Animal-Assisted Interventions for Children with Advanced Cancer:
The Impact of Canines on Stress Rebecca Brisman
Vanderbilt University
Abstract
Children and the families of children with advanced cancer are at an increased risk of experiencing stress and anxiety, and this can be especially heightened during hospital visits.
While there is extensive literature on the positive effects that animal-assisted interventions (AAI) have on the stress levels and quality of life of humans, there is little data indicating the effects that AAIs have specifically on children with advanced cancer and their families. Using a randomized control design, this study examines the effects that AAI sessions have on children with advanced cancer through a number of qualitative and quantitative methods. This research paper specifically explores the impact that AAIs had on the participants by analyzing end of study interviews. The results reveal that participants experienced a significant reduction in stress and anxiety levels, an increased willingness to go to the hospital, and an improvement in
communication between the child and caregiver. Furthermore, the results showed that the effects of the AAIs were not impacted by whether or not the participant had a pet at home.
Introduction
Children with advanced cancer and their families experience significantly higher stress and anxiety levels than those without a chronic condition. Within four weeks of a child’s
diagnosis of a serious illness, approximately 50% of parents meet the DSM-IV criteria for acute stress disorder (Muscara, 2015). Thisstudy tests the effects of using animal-assisted intervention (AAI) in the hospital setting to reduce stress and anxiety levels of children with advanced cancer and their families. AAIs involve bringing a dog into a child’s exam room or inpatient care room and allowing them to interact with the dog in the presence of a handler for a set period of time.
This research is funded by a grant from the Human Animal Bond Research Institute (HABRI) and has two main research aims.
The first research aim is in regard to the logistics of the study, where the feasibility of AAI sessions in hospitals is examined. This is done through identifying and documenting necessary modifications for safe and feasible interventions, obtaining recruitment estimates and determining recruitment barriers, evaluating elements of implementation fidelity, and verifying safety. We hypothesize that greater than 60% of children and parents approached will complete the interactions and provide positive and acceptable data. In addition, we hypothesize that the implementation fidelity will be achieved with the proposed methodology. Because this research will not be completed until next year, this paper will not be reporting the results of aim one, as we will not have complete data to make any conclusions in regard to AAI feasibility and implementation fidelity.
The second research aim is to determine the efficacy of AAI sessions for children with advanced cancer and for their caregivers. We hypothesize that children and caregivers who receive AAI (the experimental group) will experience less anxiety and stress throughout the course of the study than those who do not receive AAI (the control group). We also predict that these children will have an improved health-related quality of life throughout the course of the study period compared to patients who do not receive AAI. This paper analyzes the end of study interviews and contributes qualitative data to support our hypotheses for the second research aim.
In addition, this paper examines whether or not the participants’ experiences are impacted depending on whether or not they have pets at home. It is possible that if a participant has a dog at home, they may not really care about seeing a different dog that they do not know well at the hospital. On the other hand, it is also possible that if a participant does not have a dog at home, they may not want to see a dog at the hospital because they are not personally attached to dogs in general. However, we hypothesize that the participants will experience the same positive effects
of the AAI regardless of whether or not they have a dog at home because of the connection that humans inherently have with dogs.
Background
Both children with advanced cancer and their families experience heightened levels of stress and anxiety (Muscara, 2015). While both experience stress that impacts all aspects of their life, children with cancer experience stressors that are somewhat different than that of their parents. For mothers and fathers, the most stressful aspects of having a child with cancer are related to the uncontrollability of the experience in the context of caregiving, such as not being able to help their child get better, or concerns about their child’s survival. On the other hand, children with advanced cancer find their functional impairment and inability to do the things that they used to do more stressful than their uncertainty about their disease and chances for survival (Rodriguez, 2012). For both children and their families, this stress and anxiety contributes greatly to the difficulty of the illness experience.
In the hospital setting, such stress is often elevated for both children and their families (Commodari, 2010), as the stress of illness is inherently exacerbated in hospitals. For children, they might be stressed about their separation from their friends, discomfort or pain, change in body image, immobility, surgery, and unfamiliar environments (Menke, 1981). In addition, in hospitals, children are often subject to psychological trauma because they lack control of their environment, and “this sense of helplessness, coupled with fear and pain can cause children to feel powerless in a healthcare setting” (Lerwick, 2016). For parents, having their child
hospitalized is also an extremely stressful event that can lead to anxiety and depression during the period of hospitalization. According to a classical definition, stress is a “non-specific response of the body to any excessive environmental request” (Commodari, 2010) and often,
anxiety is a response that follows stress. Hospital stress is especially problematic because these emotional responses can delay important medical treatment, cause treatment to take more time to be completed, and ultimately reduce patient satisfaction (Lerwick, 2016).
