The Impact of Therapy Dogs on Anxiety and Emotional Management in the Pediatric Emergency Department

The Impact of Therapy Dogs on Anxiety and Emotional Management in the Pediatric Emergency Department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Therapy Dogs on Anxiety and Emotional Management in the Pediatric Emergency Department Samantha Lucrezia, Amy Edgerton, Yana Feygin, Michelle Stevenson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3870813/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives determine change in emotional management in children 4–12 years after a visit from a therapy dog and certified child life specialist (CCLS) handler, via observed modified CEMS scores (Children’s Emotional Management Scale), and to determine change in perceived anxiety reported by caregivers, via Subjective Unit of Distress (SUD) score. Methods Prospective observational study at a large/urban ED within a freestanding children’s hospital from May-July 2021. Children 4–12 years with at least mild anxiety (SUD ≥ 30) eligible. Children ineligible: current infection, transferred, presented for burn care/dog bite, history of neutropenia/oncologic process, triaged ESI category 1/2, patient/caregiver with fear/allergy to dogs, or already had undergone a procedure. Participants received a 10-minute visit with CCLS and therapy dog. Modified CEMS (accounting for mask use) and SUD scores recorded prior and after intervention by research team and caregiver, respectively. Results 95 patients approached, no families refused participation, 41 enrolled. After the intervention, modified CEMS scores significantly decreased (p < 0.001), as well as parental perceived anxiety via SUD score (p < 0.001). Mean duration of intervention was 9.10 (3.58) minutes; mean ED length of stay was 3.33 (1.50) hours. 95% of caregivers reported strong satisfaction with therapy dog. Conclusions An encounter with a therapy dog and CCLS handler significantly improves emotional management and decreases anxiety in pediatric patients in the ED. Caregivers perceive therapy dogs as calming for their child and praised the intervention. These results support future prospective randomized trials involving therapy dogs in managing pediatric distress in the ED. Figures Figure 1 Figure 2 Figure 3 Background The pediatric emergency department can be a frightening place for patients and their families. Child Life Specialists (CCLS) have been utilized for many years to help improve experiences for children when they visit the emergency department by using developmentally approved distractions, play, and educational experiences (1,2) . Therapy dogs have also been used more recently as complementary interventions within the hospital setting. Therapy dogs are canines that are specifically trained to provide affection and support for a person’s mental health. Dogs have long been considered a human’s best friend due to their often-kind demeanor, unwavering loyalty, and empathic nature (3) . Studies have shown that dogs can show sympathy towards their human handlers during times of distress and will often act to assist them when in need (3) . Animal assisted therapy has been found to significantly improve a person’s well-being, including their physical, emotional, and social functioning (4) . Therapy dogs can decrease a patient’s blood pressure, cortisol levels and even reduce morbidity and mortality. (5–7) Within healthcare, children may have frequent encounters that can be psychologically distressing and emotionally challenging, because of their lack of control, fear, and pain that children experience during their visits. These encounters can cause them to exhibit signs of anxiety, irritability, as well as aggression. These emotional responses may lead to challenges in providing care for patients, and providing different coping mechanisms for these emotions may facilitate improved healthcare visits (8) . Arguably, the emergency department is one of the most vulnerable and anxiety provoking settings for children in the hospital, as it is often where they first encounter various painful procedures and are first introduced to the hospital setting. Therefore, our primary objective was to determine if there is a change in emotional management in children after a visit from a therapy dog and certified child life specialist (CCLS) handler, and to determine if there is a change in perceived level of child anxiety reported by caregivers before and after the visit. This approach was chosen to serve as a pilot study in preparation for a future larger randomized control style study to compare this intervention to other standard ED therapies such as CCLS visit alone, or other distraction techniques. Methods We conducted a prospective observational study in the pediatric emergency department of a large, freestanding children’s hospital in an urban environment. Our healthcare system employs multiple facility dogs partnered with human handlers in their adult and pediatric clinical settings as part of the “Heel, Dog, Heal” program (9) . Most of the dogs employed in the pediatric settings are paired with a CCLS handler. During our study enrollment period, there was one existing male therapy dog and CCLS pair employed specifically within the emergency department to visit with patients and their families. CCLS and therapy dog participation in our study was voluntary and was not externally funded. Research was conducted in accordance with the ARRIVE guidelines for the ethical treatment of animal participants. Our study was approved by the University of Louisville Institutional Review Board and the protocol was registered at clinicaltrials.gov. Enrollment took place within the pediatric emergency department from May to July 2021. Our primary objective was to determine if there is a change in emotional management in children aged 4–12 years after a visit from a therapy dog and certified child life specialist (CCLS) handler, as measured by observed modified CEMS scores (Children’s Emotional Management Scale), and to determine if there is a change in perceived level of child anxiety reported by caregivers before and after the visit, as measured by the Subjective Unit of Distress (SUD) Score( 10 ). Children were approached regardless of their anxiety status. Patients with at least mild anxiety as measured by a SUD score ≥ 30 were eligible, however all patients approached were offered an opportunity to meet with the therapy dog regardless of study eligibility status. The included age range was based on the initial validation of the primary outcome measure, the (modified) Children’s Emotional Management Score which was initially validated for children 7–12 years and extended to include children ages 4–6 years in multiple studies (11–14) . Enrollment of patients in our study occurred during the COVID19 pandemic and mask use was required in our hospital for patients > 2 years of age. We therefore created a modified CEMS tool, which specifically modified the facial expression portion to not use smile or frown, and to use the perceptive expression of the subject’s eyebrows and eyes exclusively for that portion of the score (Modified CEMS Tool in Appendix). Additionally, per hospital regulations, the