with a standard treatment protocol in children and adolescents admitted to the psychiatry hospital for acute mental disorders. We used a methodology involving high quality standards for AAT research. Design: A pre-post experimental design with a randomized controlled trial (RCT) in 34 hospitalized patients (17 treatment, 17 control) was carried out. Main outcome measures: The study focused on improvement in clinical status including, global functioning measured by the Children Global Assessment Scale (C GAS), format of care and ordinary school attendance measured by a rating scale. Results: Our results indicate a statistically significant improvement in global functioning, reduction in format of care and increased ordinary school attendance in the treatment group, but not in the control group. Conclusions: Our results verify that AAT can have significant positive effects on therapeutic progress and the recovery process. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Animal-Assisted Therapy (AAT) is “a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/ human service professional with specialized expertise and within the scope of practice of his/her profession”. AAT is often designed to improve adjustment and enhance adaptive functioning as well as to decrease the source of social, emotional, cognitive problems and behavior or psychiatric condition [1]. In recent years AAT has been incorporated into different therapeutic settings and after its introduction, rapid expansion has followed. There is a significant paucity of research regarding the impact of animals on hospitalized children [2]. Overall, the reported results
* The authors are grateful to all of the patients who participated in the study, and their parents. * Corresponding author. Neurofarba Department, Children's Health Unit, University of Florence, VialePieraccini, 6-50129 Firenze, Italy. Tel.: þ39 055 4296194; fax: þ39 055 4296190. E-mail address: mariacristina.stefanini@unifi.it (M.C. Stefanini).
http://dx.doi.org/10.1016/j.ctcp.2015.01.001 1744-3881/© 2015 Elsevier Ltd. All rights reserved.
concerning well-being, particularly in the pediatric population, suggest a reduction in the stress response after individual sessions of AAT and an increase in positive mood [3]. Preliminary findings seem promising but additional data are needed to clarify the most beneficial contexts for using AAT in children [4]. As far as concerns psychiatric diseases in children and adolescents, the literature on AAT consists mainly of pilot studies on children with autism [5], mental retardation [6], mental illnessrelated diseases, and chronic or long-standing diseases such as cancer. There are no current studies investigating the influence of AAT on child or adolescent psychiatric populations during hospitalization for acute mental disorders. Despite a large body of evidence demonstrating the benefits of humaneanimal interaction, there are limited empirical support or studies validating the effectiveness of AAT [7]. As Voelker noted, the major difficulty in obtaining outcome data in AAT research is that professionals who apply these strategies do not take into account the importance of validating the outcome. Another problem in AAT research is the lack of published protocols that can guide treatment procedures and how to implement them [8]. Most studies have relied on non-experimental or quasi-experimental designs, which
M.C. Stefanini et al. / Complementary Therapies in Clinical Practice 21 (2015) 42e46
often yield inconclusive findings. An important aspect of evaluating the effectiveness of AAT is application of a control group. A recent review summarized the evidence of the effects of AAT from randomized controlled trials and found only 11 studies of mental and behavioral disorders in which this criterion was applied [9]. 1.1. Context of research The present work was implemented by the Child Neurology and Psychiatry Unit of Meyer Pediatric Hospital, University of Florence, in collaboration with the Health Sciences Department, University of Florence, and the School for Guide Dogs for the Blind of the Region of Tuscany, (pet-partners trained for Animal-Assisted Activities and AAT interventions to the standards of Pet-Partner®, ex-Delta Society) over a 14-month period. In this Unit young patients mainly with acute psychiatric disorders such as breakdown psychotic, attempted suicide, mood disorders, anxiety disorders, and eating disorders, were hospitalized, generally from 2 weeks to 3e4 months. Therapeutic interventions were carried out on the patient, his/her family and his/ her environment. The main objective in the plan of care was to restore the development and integration processes; so it was important to protect the patients from excessive external stimuli and at the same time offer experiences of normality and everyday life (such as school, external social activities, supportive relationships, etc.), to limit the damages of acute psychic failure and to improve the recovery process. 1.2. Objectives of the study 1. Implement a methodology according to high quality standards for AAT research; 2. Verify the effectiveness of AAT on clinical outcome in child and adolescent psychiatric inpatients. 2. Materials & methods 2.1. Study design A pre-post experimental design with randomized controlled trials (RCT) was used to evaluate the effects of AAT on patient outcomes. All selected participants underwent a standard treatment protocol that included: 1) psychiatric and medical assessment; 2) assessment and support therapy to family; 3) nursing matronage; 4) psycho-educational treatment; 5) individual psychotherapy; 6) therapeutic group intervention; 7) supplementary activities (such as Hospital-School, play activity, etc.). To assign patients to the treatment or control group through a randomization method that consisted in generating computerized random numbers. We then compared the adolescent psychiatric inpatients involved in the AAT intervention e the treatment group e to a respective control group that followed the standard therapeutic protocol. Behavioral and clinical measures, such as an index of the recovery process, were assessed at the beginning of the intervention (T0) and at the end of the AAT program (T1) after 3 months. 2.2. Participants A sample of 34 children and adolescents with a psychiatric diagnosis, aged from 11 to 17 years old at baseline (T0) (mean age M ¼ 15.91, SD ¼ 1.73) were recruited for the present study: 17 (8 M and 9 F) participants in the treatment group (mean age ¼ 15.35, SD ¼ 1.9), and 17 (8 M and 9 F) in the control group (mean age ¼ 16.47, SD ¼ 1.4). Inclusion criteria were: 1) acute psychiatric