Stress can be measured in the research setting in a variety of ways. When the body encounters something stressful, the hypothalamus sends a series of nerve and hormone signals that prompt the adrenal glands to release adrenaline and cortisol. Cortisol alters immune system responses and suppresses the digestive system, the reproductive system, and growth processes.
Overexposure to cortisol puts people at an increased risk of health problems including anxiety, depression, digestive problems, headaches, heart disease, sleep problems, and more (Mayo Clinic, 2019). One effective method of measuring cortisol levels is through saliva samples, which are easy to collect and offer a wide scope of application (Bozovic, 2013). Another way to quantify stress is through measuring blood pressure and heart rate, as there is a positive
correlation between psychological stress and blood pressure/heart rate increase (Mayo Clinic, 2019).
Reducing stress and anxiety through animal-assisted interventions (AAI) is a method that comes from a long history of using animals for human psychological purposes. Dr. Boris
Levinson, a child psychologist, is often credited as a pioneer in using animals for therapy purposes. However, he was not the first person to notice the therapeutic effect that dogs have on humans, as there were some previous reports in literature of the use of pets in therapy. In fact, even the American National Red Cross had previously stated that attempting to use pets in a post-war rehabilitation center for airmen was met with “unusual success” (Levinson, 1965).
However, at that point, the use of pets had been entirely coincidental, as a pet was involved by chance and its positive effects were noticed. As a child psychologist, Dr. Levinson noticed that
his patients were less anxious when his dog Jingles was in the room. As a result of his
observations, Dr. Levinson brought Jingles to child therapy sessions and later coined the term
“pet therapy.”
Dr. Samuel Corson, a pediatric psychiatrist, succeeded Dr. Levinson’s work and observed the effects that pets had on psychotherapy, noticing the positive influences that dogs had on patients. This research is credited as a “catalyst” for interest in the use of animals in human therapy (Goddard & Gilmer, 2015). Since then, animal-assisted therapy has been studied extensively and its positive effects on mitigating stress levels have been supported consistently.
Pet Partners, the largest and most prestigious non-profit registering therapy animals, was founded based on the compelling evidence of the effects that animals can have on humans. Their mission is to improve human health and well-being through the human-animal bond (Pet Partners, n.d.).
While the term “human-animal bond” is a commonly recognized phrase, just a few decades ago, that was not the case. Organizations and centers devoted to the human-animal bond first developed in the 1970s, and veterinarians eventually paved the way for this concept to develop prominence in society (Hines, 2003). The human-animal bond has emerged as a significant part of everyday life in Western society and has been consistently recorded as
something that makes humans happier. In a book that focuses on the importance of veterinarians honoring the human-animal bond, it states, “The human-animal bond has emerged into a
respected, life-enriching relationship in our contemporary society. The human-animal bond is validated and celebrated as a viable, healthy relationship, one that often takes a priority position in millions of people’s daily routines, lifestyles, and economic choices” (Villalobos and Kaplan, 2017). Furthermore, the human-animal bond is extremely valuable and worth utilizing in an effort to provide palliative care.
While there is little research regarding the effects of canines on children with advanced cancer in the hospital, there is data that demonstrates the positive effects that canines have on children. Research has shown that animal-assisted therapy can yield positive outcomes for children including “decreased feelings of loneliness, enhanced quality of life, improved physical function, decreased stress and anxiety, and increased motivation” (Fontaine, 2001). In hospitals, nurses have carefully observed and documented the effectiveness of animal-assisted therapy in the hospital. They have reported that when canine visitors come onto the pediatrics floor, children’s attitudes instantly improve. For example, one nurse recalls a child with brain damage who initially refused to complete a series of exercises to strengthen her grip, control, and range of motion. But, she was much more willing to cooperate when the therapy involved brushing a dog instead. There are extensive reports that detail similar results of animal-assisted therapy, further demonstrating the powerful effects that canines have in the healing setting (Jalongo, et al., 2004).
In another study that focuses on implementing animal therapy in a pediatric oncology population, child participants spent an entire day in the company of a dog in the hospital (Gagnon, et al., 2004). This study found that dog-assisted therapy contributed to the alleviation of psychological distress in children and parents alike. Data was collected through questionnaires that were validated by a panel of experts. However, the research lacked quantitative data. Our study includes both qualitative and quantitative data. In addition, it introduces canines in a scenario that more accurately represents how animal-assisted therapy is actually implemented in hospitals, which is over short periods of time. Previous data and the data collected in this study serve to demonstrate the positive impact of AAI in hospitals and urge health care facilities to increase the presence of canines that interact with patients.
