Anthrozoös

A multidisciplinary journal of the interactions of people and animals

ISSN: 0892-7936 (Print) 1753-0377 (Online) Journal homepage: http://www.tandfonline.com/loi/rfan20

The Effect of an Animal-Assisted Intervention on

Anxiety and Pain in Hospitalized Children

Sandra B. Barker, Janet S. Knisely, Christine M. Schubert, Jeffrey D. Green &

Suzanne Ameringer

To cite this article: Sandra B. Barker, Janet S. Knisely, Christine M. Schubert, Jeffrey D. Green &
Suzanne Ameringer (2015) The Effect of an Animal-Assisted Intervention on Anxiety and Pain in
Hospitalized Children, Anthrozoös, 28:1, 101-112

To link to this article: http://dx.doi.org/10.2752/089279315X14129350722091

Published online: 28 Apr 2015.

Submit your article to this journal

Article views: 135

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=rfan20

Download by: [b-on: Biblioteca do conhecimento online UFP] Date: 20 September 2015, At: 05:04
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 101
aNthROZOöS VOlUmE 28, ISSUE 1
PP. 101–112
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015
Address for correspondence:
Sandra B. Barker,
Department of Psychiatry,
Virginia Commonwealth
University, PO Box 980710,
Richmond, VA 23298-0710,
USA.
E-mail:
sbarker@mcvh-vcu.edu
REPRINtS aVaIlaBlE PhOtOCOPYING © ISaZ 2015
DIRECtlY FROm PERmIttED PRINtED IN thE UK
thE PUBlIShERS BY lICENSE ONlY
The Effect of an
Animal-Assisted Intervention
on Anxiety and Pain in
Hospitalized Children
Sandra B. Barker*, Janet S. Knisely*,
Christine M. Schubert†, Jeffrey D. Green‡ and
Suzanne Ameringer§
*
Department of Psychiatry, Virginia Commonwealth University,
Richmond, Virginia, USA
†
Air Force Institute of Technology, Wright-Patterson Air Force Base,
Ohio, USA
‡
Department of Psychology, Virginia Commonwealth University,
Richmond, Virginia, USA
§
School of Nursing, Virginia Commonwealth University, Richmond,
Virginia, USA
ABSTRACT Forty children between the ages of 8 and 18 years, who were
admitted to a hospital pediatric unit, were randomly assigned to an animal-
anthrozoös DOI: 10.2752/089279315X14129350722091
assisted intervention (aaI) or an active control condition (working on an
age-appropriate jigsaw puzzle). Ratings of pain and anxiety were taken both
pre- and post-condition. the attachment Questionnaire and Family life
Space Diagram (FlSD) also were administered, and information on medica-
tions taken was recorded. a significant post-condition difference was found
between groups for anxiety, with the aaI group having lower anxiety scores.
however, no significant within- or between-group pre-post changes in either
pain or anxiety were detected. Nearly two-thirds of the children (64%) re-
porting pain at baseline were receiving some type of analgesic, which may
have influenced outcomes. Findings demonstrate some support that at-
tachment may be a moderating variable: children with a secure attachment
style reported lower pain and anxiety at baseline, with large effect sizes for
differences in both anxiety (g = 1.34) and pain (g = 1.23). although the aaI
did not significantly reduce anxiety and pain in these hospitalized children,
further investigation of the influence of analgesic use and the moderating
effect of attachment style is indicated.
Keywords: animal-assisted interventions, animal-assisted therapy,
children, therapy dogs
101
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 102

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

hospitalization can be distressing to children, from painful procedures and treat-

❖ ments to unfamiliar settings, separation from parents and limited activities (Kemper
et al. 2009). While pain is a common symptom in hospitalized children, pain
management is frequently inadequate (helgadóttir 2000). anxiety or distress can heighten the
perception of pain. For example, inserting an intravenous needle is painful and distressing for
hospitalized children (Walco 2008), and greater distress is associated with increased needle
pain (Kleiber et al. 2007). Further, more anxious children report higher levels of postoperative
pain (lamontagne, hepworth and Salisbury 2001; Kain et al. 2006; Bringuier et al. 2009).
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

Non-pharmacological interventions like distraction and hypnosis can be effective in re-

