Do Dogs Detect Hypoglycemia? Two Studies Say Yes, but a Third Raises Serious Doubts

Three UK scientists, one of which is the CEO of a dog training organization that specializes in medical detection dogs, have published a study (Rooney et al. 2013) that “points to the potential value of alert dogs, for increasing glycaemic control, client independence and consequent quality of life and even reducing the costs of long term health care.” Another preliminary study (Gonder-Frederick et al., 2013), also using self-reporting, largely confirmed the results of the first study.  A third study (Dehlinger et al., 2013), however, found that trained hypoglycemia alert dogs, when faced with swabs taken from patients during hypoglycemic periods and swabs taken during normal glycemic level periods, could not distinguish them at a level greater than chance.  It will be important for future research, and for the credibility of this kind of service dog, to determine how such disparate results can be reconciled. 

The UK Study

Summarizing prior research, Rooney et al. noted that “studies relied on owners accurately recalling past events,” meaning that “the frequency with which dogs respond may be over-reported.”  They also note that previous studies of dogs have concentrated on hypoglycemic episodes exclusively, whereas their study also examined hyperglycemia.  The subjects in this study had Type 1 diabetes.

Medical Detection Dogs, the charity of one of the authors, has trained over 20 dogs in hypoglycemia alerting. This and other charities have used trained alerting behaviors that “include licking, pawing, jumping, staring, vocalizing and even fetching a blood testing kit” when an owner’s blood sugar level falls outside a target range, usually 5-15 nm/l. (Alerting by fetching a blood testing kit is a specific set of actions that is not likely to be accidental, but it must be wondered if owners might sometimes confuse some of the other actions with non-alerting activities of a dog.  It is to be hoped that the authors will follow with an article about the training methods used in this study.)  This study sought to assess claims that using such dogs facilitates tightened glycemic control, reduces hypoglycemic episodes, nocturnal lows, and calls for paramedic assistance.   

The 16 subjects completing the study were clients of Medical Detection Dogs with trained and certified or “advanced trainee dogs,” the latter being deemed to alert sufficiently accurately to participate in the study despite a lack of certification.   Subjects had lived with a hypoglycemia alert dog as short as four months and as long as seven years.  The subjects provided detailed information about how having an alert dog had changed their lives, including the estimated frequencies of low blood sugar pre-dog and with the dog, of episodes of losing consciousness, and of paramedic calls.  All subjects reported a decrease in at least one of these categories after obtaining a trained dog.  Eight people who reported having episodes of unconsciousness before getting a dog said they did not have such episodes after getting one.  Three people reported having made paramedic calls before getting a dog but not after.  Almost all subjects (15) trusted their dogs to alert to low blood sugar levels, while 13 trusted them to alert to high blood sugar levels. The scientists explain this discrepancy from the fact that alerting to high blood sugar “is a secondary task, trained subsequent to a strong alert to low blood sugar.” 

In the second phase of the study, subjects were asked to record their dog’s alerting behavior and to provide blood test results.  The study found that blood tests for eight of ten subjects showed that a sample taken after a dog’s alert was significantly more likely to be out of target range than was a routine sample.  One dog was apparently alerting at random.  The study states that for “the best performing dog, the odds of an alert being when bloods were out of range were 10,000 times higher than that of routine tests.”  Eight subjects who recorded nocturnal lows pre-dog had fewer nocturnal lows post-dog, though two had an increase post-dog.

The authors of the study state their results with some hedging on the fact that much of their data depends on self-reporting by subjects:

“The population, overall, reported reduced unconscious episodes and paramedic call outs, which if accurate, is of great importance since not only does it represent increase health and safety of the client, but also potentially significant reduced costs in health care.”    They also note that “for 80% of the clients providing sufficient data, when their dog was recorded to perform an alerting behaviour their blood was significantly more likely to be out of target range than it was during routine samples. In addition, comparison of owner’s routine test records from before and after obtaining their dog, showed highly significant overall change: all but one client being more likely to be within target range post-dog; five out of nine clients experienced a significantly reduced incidence of low blood sugars, and three of the remaining four showed a significant reduction in high blood sugars, suggesting improved glycaemic control in most clients. The two clients who showed no significant increase in percentage within target (1 and 5), had dogs which were unqualified and the clients reported to be experiencing training problems, which were subsequently resolved.” 