Methods
There is extensive literature that demonstrates the benefits of animal-assisted
interventions and their ability to reduce stress levels in children. In this study, we researched the effects that canines have on children with advanced cancer at the Monroe Carell Jr. Children’s Hospital at Vanderbilt University (MCJCHV). In particular, this paper also focuses on observing the relationship between how helpful the children found the AAI to be and whether or not he or she had pet(s) at home. The study is taking place over the course of two years, beginning in January of 2019. Approval was obtained from the Vanderbilt IRB, the Scientific Review Committee, and the Animal Care and Use Committee. This study is funded by a grant from the Human Animal Bond Research Institute (HABRI).
Inclusion Criteria
The inclusion criteria for child participants to be accepted into the study are that
participants must be between the ages of 3 and 17 years old and diagnosed with advanced cancer according to their medical records. Advanced cancer is a category defined as any stage of
refractory or recurrent cancer. Participants have been unresponsive to chemotherapy, surgery, or other treatment or they may be in any stage of recurrence. The study includes a wide range of ages to determine which ages respond best to the AAI. To ensure that the child and caregivers are safe, children or caregivers that are allergic to canines, have a self-reported fear of canines, or have a cognitive impairment are excluded from the study.
Participant Recruitment
Participants are recruited to the study through multiple steps. First, the research team works with the healthcare team (usually the nurse practitioner) in the oncology department of the hospital to help identify potential candidates using the eligibility criteria stated above. Then, the
research team uses the patient information database to determine if the families are eligible for the study. Final decisions regarding screening and inclusion are dictated by the PI (principle investigator) in collaboration with the healthcare team. When an eligible potential candidate is identified, the nurse practitioner or physician introduces the study to the family because there is a previous relationship trusting relationship. If a potential candidate is interested, they are
introduced to the PI, who describes the study to the parents and their children. If the families want to join the study, the primary caregiver signs a consent form and the child signs an assent form. The assent form, while not a legal document, ensures that the child as an individual wants to participate in the study. At MCJCHV, approximately 200 children are diagnosed with
childhood cancer each year, and approximately 40 of these children have advanced cancer as previously defined. Conservatively accommodating a drop-out rate of at least 15% leaves a minimal final analysis sample of 30 children that will complete the study.
There is a randomized control group and experimental group in the study. The assignment to treatment groups is completed in STATA using the RALLOC module on REDCap. Participant data is entered into STATA by a research assistant who then runs a
randomization code to determine treatment allocation. Caregiver-child pairs are randomly sorted into the intervention and usual care groups in a 1:1 ratio.
Baseline Surveys
For both the usual care group and AAI group, there are a series of baseline surveys that each child and caregiver fill out before beginning the study. First, the caregiver completes the Family Demographic and Information Form. This gathers data on the patient’s age, gender, ethnicity, annual household income, cancer diagnosis, and caregiver and family member
information. At the end of the baseline surveys, the caregiver has the opportunity to provide any
additional information that they feel researchers should know about their family. The caregiver is the family member that typically accompanies the child participant to their appointments at the hospital. If the patient’s mother and father both come to each appointment, the mother completes surveys as caregiver 1 and father completes surveys as caregiver 2.
The primary caregiver fills out four other baseline surveys. First, they fill out the Trait Anxiety Inventory-Adult survey, developed by Charles D. Spielberger and published by Mind Garden, Inc in 1968. This survey lists a number of statements which people have used to describe themselves (i.e. “I feel pleasant, “I wish I could be as happy as others seem to be…”
etc.), and then the caregiver selects the appropriate description to the right of the statement to indicate how they feel (these options include “Not At All,” “Somewhat,” “Moderately So,” and
“Very Much So”). The next baseline survey they fill out is the “Pediatric Inventory for Parents.”
This survey lists difficult events which parents of children that have a serious illness sometimes face (i.e. “Difficulty sleeping, “Seeing my child sad or scared,” “Being unable to go to
work/job,” etc). The caregiver rates how often the event has occurred for them in the past seven days, on a five-point scale (1=Never, 2=Rarely, 3=Sometimes, 4=Often, 5=Very often). Then, the survey lists the exact same events, but instead asks how difficult these events are when they do occur, using a five-point scale (1=Not at all, 2=A little, 3=Somewhat, 4=Very much,
5=Extremely).
