Definitions of animals used in healthcare settings.
With the exception of maggot debridement and medicinal leech therapy, active and passive medical interventions using a live animal are defined by the human-animal bond. Encounters center on the dynamic and interactive relationship between humans and animals to provide psychological or physical benefit. (1,2) This bond is the core of several therapeutic approaches using various species. The most common are assistance or service animals; therapy and activity animals; and emotional support, companion, or social animals. The efficacy of the human-animal bond as a healthcare tool greatly depends on how the animal's roles are used by a group or an individual. Unlike medical equipment, defining specific functions of a living tool is essential to the maintenance and common logistical factors that affect the health and welfare of the animal. From a legal perspective, definitions are necessary for establishing eligibility, benefits, and even liability when considering whether the standard of care is met. As the military medical community increases its use of animals, specifically canines, clarification of utility is needed to develop policy and ensure good practice.
Assistance or Service Animals
Throughout much of the world, assistance animals are categorized into guide dogs, hearing dogs, or service dogs. (3,4) However, in the United States, the synonymous term "service animal" is often used and may mean any type of assistance animal. (4) In 2010, the Americans with Disabilities Act (ADA) (42 USC [section]12101-12213 and 47 USC [section][section]225, 611) was revised with regard to the definition and use of service animals. For purposes of US law, the ADA [as amended] defines a service animal as:
any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. (5(p56250))
Further, it stipulates that
Individuals with disabilities shall be permitted to be accompanied by their service animals in all areas of a public entity's facilities where members of the public, participants in services, programs or activities, or invitees, as relevant, are allowed to go. (5(p56251))
The ADA definition of disability is a "physical or mental impairment that substantially limits one or more major life activities of such individual." (6) To be considered a service animal, a direct link must exist between the animal's work or tasks and the handler's disability. However, the animal's work must be a trained behavior and not a response that is natural to the animal. The current ADA definition does not consider violent protection (whether trained or untrained), crime deterrence due to an animal's presence, emotional support, well-being, comfort, or companionship as acceptable work or tasks for the definition of a service animal. Although animals such as primates, equines, avians, felines, porcines, and even bovines have all been trained to help humans perform daily tasks, 28 CFR [section]35.104 (as amended in 2010) limits the definition of a service animal to canines only and does not include any other species of animals, regardless of whether those other species are wild or domesticated, trained or untrained. (5(p56250)) A trained miniature horse as an alternative to an assistance dog is the one exception to permitting the use of a noncanine species in the role of a service animal in a public space. (5(p56251)) However, a miniature horse is not defined as a service animal by 28 CFR [section]36.104 and its use is subject to certain limitations, as outlined in 28 CFR [section]35.136. (5(p56250)7)
The ADA delineates further conditions and rules regarding service animals. (5(p56251)) A service animal must be house broken, under the control of the handler at all times, harnessed or leashed at all times (unless that restraint would interfere with the performance of the animal's work), and is not subject to size, weight, or breed limitations. (5(p56271)) A public entity cannot inquire about the nature of an individual's disability, but, to determine whether an animal qualifies as an assistance animal, an entity may ask the handler whether the animal is required because of a disability and what work or task the animal performs for the disabled person. The public entity cannot ask for proof of documentation that the animal is a qualified or trained assistance animal or require payment of a surcharge for access to a public space or facility, even if that entity requires payment for pet access. (5(p56251))
Canines are the most common species of assistance animals, working well as guide dogs, hearing dogs, or service dogs. Guide dogs assist the visually impaired (blind or low vision) with navigation such as avoiding obstacles, stopping at curbs and steps, and negotiating traffic. (8) Hearing dogs are trained to alert those with hearing impairment (deaf or hard of hearing) to the presence of people or household and community sounds by making physical contact and, if appropriate, leading their handlers to the source of the sound. (9) Service dogs are trained to perform a wide variety of common and customized tasks for individuals with impairments other than auditory or vision dysfunction. (10) Assistance with physical, cognitive, or psychiatric disabilities can promote functional independence and increased quality of life. Specially trained service dogs can perform a variety of tasks including, but not limited to, providing balance and counterbalance; alerting the handler to pending medical disorders such as seizures or hypoglycemia or assisting during episodes of those disorders; assisting to pull a wheel chair; retrieving a variety of large or small items; alerting to the presence of an allergen; turning lights on and off or pushing elevator and automatic door buttons; assisting with functional transfers; providing nonviolent protection or rescue work.10 Specific skills that address a particular disability may be included in their title, such as "balance dog" or "psychiatric service dog." The latter may assist individuals with psychiatric and neurological disabilities by preventing or interrupting impulsive or destructive behaviors, or mitigating behavioral health disabilities in other ways. (5(p56250)) All of the above examples of assistance dog tasks are consistent with the ADA definition of a service animal. (5(p56250))