therapy dog was not able to visit any child with evidence of active infection such as current fever, cough, vomiting or diarrhea. These symptoms were screened for via the electronic medical record and then confirmed verbally upon enrollment. Children were considered ineligible if they had evidence of active infection, were transferred from an outside facility, presented for burn care or dog bite injury, had recent history of neutropenia defined as ANC < 1500, or oncologic process, were triaged as ESI category 1 or 2, if the patient or caregiver with a fear or allergy to dogs, or if they had already undergone a painful procedure such as placement of a peripheral IV, fracture reduction, or laceration repair. Study design flow is depicted in Fig. 1 . Patients were screened for inclusion and exclusion criteria via the electronic medical record prior to being approached by the primary medical investigator and/or the medical student. The parent or guardian was then asked to estimate the level of their child’s current anxiety (SUD score) for their child. If the score was 30 or higher, the parent and child were offered participation in the study. The CCLS was not involved in recruitment or consent but did arrange for an immediate visit with the patient and therapy dog for study participants. All participants received a 10-minute visit with CCLS and therapy dog. The handler opened conversation during the visit and interacted as they normally would in the clinical setting. The dog was kept on a leash throughout the visit. Modified CEMS (accounting for mask use) and SUD scores were recorded immediately prior to and within 20 minutes after the intervention by our research team and caregiver, respectively. Modified CEMS scores were recorded by a member of the research team, who performed observations over timed two-minute time periods. A 5-question Likert scale satisfaction survey with a section provided for open comments, was provided to the parent or guardian, and collected after the intervention and prior to discharge. The tool used for recording the satisfaction survey is pictured in the appendix. In a planned analysis, Cohen’s kappa was calculated for each component of the modified CEMS score in the first 14 patients which ranged from 0.435–0.859, indicating moderate to good interrater reliability. Participants were enrolled until a predetermined sample size was met. The sample size was chosen to attain 80% power at a 5% level of significance and detect a medium (Cohen’s d = 0.5) effect of therapy and is based on previous studies that have reported larger differences (Cohen’s d = 0.6–0.76) along with additional participants to account for non-parametric testing. Differences between scores before and after the intervention were assessed using a paired Wilcoxon signed-rank test, in addition to a boxplot to illustrate the distributions for each instrument. A 2-sided p-value < 0.05 was considered statistically significant. Parent comments from the satisfaction survey were transcribed verbatim and assigned a unique identifier for tracking prior to analysis using Dedoose software. Thematic analysis was performed using a process of open, axial, and selective coding. During open coding, three study investigators (AE, SL, and MS) independently read each comment and identified codes using a constant comparative approach. Group codes were then sorted into categories and axial coding was used to examine the interrelationship of these categories as data collection and analysis progressed to develop overarching themes and a related conceptual model. Throughout the analytic process, codes, categories, themes, and related quotations were shared with the entire research team, and a final model was developed through consensus. Results Ninety-five patients were approached, no families refused participation, and forty-one met inclusion criteria and were enrolled. Demographics are described in Table 1. No patients received psychoactive medications prior to the intervention. There were slightly more females included in our study than males and mean age was 8.32 (2.45) years. A variety of primary diagnoses were represented in included participants, but the most common presentations were for lacerations or musculoskeletal injuries. Overall results are reported in Figs. 2 and 3 . Modified CEMS scores significantly decreased after the intervention in children (p < 0.001) (Fig. 2 ). There was a significant decrease in perceived anxiety from parents of their children via SUD score after the intervention (p < 0.001) (Fig. 2 ). Mean duration of intervention was 9.10 (3.58) minutes; mean ED length of stay was 3.33 (1.50) hours. Our satisfaction survey revealed that 95% of caregivers and their children reported satisfaction with the therapy dog, and experienced quality care during their visit (Fig. 3 ). Using grounded theory coding framework, qualitative analysis of thematic codes from the comments included in the satisfaction survey revealed that an encounter with a therapy dog and CCLS was perceived as a positive experience, and to be calming of both the child and the caregiver, resulting in improvement of the child’s mood (Table 2). Caregivers expressed an appreciation for the dog and program, along with a desire to replicate the experience in the future (Table 3). Discussion This study demonstrates novel evidence that a visit with a therapy dog and CCLS handler can improve emotional management and reduce perceived anxiety among pediatric patients in the emergency setting. We found that after a 10-minute visit with a therapy dog, there was a decreased level of parental perceived anxiety of their child which was statistically significant. Additionally, our study revealed a statistically significant improvement in the perceived emotional regulation of enrolled participants after a visit with a therapy dog and CCLS. The use of therapy dogs within the pediatric emergency department was generally well received per our satisfaction survey and no subjects refused participation in the study. Qualitative data obtained from the comments included in the satisfaction survey, revealed four overarching themes which included enhanced calmness of the parent and child, elevation of the child’s mood, and praise for the intervention. These comments further supported our quantitative results that therapy dogs can improve the emotional management of children in the pediatric emergency department. Therapy dogs have been found to have positive impacts in various pediatric healthcare settings such as oncology units, surgical suites, dental clinics, inpatient units, and outpatient lab draws (15–19) . In one study of adult patients visiting a general emergency department, median anxiety levels decreased significantly after a 15-minute visit with a therapy dog (20) . A survey performed in an adult emergency department found that 80% of patients would choose to have an opportunity to visit with a therapy dog during their visit (21) . Additionally, in a survey study performed in 2012 amongst patients and staff in an emergency department, 87.8% of patients and 92% of staff were in approval of therapy dog presence in the ED for both adult and pediatric patients (22) . A recent