Next, the caregiver fills out the Pediatric Quality of Life Inventory (PedsQL) Parent Report for Toddlers, Children, or Teens. This survey is different depending upon the age of the child. The caregiver is given a specific survey corresponding with the age range that their child falls under (these ranges include ages 2-4, 5-7, 8-12, 13-17). On the survey, there is a list of types of functions (physical, emotional, social, and school) that might be a problem for the child.
The parent has to rate on a five-point scale (1=Never, 2=Almost Never, 3=Sometimes, 4=Often, 5=Almost Always) how much of a problem specific functions within these categories have been.
Finally, they fill another PedsQL Parent Report, which is specialized for children with cancer.
Here, parents use the same scale to rate how much of a problem their child has with certain problems relating to their cancer specifically (Pain and Hurt, Nausea, Procedural Anxiety, Treatment Anxiety, Worry, Cognitive problems, Perceived Physical Appearance, and
Communication). If the child’s father is present, he fills out surveys as caregiver 2: If the child’s mother is present, she fills out surveys as caregiver 1.
The child participant also fills out several baseline surveys. First, they fill out the Trait- Anxiety Inventory-Child Survey, which is similar to the one given to the adults. There is a list of statements that children use to describe themselves (i.e. “I worry about making mistakes,” “I feel like crying,” “I am secretly afraid,” etc.) that the children rate on a three point scale (1=hardly ever, 2=sometimes, 3=often).
Next, the child participants fill out the PedsQL Report for children or teens (children younger than 8 years old do not fill out this survey). This survey is also very similar to the one that the caregiver fills out, but lists types of functions (health and activities, feelings, getting along with others, school) that might be a problem for the child. The child has to rate on a five- point scale (1=Never, 2=Almost Never, 3=Sometimes, 4=Often, 5=Almost Always) how much of a problem these functions have been for them. Finally, they fill the PedsQL Report that is specialized for children with cancer. Here, they use the same scale to rate how much of a problem they have with certain issues (Pain and Hurt, Nausea, Procedural Anxiety, Treatment Anxiety, Worry, Cognitive problems, Perceived Physical Appearance, and Communication).
Animal-Assisted Interaction Group
Once the consenting/assenting, baseline surveys, and randomization have been completed, the study is ready to begin for each child. For the participants that are randomly selected to be in the AAI group, the interventions occur once a week. They are arranged to happen before the participants have their appointments, which is when they typically feel most stressed. This is controlled to ensure that data is not taken during or after blood is drawn or after the participant has an important appointment or scan. This ensures that each week, data is taken during similar scenarios, and therefore, the participants are coping with similar stressors. The data is either taken in the oncology/hematology clinic, where families meet with their doctors about their treatment progress, get blood drawn, and receive chemotherapy, or in the inpatient care unit, where patients are staying because their illness or treatment is preventing them from leaving the hospital. The study lasts for 12 weeks (3 months) per participant.
The AAI occurs when the participants are in their exam room before their appointment waiting for their doctor. Minutes before the AAI occurs, a research assistant administers a cotton swab for the participant to put in his or her mouth and cover with saliva. Within the same day, the saliva sample is brought to the Vanderbilt Hormone Assay & Analytical Services Core at the Vanderbilt Medical Center, where it is analyzed for cortisol levels. The saliva sample taken corresponds to the cortisol levels in the patient 20 minutes prior to measuring. After taking saliva samples, the research assistant or trained professional measures the participant’s blood pressure on a consistent arm using the dynamic Pro 1000 Vital Signs Monitor to assess blood pressure and heart rates of the children. Finally, a video camera is assembled facing the participant in the location where the AAI will occur. All of the sessions are video recorded with 10% reviewed by the PI to ensure treatment fidelity through objective verification of delivery and evaluated according to criteria developed a priori.
During the AAI, an eligible handler brings the canine into the exam room, where neither the PI nor research assistant is present. This is to prevent any influence or biased reaction from the participants. The eligible handler must be in good standing with their animal-assisted therapy organization, indicated by current registration, vaccinations, no open wounds, parasites, or apparent infections. In addition, the canine used for the AAI must be a Pet Partners Certified therapy dog. The AAI lasts for 15 minutes, where participants are guided in interacting with the dog through verbal instructions from the handler. In addition, there is an AAI Activity Form that lists 22 activities chosen by Pet Partners, which serves to assist individuals in how to reach their full potential through AAI. The handler guides the participants in choosing some of these activities, such as brushing the canine, giving it treats, and teaching it tricks. The handler also ensures that the interaction goes smoothly and safely. In every case of this study, a two-year-old Teddy bear Goldendoodle named Misha was the canine used for the AAI sessions.
