Under the US Department of Justice's regulations implementing parts of the Americans with Disabilities Act related to public accommodations and commercial facilities, service animals are defined as dogs that have been “individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability.”1 Importantly, the work or tasks service animals perform must be directly related to the individual's disability, animals other than dogs (and, in some instances, miniature horses) are not considered service animals under these regulations, and animals whose sole function is the provision of emotional support are not considered service animals.
In contrast to service animals, emotional support animals (ESAs) are defined as animals that provide “emotional support that alleviates one or more symptoms or effects of a person's disability.”2 Although ESAs are not covered under the Americans with Disabilities Act, they have legal status under the Fair Housing Act and the Air Carrier Access Act, which allow individuals with disabilities to access housing and air transportation, accompanied by an ESA.3
The AVMA has provided information on the definitions of ESAs and service animals and the rights of individuals with ESAs versus the very different rights of individuals with service animals.4 However, there currently is much confusion over what qualifies an animal to be an ESA, which has led, unfortunately, to an increase in the number of individuals who falsely identify their pets as ESAs because of a lack of understanding or who fraudulently do so to gain access to areas where pets are not normally allowed or to avoid fees typically charged to accommodate pets.
In addition, there are numerous websites that falsely claim to provide certification that an animal is an ESA or purport to be a registry for ESAs, even though no ESA certification process or registries have been formally recognized by the federal government. Given this confusion, we wanted to clarify the process by which a person can prove a need for an ESA and discuss the role veterinarians have in assisting clients identify and care for ESAs.
Demonstrating a Need for an ESA
Under current federal legislation, people seeking to own an ESA must have a disability that can be alleviated or ameliorated through emotional support provided by an animal. Veterinarians are not in a position to determine whether any particular individual would benefit from an ESA, and people seeking an ESA should be referred to a primary care physician, psychiatrist, psychologist, social worker, or other licensed health-care provider for appropriate documentation attesting to the clinical need for an ESA.
For an individual to prove that he or she has a need for an ESA, a licensed health-care professional who is knowledgeable of that individual's mental health condition and treatment needs must document that an animal is therapeutically needed to reduce the symptoms of the individual's disability. The support that is provided by an ESA occurs through the benefits of everyday human-animal interactions. Although anyone can experience benefits as a result of human-animal interactions, it is the impact of those benefits on the symptoms of a given person's disability that makes an ESA therapeutically appropriate. Such benefits include, but are not limited to, physical (eg, decreased heart rate, blood pressure, and respiratory rate), social (eg, direct benefits such as reduced loneliness and indirect benefits such as increased socialization with others resulting from the presence of the animal), and psychological (eg, having a purpose and feeling needed) benefits.5 As stated earlier, an ESA does not need to have specific training to provide these benefits, and ESAs are generally indistinguishable from companion animals except in how they can ameliorate a person's disability symptoms. Patients who qualify for an ESA should be provided with a letter from their health-care provider documenting the need for the ESA,6 and a copy should be kept in the patient's medical chart.
The Role of Veterinarians
Individuals with a demonstrated need for an ESA may request that an existing pet be designated as their ESA or may seek to acquire an animal specifically for that purpose. In those situations when a person intends to obtain an animal to be an ESA, the veterinarian should assist with ensuring the animal is suitable for the role and will not experience impaired health or welfare as a result.
Dogs and cats are the most common ESAs, but a wide spectrum of domesticated animals can be designated as ESAs. The only requirement is that the animal must be appropriate and consistent in its behavior in settings where it will accompany the owner. However, there are presently no legal provisions or processes to ensure that animals fulfill this requirement. In addition, no formal federal policies currently require that a veterinarian evaluate the suitability of an ESA, although some airlines may request documentation from a veterinarian regarding the animal's current health status.
In assisting an individual acquire an ESA, the veterinarian should have specific knowledge of the species the owner is requesting, because certain species may not be suitable in certain situations (eg, flying) or may become distressed in public spaces. The veterinarian should ensure that the animal is free from infectious diseases, especially diseases that may be transmitted to people, and that the animal is in good health or that any health conditions are appropriately controlled. The animal should be well adapted to the owner and to activities outside the home; thus, juvenile animals and newly acquired animals typically are not suitable as ESAs. And, the animal should be enrolled in an appropriate wellness plan that includes regular examinations by a veterinarian. All ESAs should be appropriately vaccinated with core vaccines and veterinarian-recommended noncore vaccines. Core vaccines, particularly rabies vaccines, must be administered according to local and state regulations. Noncore vaccines, such as vaccines against leptospirosis, borreliosis, canine influenza, and Bordetella infection, should be chosen on the basis of the lifestyle and risk factors of the ESA. Regular ectoparasite and endoparasite control with veterinarian-approved products should be administered on the basis of regional risk. Additionally, all ESAs should possess both permanent (microchip) and visual (collar) identification registered to the owner's current address.