ducing pain and distress in children (liossi and hatira 2003; Stinson et al. 2006; Chambers
et al. 2009; liossi, White and hatira 2009). animal-assisted interventions (aaIs), also a non-
pharmacological approach, are becoming more accepted in healthcare settings. however,
little evidence exists on the effects of aaIs on pain and anxiety in hospitalized children.
aaIs have been associated with some physiological and psychological benefits, including
improved cardiovascular and stress response indicators (Friedmann et al. 1983; Wilson, 1987;
Vormbrock and Grossberg 1988; Demello 1999; motooka, Yokoyama and Kennedy 2006;
Friedmann et al. 2007; Barker et al. 2010; Beetz et al. 2011), reductions in indicators of neg-
ative mood (e.g., anxiety, depression, fear, loneliness) (Wilson 1991; Barker and Dawson 1998;
Pepper 2000, Banks and Banks 2002; Barker, Pandurangi and Best 2003; Banks and Banks
2005; Pedersen et al. 2011), and increased social behavior (Kongable, Buckwalter and Stolley
1989; hall and malpus 2000; marr et al. 2000; mcNicholas and Collis 2000; Kršková,
talarovičová and Olexová 2010; O’haire et al. 2013). literature reviews on aaI consistently
conclude that evidence supports some benefits of such interactions, while criticizing the lack
of methodological rigor in many studies (Barba 1995, Garrity and Stallones 1998; hooker,
Freeman and Stewart 2002; Nimer and lundah 2007; Barker and Wolen 2008; matuszek
2010; lasa et al. 2011).
a recent meta-analysis of animal-assisted therapy (aat), a specific type of aaI defined as
“the deliberate inclusion of an animal into a treatment plan” (p. 225), examined effect sizes for
49 studies (Nimer and lundah 2007). the authors report large effect sizes for changes in
autism spectrum disorder outcomes, moderate effect sizes for behavioral and medical out-
comes, and low to moderate effect sizes for well-being outcomes. the majority of these stud-
ies focused on adults; only 12 investigated children (Nimer and lundahl 2007).
Few studies focus on benefits of aaIs in pediatric settings, perhaps in part due to
methodological complexities, including consent and assent issues. aaIs in hospital set-
tings typically involve trained therapy dogs and their owners visiting with children for brief
periods. Studies frequently lack methodological rigor and have yielded mixed results.
Several studies have measured physiological outcomes to assess the effect of aaIs in re-
ducing distress. an early study reported significant reductions in systolic blood pressure
(SBP), heart rate (hR), mean arterial pressure, and distress scores in 23 children under-
going a routine physical examination with and without a dog present (Nagengast et al.
anthrozoös

1997). Several subsequent studies failed to find similar effects. a randomized controlled
study of 34 children with and without a dog present during physical examination reported
no significant between-group differences in physiological arousal, although less behav-
ioral distress was reported with the dog present (hansen et al. 1999). another study re-
ported no effect of dog presence on either physiological arousal or behavioral distress for
102

40 children undergoing a dental exam with or without a dog present (havener et al. 2001).
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 103

Barker et al.

Similar results are reported for a sample of 58 acute-care pediatric patients. No significant
differences were found in SBP or hR between the aaI and a control condition; however,
respiratory rates were higher and self-reported pain levels lower in the aaI group (Braun
et al. 2009). Participants were not randomly assigned to groups, the aaI group included
significantly more pet-owning children, and children with dog fears or allergies were as-
signed to the control group.
Few studies have included an active condition to control for the interaction inherent in most
aaIs. One study using play as a control condition with a sample of 70 hospitalized children
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

found reductions in hR and positive behavioral affect associated with the aaI, though no sig-
nificant differences in SBP, salivary cortisol, or parental or children’s mood ratings were found
between groups (Kaminski, Pellino and Wish 2002). Participants were not randomly assigned
to conditions and behavioral coders were not blind to conditions.
more recently, investigators compared BP, hR, and self-reported anxiety and medical fear
in a sample of 15 pediatric patients participating in an aaI and puzzle-building (tsai, Fried-
mann and thomas 2010). SBP decreased during both conditions, continued to decrease after
the aaI, but increased following puzzle-building. hR increased during both conditions. No dif-
ferences were found for the self-report measures, collected only post condition.
Investigating the effect of an aaI on pain perception in 25 pediatric surgical patients, in-
vestigators reported reduced physical and emotional pain in this one-group, pre-post design
in which intervention duration varied considerably (Sobo, Eng and Kassity-Krich 2006).
It is difficult to draw conclusions from the mixed results of these studies. Subject medical
acuity, intervention and control conditions, and methodology vary greatly, emphasizing the
need for more rigorous research.
Attachment and AAI
Several theoretical foundations have been extended to explain the benefit of aaIs, includ-
ing social support and attachment (Endenburg 1995; Collis and mcNicholas 1998;
Stammbach and turner 1999; Kurdek 2009). attachment theory has particular implications
for aaIs with children.
Bowlby (1969) proposed that attachment, a series of interlocking behavioral systems,
evolved to keep helpless offspring close to their caregivers. these behaviors include crying to
restore proximity, soothing an upset child, and running toward the mother when upset or
stressed. Of particular relevance, attachment figures serve as a safe haven or refuge when in-
dividuals feel distressed or vulnerable. ainsworth et al. (1978) discovered individual differences
in children’s responses to threat and the extent to which they are comforted by caregivers (i.e.,
secure, avoidant, and anxious ambivalent attachment styles).
Researchers exported this theory to adult romantic relationships (e.g., Green and Camp-
bell 2000), as well as to attachment to other figures, such as God (Kirkpatrick 1998). Evidence
also suggests that individuals may form strong attachments to pets (Barker and Barker 1988;
melson, Peet and Sparks 1991; Steiner et al. 2013). Pets provide attachment security (Beck
and madresh 2008) and may serve attachment functions such as proximity maintenance as
anthrozoös

much as close family members (Kurdek 2008). In some stressful situations, an animal may be
more comforting than a human; one study gave a social stress test to boys, finding reduced
cortisol in boys accompanied by a dog versus a person (Beetz et al. 2011). Not addressed in
the existing studies of aaIs and pediatric patients is the potential influence of attachment style
103