Therapy and Activity Animals
While federal law does not define therapy and activity animals, some states do have laws defining such animals. (11) Regardless of a therapy or activity animal's legal definition, they are not service animals and do not have public access privileges afforded to service animals. The main distinction between therapy or activity animals and service animals is that the former, through the use of the human-animal bond, provide services to other people (with or without disabilities) under the direction of their handlers, whereas, the latter are trained to do work or tasks solely for their dedicated handler with a disability. (11) They are expected to work reliably and safely with others, often with many distractions. Recognizing that the therapeutic effects of the human-animal bond are not exclusive to people with disabilities, (1,12,13) several professional and animal advocacy organizations have defined the various types of nonassistance/service animals. One such organization, Delta Society, has defined both animal-assisted therapy (AAT) and animal-assisted activities (AAA) animals. (14)
Animal-assisted therapy is part of a goal-directed, individualized healthcare treatment plan for individuals with physical, social, emotional, or cognitive dysfunction, where the AAT intervention is documented in the patient's health record. Animal-assisted therapy is conducted on scheduled visits, of a regular interval and directed or delivered by a professional within the practice scope of a health/human service provider. Animal-assisted therapy animals may or may not have previous formal assistance/service dog training. Examples of AAT may be a patient with balance dysfunction using a trained dog wearing a rigid-handled harness to assist with gait training, or the use of trained dogs in military combat stress control units for behavioral health interventions.
Comparatively, AAA are untailored "meet and greet" activities without specific treatment goals. Animal-assisted activities can be conducted in group settings with many people, and no documentation is necessary. Unlike a therapy program, the AAA visits and activities can be spontaneous, of any length or frequency, and conducted by any handler. Examples of AAA might include a volunteer handler with dog visiting a hospital pediatric oncology ward to raise the spirits of children, or a dog training organization bringing their animals to an outpatient facility to positively interact with Wounded Warriors.
Animals used in AAT and AAA are often dogs, but also frequently include equines, such as hippotherapy programs, which use horses as part of an integrated rehabilitation treatment program supervised by a healthcare therapist. (15,16) Resident or facility animals can be AAT or AAA animals and are similar in that each works with a volunteer or professional whose training falls under the auspices of a formal program. The work of a facility animal can include visitations or professional therapy in one or more locations. A very common example of facility animals is the simple presence of fish in a doctor's office. However, dogs are common as well and can provide a more intimate and effective human-animal bond experience. Resident animals can live or work in a facility full time. They are often owned by the organization or a facility staff member and can be handled and cared for by the staff, volunteers, or residents. After appropriate training and screening, resident animals may formally participate in a facility's planned or spontaneous activities and therapies with patients or residents. (17) Resident animals may also function in the role of emotional support, companion, social, or mascot animals.
Emotional Support, Companion, Social, and Mascot Animals
Although the medical evidence for the health benefits of the human-animal bond is not definitive, (18) evidence suggests that pets can promote health and wellbeing in disabled and able persons alike. (12,19) Skills that are inherent to a canine do not necessarily assist an individual in completing a task, but instead can provide emotional support to an individual. Emotional support animals provide comfort to persons with psychiatric disability but do not perform trained tasks to assist the individuals. Because the comfort offered by the mere presence of an animal is not a trained skill, emotional support animals are not covered under US laws that apply specifically to service animals, unlike a psychiatric service animal that provides specific trained work or a task to help mitigate a handler's psychiatric disability. However, some persons with psychiatric disability served by emotional support animals may be afforded certain housing rights as a "reasonable accommodation" under Section 504 of the Rehabilitation Act of 1973 (29 USC [section]701) and the Federal Fair Housing Amendments Act of 1988 (FHAA) (42 USC [section]3601-3619). (20,21) Emotional support canines are sometimes referred to by other terms such as "social dog," "companion dog," or "therapy dog." Social, emotional support, companion, or therapy animals may be untrained or animals that were once considered for formal assistance/service dog training but, due to health, disposition, trainability, or other factors, did not complete the training. (11) Such dogs are often made available as pets for people with certain disabilities. Nonetheless, emotional support animals are not legally considered pets due to their qualifications under Section 504 and FHAA, but a companion animal is synonymous with a pet. The meanings of a social/companion animal are nearly self-explanatory. Conversely, the varied meanings of what is therapeutic in regards to a therapy animal, are not as clear or concrete. Furthermore, the variety of perspectives with regard to therapeutic efficacy range from the individual(s) experiencing and facilitating the human-animal bond, up to and including the federal government that influences accommodation, public access, and healthcare.