Animal-Assisted Interaction Group Data Collection
When the intervention ends, the research assistant enters and stops the video recording.
Then, the research assistant or trained professional takes the participant’s blood pressure on the same arm as before the AAI using the dynamic Pro 1000 Vital Signs Monitor to assess blood pressure and heart rates of children. The cotton swab is not distributed to the participant until 20 minutes after the interaction ended to ensure that it is measuring how the participant felt directly after the interaction ended.
After blood pressure and heart rate are taken, the participant and caregivers fill out weekly surveys on two separate Microsoft tablets. The caregiver fills out the State Anxiety Inventory- Adult form. This form asks them to rate how they are feeling (i.e. “I feel calm,” “I am presently worrying over possible misfortunes,” etc.) on a four-point scale (1=Not at all,
2=Somewhat, 3=Moderately so, 4=Very much so). The child fills out a similar State Anxiety Inventory- Child form, which asks them to select different descriptions of how they feel (i.e.
cheerful, troubled, frightened, etc.). These are the weekly surveys, which are taken after all 12 AAIs. Both of these surveys were developed by Charles D. Spielberger and published by Mind Garden, Inc in 1968. After each month, there the caregiver and child fill out monthly surveys (three months total), which are taken from the baseline surveys. For adults, these include the Pediatric Inventory for parents, the PedsQL Parent Report, and the PedsQL Parent Report Cancer Module. If there is another caregiver that filled out a baseline survey, he or she completes the Pediatric Inventory for Parents—Caregiver II survey. Caregiver II only fills out this monthly survey and not the weekly surveys. The monthly surveys for the children are the PedsQL Child Report and the PedsQL Child Report Cancer Module. Table 1 outlines the measurement, time, and schedule of each type of data collection.
After the surveys are complete, the handler meets with a research assistant and checks off the list of activities performed by both the child and the caregiver from the activity form. In addition, the handler indicates who was present with the participant, what their relationship is to the participant, and whether or not they participated in the AAI. Then, the handler describes the interaction in detail, which the research assistant transcribes.
Table 1. Measures and Schedule
Variable Measure Time Schedule
AIM 1 minute
Safety/Feasibility AAT Activity Log s 5 Before AAI
Feasibility Recruitment Rate and Attrition
During consent/assent Intervention
Fidelity/Safety
Videotaping of All Sessions During AAI
AIM 2 Child
Anxiety –Trait State-Trait Anxiety Inventory for Children (STAIC) Trait Form
5
Baseline
Anxiety – State STAIC State Form 5 Weekly after AAI
Quality of Life Pediatric Quality of Life Inventory-PedsQL General and Cancer
15
Baseline and monthly Heart Rate and B/P Heart Rate and Blood Pressure
Log
2 Before and after each Acute Stress Saliva Samples (Cortisol) 3 Baseline and after weeklyAAI Perceptions of AAI Open-Ended Interview Questions 15 End of StudyAAI
Parent
Family Demographic Form 10 Baseline
Child Quality of Life PedsQL General and Cancer- Proxy
15 Baseline and monthly Anxiety – Trait STAI – Trait Form (Adult) 5 Baseline Anxiety – State STAI –State Form (Adult) 5 Weekly after AAI Perceptions of AAI Open Ended Questions
(intervention)
15 End of Study
Animal-Handler (intervention) group only)
Personal Characteristics
Demographic and Information Form
10 Baseline
Canine Assessment Canine Behavioral Assessment (CBARQ)
10 Baseline
After the participant has completed three months of the study, their end of study
interview is conducted by a research assistant. This is because research assistants are not present during the enrollment phase of the study, so there is no response bias that might exist if the interviews were conducted by the PI. The interview questions include:
1. What was it like to participate in this project?
2. What parts of it were helpful or not helpful?
3. Did the study help with anxiety, willingness to come to the clinic or hospital, or communication between you (the caregiver) and your child?
4. What did you not like about the project and what did you wish could be different?
5. Do you have a pet at home? If so, do you believe that affected how helpful animal- assisted interventions were? Why or why not?
These interviews are securely recorded and then later transcribed and uploaded to REDCap by the research assistant. They were conducted in a semi-structured format, so while the interviewer generally focused on questions in the script, the responses of participants would sometimes lead to similar follow up questions in order to gain more thorough responses.
Usual Care Group Data Collection
If the participant is randomly selected for the usual care group, the research team collects data from them once a week for three months before they have their appointments either on the hematology/oncology floor or in inpatient care. They fill out the same baseline surveys as the AAI group (Family Demographic and Information Form), Trait Anxiety Inventory- Adult, Pediatric Inventory for Parents, PedsQL Parent Report, PedsQL Parent Report Cancer Module, Trait Anxiety Inventory-Child, PedsQL Child Report, and PedsQL Child Report Cancer Module.
