Animal-assisted therapy

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Animal-assisted therapy (AAT) is a type of therapy that involves animals as a form of treatment. The goal of AAT is to improve a patient’s social, emotional, or cognitive functioning. Advocates state that animals can be useful for educational and motivational effectiveness for participants.[1] A therapist who brings along a pet may be viewed as being less threatening, increasing the rapport between patient and therapist.[2] Animals used in therapy include domesticated pets, farm animals and marine mammals (such as dolphins). While the research literature presents the relationship between humans and companion animals as generally favorable, methodological concerns about the poor quality of the data have led to calls for improved experimental studies.[3]
Wilson’s (1984) biophilia hypothesis is based on the premise that our attachment to and interest in animals stems from the strong possibility that human survival was partly dependent on signals from animals in the environment indicating safety or threat. The biophilia hypothesis suggests that now, if we see animals at rest or in a peaceful state, this may signal to us safety, security and feelings of well-being which in turn may trigger a state where personal change and healing are possible [4]

Dogs are common in animal-assisted therapy.

History[edit]

Animal-assisted therapy sprouted from the idea and initial belief in the supernatural powers of animals and animal spirits. It first appeared in the groupings of early hunter gatherer societies. In modern times animals are seen as "agents of socialization" and as providers of "social support and relaxation." [5] Though animal assisted therapy is believed to have begun in these early human periods it is undocumented and based on speculation. The earliest reported use of AAT for the mentally ill took place in the late 18th century at the York Retreat in England, led by William Tuke.[6] Patients at this facility were allowed to wander the grounds which contained a population of small domestic animals. These were believed to be effective tools for socialization. In 1860, the Bethlem Hospital in England followed the same trend and added animals to the ward, greatly influencing the morale of the patients living there.[6]

Sigmund Freud kept many dogs and often had his chow Jofi present during his pioneering sessions of psychoanalysis. He noticed that the presence of the dog was helpful because the patient would find that their speech would not shock or disturb the dog and this reassured them and so encouraged them to relax and confide. This was most effective when the patient was a child or adolescent.[7] The theory behind AAT is what is known as Attachment theory.

Therapy involving animals was first used in therapy by Dr. Boris Levinson who accidentally discovered the use of pet therapy with children when he left his dog alone with a difficult child, and upon returning, found the child talking to the dog.[8] However, in other pieces of literature it states that it was founded as early as 1792 at the Quaker Society of Friends York Retreat in England.[9] Velde, Cipriani & Fisher also state “Florence Nightingale appreciated the benefits of pets in the treatment of individuals with illness. The US military promoted the use of dogs as a therapeutic intervention with psychiatric patients in 1919 at St Elizabeth’s Hospital in Washington, DC. Increased recognition of the value of human–pet bonding was noted by Dr. Boris Levinson in 1961”.[9]

Today[edit]

Golden Retrievers are often trained as assistance dogs.

Animals can be used in a variety of settings such as prisons, nursing homes, mental institutions,[10] hospitals and in the home.[2] Assistance dogs can assist people with many different disabilities; they are capable of assisting certain life activities and help the individuals navigate outside of the home.[2]

Steps in animal-assisted therapy include three stages for physical and psychological health improvement.

Stage One:
Patient goes to session with therapist without animals present to assess therapy needs. The next session the animal is introduced to the client and interactions between the animal and client begin.

Stage Two:
Developing a bond between the animal and client by developing motor skills. Examples include feeding the animal treats or grooming. Then an introduction of verbal skills using verbal commands such as stay and sit. Therapists use animals as a form of motivation for the client. The client is asked to perform tasks like getting water and food for their animal to improve motor functions like walking. Positive social interactions with animals is translated and generalized to positive human interactions.