on pain or anxiety.
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 104

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

Facing stressful situations, securely attached individuals are more likely to seek reassurance
from and feel soothed by attachment figures relative to insecurely attached (avoidant and
ambivalent) individuals (Simpson, Rholes and Nelligan 1992). attachment style differences
also are associated with different subjective experiences of pain (andrews, meredith and
Strong 2011). In addition, attachment style can affect reactions to animal visitation:
institutionalized elderly individuals with an avoidant attachment style reported decreases in
subjective well-being after dog visitation, the opposite of reactions by individuals with secure
and ambivalent attachment styles (Colby and Sherman 2002). thus, it is reasonable to
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

hypothesize that attachment style may moderate the effect of aaIs, and securely attached
children may benefit more than insecurely attached children.
the current study sought to extend previous investigations of aaIs in children by randomly
assigning participants to conditions, utilizing self-report measures familiar to the pediatric pop-
ulation, and including attachment as a potential moderating variable. the primary study aim
was to investigate the effect of a 10-minute aaI on anxiety and pain in pediatric patients in an
acute-care hospital. also of interest was whether attachment moderates the effect of the aaI
on these outcomes.

Methods
all children admitted to Children’s hospital of Richmond at Virginia Commonwealth University
were screened for study participation. Inclusion criteria were children between ages 8 and 18
years, able to understand and speak English, not on contact precautions, not afraid of or
allergic to dogs, not hospitalized in the Pediatric Intensive Care Unit, no known cognitive im-
pairments, language or hearing difficulties, and discharge not anticipated within 48 hours. a
child life specialist who normally coordinates pediatric animal-assisted activities pre-screened
each patient for study eligibility. a research assistant confirmed eligibility and obtained parental
permission and child assent. Recruitment continued for approximately 12 months until 40
children completed the study. the study was approved by Virginia Commonwealth University’s
Institutional Review Board.
Instruments
Pain and anxiety were each assessed using a single-item, 11-point, numeric rating scale (NRS).
the use of a single-item pain NRS (Pain NRS) has been validated for children as young as 8
years, with significant correlations with the Faces Pain Scale-Revised (r = 0.87) and the Visual
analog Scale (r = 0.89; von Baeyer et al. 2009). Since the Pain NRS is routinely used on the
pediatric services, a similar format was used for assessing anxiety. the Pain NRS was an-
chored with “no pain” to “worst possible pain,” and the anxiety NRS was anchored with ‘’not
at all nervous, afraid, or worried” to “very nervous, afraid, or worried” (Downie et. al. 1978;
Palermo and Drotar 1996).
Children between the ages of 12 and 18 completed the attachment Questionnaire for
Children (aQC; Sharpe et al. 1998), a brief instrument validated in children, involving selecting
one of three descriptive paragraphs indicative of secure, avoidant, or anxious/ambivalent at-
anthrozoös

tachment styles. Sharpe et al. (1998) provide support for construct validity in his study in which
girls classified as insecurely attached had significantly lower self-esteem scores than those
classified as securely attached.
the Family life Space Diagram (FlSD; mostwin 1980) was used to assess children’s emo-
104

tional closeness with their immediate family members and any pets. the FlSD, validated in
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 105

Barker et al.

human–animal bond research (Barker and Barker 1990) and used with children as young as
6 years (Barker and Barker 1988), required children to place shapes representing themselves,
their family members, and pets with respect to a circle representing their family. Construct
validity is supported by significant differences in distances representing emotionally close re-
lationships compared with relationships that are not emotionally close (p = 0.01; Barker and
Barker 1990). Distances were measured from the self-symbol to all family members and pets
drawn. the FlSD served as a concurrent validation measure for the 3-item aQC, and provided
a measure of relationship closeness for all children.
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

Procedures
the study took place mid-morning in the participant’s hospital room within three days of
admission. Children were randomly assigned to either a 10-minute aaI or an active
attention/distraction condition of the same duration. the aaI was provided by seven
volunteers, all members of the hospital’s therapy dog program with prior experience visiting pe-
diatrics. the participating dogs were of various sizes, both genders, and included a labrador
Retriever, Shetland Sheepdog, Jack Russell terrier, maltese, and three mixed-breed dogs.
the aaI consisted of a visit by one of the owner–dog teams following their usual visitation pro-
cedures in compliance with hospital policies, including safeguards for the dog. Children were
permitted to freely interact with the dogs in their rooms. Volunteers were instructed to avoid
discussion of the child’s illness, discomfort, treatment, or other stressful issues, and to focus
conversation on neutral topics like the therapy dog, favorite activities, and pets at home. the
attention/distraction condition involved building an age-appropriate jigsaw puzzle with the
research assistant to control for activity and the volunteer’s presence in the aaI condition. the
aaI was offered after the study for those assigned to the puzzle condition.
a research assistant administered the FlSD, aQC (children 12–18 years of age only), Pain
NRS, and anxiety NRS immediately before and after the assigned condition. Post-Pain NRS
was collected if the child’s baseline pain level was scored a 3 or higher. Demographic infor-
mation, primary problem leading to admission, and pain medication administered within four
hours of study participation were collected from the child’s chart.
Data Analysis
Descriptive statistics were computed on all variables using means and standard deviations for
continuous variables, and counts and frequencies for categorical variables. Chi-square tests
were used to assess differences among categorical variables. Because of violation in para-
metric assumptions due to non-normality of data and small sample sizes, group comparisons
on continuous measures were conducted using the Kruskal-Wallis and Wilcoxon Rank Sum
nonparametric procedures. a Bonferroni correction was applied to adjust the alpha value when
making multiple comparisons. hedges’s g was used to compute effect sizes using a pooled
variance where appropriate. all tests were set to a family alpha = 0.05 level of significance.