43
diagnosis; 2) developmental age; 3) able to give informed consent. All patients' tutors gave their informed consent. Patients were excluded if they had fear, aversion or allergies to animals or were going to be hospitalized only for a very short time. Diagnosis was made according to ICD-9 criteria. In the total sample of patients, 20.6% had mood disorders, 8.8% schizophrenia, 5.9% anxiety disorders, and 64.7% eating disorders. 76.5% of recruited patients received pharmacological therapy; 55.9% of the patients had other psychiatric diagnoses; 26.5% of the patients had already received previous treatment for psychopathology. More detailed characteristics of the study population are reported in Table 1. 2.3. Procedure Before collecting data, we implemented a preliminary phase that included: a) training of staff members for the Animal-Assisted Activities (AAA) and AAT programs; b) definition of population; c) planning of therapeutic intervention. In order to reach high methodological standards we reduced the number of variables that could bias interpretation of the results. Selection criteria involved randomization of patients into treatment or control groups. At the beginning of the AAT intervention there were no differences in patients' demographical, behavioral and clinical condition in the control and treatment groups. Evaluators and clinicians were blinded about which treatment group a patient was in. The research was conducted in accordance with the guidelines for the ethical treatment of human participants of the American Psychological Association. Protocol research was approved by the hospital ethics committee. After explaining the proposed research, informed consent was provided by both parents, or legal tutors of all participants. A patient could withdraw from participation at any time during the study. 2.4. AAT intervention The AAT intervention consisted in structured sessions in accordance with the individual therapeutic goals for each patient. Patients participated in weekly sessions for about 3 months. This therapeutic program had four phases: 1) familiarization with the animal and the handler; 2) individual intervention; 3) group activity; 4) discussion of the AAT experience. Each session, that was Table 1 Patients' demographic and clinical characteristics.
Sex F M Diagnosis (ICD-9) Eating disorder Mood disorder Schizophrenia Anxiety disorders Co-morbid diagnosis Pharmacological therapy Previous treatment Admission state Recovery Day hospital
C GAS Format of hospital care Ordinary school attendance
Treatment group (N ¼ 17)
Control group (N ¼ 17)
N
%
N
%
8 9
47.1 52.9
8 9
47.1 52.9
10 3 2 2 11 13 6
58.8 17.6 11.8 11.8 64.7 76.5 35.3
12 4 1 8 13 3
70.6 23.5 5.9 47.1 76.5 17.6
11 6
64.7 35.3
10 7
58.8 41.2
Means
SD
Means
SD
38.29 2.12 1.12
7.39 1.45 0.48
41.24 2.24 1.35
8.75 1.34 0.70
44
M.C. Stefanini et al. / Complementary Therapies in Clinical Practice 21 (2015) 42e46
entirely videotaped by a staff member, last approximately 45 min during which participants interacted with a dog and its handler. The repertoire of AAT intervention covers a wide range of activities and consists in: play activities, physical contact, grooming, cleaning, basic obedience commands, walking, and agility routes (protocol code). The AAT was conducted in the hospital's garden or in an activity room when weather was bad. All subjects in the treatment group took part in the AAT project on a regular basis; no sessions were missed despite the low level of global functioning associated with the severity of the patient's clinical condition. The dogs were periodically examined by a veterinarian who followed a sanitary protocol according to Pet-Partner® guidelines. Patients included in the AAT program participated in two preliminary AAA sessions to establish an appropriate animal e patient couple that remained stable until the end of the treatment. 2.5. Instruments and measurements (1) Global functioning. The Children Global Assessment Scale C GAS (Schaffer D et al., 1983) provides a measurement of global functioning in children and adolescents (6e17 years old), with a rating scale ranging from 0 to 100 points. (2) Format of hospital care. This is a 3-point rating scale, generally used by clinicians in child and adolescent psychiatry units, to assess the clinical severity of each patient. The scores range from 1 to 3 and describe a different type of hospital regime (3 ¼ recovery; 2 ¼ day hospital; 1 ¼ control visit). A high score reflects major impairment. (3) Ordinary school attendance. This is 3-point rating scale commonly used in child and adolescent psychiatry units. The scores range from 1 to 3 and describe different types of school attendance by the patient (1 ¼ only Hospital School attendance; 2 ¼ some hours in ordinary school; 3 ¼ regular attendance of ordinary school). A high score reflects less impairment. (4) Observation of AAT. Each AAT session was completely videotaped. Videotapes were evaluated and coded by two independent investigators according to an observational form, composed of 28 items designed to code behavioral patterns observed during a single videotaped session. Each item was rated on a 4-point scale ranging from 1 (never) to 4 (always). This observational form includes 6 scales: 1) participation, 2) interaction with the animal, 3) socialization with peer, 4) socialization with adult, 5) withdrawal behaviors, 6) affection toward the animal. The inter-evaluator agreement was 98%.