Stage Three:
Therapist monitors improvement with animal interaction and human interaction and judges positive social situation. Patients are then given power and independence with the freedom to make choices for the animal assisted therapy partner. After client can interact with humans as well as they can with animals treatment is complete.[11]

As with all other interventions, assessing whether a program is effective as far as its outcomes are concerned is easier when the goals are clear and are able to be specified. The literature review identified a range of goals for animal assisted therapy programs relevant to children and young people. They include enhanced capacity to form positive relationships with others i-relief in pet ownership.[12]

Marcus et al.[13] conducted a study using therapy dogs in an Outpatient Pain management clinic. Patients sat in either a waiting room, or a room with a therapy dog in it. Results demonstrated that there were significant improvements on pain, mood, and other distressful measures when patients or family members were placed in the therapy dog room. The study took place over a 2 month time period. They concluded that patients visited by these therapy dogs have a reduction in their pain rating and an improvement in their mood, with this in mind, there have been many nursing homes and hospitals that elicit the help of cats and dogs as a comfort for patients in their time of need. Patients in these scenarios report elevated mood and comfort when the animal is around. It is also thought that animals create a more positive environment for the hospital or clinic itself, with staff member also reporting elevated moods, as well as creating a more positive appearance of the clinician to the patient. Preliminary findings suggest that stress reduction in healthcare professionals may occur after as little as 5 minutes of interaction with a therapy dog.[14] Another example is Cole's 2007[15] study on patients who were in critical care after experiencing heart failure. The patients were visited three different times over a period of three months by either a volunteer with a therapy dog, a volunteer by themselves, or the usual care that they had been receiving. The results showed a significant decrease in the cardiopulmonary pressure, neurohormone level, and anxiety level of those patients who received the twelve minute visit by the therapy dog. Cole cites many other resources such as Blascovich,[16] and Shykoff [17] where AAT has helped reduce blood pressure and stress among individuals, however these studies focus more on pet ownership as a method rather than AAT.

Pets may promote kindness in children.

Becoming AAT certified[edit]

In order to become Animal-Assisted Therapy certified, a pet owner must go through Pet Partners, formerly Delta Society,[18] a nonprofit organization that emphasizes the use of animals in therapy to help people live healthier and happier lifestyles.[19] There is a simple four step process that Pet Partners offers to become a registered Pet Partners Team. The first step is on online or in classroom course where the pet handler, or owner, is trained to guide the animal in therapy sessions. They are also trained on what signs to look for in the patients to make sure they are comfortable and at ease. The next step is a screening of the health of the animal for any diseases or issues that may inhibit the animal from being useful in therapy. The animal needs to be approved by a professional veterinarian before moving on to the next step. The third step includes a test that checks the skills and ability of the animal and handler to react in therapy sessions. The last step is the submission of the Registration Application. Once approved, the animal and their owner are certified to assist in therapy in hospitals, retirement homes, and other places.[20]

Benefiting children[edit]

Children also can receive positive benefits from Animal Assisted therapy in the class setting. Frieson[21] (2010) conducted a study with children and therapy dogs in a class room setting and found that the animals provide a social and emotional support system for the child, with assumptions that because the animal seems non-judgmental to the child, it is perceived as comforting, raises the child's self-esteem and makes it easier for the child to express themselves.[22]

Therapists rely on techniques such as monitoring a child’s behavior with animal, their tone of voice, and indirect interviewing. These techniques are used, along with the child’s pet or other animal, in order to gain information.[8] Before pet therapy can be useful, the child and the animal must first develop a sense of comfort with each other, which is easier to achieve if the child’s own pet is used.[8] The applied technique that generates the most helpful information about the victim’s experience is telling the child that the animal wants to know how they are feeling or what happened. Applying pet therapy to victims of sexual assault can also reduce depression, anxiety, and other symptoms of post-traumatic stress disorder. Pet therapy promotes social interaction and is increasingly more accessible to those who already have pets. Victims of sexual assault are less likely to be anxious and are comforted by the presence of a companion that is offered through pet therapy.[23] While there are other ways in which victims of sexual assault can receive therapy, the application of pet therapy does have a certain degree of success in these situations. For example, pet therapy helps the counselor and victim develop a positive alliance and a great sense of rapport more quickly.[23] As mentioned before, the presence of a pet or other animal helps victims of sexual assault feel more comfortable in a therapy setting. The application of pet therapy in sexual assault cases has also contributed positively to victims outside of counseling sessions.[23] The positive feelings that pet therapy induces during therapy sessions with sexual assault victims will carry over with victims outside of therapy. The increased comfort that having a companion builds will also help victims remain more comfortable from day to day, which will lead to fast recovery.[8] Studies of the human-companion animal bond reveal many physiological and psychological benefits. “Petting a dog with which one is bonded to promotes relaxation, characterized by decreased blood pressure and increases in peripheral skin temperature”.[9] Other benefits include releasing stress, increasing morale, increased calmness, decrease preoperative anxiety, improve patient outlook, reduce the need for preoperative medication, reduce fear and anxiety in patients with a psychiatric condition. Velde, Cipriani & Fisher (2005) also stated “Motivation is increased with animal interaction. For example, persons who had refused therapy came to the therapy sessions when they knew animals were going to be present.[9] Interaction with animals changes the morale of long-term care residents. Occupational therapy participants continue doing therapeutic activities for a longer duration when animals are present, thereby potentially increasing the benefits of this therapy.[9]