Results
anthrozoös

Ninety-two children were screened for the study with 19 (21%) not consented because of
early discharge, unavailability due to surgery, and parents not available to consent. twenty
(22%) declined to participate due to a variety of reasons: allergies/asthma, fear of dogs, or not
feeling well. Fifty-three children were enrolled and block randomized into either the aaI group
or puzzle group. thirteen children did not complete data collection: six were discharged; three
105

felt too sick; one was in too much pain, two because of therapy dog scheduling, and one
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 106

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

Table 1. Mean (M), median (Mdn), standard deviation (SD), and interquartile range (IQR) for
anxiety and pain scores pre- and post-intervention.
AAI (n = 20) Puzzle (n = 20)
Variable n M SD Mdn (IQR) n M SD Mdn (IQR)
Time = Pre
anxiety 20 1.78 2.54 0.0 (3.5) 20 3.55 3.66 2.0 (6.5)
Pain 10 5.50 1.78 2.0 (5.5) 12 5.58 2.19 3.5 (4.5)
Time = Post
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

anxiety 20 1.25* 2.67 0.0 (1.5) 20 2.63* 2.48 2.0 (5.0)

Pain 10 5.20 3.22 5.0 (4.0) 12 4.92 1.44 5.0 (2.5)
Change (Post–Pre)
anxiety 20 –0.53 1.37 0.0 (1.8) 20 –0.93 1.66 0.0 (1.5)
Pain 10 –0.30 1.77 –0.5 (1.0) 12 –0.67 1.56 0.0 (1.0)
*p = 0.03; effect size, hedges’s g = 0.53, comparing differences between aaI and puzzle groups for
pre-, post-, and the change in score.

gave no reason. Forty children completed the study. mean participant age was 11.83, rang-
ing from 8 to 17 years. the majority (64%, n = 25) of children were white, followed by african-
american (23%, n = 9) and other (13%, n = 6). Gender was evenly distributed (19 boys and
21 girls). the majority (70%, n = 28) of the children owned a pet. twelve children owned only
a dog; 11 owned a dog and at least one other pet; five owned at least one other pet, but no
dog; and 12 children owned no pet. there were no significant differences between groups in
age (Wilcoxon p = 0.10), gender (␹2 =2.51, df = 1, p = 0.11), ethnicity (␹2 = 0.10, df = 1,
p = 0.90), or pet ownership (␹2 = 0.48, df = 1, p = 0.49).
Children were admitted to the hospital for 31 different conditions, the most frequently
reoccurring (n = 3) being appendicitis and abdominal pain. For the 25 children reporting pain
levels of at least 3, 64% (n = 16; 7 intervention, 9 control) received analgesics within four hours
of study participation: opioids (n = 5), non-steroidal anti-inflammatory drugs (n = 9), and acet-
aminophen (n = 2) medications.
Effect of the AAI on Anxiety and Pain
Sixty percent (n = 12) of the aaI group and 25% (n = 5) of the control group rated pre-condition
anxiety levels at zero. Fifty percent (n = 10) of the aaI group and 40% (n = 8) of the control group
rated pre-condition pain levels at less than 3. Because pain and anxiety data were skewed, me-
dians as well as means for anxiety and pain by treatment group and measurement time point
are presented in table 1. Samples for pain are smaller due to study design: post-condition pain
scores were only assessed for those children with baseline pain scores of 3 or greater.
there were no significant baseline group differences for anxiety (Wilcoxon p = 0.10) or pain
(Wilcoxon p = 0.36). Non-significant decreases were found in anxiety and pain for both groups.
Post-condition scores differed significantly between groups on anxiety (Wilcoxon p = 0.03;
g = 0.53) but not on pain (Wilcoxon p = 0.97). the aaI group had lower anxiety scores post-
anthrozoös

intervention. however, change scores did not differ significantly between groups on anxiety
(Wilcoxon p = 0.67) or pain (Wilcoxon p = 0.92).
Anxiety, Pain, and Attachment
attachment scores (aQC) were obtained for the 22 children aged 12 to 18 years. Of these, 13
106

reported a secure attachment style (59.1%), seven reported an avoidant attachment style
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 107

Barker et al.

Table 2. Mean (M), median (Mdn) standard deviation (SD) and effect size (Hedges’s g) for
anxiety and pain levels by attachment style.
Secure Avoidant g‡ Anxious
Variable n Mdn M SD n Mdn M SD n Mdn M SD
Anxiety
Pre-test* 13 2.0 1.77 2.13 7 6.0 5.43 3.64 1.34 2 5.8 5.75 4.60
Change
(post-pre) 13 0.0 –0.54 1.13 7 –2.0 –1.07 2.24 2 –2.8 –2.75 1.77
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

Pain
Pre-test† 13 2.0 2.46 2.70 7 6.0 5.43 1.72 1.23 2 4.0 4.00 5.66
Change
(post-pre) 5 –1.0 –0.60 1.14 7 0.0 –0.14 1.77 1 –2.0 –2.00 N/a
*Significant difference between secure and avoidant at pre-condition in anxiety (p = 0.04).
Significant difference between secure and avoidant at pre-condition in pain (p = 0.04).
†

g = effect sizes between secure and avoidant attachment styles.