In addition, each week, they fill out the same State Anxiety Inventory-Adult and State Anxiety Inventory-Child. However, their blood pressure, heart rate, and cortisol samples are not
measured. They also complete the other baseline surveys monthly. At the end of the study, they do not have the end of study interview. For their participation in the study, participants in the usual care group are rewarded with a $10 Amazon gift card for each session they participate in, and $50 at the end of the study.
My specific role in this study has been to facilitate many of the AAIs and usual care appointments at MCJCHV. Here, I coordinate with the animal handler to organize the AAIs.
During the sessions, I measure blood pressure and heart rate and administer cotton swabs for saliva samples to be taken. I also distribute REDCap surveys to the caregiver and children after
each session and interview the handler after each AAI. Finally, I am the research assistant in charge of conducting end of study interviews. In my research paper, I am analyzing the end of study interviews to make conclusions based on research aim 2. In addition, I am using the end of study interviews to analyze the role that having a pet at home plays in the efficacy of AAIs. This is something that the PI is not focusing on and that I am studying independently.
Expected Pitfalls
Potential pitfalls in this study include the difficulty of meeting the recruiting estimates described above and the conflicts in scheduling of the animal-assisted interventions. The AAIs occur when the participants come in the hospital for appointments, which is not always
consistent. In addition, considering the nature of the participants in the study, there could be attrition through death.
Future of the study
Because this 24-moth study is not set to be completed until next year, the quantitative data is not available to be analyzed statistically. The way that it will be analyzed when the study is complete is described below:
Aim 1, which focuses on the intervention feasibility, will be analyzed by observing the rates of participation for those that consented in comparison to those that were recruited, and how many of them completed the study. The comparisons will be conducted using the Chi- Square Tests of Independence, and all tests of statistical significance will maintain a maximum alpha=0.05 (p<0.05). Aim 2, which focuses on the outcomes of the intervention, will be analyzed by observing the efficacy of AAI. There will be descriptive and graphical summaries generated of the measurements at each time of assessment. Mixed effects general linear models that correct standard errors for repeated assessments will be used to test for the interactive effect of the
animal-assisted intervention (AAI) and time in the study on the primary outcomes controlling for respective baseline values. Given measurement error inherent in psycho-social measures, more
in-depth individual-level investigations will use reliable change indices (RCI)43-45 of the stress/anxiety and QoL outcome measures. Each group’s distributions will be examined to determine the proportion of participants demonstrating decreased anxiety and stress and enhanced quality of life.
Results
The end of study interviews that have been conducted are available for analysis and are what have helped contribute to determining the efficacy of AAI at this point in the study. As of April 1st, 24 participants have been enrolled in the study and 6 of them had interviews that are available for analysis. Although the interview was divided into five different questions, families often expanded their responses in earlier questions so that later questions were answered.
Therefore, the results are presented in a format that highlights each theme that was observed throughout the interviews.
Table 2: Interviewed Participants Background Information Participant
ID number
Age Gender Race Pets at home Family
Income Range
Diagnosis
7 9 Male Asian 0 $100,000 or
more
Anaplastic large cell lymphoma
9 13 Male Caucasian 7 (dog, cat,
fish)
$75,000 to
$99,999
Anaplastic large cell lymphoma
14 8 Female Caucasian 4 (dog, cat) $25,000 to
$34,999
Osteosarcoma
15 17 Female Hawaiian 0 $15,000 to
$24,999 Mass
17 3 Male Caucasian 0 $75,000 to
$99,999 Pilomyxoid ascyt
19 11 Female Caucasian 3 $50,000 to
$74,999
Pylocytic astrocytoma
Reduction in anxiety
The most common theme in the end of study interviews was an expression of the fact that the study lowered the anxiety levels of participants and their families. While some participants simply commented, “I liked it very much,” some expanded their comments. For example, participant #7 responded, “I liked seeing Misha every week.” When the interviewer asked what about the study he liked, the participant responded, “Because, stuff happens.” From this, his mother expanded that here, her son is referring to the challenges that come with being a cancer patient at the hospital, and how having a dog around made things less stressful for them.
Participants frequently commented on the way that the AAIs made the hospital experience more enjoyable and less stressful and intimidating.