Mental institutions, hospitals and nursing homes[edit]

A 1998 study looked at the use of AAT in reducing anxiety levels of institutionalized patients. They determined that anxiety levels were significantly reduced in patients with mood disorders and psychotic disorders after a session of AAT. In fact, for the patients with psychotic disorders, those who participated in AAT had twice the reduction in anxiety scores as those who participated in some other form of recreational activity. This suggests the low demands of human-animal interaction was effective for individuals with psychotic disorders as compared to traditional therapy.[24] A controlled study of 20 elderly schizophrenic patients found significant improvements through the use of cats and dogs as companions, indicating that this population may benefit from the companionship of an animal, especially if they do not have access to friends or family.[25][medical citation needed] Pets may also provide an opportunity for fun and relaxation.[2] Another example can be seen with the famous case of Oscar the cat and a Providence, Rhode Island nursing home. Patients and family member reported a sense of calming when the cat would enter their room. Although the cat was a sign that the patient was dying, family members were thankful for the comfort that the cat seemed to instill in their loved one. The cat would jump on the patients lap and stay with them until they passed. In [26] National Capital Therapy Dogs Inc., a non-profit, all-volunteer organization that provides animal-assisted therapy to many people in health facilities, shelters, schools and libraries, has more than fifty teams of pet/human therapist combinations that work with patients that have severe medical conditions. They are able to improve morale for people who are undergoing intense medical treatments, reducing depression and anxiety as well as chronic pain.

Nursing homes[edit]

Animal assisted therapy draws on the bond between animals and humans in order to help improve and maintain an individual’s function and is being used to assist in the process of enhancing the individual’s quality of life in nursing homes.[27] Psychologists and therapists notice increasing unfavorable behaviors of elderly people that are transferred to nursing homes. Once the patients become settled into their new environment, they lose their sense of self-efficacy and independence. Simple, everyday tasks are taken away from them and the patients become lethargic, depressed, and anti-social if they do not have regular visitors.[28]

Animal assisted therapy (AAT) is a type of therapy that incorporates animals in the treatment of a person; especially elderly people in nursing homes or long term care (LTC) facilities. The goal of using animals as a treatment option is to improve the person’s social, emotional, and cognitive functioning and reduce passivity. When elderly people are transferred to nursing homes or LTC facilities, they often become passive, agitated, withdrawn, depressed, and inactive because of the lack of regular visitors or the loss of loved ones.[29] Supporters of AAT say that animals can be helpful in motivating the patients to be active mentally and physically, keeping their minds sharp and bodies healthy.[30] Therapists or visitors who bring animals into their sessions at the nursing home are often viewed as less threatening, which increases the relationship between the therapist/visitor and patient.[31]

There are numerous techniques used in AAT, depending on the needs and condition of the patient. For elderly dementia patients, hands on interactions with the animal are the most important aspect. Animal assisted therapy provides these patients with opportunities to have close physical contact with the animals warm bodies, feeling heartbeats, caress soft skins and coats, notice breathing, and giving hugs. Animal assisted therapy counselors also plan activities for patients that need physical movement. These planned tasks include petting the animal, walking the animal, and grooming the animal. These experiences seem so common and simple, but elderly dementia patients do not typically have these interactions with people because their loved ones have passed or no one comes to visit them. Their mind needs to be stimulated in the ways it once was. Animals provide a sense of meaning and belonging to these patients and offer something to look forward to during their long days.[28]

The AAT program encourages expressions of emotions and cognitive stimulation through discussions and reminiscing of memories while the patient bonds with the animal. Many of the troubling symptoms in elderly dementia patients include decreased physical functioning, apathy, depression, loneliness, and disturbing behaviors and are all positively affected by AAT interventions. Animal assisted therapy is very useful in helping these negative behaviors decrease by focusing their attention on something positive (the animal) rather than their physical illness, motivating them to be physically active and encouraging communication skills for those with memory loss.[28] Numerous researchers found that communication with animals have a positive effect on older adults by increasing their social behavior and verbal interaction, while also decreasing tense behavior and loneliness.[32]

Types[edit]

There are many types of AAT ranging from the use of dogs, to cats, even to small animals such as fish and hamsters. The most popular forms of AAT include Canine therapy, Dolphin therapy, and Equine therapy.