systematic review was completed to examine the effect of animal assisted therapy on patients, families, and healthcare workers within general emergency departments, finding limited existing literature and supporting the need for further studies in the emergency department setting (23) . Remarkably, there is only one study to date which has evaluated the effect of therapy dogs in a pediatric emergency department, and this study was completed in a short-stay observation unit within their emergency department in Italy. (24) This randomized control trial compared the use of therapy dogs to clowns and music therapy in the short-stay observation unit and found that all three nonpharmacologic interventions decreased anxiety to the same degree, but none of the interventions significantly affected perceived pain in the enrolled pediatric subjects. The demonstrated benefits of therapy dogs within pediatric healthcare include improved postoperative pain levels (25), enhanced global functioning of adolescents with mental disorders (26) , as well as decreased levels of distress during venipuncture (27) . Although feasibility of therapy dogs within emergency departments can be seen as challenging due to the rapid pace and high turnover of patients, our study demonstrates how their involvement in the ED can allow for improved emotional management in pediatric patients, as well as decreased parental perceived anxiety. Our study had several limitations. First, it was an observational pilot study intended to provide baseline data for a randomized controlled trial, and therefore observers and parents could not be blinded to the intervention. The intervention was also not completely standardized, as the CCLS handler was told to behave with the therapy dog as they normally would. However, the duration of the intervention was standardized and the mean length of the duration of the intervention was close to our target range of 10 minutes. Studies have indicated that a higher CEMS score is associated with higher heart rates, and higher mean arterial blood pressures, indicating more negative levels of emotional distress (28) . Although we demonstrated a statistically significant improvement in emotional management amongst subjects via the modified CEMS score, the change in score before and after the intervention was only assessed at one point in time during the ED visit, and it is unclear what change represents a clinical significance in patients. Additionally, we chose to perform a pilot study because estimates of the performance of CEMS is not clearly studied within the pediatric emergency department setting. Moving forward, our study supports the use of CEMS scores to power comparative randomized controlled trials in the pediatric emergency department setting. Lastly, because of the ongoing COVID19 pandemic, modification of the CEMS tool to account for mask use in children was necessary, although not yet validated. Regardless, exposure to a therapy dog and CCLS handler significantly decreased emotional distress in pediatric patients in the emergency department. The results from our study provide important preliminary data for future prospective randomized comparative trials involving therapy dogs in managing anxiety levels in the pediatric emergency department and support existing therapy dog programs in the pediatric emergency department. Declarations Funding and Support None Conflict of Interest None of the authors have any conflicts of interest to disclose per ICMJE conflict of interest guidelines. Author Contribution SL, AE and MS conceived this study. MS and YF analyzed the data. YF is a statistician and has performed a statistical review and approved of the methodology. SL drafted the manuscript, and all authors contributed substantially and approved its final version. SL takes responsibility for the paper as a whole. References Stevenson MD, Bivins CM, O'Brien K, et al. 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World journal of clinical pediatrics , 5 (2), 143–150. https://doi.org/10.5409/wjcp.v5.i2.143 “Norton Healthcare's & Norton Children's Facility Dog Program.” Norton Healthcare , 10 Mar. 2023, https://nortonhealthcare.com/facility-dog-program/. Kaplan, D. M., Smith, T., & Coons, J. (1995). A validity study of the subjective unit of discomfort (SUD) score. Measurement and Evaluation in Counseling and Development, 27(4), 195–199. Wong, C. L., Ip, W. Y., Kwok, B. M. C., Choi, et al. (2018). Effects of therapeutic play on children undergoing cast-removal procedures: a randomised controlled trial. BMJ open , 8 (7), e021071. https://doi.org/10.1136/bmjopen-2017-021071 Lin, C. J., Liu, H. P., Wang, P. Y. et al. (2019). The Effectiveness of Preoperative Preparation for Improving Perioperative Outcomes in Children and Caregivers. Behavior modification , 43 (3), 311–329. https://doi.org/10.1177/0145445517751879 Hall, J. E., Patel, D. P., Thomas, J. W., et al. (2018). 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Can presence of a dog reduce pain and distress in children during venipuncture? Pain Manag Nurs. 2015 Apr;16(2):89-95. doi: 10.1016/j.pmn.2014.04.004. Epub 2014 Nov 4. PMID: 25439114. Kline, Jeffrey A et al. “Controlled clinical trial of canine therapy versus usual care to reduce patient anxiety in the emergency department.” PloS one vol. 14,1 e0209232. 9 Jan. 2019, doi:10.1371/journal.pone.0209232 Reddekopp, Joanne et al. “Patient Opinion of Visiting Therapy Dogs in a Hospital Emergency Department.” International journal of environmental research and public health vol. 17,8 2968. 24 Apr. 2020, doi:10.3390/ijerph17082968 Nahm N, Lubin J, Lubin J, Bankwitz BK, Castelaz M, Chen X, Shackson JC, Aggarwal MN, Totten VY. Therapy dogs in the emergency department. West J Emerg Med. 2012 Sep;13(4):363-5. doi: 10.5811/westjem.2011.5.6574. PMID: 22942937; PMCID: PMC3421977. Gaudet, L. A., Elliott, S. A., Ali, S., et al. (2022). Pet therapy in the emergency department and ambulatory care: A systematic review and meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine , 29 (8), 1008–1023. https://doi.org/10.1111/acem.14421 Antonelli, E. , Vagnoli, L. , Ciucci, E. , et al. (2019). A Comparison of Nonpharmacologic Interventions on the Emotional State of Children in the Emergency Department. Pediatric Emergency Care, 35 (2), 81-88. doi: 10.1097/PEC.0000000000000900. Calcaterra, V., Veggiotti, P., Palestrini, C., et al. (2015). Post-operative benefits of animal-assisted therapy in pediatric surgery: a randomised study. PloS one , 10 (6), e0125813. https://doi.org/10.1371/journal.pone.0125813 Stefanini, M. C., Martino, A., Allori, P., et al. (2015). The use of Animal-Assisted Therapy in adolescents with acute mental disorders: A randomized controlled study. 