When the mother of participant #17 was asked if the AAIs made their visits less stressful, she responded, “Oh yes, absolutely. It really kept us a lot less stressed. Having Micha really gave us light and something to look forward to when everything else was dark. It’s hard to find
something like that when your child is so sick, but Micha gave us a little bit of that.” She then later added, “We just loved these visits so much. They really helped us in such a difficult, busy, crazy time. I have plenty other kids at home, so I am always so busy. This was always a great break from everything, and he just loved it so much. Thank you for doing it.”
Willingness to come to the hospital
During each participant’s end of study interview, 100% of participants (children and caregivers included) reported that they greatly enjoyed participating in the study, and many commented that it increased their (or their child’s) willingness to come to the hospital for their appointments. For example, participant #7’s mother described:
I think from my perspective, he was more willing to go to his appointments with a better attitude. Usually, it was hard to get him out of bed those mornings. He didn’t want to go, but it turned more into, oh, we get to see Misha today. So, it was a better motivator for him. He had more things to talk about with his brothers, you know, instead of talking about the pokes that he got, he was more talking about Misha and the dog that he got to see, so that was nice. And since they’ve been wanting a dog, they’ve been asking for one just like Misha.
Similarly, the mother of participant #9 commented to her son, “I think maybe for me, I don’t know if it was the same for you, but it gave us something to look forward to when coming here instead of it just being kind of like ugh we have to go to clinic.” She later added, “It really kind of just gave us something to look forward to. Not that we really dreaded it. It just gave us
something exciting instead of just our normal clinic visits.” Participant #15 also reported that she definitely felt that knowing that she was going to be able to see the dog made her more willing to come to the hospital. The mother of participant #17 also recognized that her son was less
reluctant to go to the hospital when he knew he would get to see Micha. She said, “He was so excited and really was always so much more willing to go to the hospital. Because coming here is not fun and is hard for him to do but to be able to remind him that we would see the dog today was a huge help.”
On the other hand, the mother of participant #14 responded that she did not believe that the AAIs made coming to the hospital any less stressful, as the severity of her daughter’s condition eclipsed whatever distractions may have been present.
Caregiver/child communication
Some of the participants also reported that the AAIs helped with communication between caregivers and their children. Participant #9 reported that it “definitely” did, and the mother of participant #7 said that the AAIs “absolutely” helped with communication, and that it was “good for him.” She later added, “You know, it was more helpful for us in the mornings. It was hard to
get him out of bed on those days where he has to go to the hospital. He doesn’t like it here, but it was a good motivator for him to get dressed and get out of bed.” The mothers of participants #15 and #17 both remarked that it “It gave [them] more to talk about” with their children.
Having a dog at home
Each participant was asked if they have a dog at home, and whether or not this impacted how effective the AAIs were. The answer to this question varied depending on whether or not the participant had a pet at home. Of the participants that were interviewed, three had one or more pets at home and three participants did not. The mother of participant #7, who does not have a dog at home, felt that not having a pet made her son want to see the dog even more than if he did have a dog at home because it made the visits more exciting. She also expressed that her son is afraid of some dogs; however, he was not afraid of Misha. Participant #15, who also does not have a dog at home, had a similar response, and stated, “I think that it probably made me more excited because I don’t have a dog at home.” She also added that although she does not have a dog at home, after her experience with the AAIs, she hopes that her family gets a dog just like Misha.
Participant #9, who has four dogs, said that he felt that the study was helpful because he already had dogs at home and missed them when he was at the hospital. He mother added, “He always of course wanted to bring his dogs from home here with him here and he can’t, so I think that helped to have a doggie here because he couldn’t bring his dog from home.” Although the AAI dog did not look or act like the dog they had at home, they appreciated having her there, nonetheless.
Specifically, the participants expressed that they enjoyed doing different things with the dog during their AAIs. Participant #14 said that her favorite part was “giving her treats,” and
participant #9 expressed that he really enjoyed doing tricks with the dog. He said his favorite trick was “pretty, where she twirls.” He then added, “Our dogs at home definitely couldn’t do those tricks. I have difficulty teaching her to sit, and Dexter, our dachshund, wouldn’t even sit at all.” His mother also noted, “We might try to teach Josie to do some of that. Our older son is working on teaching her to sit. And she gets it, as long as she has a treat right there. And Micha is just so cute.” Here, the participant and his mother were expressing how the AAI was
comforting because it reminded them of their dogs at home.
Impact of the study
Some individuals also expressed that they were glad that they could participate in the study because they wanted to support this research so that they could help other sick children. The mother of participant #9 said, “I think [he] was very happy to help if it meant more dogs for everyone to get to have while they’re here. Especially inpatient, because there was a lot of times where he was inpatient and missed his doggie.” His dad then stated, “There were times where he spent a month in the hospital, and I think it would have been really nice to have a dog there.”