‡

Table 3. Mean (M), median (Mdn), and standard deviation (SD) for FLSD Distances by
attachment style.
Secure (n = 12) Avoidant (n = 6) Anxious (n = 2)
Variable M SD Mdn M SD Mdn M SD Mdn
Distances
Self-average
family member 7.00 5.13 5.16 11.32 4.66 12.9 13.93 5.91 13.9
Self-closest
family member 3.00 3.14 1.50 4.54 3.90 4.25 4.25 1.77 4.25
Self-closest pet* 7.91 6.76 5.75 9.38 9.03 7.25 7.25 5.30 7.25
*Sample sizes by attachment for closest pet are n = 8 (secure), n = 4 (avoidant), and n = 2 (anxious).

(31.8%), and two reported an anxious/ambivalent attachment style (9.1%). Comparisons

between attachment styles and anxiety and pain are reported in table 2.
Because the sample size reporting an anxious/ambivalent style was small, no statistical
comparisons were made. there were significant differences at baseline between those
endorsing secure and avoidant styles on anxiety (Wilcoxon p = 0.04, g = 1.34) and pain
(Wilcoxon p = 0.04, g = 1.23), with securely attached children reporting lower anxiety and
pain. the pre-post change in anxiety and pain was not significantly different between the two
groups (Wilcoxon p = 0.34 and p = 0.62, respectively).
Attachment and Emotional Closeness
Emotional closeness, assessed by FlSD distances, between self and closest family member
(self-closest), self and closest pet (self-pet), and self and average of all family members (self-
average) by attachment are presented in table 3. the significance level was set at p = 0.017,
anthrozoös

based on Bonferroni correction.

No significant differences were found among FlSD distances by attachment style (Kruskal-
Wallis p = 0.10) or between pet and non-pet owning children on self-average (Wilcoxon
p = 0.82) or self-closest (Wilcoxon p = 0.76) family member distances.
Within pet owners, there were significant differences between FlSD distances (Kruskal-
107

Wallis p < 0.001). Self-closest distances (Mdn = 3.5, M = 4.45, SD = 3.92) were significantly
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 108

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

Table 4. Mean (M), median (Mdn), and standard deviation (SD) FLSD distances by dog
owners, other pet owners, and non-pet owners.
Dog Owners Non-Pet Owner Other Pet Owner
(n = 20) (n = 10) (n = 5)
Variable M SD Mdn M SD Mdn M SD Mdn
Distances
Self-average
family member 10.27* 5.99 10.40 11.18 8.07 13.10 8.56 6.05 7.50
Self-closest
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

family member 4.71* 4.17 3.50 4.68 4.03 4.90 3.40 2.82 2.50
Self-closest pet 8.74 6.71 6.00 – – – 11.00 7.61 9.50
*Significantly different, p < 0.017(corrected for multiple comparisons); effect size (g) between self-average and
self-closest for dog owners = 1.08.

different than either the self-pet (Wilcoxon p = 0.002, g = 0.85) or self-average distances
(Wilcoxon p < 0.0001, g = 1.09), with the shortest distance between self and closest family
member. No significant differences were found between self-pet (Mdn = 7.0, M = 9.19,
SD = 6.80) or self-average distances (Mdn = 9.96, M = 9.93, SD = 5.92). table 4 shows a
comparison of the same distances broken down for dog owners, other pet owners, and those
without pets.
there were significant differences between distances on the FlSD for dog owners
(Kruskal-Wallis p = 0.004) but not (p = 0.67) for non-pet owners (Wilcoxon p = 0.07) as dis-
played in table 4. For dog owners, significant differences were found between self-closest
and self-average distances (Wilcoxon p = 0.003, g = 1.08) but not between self-closest and
self-pet distances (Wilcoxon p = 0.03), when corrected for multiple comparisons. there were
no significant differences in distances between self-pet and self-average family member
(Wilcoxon p = 0.31). For those with no pet, there were no significant differences (Wilcoxon p
= 0.06) between self-closest and self-average family member distances. For those who
owned other pets, there were no significant differences between any of the distances
(Kruskal-Wallis p = 0.06).

Discussion
this study sought to address a number of weaknesses in previous studies of aaI with hospi-
talized children by utilizing randomized group assignment, an active control group, and exist-
ing therapy dogs teams visiting pediatrics, as well as by addressing medications administered
and including attachment as a potential moderating variable.
No significant differences were found between or within the treatment and control (puzzle)
groups in either self-reported anxiety or pain levels, suggesting the brief aaI session did not
significantly affect anxiety and pain levels. an alternative explanation resides in the flooring ef-
fect of anxiety and pain levels. Baseline anxiety levels in the aaI group were very low, with
60% rating no anxiety; thus, no potential reductions in anxiety could likely be detected among
anthrozoös

these participants. Similarly, half of the aaI group and 40% of the control group reported base-
line pain levels of less than 3, again leaving little room for change. Outcomes may also have
been affected by the study site, a large, academic medical center with a number of pediatric
specialty and consultation services. Replication studies in other types of acute-care pediatric
facilities are needed to confirm these findings.
108
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 109

Barker et al.