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Journal of clinical nursing , 16 (10), 1919–1926. https://doi.org/10.1111/j.1365-2702.2007.01784.x Tables Table I: Demographic Features of Subjects Enrolled n 41 Sex, n(%) Male 19 (46) Female 22 (54) Age in years, mean (SD) 8.32 (2.45) Primary Diagnosis, n (%) Laceration 14 (34) Other Musculoskeletal Injury 9 (22) Extremity Fracture 6 (14.6) Closed Head Injury 2 (4.9) Eye Injury 2 (4.9) Foreign Body 2 (4.9) Other 6 (14.6) Table II: Model of Caregiver Response to Child’s Encounter with Therapy Dog: qualitative analysis of survey comments. Causal Phenomenon Categories Consequences Context/Intervening Conditions Distraction and Enjoyment Child became calmer and experienced increased relaxation and decreased anxiety Calming of the Child Note: All categories were determined to have the same consequences The consequences were: Caregivers perceived intervention as effective There was a positive outlook on dogs The experience was viewed as positive by caregivers Context: pain, discomfort, fear of hospital, injury Intervening Conditions: age, procedures, interaction with child life, baseline anxiety Distraction, Relaxation, comfort, and Enjoyment Child’s mood was improved – caregivers noted smiles and child perking up Improvement of Child’s mood Distraction, Improvement in mood of child and parental worry Caregiver became more relaxed, calmer, and experienced less anxiety Calming of the Caregiver Dog’s disposition, Dog’s behavior, and Handler’s actions Caregiver’s felt appreciated Praise for Intervention Table III: Examples of Caregiver Comments Category Excerpt Calming of the Child “My daughter really enjoyed interacting with the dog Duncan today. She says she feels more calm and happy and would love to see him every time she has to come here.” Improvement of Child’s Mood “Made her smile, first time I’d seen a smile all day. They were very pleasant and helped a great deal.” Calming of the Caregiver “The therapy dog really helped me, the mom, calm down as well, Thank you!” Praise for Intervention “The therapy dog was the best part of the visit! Such a positive and calming experience for the patients and family!” Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3870813","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268694533,"identity":"41165399-703b-4e7d-8dce-2828dee6e925","order_by":0,"name":"Samantha 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19:45:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3870813/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3870813/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50169232,"identity":"237b0256-7767-4073-a733-5d5c34e87b87","added_by":"auto","created_at":"2024-01-25 15:30:34","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249821,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of study process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3870813/v1/4dc8dbbdbba3df520016ef40.jpeg"},{"id":50169231,"identity":"dfa2aa99-cd56-401d-8851-f779e978f623","added_by":"auto","created_at":"2024-01-25 15:30:34","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":157035,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModified Children’s Emotional Manifestation Scale (CEMS) and Subjective Unit of Distress score: \u003c/strong\u003emeasured before and after intervention by research team and caregiver, respectively.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3870813/v1/e8156993ff42abfe32300813.jpeg"},{"id":50169234,"identity":"3b5bcf5c-cc97-4a0d-ac77-6fd5bdfcc675","added_by":"auto","created_at":"2024-01-25 15:30:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":215496,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eQuantitative Survey Data: \u003c/strong\u003eresults from the 5-point Likert style questionnaire provided to caregivers at the end of emergency department visit (1-strongly agree, 2-Agree, 3-undecided, 4-disagree, 5-strongly disagree).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3870813/v1/6ca4e257af9699e12c983eb0.png"},{"id":50270945,"identity":"e53cdbcd-9a20-435e-a3ba-95f914c755d7","added_by":"auto","created_at":"2024-01-28 17:22:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":532604,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3870813/v1/c1d78a1e-c1d3-4a88-b085-ce15681be972.pdf"},{"id":50170668,"identity":"8f170bf3-5227-40f3-9fd1-04c2976382fb","added_by":"auto","created_at":"2024-01-25 15:38:34","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":578902,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-3870813/v1/41a17dfb27aa335433328513.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Therapy Dogs on Anxiety and Emotional Management in the Pediatric Emergency Department","fulltext":[{"header":"Background","content":"\u003cp\u003eThe pediatric emergency department can be a frightening place for patients and their families. Child Life Specialists (CCLS) have been utilized for many years to help improve experiences for children when they visit the emergency department by using developmentally approved distractions, play, and educational experiences \u003csup\u003e(1,2)\u003c/sup\u003e. Therapy dogs have also been used more recently as complementary interventions within the hospital setting.\u003c/p\u003e \u003cp\u003eTherapy dogs are canines that are specifically trained to provide affection and support for a person\u0026rsquo;s mental health. Dogs have long been considered a human\u0026rsquo;s best friend due to their often-kind demeanor, unwavering loyalty, and empathic nature \u003csup\u003e(3)\u003c/sup\u003e. Studies have shown that dogs can show sympathy towards their human handlers during times of distress and will often act to assist them when in need \u003csup\u003e(3)\u003c/sup\u003e. Animal assisted therapy has been found to significantly improve a person\u0026rsquo;s well-being, including their physical, emotional, and social functioning \u003csup\u003e(4)\u003c/sup\u003e. Therapy dogs can decrease a patient\u0026rsquo;s blood pressure, cortisol levels and even reduce morbidity and mortality. \u003csup\u003e(5\u0026ndash;7)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWithin healthcare, children may have frequent encounters that can be psychologically distressing and emotionally challenging, because of their lack of control, fear, and pain that children experience during their visits. These encounters can cause them to exhibit signs of anxiety, irritability, as well as aggression. These emotional responses may lead to challenges in providing care for patients, and providing different coping mechanisms for these emotions may facilitate improved healthcare visits \u003csup\u003e(8)\u003c/sup\u003e. Arguably, the emergency department is one of the most vulnerable and anxiety provoking settings for children in the hospital, as it is often where they first encounter various painful procedures and are first introduced to the hospital setting. Therefore, our primary objective was to determine if there is a change in emotional management in children after a visit from a therapy dog and certified child life specialist (CCLS) handler, and to determine if there is a change in perceived level of child anxiety reported by caregivers before and after the visit. This approach was chosen to serve as a pilot study in preparation for a future larger randomized control style study to compare this intervention to other standard ED therapies such as CCLS visit alone, or other distraction techniques.