Then, his mother added, “So, I think we’re really happy to help if it means moving towards more dogs for inpatient care. Although I hope we don’t have to benefit from the inpatient side of it anymore. But if we do, at least now it is an option.”
Negative Comments
Almost every participant in the study said that there is nothing about the study that they would change. The mother of participant #7 expressed that she wished that their AAI time intervals had been longer than 15 minutes. When asked if there was anything about the study that she did not like, she said, “No, except that we wish we had more time with her.” Because they enjoyed their time with the dog so much, they felt that while the 15 minutes were helpful in
reducing stress, they wished that the dog could have stayed longer. This question also often elicited further praise from the participants, who expressed how great they thought that the study was. One mother even commented, “We enjoyed all of it. Please don’t change anything.”
Discussion
These interviews present overwhelming evidence that the AAIs reduced the stress levels of each of the participants and their families. It is clear that the participants felt that the studies reduced their anxiety because they provided a distraction from the more serious and scary events that were occurring in their lives. Although certainly not a cure to their illnesses, AAI served as a form of palliative care for the participants, as the sessions provided a brief relief and distraction from the distress and pain that participants were feeling throughout their diagnosis and treatment.
And for the parents of the participants, not only did they enjoy watching their children be momentarily distracted from their worries, they too were given a break from the immense emotional and physical stress that comes with being the parent of a child with a life-threatening illness.
With this reduction in anxiety also emerged a major recurring theme, which was an increased willingness to come to the hospital. For children with cancer, trips to the hospital become an arduous routine, as they associate discomfort, stress, and fear with their visits. And despite the remarkable and noble efforts of doctors and nurses to make a child’s hospital experience as easy, painless, and low-stress as possible, the majority of children still fear going to the hospital. And for children with advanced recurring cancer, hospital visits often become a dreaded regimen that is met with great resistance towards their parents. The interviews clearly demonstrate that being able to remind one’s child that today they would be able to spend time with a dog when they go to the hospital results in the child becoming much more likely to
comply. In addition, some parents commented that AAIs are extremely helpful in circumstances when children are in inpatient care. Being in the hospital long-term is emotionally difficult for a number of reasons, so having a dog provide brief relief from this experience makes a significant difference, and this idea is underscored by the testimonials of these participants.
Similarly, the interviews demonstrate that the AAIs helped communication between the children and their parents increase. This was most frequently attributed to the fact that the AAIs gave them more to talk about. Some of the caregivers pointed out that at the hospital, they often find that they are talking exclusively about the illness with their child. But, when they know that they are going to see the dog that day, they have something else to talk about, which makes the experience a little bit easier.
Of the six participants that were interviewed, three had no pets at home and three had at least one pet at home, which always included at least one dog. The participants that had no pets at home felt that this made their experiences more enjoyable because it made a part of coming to the hospital a special treat that they would not have if they were at home. On the other hand, the participants that had pets at home felt that this made their experiences more enjoyable because they missed their dogs when they were at the hospital, so they were excited to see a dog there, making it less a less frightening and more comfortable place. Therefore, having a pet at home was not a variable that affected the experiences that participants had during the AAIs. The palliative effect that dogs have on humans is not necessarily dependent on the previous bonds that humans have formed with animals, as it is more universal and applicable to all different types of populations.
Finally, the participants were overall very satisfied with their experience in the study and had almost nothing negative to say about it. Some specifically pointed out that they were glad to
participate because they want to help contribute to data that will lead to bringing more animals into hospitals so that other children can benefit from this palliative care. Furthermore, the age, gender, race, family income range, and diagnosis of each participants did not correlate with any differences in the effects that the study had on the participants.
Conclusion
These end of study interviews provide a preview of the positive effects that AAIs have on children with advanced cancer. The other data mentioned in the “Future of the Study” section will provide more quantitative and comprehensive evidence of these effects once the study is completed in January of 2021. The interviews help support research aim 2, as they demonstrate the efficacy of AAI sessions for children and the primary caregivers of children with advanced cancer. Children and their caregivers experienced less anxiety and stress throughout the course of the study because of the interventions, often lending to an improved health-related quality of life.
Furthermore, the interviews provide evidence for the fact that regardless of whether or not children have a dog at home, the AAIs were effective, demonstrating the innate bond that exists between animals and humans. Finally, this study underlines the importance of bringing animals into hospitals for AAIs, as they are clearly an effective form of palliative care that can make both the hospital and illness experience easier and more pleasant for both patients and their families.
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