As to what the dogs are actually alerting to, these scientists argue that odor cues are the most plausible explanation, particularly given that when this occurs when owners are asleep, behavioral cues would presumably be few, “although changes in breathing rate may occur.”  Also, some owners report the dogs alerting when they are in another room.  Thus, it “is likely that dogs detect changes in the chemical composition of their owners’ sweat, or breath (including products of ketosis)….” 

The Virginia Survey

  

A short paper appearing in Diabetes Care, Gonder-Frederick et al. also gathered data from persons with Type 1 diabetes.  The patients had received diabetic alert dogs from Service Dogs by Warren Retrievers, Inc., located in Culpeper, Virginia.  The survey asked how often respondents experienced hypoglycemia with no corresponding alert from their service dog.  More than a third (36.1%) reported no such occurrences, 27.8% reported fewer than one event per week, and 36.1% reported more than one per week. Respondents reported significant decreases of severe and moderate hypoglycemia since getting a dog, though detailed statistics were not included in the one-page summary.  Subjects reported decreased worry about hypo- and hyperglycemia, and increased participation in physical activities.  The authors of the study conclude that their preliminary results justify additional research. 

The Oregon Study

In a study that did not use self-reporting, Dehlinger et al., subjects rubbed sterile cotton swab samples by rubbing them on the skin of both arms during hypoglycemic and normal glycemic periods.  (The UK study also indicated that the dogs were “increasingly” trained “using remote odour samples collected from clients during times of hypoglycaemia” before the dog and owner were introduced.) The three dogs used in the study had been trained to press a bell after sniffing a container with a hypoglycemic swab.  The dogs were trained by Dogs Assisting Diabetics Foundation of Forest Grove, Oregon.  The owners of the dogs, and their trainer, believed the dogs were consistently able to detect hypoglycemia.  Each dog was tested with 24 samples by being presented with a sample from 30 to 45 seconds.  The overall results for each dog, and combined, are contained in the following table.

	Dog 1	Dog 2	Dog 3
Percent correct, each	54.2	58.3	50.0
Percent correct, all	54.2
Sensitivity, each	50.0	58.3	58.3
Sensitivity, all	55.5
Specificity, each	58.3	58.3	41.7
Specificity, all	52.8

The researchers did not provide an explanation as to why dogs trained to alert to hypoglycemic swabs could not do so in their experimental setting.  The researchers concluded that “trained dogs were largely unable to identify skin swabs obtained from hypoglycemic T1D subjects.” They indicate that future studies should factor in behavioral effects, and should perhaps look at swabs taken only from the usual human companions of the dogs. 

I am particularly concerned about this study because a researcher with whom I occasionally work told me that he met a detection dog trainer at a diabetes conference.  Concerned that her description of how the dogs worked allowed for a Clever Hans effect, he asked to use three dogs for a quick double-blind study.  The dogs did not perform better than chance. 

How Can the Inconsistencies Be Explained? 

There are a number of ways that the inconsistencies of the studies might be explained. Chemical changes might be complex, and vary in the sweat of different owners.  Dogs trained from sweat swabs from the skin of multiple owners might, once deployed with a single owner, display different levels of recognition of hypoglycemia.  If dogs primarily or even partially recognize low or high blood sugar from behavioral changes in their owners, this could also explain some inconsistencies.  If it is ultimately verified that dogs recognize changes in blood sugar changes when their owners are asleep, behavioral recognition might be reduced to detection of changes in breathing patterns.  It is also possible that if dogs recognize changes in blood sugar from a mixture of chemical and behavioral changes, a study only looking only at chemical changes, as is true of the third paper discussed above, will not produce good results. 