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a prospective observational study in the pediatric emergency department of a large, freestanding children\u0026rsquo;s hospital in an urban environment. Our healthcare system employs multiple facility dogs partnered with human handlers in their adult and pediatric clinical settings as part of the \u0026ldquo;Heel, Dog, Heal\u0026rdquo; program \u003csup\u003e(9)\u003c/sup\u003e. Most of the dogs employed in the pediatric settings are paired with a CCLS handler. During our study enrollment period, there was one existing male therapy dog and CCLS pair employed specifically within the emergency department to visit with patients and their families. CCLS and therapy dog participation in our study was voluntary and was not externally funded. Research was conducted in accordance with the ARRIVE guidelines for the ethical treatment of animal participants.\u003c/p\u003e \u003cp\u003e Our study was approved by the University of Louisville Institutional Review Board and the protocol was registered at clinicaltrials.gov. Enrollment took place within the pediatric emergency department from May to July 2021.\u003c/p\u003e \u003cp\u003eOur primary objective was to determine if there is a change in emotional management in children aged 4\u0026ndash;12 years after a visit from a therapy dog and certified child life specialist (CCLS) handler, as measured by observed modified CEMS scores (Children\u0026rsquo;s Emotional Management Scale), and to determine if there is a change in perceived level of child anxiety reported by caregivers before and after the visit, as measured by the Subjective Unit of Distress (SUD) Score(\u003csup\u003e10\u003c/sup\u003e). Children were approached regardless of their anxiety status. Patients with at least mild anxiety as measured by a SUD score\u0026thinsp;\u0026ge;\u0026thinsp;30 were eligible, however all patients approached were offered an opportunity to meet with the therapy dog regardless of study eligibility status. The included age range was based on the initial validation of the primary outcome measure, the (modified) Children\u0026rsquo;s Emotional Management Score which was initially validated for children 7\u0026ndash;12 years and extended to include children ages 4\u0026ndash;6 years in multiple studies \u003csup\u003e(11\u0026ndash;14)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEnrollment of patients in our study occurred during the COVID19 pandemic and mask use was required in our hospital for patients\u0026thinsp;\u0026gt;\u0026thinsp;2 years of age. We therefore created a modified CEMS tool, which specifically modified the facial expression portion to not use smile or frown, and to use the perceptive expression of the subject\u0026rsquo;s eyebrows and eyes exclusively for that portion of the score (Modified CEMS Tool in Appendix). Additionally, per hospital regulations, the therapy dog was not able to visit any child with evidence of active infection such as current fever, cough, vomiting or diarrhea. These symptoms were screened for via the electronic medical record and then confirmed verbally upon enrollment.\u003c/p\u003e \u003cp\u003eChildren were considered ineligible if they had evidence of active infection, were transferred from an outside facility, presented for burn care or dog bite injury, had recent history of neutropenia defined as ANC\u0026thinsp;\u0026lt;\u0026thinsp;1500, or oncologic process, were triaged as ESI category 1 or 2, if the patient or caregiver with a fear or allergy to dogs, or if they had already undergone a painful procedure such as placement of a peripheral IV, fracture reduction, or laceration repair.\u003c/p\u003e \u003cp\u003eStudy design flow is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients were screened for inclusion and exclusion criteria via the electronic medical record prior to being approached by the primary medical investigator and/or the medical student. The parent or guardian was then asked to estimate the level of their child\u0026rsquo;s current anxiety (SUD score) for their child. If the score was 30 or higher, the parent and child were offered participation in the study. The CCLS was not involved in recruitment or consent but did arrange for an immediate visit with the patient and therapy dog for study participants.\u003c/p\u003e \u003cp\u003eAll participants received a 10-minute visit with CCLS and therapy dog. The handler opened conversation during the visit and interacted as they normally would in the clinical setting. The dog was kept on a leash throughout the visit. Modified CEMS (accounting for mask use) and SUD scores were recorded immediately prior to and within 20 minutes after the intervention by our research team and caregiver, respectively. Modified CEMS scores were recorded by a member of the research team, who performed observations over timed two-minute time periods. A 5-question Likert scale satisfaction survey with a section provided for open comments, was provided to the parent or guardian, and collected after the intervention and prior to discharge. The tool used for recording the satisfaction survey is pictured in the appendix.\u003c/p\u003e \u003cp\u003eIn a planned analysis, Cohen\u0026rsquo;s kappa was calculated for each component of the modified CEMS score in the first 14 patients which ranged from 0.435\u0026ndash;0.859, indicating moderate to good interrater reliability. Participants were enrolled until a predetermined sample size was met. The sample size was chosen to attain 80% power at a 5% level of significance and detect a medium (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5) effect of therapy and is based on previous studies that have reported larger differences (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.6\u0026ndash;0.76) along with additional participants to account for non-parametric testing. Differences between scores before and after the intervention were assessed using a paired Wilcoxon signed-rank test, in addition to a boxplot to illustrate the distributions for each instrument. A 2-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eParent comments from the satisfaction survey were transcribed verbatim and assigned a unique identifier for tracking prior to analysis using Dedoose software. Thematic analysis was performed using a process of open, axial, and selective coding. During open coding, three study investigators (AE, SL, and MS) independently read each comment and identified codes using a constant comparative approach. Group codes were then sorted into categories and axial coding was used to examine the interrelationship of these categories as data collection and analysis progressed to develop overarching themes and a related conceptual model. Throughout the analytic process, codes, categories, themes, and related quotations were shared with the entire research team, and a final model was developed through consensus.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eNinety-five patients were approached, no families refused participation, and forty-one met inclusion criteria and were enrolled. Demographics are described in Table\u0026nbsp;1. No patients received psychoactive medications prior to the intervention. There were slightly more females included in our study than males and mean age was 8.32 (2.45) years. A variety of primary diagnoses were represented in included participants, but the most common presentations were for lacerations or musculoskeletal injuries.