a potentially confounding variable is that analgesics were being taken by many of the
children. While we were interested in assessing medication as a potential moderating
variable, most children reporting a pain level of 3 or greater were on non-steroidal anti-
inflammatory drugs or acetaminophen, which would not typically affect an individual’s level
of anxiety as opioids possibly could. Further, most had been administered these medica-
tions at least four hours prior to the start of the study, which is most likely past their peak
analgesic effect time.
these non-significant results are consistent with those reported in a study also compar-
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

ing aaI and control (puzzle) conditions in hospitalized children (tsai, Friedmann and thomas
2010). although reductions in BP were found, the authors found no differences in self-reported
anxiety and medical fear. also using an active control condition (play) with hospitalized children,
Kaminski, Pellino and Walsh (2002) failed to find a significant effect of an aaI on cortisol, BP,
or mood, but did find reductions in heart rate and positive behavioral affect. medication use
was not addressed in either study.
Some support was found for attachment as a potential moderating variable. Securely at-
tached children reported lower pain and anxiety levels at baseline. the findings were significant
with large effect sizes, even though the age appropriateness for the aQC limited the sample size
(n = 22). Further studies with larger sample sizes are needed to confirm these findings.
FlSD results revealed no differences in emotional closeness to family members by pet and
non-pet owning children. however, differences were found for dog-owning children. Results
suggest children are as emotionally close to their (closest) pet dog as they are to their closest
family member. these results differ from those in an earlier non-clinical sample of children who
were emotionally closer to their closest family member than to either their pet dog or other fam-
ily members (Barker and Barker 1988). Perhaps the vulnerability of being hospitalized or the
absence from one’s pets enhances the emotional closeness of children to their pet dogs. more
studies are needed to further explore children’s closeness to their pets and the effect that
closeness may have in facing distressing situations.
Strengths of this study include random assignment, an active control group, using exist-
ing therapy dogs visiting pediatrics, collecting medications administered, and including at-
tachment as a potential moderating variable. there are a number of study limitations. the
sample size is small and further limited by floor effects in pain and anxiety levels. It is not known
how the heterogeneity in medical conditions and medications may have affected study out-
comes, and future studies with clinical populations should address these potential confound-
ing variables. Finally, although this study’s 10-minute intervention is consistent with brief aaIs
routinely conducted with hospitalized children, investigations with longer and multiple aaI
sessions are needed to explore potential dose effects.
Consistent with a number of published studies, these findings fail to support an effect of
aaIs on anxiety and pain in children hospitalized in an acute-care setting. however, results
do support a strong emotional closeness between hospitalized children and their pet dogs,
and also suggest that attachment style may be a potential moderating variable with this
anthrozoös

population. Both warrant further investigation.

Acknowledgements
this study was supported in part by the Center for human–animal Interaction, School of
medicine, at Virginia Commonwealth University. the authors acknowledge and thank Dr. Nancy
109

mcCain, Dr. marty montpetit, Research assistants Kelley Snowa, lia Schwartz, and lorena
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 110

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

Salom, Child life Specialists heather Kinney, Siri Bream, and Ilona Scanlon, and the Center
Dogs On Call teams for their contributions to this study.

References
ainsworth, m. D. S., Blehar, m. C., Waters, E. and Wall, S. 1978. Patterns of Attachment: A Psychological Study
of the Strange Situation. hillsdale, NJ: lawrence Erlbaum.
andrews, N. E., meredith, P. J. and Strong, J. 2011. adult attachment and reports of pain in experimentally-
induced pain. European Journal of Pain 15: 523–530.
Banks, m. R. and Banks, W. a. 2002. the effects of animal-assisted therapy on loneliness in an elderly
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

population in long-term care facilities. The Journals of Gerontology Series A: Biological Sciences and Medical
Sciences 57: m428–432.
Banks, m. R. and Banks, W. a. 2005. the effects of group and individual animal-assisted therapy on loneliness
in residents of long-term care facilities. Anthrozoös 18: 396–408.
Barba, B. E. 1995. a critical review of research on the human/companion animal relationship: 1988–1993.
Anthrozoös 8: 9–19.
Barker, S. B. and Barker, R. t. 1988. the human–canine bond: Closer than family ties. Journal of Mental Health
Counseling 10: 46–56.
Barker, S. B. and Barker, R. t. 1990. Investigation of the construct validity of the Family life Space Diagram.
Journal of Mental Health Counseling 12: 506–514.
Barker, S. B. and Dawson, K. S. 1998. the effects of animal-assisted therapy on anxiety ratings of hospitalized
psychiatric patients. Psychiatric Services 49: 797–801.
Barker, S. B., Knisely, J. S., mccain, N. l., Schubert, C. m. and Pandurangi, a. K. 2010. Exploratory study of
stress-buffering response patterns from interaction with a therapy dog. Anthrozoös 23: 79–91.
Barker, S. B., Pandurangi, a. K. and Best, a. m. 2003. Effects of animal-assisted therapy on patients’ anxiety,
fear, and depression before ECt. Journal of ECT 19: 38–44.
Barker, S. B. and Wolen, a. R. 2008. the benefits of human–companion animal interaction: a review. Journal
of Veterinary Medical Education 35: 487–495.
Beck, l. and madresh, E. a. 2008. Romantic partners and four-legged friends: an extension of attachment
theory to relationships with pets. Anthrozoös 21: 43–56.
Beetz, a., Kotrschal, K., turner, D. C., hediger, K., Ulnas-moberg, K. and Julius, h. 2011. the effect of a real
dog, toy dog and friendly person on insecurely attached children during a stressful task: an exploratory study.
Anthrozoös 24: 349–368.
Bowlby, J. 1969. Attachment and Loss: Volume 1. Attachment. New York: Basic Books.
Braun, C., Stangler, t., Narveson, J. and Pettingell, S. 2009. animal-assisted therapy as a pain relief intervention
for children. Complementary Therapies in Clinical Practice 15: 105–109.
Bringuier, S., Dadure, C., Raux, O., Dubois, a., Picot, m.-C. and Capdevila, X. 2009. the perioperative validity
of the visual analog anxiety scale in children: a discriminant and useful instrument in routine clinical practice
to optimize postoperative pain management. Anesthesia and Analgesia 109: 737–744.
Chambers, C. t., taddio, a., Uman, l. S. and mcmurtry, C. m. 2009. Psychological interventions for reducing
pain and distress during routine childhood immunizations: a systematic review. Clinical Therapeutics 31
(Suppl. 2): S77–S103.
Colby, P. m. and Sherman, a. 2002. attachment styles impact on pet visitation effectiveness. Anthrozoös 15:
150–165.
Collis, G. m. and mcNicholas, J. 1998. a theoretical basis for health benefits of pet ownership: attachment
versus psychological support. In Companion Animals in Human Health, 105–222, ed. C. C. Wilson and D.
C.turner. thousand Oaks, Ca: Sage Publications.
Demello, l. R. 1999. the effect of the presence of a companion-animal on physiological changes following the
anthrozoös