Because service as an ESA may threaten an animal's health or welfare, the veterinarian should solicit information on the environments to which the animal may be subjected. For example, a bird may be sensitive to mild changes in temperature or air pressure while traveling, and the client should be educated about these risks and how to minimize them or should be advised that the risks are such that the animal should not be used in this capacity.
Most importantly, the veterinarian should ensure that the animal's temperament is suitable for service as an ESA. This includes assessing whether there is any evidence of stress or aggressive behavior when the animal is in public or in other places where it might be taken in its role as an ESA. Various resources for assessing the temperament of animals are available, but simply witnessing the behavior of the animal in the veterinary clinic is a good start. The veterinarian can also question the owner about the animal's past behavior in various situations or might consider accompanying the owner and animal in visits to public places. All of these can help the veterinarian in assessing an animal's suitability for service as an ESA. However, caution should be exercised in providing written descriptions that might be interpreted as a guarantee of good behavior in a strange environment such as an airplane cabin.
Some clients may wish to adopt a puppy or kitten as an ESA. However, the behavior and temperament of immature animals may be quite different from that of adults, so veterinarians and owners should be prudent in their expectations that a particular puppy or kitten will definitely become an ESA. Raising young animals, particularly puppies, may also place additional stress on the person obtaining an ESA, and it is crucial that the additional demands related to house training and otherwise raising a young animal be explained to the person obtaining the animal as an ESA. If adopting a puppy or kitten from a known dam or sire, a client should consider the behavior of the dam and sire as well as related dogs or cats from previous litters. The advantage of adopting a purebred dog is that breed-specific behaviors can be, to some extent, predicted,7 which may help in assessing the suitability of a dog as an ESA. Cat behavior may be more difficult to predict, because most cats are mixed breeds (eg, domestic shorthairs), but breed-specific differences in behavior do exist.8 One of the greatest challenges a cat may encounter as an ESA is remaining composed during travel to and from the airport and while on a plane, which involves experiences different from the stressors encountered in a home setting.
Friendly and outgoing animals are more likely to be suitable as ESAs. An example of a shelter animal ESA placement program is the Hope and Recovery Pet Program, which operates through a collaboration between ProMedica (a regional health-care system serving Northwest Ohio and Southwest Michigan), the Toledo Area Humane Society, and the University of Toledo. Shelter staff are actively involved with assessing animal temperament and activity and in helping match adopters with appropriate ESAs.9
Animals that exhibit aggression toward people or other animals do not make good ESAs, and the veterinarian should advise the owner to seek additional training and behavior counseling. Also, although an ESA may not directly contact or harm another individual, it still has the potential to cause a disturbance to others by, for example, vocalizing excessively. These types of situations should be managed on a case-by-case basis, and the veterinarian should provide guidance to help minimize the potential that an ESA will be denied access because of aggression or other behavioral problems.
Legal and Ethical Issues
Veterinarians face many challenges pertaining to the health and welfare of ESAs, especially because there currently are no federal regulations governing the suitability of animals for service as ESAs. Veterinarians should be familiar with the roles of an ESA and the potential impact of service as an ESA on the animal itself, the owner, the public, and the environment.
Notably, veterinarians are not responsible for policing whether animals have been legitimately or illegitimately designated as ESAs. Even if a veterinarian suspects that an owner has fraudulently identified an animal as an ESA, the veterinarian should at most gather more information, with the intent of educating the individual about the appropriate use of ESAs without chastising the person or possibly compromising the veterinarian-client-patient relationship. If a veterinarian does not believe an animal to be an appropriate ESA on the basis of health status or behavior, the veterinarian should communicate these concerns with the owner and avoid endorsing the animal as an ESA.