\u003c/p\u003e \u003cp\u003eOverall results are reported in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Modified CEMS scores significantly decreased after the intervention in children (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a significant decrease in perceived anxiety from parents of their children via SUD score after the intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Mean duration of intervention was 9.10 (3.58) minutes; mean ED length of stay was 3.33 (1.50) hours. Our satisfaction survey revealed that 95% of caregivers and their children reported satisfaction with the therapy dog, and experienced quality care during their visit (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsing grounded theory coding framework, qualitative analysis of thematic codes from the comments included in the satisfaction survey revealed that an encounter with a therapy dog and CCLS was perceived as a positive experience, and to be calming of both the child and the caregiver, resulting in improvement of the child\u0026rsquo;s mood (Table\u0026nbsp;2). Caregivers expressed an appreciation for the dog and program, along with a desire to replicate the experience in the future (Table\u0026nbsp;3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates novel evidence that a visit with a therapy dog and CCLS handler can improve emotional management and reduce perceived anxiety among pediatric patients in the emergency setting. We found that after a 10-minute visit with a therapy dog, there was a decreased level of parental perceived anxiety of their child which was statistically significant. Additionally, our study revealed a statistically significant improvement in the perceived emotional regulation of enrolled participants after a visit with a therapy dog and CCLS.\u003c/p\u003e \u003cp\u003eThe use of therapy dogs within the pediatric emergency department was generally well received per our satisfaction survey and no subjects refused participation in the study. Qualitative data obtained from the comments included in the satisfaction survey, revealed four overarching themes which included enhanced calmness of the parent and child, elevation of the child\u0026rsquo;s mood, and praise for the intervention. These comments further supported our quantitative results that therapy dogs can improve the emotional management of children in the pediatric emergency department.\u003c/p\u003e \u003cp\u003eTherapy dogs have been found to have positive impacts in various pediatric healthcare settings such as oncology units, surgical suites, dental clinics, inpatient units, and outpatient lab draws \u003csup\u003e(15\u0026ndash;19)\u003c/sup\u003e. In one study of adult patients visiting a general emergency department, median anxiety levels decreased significantly after a 15-minute visit with a therapy dog \u003csup\u003e(20)\u003c/sup\u003e. A survey performed in an adult emergency department found that 80% of patients would choose to have an opportunity to visit with a therapy dog during their visit \u003csup\u003e(21)\u003c/sup\u003e. Additionally, in a survey study performed in 2012 amongst patients and staff in an emergency department, 87.8% of patients and 92% of staff were in approval of therapy dog presence in the ED for both adult and pediatric patients \u003csup\u003e(22)\u003c/sup\u003e. A recent systematic review was completed to examine the effect of animal assisted therapy on patients, families, and healthcare workers within general emergency departments, finding limited existing literature and supporting the need for further studies in the emergency department setting \u003csup\u003e(23)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRemarkably, there is only one study to date which has evaluated the effect of therapy dogs in a pediatric emergency department, and this study was completed in a short-stay observation unit within their emergency department in Italy.\u003csup\u003e(24)\u003c/sup\u003e This randomized control trial compared the use of therapy dogs to clowns and music therapy in the short-stay observation unit and found that all three nonpharmacologic interventions decreased anxiety to the same degree, but none of the interventions significantly affected perceived pain in the enrolled pediatric subjects.\u003c/p\u003e \u003cp\u003eThe demonstrated benefits of therapy dogs within pediatric healthcare include improved postoperative pain levels \u003csup\u003e(25),\u003c/sup\u003e enhanced global functioning of adolescents with mental disorders \u003csup\u003e(26)\u003c/sup\u003e, as well as decreased levels of distress during venipuncture \u003csup\u003e(27)\u003c/sup\u003e. Although feasibility of therapy dogs within emergency departments can be seen as challenging due to the rapid pace and high turnover of patients, our study demonstrates how their involvement in the ED can allow for improved emotional management in pediatric patients, as well as decreased parental perceived anxiety.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, it was an observational pilot study intended to provide baseline data for a randomized controlled trial, and therefore observers and parents could not be blinded to the intervention. The intervention was also not completely standardized, as the CCLS handler was told to behave with the therapy dog as they normally would. However, the duration of the intervention was standardized and the mean length of the duration of the intervention was close to our target range of 10 minutes.\u003c/p\u003e \u003cp\u003eStudies have indicated that a higher CEMS score is associated with higher heart rates, and higher mean arterial blood pressures, indicating more negative levels of emotional distress \u003csup\u003e(28)\u003c/sup\u003e. Although we demonstrated a statistically significant improvement in emotional management amongst subjects via the modified CEMS score, the change in score before and after the intervention was only assessed at one point in time during the ED visit, and it is unclear what change represents a clinical significance in patients. Additionally, we chose to perform a pilot study because estimates of the performance of CEMS is not clearly studied within the pediatric emergency department setting. Moving forward, our study supports the use of CEMS scores to power comparative randomized controlled trials in the pediatric emergency department setting. Lastly, because of the ongoing COVID19 pandemic, modification of the CEMS tool to account for mask use in children was necessary, although not yet validated.\u003c/p\u003e \u003cp\u003eRegardless, exposure to a therapy dog and CCLS handler significantly decreased emotional distress in pediatric patients in the emergency department. The results from our study provide important preliminary data for future prospective randomized comparative trials involving therapy dogs in managing anxiety levels in the pediatric emergency department and support existing therapy dog programs in the pediatric emergency department.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding and Support\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eNone of the authors have any conflicts of interest to disclose per ICMJE conflict of interest guidelines.