Office of The Army Surgeon General/Army Medical Command Policy
A recently issued policy memorandum (22) from the Office of The Surgeon General/Army Medical Command provides definitions for various types of animals for purposes of establishing policy guidance and procedures for the use of animals in Army healthcare. It is the intent of this policy that, although the Army is not generally bound by the ADA, Army Medical Command facilities "will abide by [ADA] provisions to as great a degree as is practicable and when such adherence does not hamper readiness." (22) As such, the policy similarly defines animals as above with a few differences to note. The policy defines service animals as dogs only. Additionally, the policy defines "service-dogs-in-training" as dogs undergoing training as part of Wounded Warrior therapeutic internship opportunities in which wounded Soldiers train service dogs for fellow service members. Some state regulations grant public facility/space access to trainers while they instruct clients with disabilities and/ or the service-dogs-in-training. (23) "Recreational animals" are defined as "animals not owned by an individual and used solely for recreational purposes," (22) for example, horses ridden at a dude (tourist) ranch. The terms "companion," "emotional support animals," and "pets" are synonymous and defined as "any animal owned by individual Soldiers or beneficiaries not meeting the definition of a service animal." (22) Military working dogs are government-procured and owned dogs used for military working purposes, such as explosive detection, security, or search and rescue. Finally, the policy defines mascots as animals adopted by nondeployed Army units for purposes of esprit de corps. (22)
According to the governing triservice regulation, (24) to qualify as a mascot, the animal must be on orders signed by an officer of 0-5 grade or higher. Such mascots are owned by the Department of Defense and, thus, are eligible for veterinary medical/surgical care and support services. (25) However, animal mascot or pet adoption is subject to the policies and limitations of animal adoptions which are imposed by theater commands in respective areas of responsibility, such as the prohibition of animal adoption in the deployed environment per US Central Command Area of Responsibility General Order Number 1B (GO-1B), dated March 13, 2006. *
The overwhelming novelty of experiencing animals in a therapeutic setting relies on the familiarity that American culture has with canines and family pets. More specifically, military patients respond well to the animal interaction and with less concern whether a service dog has public access; whether an emotional support dog's efficacy can be proven; or whether a therapy dog fosters rehabilitative care. For many, a dog's all-accepting disposition and wide range of intangible health promoting factors is a welcome oasis in a setting where anxiety, pain, or decreased function are often prevalent. Some of the defining characteristics of the different types of animals involved in healthcare are presented in the Table. Understanding the legal, professional, and common definitions of these types of animals will help providers deliver the best care and develop appropriate policy to maximize the tangible and intangible benefits of the human-animal bond.
(1.) History and mission page. Center for the Human-Animal Bond, Purdue University School of Veterinary Medicine website. http://www.vet.purdue.edu/chab/. Accessed November 7, 2011.
(2.) Wellness guidelines for animals in animal-assisted activity, animal-assisted therapy and resident animal programs . American Veterinary Medical Association website. http://www.avma.org/issues/policy/animal_assisted_activity.asp. Updated April 2011. Accessed November 7, 2011.
(3.) About assistance dogs. Assistance Dogs International Inc website. http://www.assistancedogsinternational.org/aboutAssistanceDogs.php. Accessed November 7, 2011.
(4.) Frequently asked questions page [What Are Service Animals?]. Service Dog Central website. http://www.servicedogcentral.org/content/faq. Accessed November 7, 2011.
(5.) 75 Federal Register Vol 75(178) (2010) (codified at 28 CFR [section]36). http://www.ada.gov/regs2010/titleIII_2010/titleIII_2010_fr.pdf. Accessed January 13, 2012.
(6.) 28 CFR [section]35.104 (1991). Available at: http://www.dol.gov/oasam/regs/cfr/28cfr/Part35/35104.htm. Accessed November 7, 2011.