termination of cognitive stressors. Psychology and Health 14: 859–868.

Downie, W. W., leatham, P. a., Rhind, V. m., Wright, V., Branco, J. a. and anderson, J. a. 1978. Studies with
pain rating scales. Annals of the Rheumatic Disease 37: 378–381.
Endenburg, N. 1995. the attachment of people to companion animals. Anthrozoös 8: 83–89.
Friedmann, E., Katcher, a. h., thomas, S. a., lynch, J. J. and messent, P. R. 1983. Social interaction and
blood pressure. Influence of animal companions. Journal of Nervous and Mental Disease 171: 461–465.
110
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 111

Barker et al.

Friedmann, E., thomas, S. a., Cook, l. K., tsai, C. and Picot, S. J. 2007. a friendly dog as potential moderator
of cardiovascular response to speech in older hypertensives. Anthrozoös 20: 51–63.
Garrity, t. F. and Stallones, l. 1998. Effects of pet contact on human well-being: Review of recent research.
In Companion Animals in Human Health, 3–22, ed. C. C. Wilson and D. C. turner. thousand Oaks, Ca:
Sage Publications.
Green, J. D. and Campbell, W. K. 2000. attachment and exploration in adults: Chronic and contextual
accessibility. Personality and Social Psychology Bulletin 26: 452–461.
hall, P. l. and malpus, Z. 2000. Pets as therapy: Effects on social interaction in long-stay psychiatry. British
Journal of Nursing 9: 2220–2225.
hansen, K. m., messinger, C. J., Baun, m. m. and megel, m. 1999. Companion animals alleviating distress in
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

children. Anthrozoös 12: 142–148.

havener, l., Gentes, l., thaler, B., megel, m., Baun, m., Driscoll, F., Beiraghi, S. and agrawal, N. 2001. the
effects of a companion animal on distress in children undergoing dental procedures. Issues in Comprehensive
Pediatric Nursing 24: 137–152.
helgadóttir, h. l. 2000. Pain management practices in children after surgery. Journal of Pediatric Nursing 15:
334–340.
hooker, S. D., Freeman, l. h. and Stewart, P. 2002. Pet therapy research: a historical review. Holistic Nursing
Practice 16: 17–23.
Kain, Z. N., mayes, l. C., Caldwell-andrews, a. a., Karas, D. E. and mcclain, B. C. 2006. Preoperative
anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 118:
651–658.
Kaminski, m., Pellino, t. and Wish, J. 2002. Play and pets: the physical and emotional impact of child-life and
pet therapy on hospitalized children. Childrens Health Care 31: 321–335.
Kemper, K. J., Fletcher, N. B., hamilton, C. a. and mclean, t. W. 2009. Impact of healing touch on pediatric
oncology outpatients: Pilot study. Journal of The Society For Integrative Oncology 7: 12–18.
Kirkpatrick, l. a. 1998. God as a substitute attachment figure: a longitudinal study of adult attachment style and
religious change in college students. Personality and Social Psychology Bulletin 24: 961–973.
Kleiber, C., Schutte, D. l., mccarthy, a. m., Floria-Santos, m., murray, J. C. and hanrahan, K. 2007. Predictors
of topical anesthetic effectiveness in children. The Journal of Pain 8: 168–174.
Kongable, l. G., Buckwalter, K. C. and Stolley, J. m. 1989. the effects of pet therapy on the social behavior of
institutionalized alzheimer’s clients. Archives of Psychiatric Nursing 3: 191–198.
Kršková, l., talarovičová, a. and Olexová, l. 2010. Guinea pigs—the “small great” therapist for autistic children,
or: Do guinea pigs have positive effects on autistic child social behavior? Society & Animals 18: 139–151.
Kurdek, l. a. 2008. Pet dogs as attachment figures. Journal of Social and Personal Relationships 25:
247–266.
Kurdek, l. a. 2009. Pet dogs as attachment figures for adult owners. Journal of Family Psychology 23:
439–446.
lamontagne, l. l., hepworth, J. t. and Salisbury, m. h. 2001. anxiety and postoperative pain in children who
undergo major orthopedic surgery. Applied Nursing Research 14: 119–124.
lasa, S. m., Ferriero, G., Brigatti, E., Valero, R. and Franchignoni, F. 2011. animal-assisted interventions in
internal and rehabilitation medicine: a review of the recent literature. Panminerva Medica 53: 129–136.
liossi, C. and hatira, P. 2003. Clinical hypnosis in the alleviation of procedure-related pain in pediatric oncology
patients. International Journal of Clinical and Experimental Hypnosis 51: 4–28.
liossi, C., White, P. and hatira, P. 2009. a randomized clinical trial of a brief hypnosis intervention to control
venepuncture-related pain of paediatric cancer patients. Pain 142: 255–263.
marr, C. a., French, l., thompson, D., Drum, l., Greening, G., mormon, J., henderson, I. and hughes, C. W.
2000. animal-assisted therapy in psychiatric rehabilitation. Anthrozoös 13: 43–47.
matuszek, S. 2010. animal-facilitated therapy in various patient populations: Systematic literature review. Holistic
anthrozoös