3. Results 3.1. Preliminary analyses We found that there was no significant difference in clinical variables, such as diagnosis (c2 (3) ¼ 2.65, n.s.), comorbidity (c2 (1) ¼ 1.07, n.s.), pharmacological therapy, previous treatment (c2 (1) ¼ 1.36, n.s.) and admission state (c2 (1) ¼ 0.12, n.s.) at T0 between the two groups. Similarly, no differences emerged for independent samples in format of care (t (1.32) ¼ 0.34, n.s.), ordinary school attendance (t (1.32) ¼ 1.13, n.s.), and general functioning (t (1.32) ¼ 1.58, n.s.). 3.2. Pre-post analyses There were significant differences between the treatment and control groups in changes occurring from T0 to T1. In particular, a major increase in format of hospital care (t (32) ¼ 2.41, p ¼ .02), ordinary school attendance (t (32) ¼ 2.25, p < .03), and global functioning (t (32) ¼ 4.57, p < .0001), occurred in the treatment group, as shown in Figs. 1e3. We also noted significant changes in patients' scores in all observational scales from the beginning to the end of the AAT intervention. In particular, patients showed higher participation (t (1.16) ¼ 6.49, p < .0001), more interaction with their animal (t (1.16) ¼ 6.65, p < .0001), and more affective behaviors with them (t (1.16) ¼ 9.19, p < .0001). Similarly, patients showed more socialized behaviors with adults (t (1.16) ¼ 7.18, p < .0001) and peers (t (1.16) ¼ 6.47, p¼ < .0001), and a significant reduction in social withdrawal behaviors (t (116) ¼ 2.02, p < .04) (see Table 2). 4. Discussion Most of the AAT research on young populations [10,11] has investigated the positive influence on psychological, physiological, and behavioral well-being [12e14], but there are no studies up to now about how an AAT program can have an impact on the care process [15]. This study analyzed the effects of AAT on clinical outcomes in a child and adolescent psychiatric sample, using an experimental design with a control group and multiple assessment methods (clinical and observational) that were susceptible to recorded changes over time. Overall the results show good feasibility and significant clinical and behavioral improvements in patients. Our results also show that patients of the treatment group had a significant increase in
2.6. Analyses Descriptive statistics were performed on demographic, clinical, and behavioral variables. The c2 test was employed to explore differences in demographic characteristics of the two groups at T0. A T-test for independent samples was performed to examine differences in clinical and behavioral variables, as well in global functioning (C GAS) of patients in the two groups at Time 0. The Ttest for independent samples was used to analyze significant prepost differences within each group in terms of format of hospital care, ordinary school attendance and global functioning. Finally, the matched-paired t-test was employed to analyze pre-post differences in observational form items in the treatment group. Statistical analyses were performed using SPSS version 20. For testing hypothesis the significance level was set a priori at a two-tailed type I error rate of .05.
Fig. 1. Mean scores for C-GAS for treatment and control groups at T0 and T1.
M.C. Stefanini et al. / Complementary Therapies in Clinical Practice 21 (2015) 42e46
Fig. 2. Mean scores for ordinary school attendance for treatment and control groups at T0 and T1.
45
catalyze social interactions and to create a more relaxed environment [16]. We believe that there are specific elements of care in AAT for young psychiatric inpatients that we still have to investigate further. For example, the particular relationship between animal and young patients should be more deeply explored. This relationship is mainly behavioral, but also emotionally warm and welcoming, without being judgmental or demanding. Furthermore, the young patients who feel fragile, needy and dependent on others in the hospital context, can experience themselves as caretakers of someone else in the AAT environment. This experience can improve their sense of self-agency and self-cure, and these positive effects are not limited to the humaneanimal bond, but can be extended to the patient's global functioning and to the entire process of care. For all these reasons, the use of AAT with young people admitted to a Psychiatry Hospital is a useful instrument which can help make progress in an intensive therapeutic program. 5. Limitations and projects
Fig. 3. Mean scores for format of hospital care for treatment and control groups at T0 and T1.