(7.) Fact sheet: highlights of the final rule to amend the Department of Justice's regulation implementing Title II of the ADA (2011). Department of Justice website. http://www.ada.gov/regs2010/factsheets/title2_factsheet.html. Accessed November 7, 2011.
(8.) About guide dogs page. Assistance Dogs International, Inc website. http://www.assistancedogsinternational.org/guide.php. Accessed November 7, 2011.
(9.) About hearing dogs page. Assistance Dogs International, Inc website. http://www.assistancedogsinternational.org/hearing.php. Accessed November 7, 2011.
(10.) About service dogs page. Assistance Dogs International, Inc website. http://www.assistancedogsinternational.org/service.php. Accessed November 7, 2011.
(11.) Service animal basics page. Delta Society website. http://www.deltasociety.org/Page.aspx?pid=303. Accessed November 7, 2011.
(12.) Horowitz S. The human-animal bond: health implications across the lifespan. Alternative Compl Ther. 2008;14(5):251-256.
(13.) Issues: human-animal bond. American Veterinary Medical Association website. http://www.avma.org/issues/humananimalbond/defaultasp. Accessed November 7, 2011.
(14.) Animal-assisted activities/therapy 101. Delta Society website. http://www.deltasociety.org/Page.aspx?pid=317. Accessed November 7, 2011.
(15.) Debuse D, Chandler C, Gibb C. An exploration of German and British physiotherapists views on the effects of hippotherapy and their measurement. Physiother Theor Pract. 2005;21(4):219-242.
(16.) Hippotherapy as a treatment strategy. American Hippotherapy Association website. http://www.americanhippotherapyassociation.org/hippotherapy/ hippotherapy-as-a-treatment-strategy/. Accessed November 7, 2011.
(17.) Guidelines for animal assisted activity, animal-assisted therapy and resident animal programs . American Veterinary Medical Association web-site. http://www.avma.org/issues/policy/animal_assisted_guidelines.asp. Accessed November 7, 2011.
(18.) Chur-Hansen A, Stern C, Winefield H. Gaps in the evidence about companion animals and human health: some suggestions for progress. Int J Evid Based Healthc. 2010;8(3):140-146.
(19.) Carson L. The animal/human bond: a prescription for good health. J Health Educ. 2006;37(6):361-365.
(20.) Brewer K. Housing discrimination and companion animals . Animal Legal & Historical Center website. http://www.animallaw.info/articles/ovuspetsandhousinglaws.htm. Published 2005. Accessed November 7, 2011.
(21.) Psychiatric service and emotional support animals [publication #5483.01, 2011]. Disability Rights California website. www.disabilityrightsca.org/pubs/548301.pdf. Accessed November 7, 2011.
(22.) Office of The Surgeon General. Memorandum: Overarching Guidance on the Use of Animals in the Healthcare Setting (Service Animals, Animal Assisted Therapies, and Animal Assisted Activities). Fort Sam Houston, TX: US Army Medical Command; January 30, 2012. Policy Memorandum 12-005.
(23.) Assistance Dogs International's Guide to Assistance Dog Laws. Santa Rosa, CA: Assistance Dogs International; 2006:143.
(24.) Army Regulation 40-905, SECNAVINST 6401. IB, AFI48-131: Veterinary Health Services. Washington, DC: US Departments of the Army, Navy, and Air Force; August 29, 2006. Available at: http://www.apd.army.mil/pdffiles/r40_905.pdf. Accessed January 13, 2012.
(25.) Huss RJ. Why context matters: defining service animals under federal law. Pepperdine Law Review. 2010;37:11631216. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1548674.
* Internal, limited distribution military document, not generally accessible by the public.
LTC Mills is the Physical Therapy Staff Officer, Rehabilitation and Reintegration Division, Office of the Army Surgeon General, Alexandria, Virginia.
MAJ Yeager is Chief, Occupational Therapy, Reynolds Army Community Hospital, Fort Sill, Oklahoma.