There were many more dogs in the first two studies than in the third, which had only three.  It could be that a larger number of dogs in the third study would have produced more positive results.  As noted above, the researchers did not explain why dogs trained to recognize hypoglycemic swabs did not do so effectively in their study.  The research used double-blind investigators.  Were the dogs trained in an environment where cueing was possible so that in an experimental environment where it was not the results were not significant? Was there a Clever Hans effect because the dogs were responding to the patients’ behavior?  Were other controls missing from the training environment, meaning the dogs were not really trained at the level the researchers supposed?  Were the methods of collecting sweat in training and in the experiment really identical?    

Self-reporting may be more flawed than is acknowledged in the first two studies. Patients may be seeing what they want to see, or the companionship of the dogs may make patients more attentive to their own care.  The blood samples collected by subjects in the first study after their dogs alerted were significantly more likely to be out of the target range than a routine sample.  If, however, the owners recognize the change in themselves, could they be unconsciously cueing their dogs to alert, then taking the samples.  If this turns out to be the case, are the dogs, presently recognized as service dogs, really emotional support animals?  Since they are trained to perform behaviors related to the disability of their owners, they would arguably still be service dogs, but if those behaviors do not in fact correlate with the aspect of the disability the dogs are supposedly trained to react to, is the training still related to the disability?  That is a legal question that, my guess is, courts will not look forward to considering soon.

Conclusion

Hypoglycemia alert studies bear a resemblance to seizure alert studies in that most results to date have involved self-reporting.  As I noted in the chapter on this subject in Service and Therapy Dogs in American Society, one study that videotaped two patients with dogs in an epilepsy care unit (Ortiz and Liporace, 2005) found that seizure dogs were poor in alerting before a seizure and concluded that seizure dogs “were not as effective as previously thought in predicting seizure activity.”  These authors acknowledged the small size of their sample. Another study (Krauss, Choi, and Lesser, 2007) found that seizure-alert dogs were effective in detecting psychogenic nonepileptic seizures (PNES) but not necessarily in detecting epileptic seizures. The authors stated the cases they analyzed "show that patients with abnormal illness behaviors may seek service animals for support." 

Scientific discoveries often begin with anecdotal accounts, such as the initial reports of dogs that seemed to recognize that dark patches of skin on their owners were somehow disturbing, followed by the discovery that the spots were melanomas.  This led to the phenomenon of cancer sniffers.  Rigorous studies on cancer detection by dogs, however, have led to high levels of specificity and sensitivity of 80% or more, not the anemic 50% shown here.  For scientists to be persuaded that dogs can reliably detect hypoglycemia, there will have to be something more than has been demonstrated by survey studies, no matter how sophisticated, since these studies are inevitably subjective, sometimes little more than a distillation of multiple anecdotal reports.  

It is important that hypoglycemia alerting be verified in strict double-blind settings, and it can be expected that such conflicting results as discussed here, and the ultimately positive benefits if alerting is verified to actually occur, will encourage additional research and open the spigot for funding such research.  The law should sit on the sidelines for a time, as long as dogs that are claimed to have blood sugar level detection abilities are also trained well enough not to be a distraction to other patrons or passengers in public places and transportation.  Nevertheless, even here there should be an expectation that this type of alerting can eventually be supported by highly controlled scientific results. 

This blog was written by John Ensminger and L.E. Papet. Thanks to Dr. Tadeusz Jezierski for comments. 

Sources:

Dehlinger, K., Tarnowski, K., House, J.L., Los, E., Hanavan, K., Bustamante, B., Ahmann, A.J., and Ward, W.K. (2013).  Can Trained Dogs Detect a Hypoglycemic Scent in Patients with Type 1 Diabetes?  Diabetes Care, 36, e-98-9.

Gonder-Frederick, L., Rice, P., Warren, D., Vajda, K., and Shepard, J. (2013). Diabetic Alert Dogs: A Preliminary Survey of Current Users. Diabetes Care, 36, e47.

Krauss, G.L., Choi, J.S., and Lesser, R.P. (2007).  Pseudoseizure Dogs. Neurology 68(4), 308-9.

Ortiz, R., and Liporace, J. (2005).  “Seizure-alert dogs”: Observations from an Inpatient Video/EEC Unit.” Epilepsy and Behavior, 6(4), 620-622.