their global functioning, a significant reduction of time spent in hospital, and a significant increase of ordinary school attendance compared with the control group patients. Furthermore, 3 months after their participation in the AAT intervention, they showed significant changes in social participation and social interaction skills with adults and peers, more active and frequent interactions with their assigned animal and more affective behaviors towards them. These findings lead us to conclude that the benefits of AAT conducted with methodological rigor (according to national and international guidelines) are not only related to a generic and nonspecific promotion of well-being, but may contribute to the processes of adaptive integration (social and relational) even in severely compromised psychiatric patients. One possible explanation for this success is the role of the animal as a catalyst in the therapeutic process. Animals may represent a valid help in therapeutic contexts thanks to their ability to
Table 2 Mean scores in observational form scale for treatment group at T0 and at T1. Scale
Participation Interaction with the animal Socialization with adult Socialization with peer Social withdrawal Affection toward the animal
Pre-test
Post-test
Means
SD
Means
SD
2.27 2.38 1.73 1.76 2.88 2.23
0.49 0.52 0.72 0.83 1.11 0.58
3.21 3.19 3.17 3.11 3.52 3.45
0.60 0.43 0.72 1.05 0.87 0.49
Although our results are encouraging, this study has several limitations. The study sample was rather small and it would be useful to confirm these findings in a larger population, also collaborating with other hospitals that adopt the same methodology. Secondly, it would be very interesting to verify the stability of the patient's change by a follow-up at 6 and 12 months. Finally, further work is needed to more deeply explore the relationship patterns and mechanisms between patient and animal, and especially in the complex triangle of operators, patient and animal. We are continuing our study currently by exploring which target populations with different sources of impairment (anxiety disorders, mood disorders, and eating disorders) respond most significantly to the AAT, in order to define a specific indication of this treatment for different psychopathological syndromes. Conflict of interest statement None declared. Acknowledgment The authors thank Dr. Mary Forrest for correcting the English. References [1] Fine AH, editor. Handbook on animal-assisted therapy: theoretical foundations and guidelines for practice. London: Academic Press; 2006. [2] Kaminski M, Pellino T, Wish J. Play and pets: the physical and emotional impact of child-life and pet therapy on hospitalized children. Child Health Care 2002;31(4):321e35. http://dx.doi.org/10.1207/S15326888CHC3104_5. [3] Barker SB, Pandurangi AK, Best AM. Effects of animal-assisted therapy on patients' anxiety, fear, and depression before ECT. J ECT 2003;19(1):38e44. http://dx.doi.org/10.1097/00124509-200303000-00008. [4] Endenburg N, van Lith HA. The influence of animals on the development of children. Vet J 2011;190:208e14. http://dx.doi.org/10.1016/j.tvjl.2010.11.020. [5] Martin F, Farnum J. Animal assisted therapy for children with pervasive developmental disorders. West J Nurs Res 2002;24:657e70. http://dx.doi.org/ 10.1177/019394502320555403. [6] Laun L. Benefits of pet therapy in dementia. Home Healthc Nurse 2003;21(1): 49e52. http://dx.doi.org/10.1097/00004045-200301000-00011. [7] Fine AH. Animal assisted therapy and clinical practice. Seattle, WA. In: Psycholegal associates CEU meeting; 2003, Nov. 01. [8] Fine AH. Incorporating animal-assisted therapy into psychotherapy: guidelines and suggestions for therapists. In: Fine AH, editor. Handbook on animalassisted therapy. Theoretical foundations and guidelines for practice. 2nd ed. San Diego: Academic Press; 2006. p. 169e87. [9] Kamioka H, Shinpei O, Kiichiro T, Hyuntae P, Hiroyasu O, Shuichi H, et al. Effectiveness of animal-assisted therapy: a systematic review of randomized
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controlled trials. Complement Ther Med 2014. http://dx.doi.org/10.1016/ j.ctcp.2009.05.004. [10] Mallon G. Utilization of animals as therapeutic adjuncts with children and youth: a review of the literature. Child Youth Care Forum 1992;21:53e67. http://dx.doi.org/10.1007/bf00757348. [11] Вraun C, Strangler T, Narveson J, Pettingel S. Animal-assisted therapy as a pain relief intervention for children. Complementary Ther Clin Pract 2009;15: 105e9. [12] Havener L, Gentes L, Thaler B, Megel ME, Baun MM, Driscoll FA, et al. The effects of a companion animal on distress in children undergoing dental procedures. Issues Compr Pediatr Nurs 2001;24:137e52. http://dx.doi.org/ 10.1080/01460860118472.