Dolphin therapy[edit]

Dolphin assisted therapy refers to the practice of swimming with dolphins. Proponents claim for such encounters "extraordinary results of the therapy and breakthroughs in outcomes",[33] however this form of therapy has been strongly criticised as having no long term benefit,[34] and being based on flawed observations.[35] Psychologists have cautioned that dolphin assisted therapy is not effective for any known condition and presents considerable risks to both human patients and the captive dolphins.[36]

Equine therapy[edit]

Hippotherapy can be used as a treatment for people with physical or mental challenges.
Main article: Hippotherapy

A distinction exists between hippotherapy and therapeutic horseback riding. The American Hippotherapy Association defines hippotherapy as a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes, while the Professional Association of Therapeutic Horsemanship International (PATHI) defines therapeutic riding as a riding lesson specially adapted for people with special needs.[37] According to Marty Becker, hippotherapy programs are active "in twenty-four countries and the horse's functions have expanded to therapeutic riding for people with physical, psychological, cognitive, social, and behavioral problems".[38] Hippotherapy has also been approved by the American Speech and Hearing Association as a treatment method for individuals with speech disorders.[37] In addition, equine assisted psychotherapy (EAP) uses horses for work with persons who have mental health issues. EAP often does not involve riding.[39][40] Additional information pertaining to equine assisted therapy can be seen with Laira Gold's open clinical study of EAT [41]

Criticisms[edit]

Although animal assisted therapy has been considered a new way to deal with depression, anxiety, Autism, and childhood aliments such as Attention deficit hyperactivity disorder, there has been criticism as to the effectiveness of the process. According to Lilienfeld and Arkowitz animal-assisted therapy is better considered a temporary fix. They point to the lack of longitudinal data or research to see if there is evidence for long term improvement in patients undergoing the therapy. They then suggest that this further supports the idea that AAT is more of an affective method of therapy rather than a behavioral treatment. They also state the dangers of these therapy programs in particular the Dolphin assisted therapy. Dolphin assisted therapy has not been shown to have significant results when dealing with a child's behavior. Instead Lilienfeld suggest that again animal assisted therapy might be a short term reinforcer, not a long term one. They also suggest that studies dealing with children should look into more balanced measures, such as having one group of children in the Dolphin group and the other in a setting where they still receive positive reinforcement. It is also suggested that DAT is harmful to the dolphins themselves; by taking dolphins out of their natural environment and putting them in captivity for therapy can be hazardous to their well being.[42] There are not many quantitative studies about the impact of swimming with dolphins have on social behavior.[43] Of the few studies, data has seemed limited or mixed in results. The first research on the effects of Dolphin-Assisted Therapy as a treatment was a case study by Betsy Smith in 1987. The dolphins were used to motivate a child with autism to communicate.[43] Smith concluded that the use of Dolphin-Assisted Therapy has shown promising results on increasing attention spans and improved interaction and play behavior in the children. Other studies after concerning Dolphin Assisted Therapy yielded about the same results but failed to take into account other situational factors, what is also known as a confound, one or more effective ingredient in a study [44] that may have an impact on results in the study. Heimlich discussed in her study of AAT's effect on severely disabled children that without evidence that this type of therapy works outside a laboratory setting, assumptions can not be made that it is an effective form of therapy.[45][undue weight? ] In addition, O'Haire noted that while most studies had reported positive results for autism, these studies were limited by "many methodological weaknesses," concluding that further research is needed.[46]