LTC James T. Mills, III, SP, USA
MAJ Arthur F. Yeager, SP, USA
Classification of types of animals used in various healthcare settings and situations. Guide Dog Hearing Dog Service Dog Legally defined Yes (5) Yes (5) Yes (5) Federal legal definition Yes (5) Yes (5) Yes (5) as an assistance/service animal Federal legal protections Yes (5) Yes (5) Yes (5) for access to public facilities and spaces Federal legal Yes (5, 25) Yes (5, 25) Yes (5, 25) protections for access to housing Performs trained tasks/ Yes (5) Yes (5) Yes (5) work for a dedicated handler Used as part of a No No No facility's planned or spontaneous activities Used as part of a No No No healthcare treatment plan Used to achieve specific N/A N/A N/A healthcare treatment goals Used with individualized N/A N/A N/A or group sessions Medical documentation N/A N/A N/A required. Visit schedule and length N/A N/A N/A is predetermined. Visit conducted/ N/A N/A N/A supervised by a healthcare professional or any handler. Can be a pet No No No Used to provide comfort No No No Used for recreation No No No Used for esprit de corps No No No Service Miniature Horse AAT Animal Legally defined Yes (5) In some states (11) Federal legal definition No (5,7) No (5) as an assistance/service animal Federal legal protections With certain No (24) for access to public conditions (5) facilities and spaces Federal legal With certain No (25) protections for access conditions (5, 25) to housing Performs trained tasks/ Yes (5) No (11) work for a dedicated handler Used as part of a No Planned (14) facility's planned or spontaneous activities Used as part of a No Yes (14) healthcare treatment plan Used to achieve specific N/A Yes (14) healthcare treatment goals Used with individualized N/A Individual (14) or group sessions Medical documentation N/A Yes (14) required. Visit schedule and length N/A Yes (14) is predetermined. Visit conducted/ N/A Healthcare supervised by a professional (14) healthcare professional or any handler. Can be a pet No Maybe (11) Used to provide comfort No No (11) Used for recreation No No Used for esprit de corps No No Emotional support AAA Animal Animal Legally defined In some In some states (11) states (25) Federal legal definition No (5) No (5) as an assistance/service animal Federal legal protections No (24) No (5) for access to public facilities and spaces Federal legal No (25) Maybe (20,21,25) protections for access to housing Performs trained tasks/ No (11) No (21) work for a dedicated handler Used as part of a Both (14) No facility's planned or spontaneous activities Used as part of a No (14) No healthcare treatment plan Used to achieve specific No (14) N/A healthcare treatment goals Used with individualized Both (14) N/A or group sessions Medical documentation No (14) N/A required. Visit schedule and length No (14) N/A is predetermined. Visit conducted/ Any N/A supervised by a handler (14) healthcare professional or any handler. Can be a pet Maybe (11) Maybe (11) Used to provide comfort Maybe (11) Yes (21) Used for recreation No No Used for esprit de corps No No Resident/ Social/ Facility Companion Therapy Animal Animal Dog Legally defined No (5) No (11) No (11) Federal legal definition No (5) No (5) No as an assistance/service animal Federal legal protections No (5) No (5) No for access to public facilities and spaces Federal legal No No No protections for access to housing Performs trained tasks/ No No No work for a dedicated handler Used as part of a Maybe (17) No Both facility's planned or spontaneous activities Used as part of a Maybe (17) No No healthcare treatment plan Used to achieve specific Maybe (17) N/A N/A healthcare treatment goals Used with individualized Maybe (17) N/A N/A or group sessions Medical documentation Maybe (17) N/A N/A required. Visit schedule and length Maybe (17) N/A N/A is predetermined. Visit conducted/ Maybe (17) N/A N/A supervised by a healthcare professional or any handler. Can be a pet Maybe (17) Yes (11) Yes (11) Used to provide comfort Maybe Maybe Maybe Used for recreation No No No Used for esprit de corps No No No Recreational Animal Mascot Legally defined No No Federal legal definition No No as an assistance/service animal Federal legal protections No No for access to public facilities and spaces Federal legal No No protections for access to housing Performs trained tasks/ No No work for a dedicated handler Used as part of a Both Both facility's planned or spontaneous activities Used as part of a No No healthcare treatment plan Used to achieve specific N/A N/A healthcare treatment goals Used with individualized N/A N/A or group sessions Medical documentation N/A N/A required. Visit schedule and length N/A N/A is predetermined. Visit conducted/ N/A N/A supervised by a healthcare professional or any handler. Can be a pet Yes Yes Used to provide comfort Maybe Maybe Used for recreation Yes (22) No Used for esprit de corps No Yes (22) AAT indicates animal-assisted therapy. AAA indiates animal-assisted activities.