[13] Wu AS, Niedra R, Pendergast L, McCrindle BW. Acceptability and impact of pet visitation on a pediatric cardiology inpatient unit. J Pediatr Nurs 2002;17: 354e62. http://dx.doi.org/10.1053/jpdn.2002.127173. [14] Ming Lee Yeh A. Canine AAT model for autistic children. Tokyo Japan: at Taiwan International Association of human-animal interaction international conference. 10/5e8/2008. [15] Coacley AB, Mahoney HK. Creating therapeutic and healing environment with a pet therapy program. Complement Ther Clin Pract 2009;15(3):141e6. http://dx.doi.org/10.1016/j.ctcp.2009.05.004. [16] Cirulli F, Borgi M, Berry A, Francia N, Alleva E. Animal-assisted interventions as 2011;47(4):341e8. innovative tools for mental health. Ann Ist Super Sanita http://dx.doi.org/10.4415/ann-11-04-04.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
The use of Animal-Assisted Therapy in adolescents with acute mental disorders: A randomized controlled study* M.C. Stefanini a, *, A. Martino a, P. Allori a, F. Galeotti b, F. Tani c a
Neurofarba Department, Child's Health Unit, University of Florence, Italy Nurse and Therapist AAT, Meyer Pediatric Hospital, Florence, Italy c Department of Health Sciences, Psychology and Psychiatry Unit, University of Florence, Italy b
a b s t r a c t Keywords: Animal-Assisted Therapy in pediatric hospital Acute psychiatric disorders in children/ adolescents Methodology of AAT Randomized controlled study
Objectives: The aim of this study was to compare the effects of Animal-Assisted Therapy (AAT) with a standard treatment protocol in children and adolescents admitted to the psychiatry hospital for acute mental disorders. We used a methodology involving high quality standards for AAT research. Design: A pre-post experimental design with a randomized controlled trial (RCT) in 34 hospitalized patients (17 treatment, 17 control) was carried out. Main outcome measures: The study focused on improvement in clinical status including, global functioning measured by the Children Global Assessment Scale (C GAS), format of care and ordinary school attendance measured by a rating scale. Results: Our results indicate a statistically significant improvement in global functioning, reduction in format of care and increased ordinary school attendance in the treatment group, but not in the control group. Conclusions: Our results verify that AAT can have significant positive effects on therapeutic progress and the recovery process. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Animal-Assisted Therapy (AAT) is “a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/ human service professional with specialized expertise and within the scope of practice of his/her profession”. AAT is often designed to improve adjustment and enhance adaptive functioning as well as to decrease the source of social, emotional, cognitive problems and behavior or psychiatric condition [1]. In recent years AAT has been incorporated into different therapeutic settings and after its introduction, rapid expansion has followed. There is a significant paucity of research regarding the impact of animals on hospitalized children [2]. Overall, the reported results
* The authors are grateful to all of the patients who participated in the study, and their parents. * Corresponding author. Neurofarba Department, Children's Health Unit, University of Florence, VialePieraccini, 6-50129 Firenze, Italy. Tel.: þ39 055 4296194; fax: þ39 055 4296190. E-mail address: mariacristina.stefanini@unifi.it (M.C. Stefanini).
http://dx.doi.org/10.1016/j.ctcp.2015.01.001 1744-3881/© 2015 Elsevier Ltd. All rights reserved.
concerning well-being, particularly in the pediatric population, suggest a reduction in the stress response after individual sessions of AAT and an increase in positive mood [3]. Preliminary findings seem promising but additional data are needed to clarify the most beneficial contexts for using AAT in children [4]. As far as concerns psychiatric diseases in children and adolescents, the literature on AAT consists mainly of pilot studies on children with autism [5], mental retardation [6], mental illnessrelated diseases, and chronic or long-standing diseases such as cancer. There are no current studies investigating the influence of AAT on child or adolescent psychiatric populations during hospitalization for acute mental disorders. Despite a large body of evidence demonstrating the benefits of humaneanimal interaction, there are limited empirical support or studies validating the effectiveness of AAT [7]. As Voelker noted, the major difficulty in obtaining outcome data in AAT research is that professionals who apply these strategies do not take into account the importance of validating the outcome. Another problem in AAT research is the lack of published protocols that can guide treatment procedures and how to implement them [8]. Most studies have relied on non-experimental or quasi-experimental designs, which
M.C. Stefanini et al. / Complementary Therapies in Clinical Practice 21 (2015) 42e46
often yield inconclusive findings. An important aspect of evaluating the effectiveness of AAT is application of a control group. A recent review summarized the evidence of the effects of AAT from randomized controlled trials and found only 11 studies of mental and behavioral disorders in which this criterion was applied [9]. 1.1. Context of research The present work was implemented by the Child Neurology and Psychiatry Unit of Meyer Pediatric Hospital, University of Florence, in collaboration with the Health Sciences Department, University of Florence, and the School for Guide Dogs for the Blind of the Region of Tuscany, (pet-partners trained for Animal-Assisted Activities and AAT interventions to the standards of Pet-Partner®, ex-Delta Society) over a 14-month period. In this Unit young patients mainly with acute psychiatric disorders such as breakdown psychotic, attempted suicide, mood disorders, anxiety disorders, and eating disorders, were hospitalized, generally from 2 weeks to 3e4 months. Therapeutic interventions were carried out on the patient, his/her family and his/ her environment. The main objective in the plan of care was to restore the development and integration processes; so it was important to protect the patients from excessive external stimuli and at the same time offer experiences of normality and everyday life (such as school, external social activities, supportive relationships, etc.), to limit the damages of acute psychic failure and to improve the recovery process. 1.2. Objectives of the study 1. Implement a methodology according to high quality standards for AAT research; 2. Verify the effectiveness of AAT on clinical outcome in child and adolescent psychiatric inpatients. 