Rooney, N.J., Morant, S., and Guest, C. (August 2013). Investigation into the Value of Trained Glycaemia Alert Dogs to Clients with Type 1 Diabetes.  PLOS/One 8(8), 369921. 

When a Therapy Dog Bites

A handler who belongs to a national therapy dog organization, as I do, is required to certify annually that the dog has not bitten anyone or shown overt aggression since the previous renewal of membership.  This requirement is not limited to incidents that happen during visitations.  A recent case from New York involved a therapy dog that bit a guest at a party in the home of his owner.  The certifying organization was not informed of the bite (until I sent them an email asking for comment), and the dog's certification continued for two years after the incident.  Should the dog have been allowed to continue a visitation schedule? I look at the issues of this case in a commentary posted on the website of the Animal Legal and Historical Center.

Psychiatrist’s Letter Proves Crucial in Patient's Dispute with Landlord over Dog

Dr. J.L. Thomas and I wrote an article for psychological and medical professionals regarding letters that such professionals are asked to write on behalf of patients with service and support animals.  In the article, which appeared in the Journal of Forensic Psychology Practice, we analyzed letters that were influential in legal cases where patients sued to gain access to public accommodations, transportation, or housing.  We also analyzed letters that had the opposite effect, either not helping patients or actually harming their cases.  A recent case from a federal district court in California involves a letter from a psychiatrist that was the primary evidence that persuaded the judge to grant summary judgment for the patient who had sued the landlords for failing to grant her a reasonable accommodation to live with a dog that, according to the psychiatrist, was “of much benefit to her mental state and necessary for her continued stabilization.” 

Difficulty with a Landlord

Sharon Smith suffers from various mental disabilities, with symptoms that include depression, frequent bouts of crying, and anxiety.  Her psychiatrist, Dr. David L. Friedman, concluded that she was “temporarily totally disabled,” and diagnosed her as having adjustment disorder, pain disorder, and insomnia.  Smith herself states that her mental disabilities inhibit her ability to take care of herself, get out of bed, interact with others, and remain focused.  She also suffers from injuries to both wrists, for which she has received surgery but has not fully recovered.

Smith has lived with a companion dog, Layla, a ten-pound terrier.  Smith asserts that the dog helps to alleviate the symptoms of her mental disabilities, and stated in a declaration to the federal district court for the Central District of California that Layla “helps me keep a regular routine of caring for myself, motivates me to get out bed, clean, maintain relationships with friends and family, and to exercise.” 

In June 2012, Smith moved into an apartment rented by Harold and Zelma Powdrill before seeing, signing, or reviewing a lease agreement.  She informed Philip Powdrill, a son of the owners, that she would be living with a dog, which she told him was a companion animal necessary to address her disabilities.  Philip sent a text message to Smith asking her how the dog was doing in its new home. 

On June 30, Valerie Powdrill, the daughter of the owners, gave Smith a copy of the rental agreement to review and sign.  The agreement included a no-pets clause that stated:  “No dog, cat, bird, or other domestic pet or animal of any kind may be kept on or about the premises without LANDLORD’s written consent.”  Smith signed the lease but did not initial the page with the no-pet provision. 

According to the federal district court for the Central District of California:

“Uncomfortable with representations by Philip Powdrill that she could keep the dog so long as she kept it on the ‘down low,’ … , on or about July 12, 2012 Plaintiff sent a handwritten letter to Defendants requesting an exception to the no-pet policy…. In the letter, Plaintiff introduced herself as a new tenant and stated that she has undergone surgery to both her hands due to workplace injuries, receives disability benefits, and is currently attending physical and mental therapy…. Plaintiff stated that she was unaware of the no-pet policy when she moved in and requested an accommodation to allow her to keep the dog because it had been deemed a necessary form of emotional support by her doctor…. She described the dog as ‘well trained, doesn't bark, [and] completely house broken.’”