If an ESA becomes ill, the owner should not expect the animal to fulfill its role as an ESA until it has recovered. The owner should be aware of any potential adverse effects of prescribed medications, especially sedatives and behavior-modifying drugs that may alter mental status or affect the animal's ability to function. An owner may request that an animal with a chronic disease, such as cancer or degenerative joint disease, be designated as an ESA, and the veterinarian should use his or her judgment to determine whether, if the disease is appropriately treated, the animal's ability to serve as an ESA would be negatively impacted or the animal itself would be negatively affected.
Conclusions
Recently, Brooks et al10 conducted a systematic search of studies exploring the role of companion animals in the management of mental health conditions and concluded that pets can provide benefits. However, they also determined that additional research is required to test the nature and extent of these benefits and to identify the best means to incorporate pets in the support of people with disabilities.
At the same time, a recent anonymous, online survey11 of public perceptions of service dogs and ESAs revealed widespread misconceptions regarding definitions, rules, regulations, and rights associated with them. The survey found that despite recent media focus on abuses and false representation of some animals, most of those surveyed still felt that most people were not taking advantage of the current system but expressed concern about the legitimacy and access rights of ESAs.
Veterinarians are increasingly being asked to support the use of ESAs, but there currently is no regulatory framework to assist veterinarians in understanding the role they play. Thus, all decisions a veterinarian makes in relation to ESAs should follow a clear standard protocol to avoid arbitrary and possibly discriminatory actions. Once a veterinarian has determined that a particular ESA would likely be suitable, the veterinarian should ensure that the health and welfare of the animal are cared for and recommend that the animal receive appropriate training for its intended role.
The AVMA encourages veterinarians to be familiar with the legal status and protections accorded to owners of ESAs and advocates that veterinarians discourage inaccurate or misleading descriptions of those animals’ roles. It is required that an ESA's status be supported by a statement of need from a licensed human health-care professional. Veterinarians should work collaboratively with human health-care providers in developing and supporting guidance for the appropriate use of animals for therapeutic purposes and to assist people with disabilities.
Emotional support animals are increasingly understood to be beneficial for a wide variety of human health conditions; however, the procedures that are in place today do not always ensure that there is a legitimate need for an ESA or that a particular animal is suitable to serve as an ESA. Active teamwork between clients, veterinarians, and human health-care professionals could ensure that more benefits are experienced by people and their animals, while limiting the risks of misidentified animals and unintended outcomes.
References
1. US Department of Justice. Americans with Disabilities Act Title III Regulations. Available at: www.ada.gov/regs2010/titleIII_2010/titleIII_2010_regulations.htm. Accessed Sep 24, 2018.
2. US Department of Housing and Urban Development. Service animals and assistance animals for people with disabilities in housing and HUD-Funded Programs. Fair Housing and Equal Opportunity Notice: FHEO-2013-01. Available at: portal.hud.gov/hudportal/documents/huddoc?id=servanimals_ntcfheo2013-01.pdf. Accessed Mar 30, 2018.
3. US Department of Transportation. Service animal guidance. Available at: www.transportation.gov/airconsumer/service-animal-guidance. Accessed Mar 30, 2018.
4. AVMA. Assistance animals: rights of access and the problem of fraud. Available at: www.avma.org/KB/Resources/Reports/Documents/Assistance-Animals-Rights-Access-Fraud-AVMA.pdf. Accessed Mar 24, 2018.
5. Hoy-Gerlach J, Wehman S. Human-animal interactions: a social work guide. Washington, DC: NASW Press, 2017.
6. Ensminger JJ, Thomas JL. Writing letters to help patients with service and support animals. J Forensic Psychol Pract 2013;13:92–115.
7. Hart BL, Hart LA. The perfect puppy: how to choose your dog by its behavior. New York: W Freeman and Co, 1988.
8. Hart BL, Hart LA. Your ideal cat—insights into breed and gender differences in cat behavior. West Lafayette, Ind: Purdue University Press, 2013.
9. Hoy-Gerlach J, Delgado M, Sloane H, et al. Rediscovering connections between animal welfare and human welfare: creating social work internships at a humane society. J Soc Work doi: 10.1177/1468017318760775.
10. Brooks HL, Rushton K, Lovell K, et al. The power of support from companion animals for people living with mental health problems: a systematic review and narrative synthesis of the evidence. BMC Psychiatry 2018;18:31.
11. Schoenfeld-Tacher R, Hellyer P, Cheung L, et al. Public perceptions of service dogs, emotional support dogs, and therapy dogs. Int J Environ Res Public Health 2017;14:642.