2. Materials & methods 2.1. Study design A pre-post experimental design with randomized controlled trials (RCT) was used to evaluate the effects of AAT on patient outcomes. All selected participants underwent a standard treatment protocol that included: 1) psychiatric and medical assessment; 2) assessment and support therapy to family; 3) nursing matronage; 4) psycho-educational treatment; 5) individual psychotherapy; 6) therapeutic group intervention; 7) supplementary activities (such as Hospital-School, play activity, etc.). To assign patients to the treatment or control group through a randomization method that consisted in generating computerized random numbers. We then compared the adolescent psychiatric inpatients involved in the AAT intervention e the treatment group e to a respective control group that followed the standard therapeutic protocol. Behavioral and clinical measures, such as an index of the recovery process, were assessed at the beginning of the intervention (T0) and at the end of the AAT program (T1) after 3 months. 2.2. Participants A sample of 34 children and adolescents with a psychiatric diagnosis, aged from 11 to 17 years old at baseline (T0) (mean age M ¼ 15.91, SD ¼ 1.73) were recruited for the present study: 17 (8 M and 9 F) participants in the treatment group (mean age ¼ 15.35, SD ¼ 1.9), and 17 (8 M and 9 F) in the control group (mean age ¼ 16.47, SD ¼ 1.4). Inclusion criteria were: 1) acute psychiatric
43
diagnosis; 2) developmental age; 3) able to give informed consent. All patients' tutors gave their informed consent. Patients were excluded if they had fear, aversion or allergies to animals or were going to be hospitalized only for a very short time. Diagnosis was made according to ICD-9 criteria. In the total sample of patients, 20.6% had mood disorders, 8.8% schizophrenia, 5.9% anxiety disorders, and 64.7% eating disorders. 76.5% of recruited patients received pharmacological therapy; 55.9% of the patients had other psychiatric diagnoses; 26.5% of the patients had already received previous treatment for psychopathology. More detailed characteristics of the study population are reported in Table 1. 2.3. Procedure Before collecting data, we implemented a preliminary phase that included: a) training of staff members for the Animal-Assisted Activities (AAA) and AAT programs; b) definition of population; c) planning of therapeutic intervention. In order to reach high methodological standards we reduced the number of variables that could bias interpretation of the results. Selection criteria involved randomization of patients into treatment or control groups. At the beginning of the AAT intervention there were no differences in patients' demographical, behavioral and clinical condition in the control and treatment groups. Evaluators and clinicians were blinded about which treatment group a patient was in. The research was conducted in accordance with the guidelines for the ethical treatment of human participants of the American Psychological Association. Protocol research was approved by the hospital ethics committee. After explaining the proposed research, informed consent was provided by both parents, or legal tutors of all participants. A patient could withdraw from participation at any time during the study. 2.4. AAT intervention The AAT intervention consisted in structured sessions in accordance with the individual therapeutic goals for each patient. Patients participated in weekly sessions for about 3 months. This therapeutic program had four phases: 1) familiarization with the animal and the handler; 2) individual intervention; 3) group activity; 4) discussion of the AAT experience. Each session, that was Table 1 Patients' demographic and clinical characteristics.
Sex F M Diagnosis (ICD-9) Eating disorder Mood disorder Schizophrenia Anxiety disorders Co-morbid diagnosis Pharmacological therapy Previous treatment Admission state Recovery Day hospital
C GAS Format of hospital care Ordinary school attendance
Treatment group (N ¼ 17)
Control group (N ¼ 17)
N
%
N
%
8 9
47.1 52.9
8 9
47.1 52.9
10 3 2 2 11 13 6
58.8 17.6 11.8 11.8 64.7 76.5 35.3
12 4 1 8 13 3
70.6 23.5 5.9 47.1 76.5 17.6
11 6
64.7 35.3
10 7
58.8 41.2
Means
SD
Means
SD
38.29 2.12 1.12
7.39 1.45 0.48
41.24 2.24 1.35
8.75 1.34 0.70
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entirely videotaped by a staff member, last approximately 45 min during which participants interacted with a dog and its handler. The repertoire of AAT intervention covers a wide range of activities and consists in: play activities, physical contact, grooming, cleaning, basic obedience commands, walking, and agility routes (protocol code). The AAT was conducted in the hospital's garden or in an activity room when weather was bad. All subjects in the treatment group took part in the AAT project on a regular basis; no sessions were missed despite the low level of global functioning associated with the severity of the patient's clinical condition. The dogs were periodically examined by a veterinarian who followed a sanitary protocol according to Pet-Partner® guidelines. Patients included in the AAT program participated in two preliminary AAA sessions to establish an appropriate animal e patient couple that remained stable until the end of the treatment. 2.5. Instruments and measurements (1) Global functioning. The Children Global Assessment Scale C GAS (Schaffer D et al., 1983) provides a measurement of global functioning in children and adolescents (6e17 years old), with a rating scale ranging from 0 to 100 points. (2) Format of hospital care. This is a 3-point rating scale, generally used by clinicians in child and adolescent psychiatry units, to assess the clinical severity of each patient. The scores range from 1 to 3 and describe a different type of hospital regime (3 ¼ recovery; 2 ¼ day hospital; 1 ¼ control visit). A high score reflects major impairment. (3) Ordinary school attendance. This is 3-point rating scale commonly used in child and adolescent psychiatry units. The scores range from 1 to 3 and describe different types of school attendance by the patient (1 ¼ only Hospital School attendance; 2 ¼ some hours in ordinary school; 3 ¼ regular attendance of ordinary school). A high score reflects less impairment. (4) Observation of AAT. Each AAT session was completely videotaped. Videotapes were evaluated and coded by two independent investigators according to an observational form, composed of 28 items designed to code behavioral patterns observed during a single videotaped session. Each item was rated on a 4-point scale ranging from 1 (never) to 4 (always). This observational form includes 6 scales: 1) participation, 2) interaction with the animal, 3) socialization with peer, 4) socialization with adult, 5) withdrawal behaviors, 6) affection toward the animal. The inter-evaluator agreement was 98%.