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eSL, AE and MS conceived this study. MS and YF analyzed the data. YF is a statistician and has performed a statistical review and approved of the methodology. SL drafted the manuscript, and all authors contributed substantially and approved its final version. SL takes responsibility for the paper as a whole.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStevenson MD, Bivins CM, O\u0026apos;Brien K, et al. Child life intervention during angiocatheter insertion in the pediatric emergency department. Pediatr Emerg Care. 2005 Nov;21(11):712-8. doi: 10.1097/01.pec.0000186423.84764.5a. PMID: 16280943\u003c/li\u003e\n\u003cli\u003eSanchez Cristal, Natasha et al. \u0026ldquo;Child Life Reduces Distress and Pain and Improves Family Satisfaction in the Pediatric Emergency Department.\u0026rdquo; \u003cem\u003eClinical pediatrics\u003c/em\u003e vol. 57,13 (2018): 1567-1575. doi:10.1177/0009922818798386\u003c/li\u003e\n\u003cli\u003eSpringer. \u0026quot;Empathetic dogs lend a helping paw: Study shows that dogs that remain calm and show empathy during their owner\u0026apos;s distress help out faster.\u0026quot; ScienceDaily. 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Play interventions to reduce anxiety and negative emotions in hospitalized children. \u003cem\u003eBMC pediatrics\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e, 36. https://doi.org/10.1186/s12887-016-0570-5\u003c/li\u003e\n\u003cli\u003eCalcaterra, Valeria et al. \u0026ldquo;Post-operative benefits of animal-assisted therapy in pediatric surgery: a randomised study.\u0026rdquo; \u003cem\u003ePloS one\u003c/em\u003e vol. 10,6 e0125813. 3 Jun. 2015, doi:10.1371/journal.pone.0125813\u003c/li\u003e\n\u003cli\u003eLindstr\u0026ouml;m Nilsson, Maria et al. \u0026ldquo;Children report positive experiences of animal-assisted therapy in paediatric hospital care.\u0026rdquo; \u003cem\u003eActa paediatrica (Oslo, Norway : 1992)\u003c/em\u003e vol. 109,5 (2020): 1049-1056. doi:10.1111/apa.15047\u003c/li\u003e\n\u003cli\u003eMcCullough, Amy et al. \u0026ldquo;Measuring the Effects of an Animal-Assisted Intervention for Pediatric Oncology Patients and Their Parents: A Multisite Randomized Controlled Trial [Formula: see text].\u0026rdquo; \u003cem\u003eJournal of pediatric oncology nursing : official journal of the Association of Pediatric Oncology Nurses\u003c/em\u003e vol. 35,3 (2018): 159-177. doi:10.1177/1043454217748586\u003c/li\u003e\n\u003cli\u003eNammalwar, Rangeeth Bollam, and Priyaa Rangeeth. \u0026ldquo;A bite out of anxiety: Evaluation of animal-assisted activity on anxiety in children attending a pediatric dental outpatient unit.\u0026rdquo; \u003cem\u003eJournal of the Indian Society of Pedodontics and Preventive Dentistry\u003c/em\u003e vol. 36,2 (2018): 181-184. doi:10.4103/JISPPD.JISPPD_54_18\u003c/li\u003e\n\u003cli\u003eVagnoli L, Caprilli S, Vernucci C, et al. Can presence of a dog reduce pain and distress in children during venipuncture? Pain Manag Nurs. 2015 Apr;16(2):89-95. doi: 10.1016/j.pmn.2014.04.004. Epub 2014 Nov 4. PMID: 25439114.\u003c/li\u003e\n\u003cli\u003eKline, Jeffrey A et al. \u0026ldquo;Controlled clinical trial of canine therapy versus usual care to reduce patient anxiety in the emergency department.\u0026rdquo; \u003cem\u003ePloS one\u003c/em\u003e vol. 14,1 e0209232. 9 Jan. 2019, doi:10.1371/journal.pone.0209232\u003c/li\u003e\n\u003cli\u003eReddekopp, Joanne et al. \u0026ldquo;Patient Opinion of Visiting Therapy Dogs in a Hospital Emergency Department.\u0026rdquo; \u003cem\u003eInternational journal of environmental research and public health\u003c/em\u003e vol. 17,8 2968. 24 Apr. 2020, doi:10.3390/ijerph17082968\u003c/li\u003e\n\u003cli\u003eNahm N, Lubin J, Lubin J, Bankwitz BK, Castelaz M, Chen X, Shackson JC, Aggarwal MN, Totten VY. Therapy dogs in the emergency department. West J Emerg Med. 2012 Sep;13(4):363-5. doi: 10.5811/westjem.2011.5.6574. PMID: 22942937; PMCID: PMC3421977.\u003c/li\u003e\n\u003cli\u003eGaudet, L. A., Elliott, S. A., Ali, S., et al. (2022). Pet therapy in the emergency department and ambulatory care: A systematic review and meta-analysis. \u003cem\u003eAcademic emergency medicine : official journal of the Society for Academic Emergency Medicine\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(8), 1008\u0026ndash;1023. https://doi.org/10.1111/acem.14421\u003c/li\u003e\n\u003cli\u003eAntonelli, E. , Vagnoli, L. , Ciucci, E. , et al. (2019). A Comparison of Nonpharmacologic Interventions on the Emotional State of Children in the Emergency Department. \u003cem\u003ePediatric Emergency Care, 35 \u003c/em\u003e(2), 81-88. doi: 10.1097/PEC.0000000000000900.\u003c/li\u003e\n\u003cli\u003eCalcaterra, V., Veggiotti, P., Palestrini, C., et al. (2015). Post-operative benefits of animal-assisted therapy in pediatric surgery: a randomised study. \u003cem\u003ePloS one\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(6), e0125813. https://doi.org/10.1371/journal.pone.0125813\u003c/li\u003e\n\u003cli\u003eStefanini, M. C., Martino, A., Allori, P., et al. (2015). The use of Animal-Assisted Therapy in adolescents with acute mental disorders: A randomized controlled study. \u003cem\u003eComplementary therapies in clinical practice\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 42\u0026ndash;46. https://doi.org/10.1016/j.ctcp.2015.01.001\u003c/li\u003e\n\u003cli\u003eVagnoli, L., Caprilli, S., Vernucci, C., et al. (2015). Can presence of a dog reduce pain and distress in children during venipuncture?. \u003cem\u003ePain management nursing : official journal of the American Society of Pain Management Nurses\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(2), 89\u0026ndash;95. https://doi.org/10.1016/j.pmn.2014.04.004\u003c/li\u003e\n\u003cli\u003eLi H. C. (2007). Evaluating the effectiveness of preoperative interventions: the appropriateness of using the Children\u0026apos;s Emotional Manifestation Scale. \u003cem\u003eJournal of clinical nursing\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(10), 1919\u0026ndash;1926. https://doi.org/10.1111/j.1365-2702.2007.01784.x\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I: Demographic Features of Subjects Enrolled\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003en\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e41\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSex, n(%)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e19 (46)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22 (54)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAge in years, mean (SD)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8.32 (2.45)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003ePrimary Diagnosis, n (%)\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLaceration\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e14 (34)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eOther Musculoskeletal Injury\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9 (22)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eExtremity Fracture\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6 (14.