The Psychiatrist’s Letter

To her own letter, Smith attached a letter from her psychiatrist, Dr. Friedman, stating:

“Please be advised that I have been treating Ms. Smith since April 2012. As part of her psychiatric difficulty she suffers from a severe Adjustment Disorder, Pain Disorder, and Insomnia. Due to Ms. Smith's psychiatric condition, having a companion animal would be of much benefit to her mental state and necessary for her continued stabilization. I believe, Ms. Smith should be allowed to have such animal at her place of residence. Should you have any questions please do not hesitate to contact this office.”

Zelma Powdrill replied to Smith’s letter on July 16, 2012, denying the request for an accommodation.  The letter said that Smith had given differing explanations as to who owned the dog and whether it would be living with her, adding:  "Your letter dated July 12, 2012, asking us to allow you and the dog to stay, indicates you are in possession of a dog in the apartment…. Our lease clearly states no pets are allowed, therefore we have enclosed a NOTICE TO PERFORM CONDITIONS AND COVENANTS OR QUIT."  The notice was attached, stating that Smith had three days to comply or leave the premises.

On July 24, 2012, a former case analyst at the Housing Rights Center, Gabriela Garcia, called and spoke to Zelma Powdrill, telling her that Smith was a person with mental disabilities and requires the use of a companion animal to alleviate the symptoms of her disabilities.  Zelma insisted that she would not allow Smith to keep the companion dog in the unit, saying that it would result in extra costs to renovate the apartment, that dogs are meant to be kept outside, and that she wanted Smith out of the unit.  Garcia sent a letter to Zelma concerning their conversation and confirming the Powdrills’ refusal to grant the requested accommodation.

Smith vacated the apartment on March 7, 2013. 

Tenant Files Lawsuit

Smith filed suit under the Fair Housing Amendments Act, the California Fair Employment and Housing Act, the California Disabled Persons Act, and on other grounds, asserting that the Powdrills’ actions had caused her emotional distress, including stress, heightened depression, increased anxiety, fear of retaliation and eviction, and humiliation.  She sought compensatory and punitive damages, as well as attorney’s fees.  The federal district court granted summary judgment to Smith under the three Acts, meaning that the primary issue left to litigate will be the amount of damages for which the Powdrills will be liable. 

Conclusion

As Dr. Thomas and I note in our article, it should not be necessary to give a diagnosis in a letter but, particularly in housing situations, the inclusion of a diagnosis has often been persuasive to courts and appears to have been so here. The letter was obviously written by the doctor himself, as opposed to reading as if downloaded from a website or written by the patient for the doctor to sign.  It avoids any overly broad statement about what benefit the dog will provide—that is, no cure is claimed.  Rather, it simply states that “a companion animal would be of much benefit to her mental state and necessary for her continued stabilization.”  Finally, the psychiatrist indicates his willingness to talk with the landlords if they should wish.  It was the refusal of the landlords to engage in any kind of dialogue with the tenant, to find out anything more about what the dog meant to her, to even consider that it might not just be a pet, that doomed their case. If Dr. Thomas and I ever revise our article, this decision will be included. 

AKC Test Qualifies Emotional Support Animals for VA Study: Is the VA Considering New Policies on Service Dogs and ESAs?

In a "Sources Sought/Request for Information" posted on the federal business opportunities website, FedBizOpps.Gov, where government contracts are announced, the Department of Veterans Affairs says it is looking for suppliers of dogs “to determine the efficacy of service dogs in the treatment of Posttraumatic Stress Disorder (PTSD).”  The study began two years ago, but is now to be revised and expanded to include emotional support dogs as well as service dogs. 

The dogs for this study must be provided by nonprofit 501(c)(3) organizations, in accordance with Public Law 111-84, the defense appropriations act of 2009.  At § 1077, that legislation provided that the Secretary of Veterans Affairs was to begin “a three-year study to assess the benefits, feasibility, and advisability of using service dogs for the treatment or rehabilitation of veterans with physical or mental injuries or disabilities, including post-traumatic stress disorder.”  The appropriations act allows the VA to “reimburse partners $10,000 for each dog provided to a veteran who enrolls in the study and successfully completes a training program offered by one of the partners.” 