3. Results 3.1. Preliminary analyses We found that there was no significant difference in clinical variables, such as diagnosis (c2 (3) ¼ 2.65, n.s.), comorbidity (c2 (1) ¼ 1.07, n.s.), pharmacological therapy, previous treatment (c2 (1) ¼ 1.36, n.s.) and admission state (c2 (1) ¼ 0.12, n.s.) at T0 between the two groups. Similarly, no differences emerged for independent samples in format of care (t (1.32) ¼ 0.34, n.s.), ordinary school attendance (t (1.32) ¼ 1.13, n.s.), and general functioning (t (1.32) ¼ 1.58, n.s.). 3.2. Pre-post analyses There were significant differences between the treatment and control groups in changes occurring from T0 to T1. In particular, a major increase in format of hospital care (t (32) ¼ 2.41, p ¼ .02), ordinary school attendance (t (32) ¼ 2.25, p < .03), and global functioning (t (32) ¼ 4.57, p < .0001), occurred in the treatment group, as shown in Figs. 1e3. We also noted significant changes in patients' scores in all observational scales from the beginning to the end of the AAT intervention. In particular, patients showed higher participation (t (1.16) ¼ 6.49, p < .0001), more interaction with their animal (t (1.16) ¼ 6.65, p < .0001), and more affective behaviors with them (t (1.16) ¼ 9.19, p < .0001). Similarly, patients showed more socialized behaviors with adults (t (1.16) ¼ 7.18, p < .0001) and peers (t (1.16) ¼ 6.47, p¼ < .0001), and a significant reduction in social withdrawal behaviors (t (116) ¼ 2.02, p < .04) (see Table 2). 4. Discussion Most of the AAT research on young populations [10,11] has investigated the positive influence on psychological, physiological, and behavioral well-being [12e14], but there are no studies up to now about how an AAT program can have an impact on the care process [15]. This study analyzed the effects of AAT on clinical outcomes in a child and adolescent psychiatric sample, using an experimental design with a control group and multiple assessment methods (clinical and observational) that were susceptible to recorded changes over time. Overall the results show good feasibility and significant clinical and behavioral improvements in patients. Our results also show that patients of the treatment group had a significant increase in
2.6. Analyses Descriptive statistics were performed on demographic, clinical, and behavioral variables. The c2 test was employed to explore differences in demographic characteristics of the two groups at T0. A T-test for independent samples was performed to examine differences in clinical and behavioral variables, as well in global functioning (C GAS) of patients in the two groups at Time 0. The Ttest for independent samples was used to analyze significant prepost differences within each group in terms of format of hospital care, ordinary school attendance and global functioning. Finally, the matched-paired t-test was employed to analyze pre-post differences in observational form items in the treatment group. Statistical analyses were performed using SPSS version 20. For testing hypothesis the significance level was set a priori at a two-tailed type I error rate of .05.
Fig. 1. Mean scores for C-GAS for treatment and control groups at T0 and T1.
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Fig. 2. Mean scores for ordinary school attendance for treatment and control groups at T0 and T1.
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catalyze social interactions and to create a more relaxed environment [16]. We believe that there are specific elements of care in AAT for young psychiatric inpatients that we still have to investigate further. For example, the particular relationship between animal and young patients should be more deeply explored. This relationship is mainly behavioral, but also emotionally warm and welcoming, without being judgmental or demanding. Furthermore, the young patients who feel fragile, needy and dependent on others in the hospital context, can experience themselves as caretakers of someone else in the AAT environment. This experience can improve their sense of self-agency and self-cure, and these positive effects are not limited to the humaneanimal bond, but can be extended to the patient's global functioning and to the entire process of care. For all these reasons, the use of AAT with young people admitted to a Psychiatry Hospital is a useful instrument which can help make progress in an intensive therapeutic program. 5. Limitations and projects
Fig. 3. Mean scores for format of hospital care for treatment and control groups at T0 and T1.