Another limitation of pet therapy also centers on the application during scenarios that involve adults who have been sexually assaulted. While pets do tend to cause more comfort to victims, pet therapy may not be the catalyst that provides positive success in therapy sessions. As mentioned above, adults tend not to focus as much on having an animal companion, and therefore, pet therapy cannot be attributed as the reason for success in those types of therapy sessions.[8] Pet therapy does not raise any ethical concerns as far as advancing nonscientific agendas. On the other hand, there are some ethical concerns that arise when applying pet therapy to younger victims of sexual assault. For example, if a child is introduced to an animal that is not their pet, the application of pet therapy can cause some concerns. First of all, some children may not be comfortable with animals or may be frightened, so there would be ethical concerns with using pet therapy, which could be avoided by asking permission to use animals in therapy. Second, a special bond is created between animal and child during pet therapy. Therefore, if the animal in question does not belong to the child, there may be some negative side effects when the child discontinues therapy. The child will have become attached to the animal, which does raise some ethical issues as far as subjecting a child to the disappointment and possible relapse that can occur after therapy discontinues.[8]

See also[edit]

References[edit]

  1. ^ "Animal Assisted Therapy". American Humane Association. 
  2. ^ a b c d Beck, Alan (1983). Between Pets and People: the Importance of Animal Companionship. New York: Putnam. ISBN 0-399-12775-5. 
  3. ^ Chur-Hansen, A.; Winefield, H. (2010). "Gaps in the evidence about companion animals and human health: some suggestions for progress". International Journal of Evidence-Based Healthcare 8 (3): 140–146. doi:10.1111/j.1744-1609.2010.00176.x. PMID 21199382.  See also: Serpell (1990), Walsh (2009), and Wilson (2006).
  4. ^ Schaefer K (2002) Human-animal interactions as a therapeutic intervention Counseling and Human Development, 34(5) pp.1-18.
  5. ^ Serpell JA. 2006. Animal-assisted interventions in historical perspective. In: Fine AH, ed. Handbook on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice. San Diego: Elsevier. p 3-17
  6. ^ a b Serpell, James (2000). "Animal Companions and Human Well-Being: An Historical Exploration of the Value of Human-Animal Relationships". Handbook on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice: 3–17. 
  7. ^ Stanley Coren (2010), "Foreword", Handbook on Animal-Assisted Therapy, Academic Press, ISBN 978-0-12-381453-1 
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  10. ^ Barker, Kathryn S.; Dawson (1998). "The Effects of Animal-Assisted Therapy on Anxiety Ratings of Hospitalized Psychiatric Patients". Psychiatric Services 49 (6): 797–801. Retrieved 2012-03-18. 
  11. ^ http://sethhillery.wix.com/animal-assisted-therapy#!__aat-timeline/page-1
  12. ^ Friedmann E, Katcher AH, Lynch JJ, Thomas SA (1980). "Animal companions and one-year survival of patients after discharge from a coronary care unit". Public Health Rep 95 (4): 307–12. PMC 1422527. PMID 6999524. 
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  14. ^ Barker, S. B.; Knisely, J. S.; McCain, N. L.; Best, A. M. (2005). "Measuring stress and immune response in healthcare professionals following interaction with a therapy dog: A pilot study". Psychological reports 96 (3 Pt 1): 713–729. doi:10.2466/pr0.96.3.713-729. PMID 16050629.  edit
  15. ^ Cole, Kathie; Anna Gawlinski; Neil Steers; Jenny Kotlerman (2007). "Animal-Assisted Therapy in Patients Hospitalized With Heart Failure". American Journal of Critical Care 16 (6): 575–85; quiz 586; discussion 587–8. PMID 17962502. 
  16. ^ Blascovich, Allen; Tomaka J; Kelsey R (1991). "Presence of human friends and pet dogs as moderators of autonomic responses to stress in women". J Pers Soc Psychol 61 (4): 582–589. doi:10.1037/0022-3514.61.4.582. PMID 1960650. 
  17. ^ Shykoff, Allen; Izzo JL Jr (2001). "Pet ownership, but not ACE inhibitor therapy, blunts home blood pressure responses to mental stress". Hypertension 38 (4): 815–820. PMID 11641292. 