Nursing Practice 24: 187–203.

mcNicholas, J. and Collis, G. m. 2000. Dogs as catalysts for social interactions: Robustness of the effect. British
Journal of Psychology 91: 61–70.
melson, G. F., Peet, S. and Sparks, C. 1991. Children’s attachment to their pets: links to socio-emotional
development. Children’s Environments Quarterly 8: 55–65.
111

mostwin, D. 1980. Life Space Approach to the Study and Treatment of a Family. Washington, DC: Catholic
University of america.
 AZ 28(1)-text_Layout 1 1/19/15 10:49 AM Page 112

the Effect of an animal-assisted Intervention on anxiety and Pain in hospitalized Children

motooka, m., Yokoyama, t. and Kennedy, N. I. 2006. Effect of dog-walking on autonomic nervous activity in
senior citizens. The Medical Journal of Australia 184: 60–63.
Nagengast, S. l., Baun, m. m., megel, m. and leibowitz, J. m. 1997. the effects of the presence of a companion
animal on physiological arousal and behavioral distress in children during a physical examination. Journal of
Pediatric Nursing 12: 323–330.
Nimer, J. and lundahl, B. 2007. animal-assisted therapy: a meta-analysis. Anthrozoös 20: 225–238.
O’haire, m. E., mckenzie, S. J., Beck, a. m. and Slaughter, V. 2013. Social behaviors increase in children with
autism in the presence of animals compared to toys. PLoS One 8: e57010.
Palermo, t. and Drotar, D. 1996. Prediction of children’s postoperative pain: the role of presurgical expectations
and anticipatory emotions. Journal of Pediatric Psychology 21: 683–698.
Downloaded by [b-on: Biblioteca do conhecimento online UFP] at 05:05 20 September 2015

Pedersen, I., Nordaunet, t., martinsen, E. W., Berget, B. and Braastad, B. O. 2011. Farm animal-assisted
intervention: Relationship between work and contact with farm animals and change in depression, anxiety,
and self-efficacy among persons with clinical depression. Issues in Mental Health Nursing 32: 493–500.
Pepper, t. D. 2000. Effects of brief exposure to a pet therapy dog on affective states of hIV-positive men (immune
deficiency). Dissertation Abstracts International: Section B: the Sciences and Engineering 61: 2216.
Simpson, J. a., Rholes, W. S. and Nelligan, J. S. 1992. Support seeking and support giving within couples in
an anxiety-provoking situation: the role of attachment styles. Journal of Personality and Social Psychology
62: 434–446.
Sobo, E. J., Eng, B. and Kassity-Krich, N. 2006. Canine visitation (pet) therapy: Pilot data on decreases in child
pain perception. Journal of Holistic Nursing 24: 51–57.
Stammbach, K. B. and turner, D. C. 1999. Understanding the human–cat relationship: human social support
or attachment. Anthrozoös 12: 162–168.
Steiner, E. t., Silver, N. C., hall, P., Downing, C., hurton, D. and Gray, P. B. 2013. Raising canine: Cross-species
parallels in parental investment. Human–Animal Interaction Bulletin 1: 38–54.
Stinson, J. N., Kavanagh, t., Yamada, J., Gill, N. and Stevens, B. 2006. Systematic review of the psychometric
properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children
and adolescents. Pain 125: 143–157.
tsai, C.-C., Friedmann, E. and thomas, S. a. 2010. the effect of animal-assisted therapy on stress responses
in hospitalized children. Anthrozoös 23: 245–258.
Von Baeyer, C. l., Spagrud, l. J., mccormick, J. C., Choo, E., Neville, K. and Connelly, m. a. 2009. three new
datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity.
Pain 143: 223–227.
Vormbrock, J. K. and Grossberg, J. m. 1988. Cardiovascular effects of human–pet dog interactions. Journal of
Behavioral Medicine 11: 509–517.
Walco, G. a. 2008. Needle pain in children: Contextual factors. Pediatrics 122: S125–S129.
Wilson, C. C. 1987. Physiological responses of college students to a pet. Journal of Nervous and Mental Disease
175: 606–612.
Wilson, C. C. 1991. the pet as an anxiolytic intervention. Journal of Nervous and Mental Disease 179: 482–489.
anthrozoös
112