their global functioning, a significant reduction of time spent in hospital, and a significant increase of ordinary school attendance compared with the control group patients. Furthermore, 3 months after their participation in the AAT intervention, they showed significant changes in social participation and social interaction skills with adults and peers, more active and frequent interactions with their assigned animal and more affective behaviors towards them. These findings lead us to conclude that the benefits of AAT conducted with methodological rigor (according to national and international guidelines) are not only related to a generic and nonspecific promotion of well-being, but may contribute to the processes of adaptive integration (social and relational) even in severely compromised psychiatric patients. One possible explanation for this success is the role of the animal as a catalyst in the therapeutic process. Animals may represent a valid help in therapeutic contexts thanks to their ability to
Table 2 Mean scores in observational form scale for treatment group at T0 and at T1. Scale
Participation Interaction with the animal Socialization with adult Socialization with peer Social withdrawal Affection toward the animal
Pre-test
Post-test
Means
SD
Means
SD
2.27 2.38 1.73 1.76 2.88 2.23
0.49 0.52 0.72 0.83 1.11 0.58
3.21 3.19 3.17 3.11 3.52 3.45
0.60 0.43 0.72 1.05 0.87 0.49
Although our results are encouraging, this study has several limitations. The study sample was rather small and it would be useful to confirm these findings in a larger population, also collaborating with other hospitals that adopt the same methodology. Secondly, it would be very interesting to verify the stability of the patient's change by a follow-up at 6 and 12 months. Finally, further work is needed to more deeply explore the relationship patterns and mechanisms between patient and animal, and especially in the complex triangle of operators, patient and animal. We are continuing our study currently by exploring which target populations with different sources of impairment (anxiety disorders, mood disorders, and eating disorders) respond most significantly to the AAT, in order to define a specific indication of this treatment for different psychopathological syndromes. Conflict of interest statement None declared. Acknowledgment The authors thank Dr. Mary Forrest for correcting the English. References [1] Fine AH, editor. Handbook on animal-assisted therapy: theoretical foundations and guidelines for practice. London: Academic Press; 2006. [2] Kaminski M, Pellino T, Wish J. Play and pets: the physical and emotional impact of child-life and pet therapy on hospitalized children. Child Health Care 2002;31(4):321e35. http://dx.doi.org/10.1207/S15326888CHC3104_5. [3] Barker SB, Pandurangi AK, Best AM. Effects of animal-assisted therapy on patients' anxiety, fear, and depression before ECT. J ECT 2003;19(1):38e44. http://dx.doi.org/10.1097/00124509-200303000-00008. [4] Endenburg N, van Lith HA. The influence of animals on the development of children. Vet J 2011;190:208e14. http://dx.doi.org/10.1016/j.tvjl.2010.11.020. [5] Martin F, Farnum J. Animal assisted therapy for children with pervasive developmental disorders. West J Nurs Res 2002;24:657e70. http://dx.doi.org/ 10.1177/019394502320555403. [6] Laun L. Benefits of pet therapy in dementia. Home Healthc Nurse 2003;21(1): 49e52. http://dx.doi.org/10.1097/00004045-200301000-00011. [7] Fine AH. Animal assisted therapy and clinical practice. Seattle, WA. In: Psycholegal associates CEU meeting; 2003, Nov. 01. [8] Fine AH. Incorporating animal-assisted therapy into psychotherapy: guidelines and suggestions for therapists. In: Fine AH, editor. Handbook on animalassisted therapy. Theoretical foundations and guidelines for practice. 2nd ed. San Diego: Academic Press; 2006. p. 169e87. [9] Kamioka H, Shinpei O, Kiichiro T, Hyuntae P, Hiroyasu O, Shuichi H, et al. Effectiveness of animal-assisted therapy: a systematic review of randomized
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controlled trials. Complement Ther Med 2014. http://dx.doi.org/10.1016/ j.ctcp.2009.05.004. [10] Mallon G. Utilization of animals as therapeutic adjuncts with children and youth: a review of the literature. Child Youth Care Forum 1992;21:53e67. http://dx.doi.org/10.1007/bf00757348. [11] Вraun C, Strangler T, Narveson J, Pettingel S. Animal-assisted therapy as a pain relief intervention for children. Complementary Ther Clin Pract 2009;15: 105e9. [12] Havener L, Gentes L, Thaler B, Megel ME, Baun MM, Driscoll FA, et al. The effects of a companion animal on distress in children undergoing dental procedures. Issues Compr Pediatr Nurs 2001;24:137e52. http://dx.doi.org/ 10.1080/01460860118472.
[13] Wu AS, Niedra R, Pendergast L, McCrindle BW. Acceptability and impact of pet visitation on a pediatric cardiology inpatient unit. J Pediatr Nurs 2002;17: 354e62. http://dx.doi.org/10.1053/jpdn.2002.127173. [14] Ming Lee Yeh A. Canine AAT model for autistic children. Tokyo Japan: at Taiwan International Association of human-animal interaction international conference. 10/5e8/2008. [15] Coacley AB, Mahoney HK. Creating therapeutic and healing environment with a pet therapy program. Complement Ther Clin Pract 2009;15(3):141e6. http://dx.doi.org/10.1016/j.ctcp.2009.05.004. [16] Cirulli F, Borgi M, Berry A, Francia N, Alleva E. Animal-assisted interventions as 2011;47(4):341e8. innovative tools for mental health. Ann Ist Super Sanita http://dx.doi.org/10.4415/ann-11-04-04.