  18. ^ "ASPCA Animal Assisted Therapy Programs". ASPCA. Retrieved 29 October 2013. 
  19. ^ "Welcome to Pet Partners!". Pet Partners. Pet Partners. Retrieved 29 October 2013. 
  20. ^ "How to Become Registered Therapy Animal Team". Pet Partners. Retrieved 29 October 2013. 
  21. ^ Friesen, L (2010). "Exploring Animal-Assisted Programs with Children in School and Therapeutic Contexts". Early Childhood Education Journal 37 (4): 261–267. doi:10.1007/s10643-009-0349-5. 
  22. ^ Reichart. "Trauma/Sexual Abuse". Retrieved 27 June 2012. 
  23. ^ a b c Lefkowitz, C., Paharia, I., Prout, M., Debiak, D., & Bleiberg, J. (2005). Animal assisted prolonged exposure: A treatment for survivors of sexual assault suffering posttraumatic stress disorder. Society Animals: Journal of Human-Animal Studies, 13, 275-295. doi:10.1163/156853005774653654
  24. ^ Barker & Dawson 1998, pp. 797–801.
  25. ^ Barak, Yoram; Savorai, Osnat; Mavashev, Svetlana; Beni, Avshalom (2001). "Animal-Assisted Therapy for Elderly Schizophrenic Patients: A One-Year Controlled Trial". American Journal of Geriatric Psychiatry 9 (4): 439–442. Retrieved 2012-03-18. [dead link]
  26. ^ "Nursing home cat can predict impending death". New york post. Retrieved 24 April 2012. 
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  28. ^ a b c .Buttner, L. L., Fitzsimmons, S., & Barba, B. (2011). Animal-assisted therapy for clients with dementia. Journal of gerontological nursing, 37
  29. ^ .Sutton, D., M. (1984). Use of pets in therapy with elderly nursing home residents. Toronto, Canada: American Psychological Association
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  31. ^ .Marx, M., S., Mansfield, J., C., Regier, N., G., Dakheel-Ali, M., Srihari, A., & Thein,k. (2010). The impact of different dog-related stimuli on engagement of persons with dementia. American journal of alzheimer’s disease and other dementias,25, 37-45.
  32. ^ .Kawamura, N., Niiyama, M., & Niiyama, H. (2009). Animal-assisted activity: Experiences of institutionalized japanese older adults. Journal of psychosocial nursing and mental health services, 47
  33. ^ "Dolphin Assisted Therapy Essentials". [dead link]
  34. ^ Nathanson, David E. (1998). "Long-Term Effectiveness of Dolphin-Assisted Therapy for Children with Severe Disabilities". Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals 11 (1): 22–32. doi:10.2752/089279398787000896. 
  35. ^ Marino, Lori; Lilienfeld, Scott O. (2007). "Dolphin-Assisted Therapy: More Flawed Data and More Flawed Conclusions". Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals 20 (3): 239–249. doi:10.2752/089279307X224782. 
  36. ^ "Dolphin 'Therapy' A Dangerous Fad, Researchers Warn". Science Daily. 2007-12-18. Retrieved 2012-03-18. 
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  38. ^ Becker 2002, p. 124.
  39. ^ "What is EAP and EAL?". Equine Assisted Growth and Learning Association. Retrieved 2012-03-18. 
  40. ^ Quiroz Rothe et al. (2005). "From kids and horses: Equine facilitated psychotherapy for children". International Journal of Clinical and Health Psychology. 5 (2): 373-383. ISSN 1697-2600
  41. ^ Klontz, B; Bivens, A.; Leinart, D.; Klontz, T. (2007). "The Effectiveness of Equine-Assisted Experiential Therapy: Results of an Open Clinical Trial.". Society & Animals 15 (3): 257–267. doi:10.1163/156853007x217195. 
  42. ^ Lilienfeld, Scott. "Is animal assisted therapy really the cat's meow?". Scientific American. Retrieved 2012-04-12. 
  43. ^ a b Brensing, Karsten. "Impact of different groups of swimmers on dolphins in swim-with-the-dolphin programs in two settings". Anthrozoos. Retrieved 2014-02-25. 
  44. ^ Marino, Lori. "Dolphin-Assisted Therapy: More Flawed Data and More Flawed Conclusions". Anthrozoos. Retrieved 2014-02-25. 
  45. ^ Heimlich, K (2001). "Animal-Assisted Therapy and the Severely Disabled Child: A Quantitative Study". Journal of Rehabilitation 67 (4): 48–54. 
  46. ^ o’Haire, M. E. (2012). "Animal-Assisted Intervention for Autism Spectrum Disorder: A Systematic Literature Review". Journal of Autism and Developmental Disorders 43 (7): 1606–1622. doi:10.1007/s10803-012-1707-5. PMID 23124442.  edit

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