What is An Emotional Support Animal?

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Patient Presentation
Two primary care pediatricians were discussing how they both had had requests for certification of an emotional support animal for their college-aged patients. Both patients were moving out of the dorms and were requesting an animal to live with them in their apartment.

“I haven’t seen her for almost 2 years and in looking through her chart, I don’t see any medical disability nor any mental health problems, so I told wrote back through the electronic medical record that she would need to contact her mental health provider. She hasn’t contacted me since,” he recounted. “I know my patient but I haven’t treated him for his mental health disability. The last time I saw him he was doing better. I also referred him back to his psychiatrist who has been treating him, but also told him that if he was having a problem to contact me again or come in,” she remarked. “We write lots of letters certifying disabilities, but I’ve been seeing more of these in the past couple of years,” he said. “Yeah, these must be more common for adult providers but still have to be difficult if you don’t really know the patient or you aren’t treating them for the particular disability,” she replied.

Discussion
Humans have had animals in their lives for millennia. Domesticated animals have been used for work, food, protection, and companionship among other activities. Dogs are a common species that are trained for a myriad of tasks including providing therapeutic benefits to persons with permanent or temporary disabilities including persons with psychiatric problems. The utilization of animals in medical/psychiatric therapeutic treatment programs is known as animal assisted activities (AAA) and animal assisted therapy (AAT). These programs have at least a 225-year history of being used. AAA tend to focus on recreation and quality of life activities, education, and motivation. AAT programs are used as part of a person’s overall therapeutic treatment plan for their disability. AAT programs are generally not stand-alone therapies.

These programs are used in “… numerous venues including schools, hospitals, mental health facilities, nursing homes, prisons, courtrooms, businesses, and physician’s offices.” They have been used successfully for anxiety, depression, behavioral problems, post-trauma including physical and mental health problems, substance abuse, grief, autism spectrum disorder, blindness, seizures, pain, and other problems. They can help “…encourage independence, self-esteem, psychology well-being, empathy and trust.”

Potential problems for using animals include:

  • Allergic reaction
  • Injuries such as bites
  • Zoonoses
  • Financial cost of training and maintaining an animal
  • Household disruption – sleeping problems, sanitation

Obviously the animal’s welfare must be appropriately attended to as well.

Learning Point
In the United States, there are certain legal statutes that are more influential regarding people with disabilities to utilize and be accompanied by an animal.

  • The Americans with Disabilities Act (ADA) allows disabled individuals to bring a service animal into local government building and public venues and is overseen by the Department of Justice. Workplace regulations are provided through the Equal Employment Opportunity Commission who provide “interpretive guidance” for employees and employers for reasonable accommodation requests for disability-related assistance animals.
  • The Fair Housing Act (FHA) has “adapted a more expansive view of what animals might act as a reasonable accommodation.” Animals are not pets but can be emotional support animals. It is overseen by the Department of Housing and Urban Development.
  • The Air Carrier Access Act uses the term service animal but with broader meaning that can include emotional support animals. However airlines are not required “…to permit an animal aboard if doing so would be unduly burdensome,…” and can deny certain types of unusual animals such as reptiles, spiders, rodents, etc.
    It is administered through the Department of Transportation.

Definitions of animals includes:

  • Service animal –
    “As defined by the ADA, a dog or miniature horse that has been individually trained to perform specific tasks that mitigate a person’s disability.”
  • Psychiatric service animal –
    “As defined by the ADA, a subset of service animal that has been individually trained to perform specific tasks, which do not include the provision of “emotional support,” that mitigate a person’s disability from psychiatric illness.”
  • Emotional support animal (ESA) –
    “An animal of any species, which does not qualify as a service animal under the ADA, that a medical provider has certified can mitigate a person’s psychiatric disability through companionship rather than by any specifically trained task(s).”
  • Therapy animal –
    “Any species of animal utilized by a trained handler, either through the animal’s presence or a guided interaction as a part of a structured animal-assisted therapy, to provide therapeutic benefit for persons with illness and suffering.”
  • Pet –
    “An animal kept for companionship or pleasure that is not clinically certified for therapeutic use in any illness or disability and is not afforded any special accommodations under the law.”

The Iowa Civil Rights Commission has sample policies and request forms here.
Letters asking for accommodations and/or certification of animal use include questions such as what reasonable accommodations the person is asking for, are these accommodations related to a disability, is the animal required because of the disability, is the animal trained and performs specific tasks, type of animal and animal health, etc.

Questions for Further Discussion
1. What types of disabilities do you write certifying letters for?
2. What types of problems do you you write similar letters for?
3. What types of AATs are available in your area?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Pet Health and Rehabilitation.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Endenburg N, van Lith HA. The influence of animals on the development of children. The Veterinary Journal. 2011;190(2):208-214. doi:10.1016/j.tvjl.2010.11.020

Mims D, Waddell R. Animal Assisted Therapy and Trauma Survivors. J Evid Inf Soc Work. 2016;13(5):452-457. doi:10.1080/23761407.2016.1166841

Hill J, Ziviani J, Driscoll C, Teoh AL, Chua JM, Cawdell-Smith J. Canine Assisted Occupational Therapy for Children on the Autism Spectrum: A Pilot Randomised Control Trial. Journal of Autism & Developmental Disorders. 2020;50(11):4106-4120. doi:10.1007/s10803-020-04483-7

Carroll JD, Mohlenhoff BS, Kersten CM, McNiel DE. Laws and Ethics Related to Emotional Support Animals. The Journal of the American Academy of Psychiatry and the Law. 2020;48(4):10.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published