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eClosed Head Injury\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2 (4.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eEye Injury\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2 (4.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eForeign Body\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2 (4.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6 (14.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II: Model of Caregiver Response to Child\u0026rsquo;s Encounter with Therapy Dog: \u003c/strong\u003equalitative analysis of survey comments.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCausal\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePhenomenon\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCategories\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eConsequences\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eContext/Intervening Conditions\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDistraction and Enjoyment\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eChild became calmer and experienced increased relaxation and decreased anxiety\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCalming of the Child\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNote: All categories were determined to have the same consequences\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eThe consequences were:\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eCaregivers perceived intervention as effective\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eThere was a positive outlook on dogs\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eThe experience was viewed as positive by caregivers\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eContext: pain, discomfort, fear of hospital, injury\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eIntervening Conditions: age, procedures, interaction with child life, baseline anxiety\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDistraction, Relaxation, comfort, and Enjoyment\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eChild\u0026rsquo;s mood was improved \u0026ndash; caregivers noted smiles and child perking up\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eImprovement of Child\u0026rsquo;s mood\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDistraction, Improvement in mood of child and parental worry\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCaregiver became more relaxed, calmer, and experienced less anxiety\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCalming of the Caregiver\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDog\u0026rsquo;s disposition, Dog\u0026rsquo;s behavior, and Handler\u0026rsquo;s actions\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCaregiver\u0026rsquo;s felt appreciated\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePraise for Intervention\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III: Examples of Caregiver Comments\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabc\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCategory\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eExcerpt\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCalming of the Child\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026ldquo;My daughter really enjoyed interacting with the dog Duncan today. She says she feels more calm and happy and would love to see him every time she has to come here.\u0026rdquo;\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eImprovement of Child\u0026rsquo;s Mood\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026ldquo;Made her smile, first time I\u0026rsquo;d seen a smile all day. They were very pleasant and helped a great deal.\u0026rdquo;\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCalming of the Caregiver\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026ldquo;The therapy dog really helped me, the mom, calm down as well, Thank you!\u0026rdquo;\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePraise for Intervention\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026ldquo;The therapy dog was the best part of the visit! Such a positive and calming experience for the patients and family!\u0026rdquo;\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3870813/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3870813/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003edetermine change in emotional management in children 4\u0026ndash;12 years after a visit from a therapy dog and certified child life specialist (CCLS) handler, via observed modified CEMS scores (Children\u0026rsquo;s Emotional Management Scale), and to determine change in perceived anxiety reported by caregivers, via Subjective Unit of Distress (SUD) score.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eProspective observational study at a large/urban ED within a freestanding children\u0026rsquo;s hospital from May-July 2021. Children 4\u0026ndash;12 years with at least mild anxiety (SUD\u0026thinsp;\u0026ge;\u0026thinsp;30) eligible. Children ineligible: current infection, transferred, presented for burn care/dog bite, history of neutropenia/oncologic process, triaged ESI category 1/2, patient/caregiver with fear/allergy to dogs, or already had undergone a procedure. Participants received a 10-minute visit with CCLS and therapy dog. Modified CEMS (accounting for mask use) and SUD scores recorded prior and after intervention by research team and caregiver, respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e95 patients approached, no families refused participation, 41 enrolled. After the intervention, modified CEMS scores significantly decreased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as well as parental perceived anxiety via SUD score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mean duration of intervention was 9.10 (3.58) minutes; mean ED length of stay was 3.33 (1.50) hours. 95% of caregivers reported strong satisfaction with therapy dog.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAn encounter with a therapy dog and CCLS handler significantly improves emotional management and decreases anxiety in pediatric patients in the ED. Caregivers perceive therapy dogs as calming for their child and praised the intervention. These results support future prospective randomized trials involving therapy dogs in managing pediatric distress in the ED.\u003c/p\u003e","manuscriptTitle":"The Impact of Therapy Dogs on Anxiety and Emotional Management in the Pediatric Emergency Department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-25 15:30:29","doi":"10.21203/rs.3.rs-3870813/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0a86602-b713-42cd-8635-c17640942dd6","owner":[],"postedDate":"January 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-28T17:14:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-25 15:30:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3870813","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3870813","identity":"rs-3870813","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}