Public Law 111-84 stated that the VA was to partner with 501(c)(3) organizations that “are accredited by, or adhere to standards comparable to those of, an accrediting organization with demonstrated experience, national scope, and recognized leadership and expertise in the training of service dogs and education in the use of service dogs.”  As I noted previously, the VA has generally chosen to ignore the “standards comparable to those of” language in the appropriations act and prefers to designate full member organizations of Assistance Dogs International as the sole source of service dogs for veterans.  (ADI candidate members are not acceptable to the VA, as stated at 77 Fed. Reg. 54372, middle column.)

Assistance Dogs International Public Access Test

In the Request for Information, the VA indicates that it is now going to be conducting a “revised study” and that for this study service dogs “will be required to meet Assistance Dogs International (ADI) Public Access Testing criteria.”  This wording is curious, in that it appears to allow for the possibility that a dog could meet the ADI’s Public Access Test, which is posted online by ADI, without necessarily being administered by anyone affiliated with ADI.  That, however, does not square with what ADI indicates on its website (last checked 11/11/2013), where the organization states that the “test was designed to be administered by professional Assistance Dog Trainers,” and cautions:

“Administering this test by non members of Assistance Dogs International is not authorized by Assistance Dogs International nor would completion of this test be considered certification by Assistance Dogs International.” 

ADI also places a copyright notice on its Public Access Test, meaning that it might claim a copyright violation against someone printing out and using the test without its permission.  I venture to note, in any case, that most therapy dogs, including mine, would have no problem passing the Public Access Test. 

American Kennel Club (AKC) Community Canine Standard

The reason for writing this blog are the references in the VA’s Request for Information regarding emotional support dogs.  Emotional support dogs are not mentioned in the 2009 defense appropriations act.  Neither are they mentioned in 38 U.S.C. 1714, which provides that the VA may provide “service dogs trained for the aid of persons with mental illnesses, including post-traumatic stress disorder.”  Two current House bills deal with veterans' service dog issues but also do not mention emotional support animals (H.R. 183 and 2847, both of which are hold-overs from the 112^th Congress and neither of which has a good shot of passing at the moment). 

The VA states that “emotional support dogs will be required to meet the new American Kennel Club (AKC) Community Canine© standard, which is an advanced extension of the AKC Canine Good Citizen© testing.”  Many therapy dog handlers in the United States, including me, have dogs that have qualified as Canine Good Citizens. 

The AKC announced in the akcgazette of July 2013 (vol. 130, no. 7), that its Board had “VOTED to approve the creation of an advanced CGC testing program called AKC Community Canine.”  Dogs that pass the test are awarded the title of “Community Canine (CMC).” The test was officially available on October 1, 2013.  That I could find, the AKC website does not seem to indicate that the organization sees this particular test as a means of verifying that a dog qualifies as an emotional support animal.  Rather, the organization describes the title as testing a dog’s skills in natural settings, rather than in a ring isolated from real world situations.

So why does the VA see such a function for the test?  It may be, that as with choosing ADI to bless service dogs, the VA has chosen the AKC to consecrate emotional support dogs.  There are differences here from the service dog situation, however.  By saying that only an ADI organization can create a service dog, the VA has allowed that organization and its full members to hold a monopoly on training service dogs for veterans.  The AKC tests, on the other hand, are administered by a broad system of evaluators for dogs trained by anyone.  In New York State alone there are more than 400 AKC Evaluators according to a search engine provided by the AKC, many within a short drive of where I live in Ulster County.  The Evaluators charge a small fee, but are generally only marginally remunerated for performing the tests.  Many tests may be parts of other testing programs, such as for therapy dogs.  If there is a monopoly, it seems to be a fairly harmless one. 

Comparing the ADI Public Access Test, the AKC Tests, and Therapy Dog Qualification  

Many animals that qualify under the AKC tests might be trained at levels, at least as to behavior in public settings, not much different from what is expected of service animals.  The following table roughly attempts to correlate the testing requirements of ADI’s Public Access Test, the AKC’s CGC and Community Canine tests, and a standard therapy dog test.

ADI Public Access Test	AKC CGC Test	AKC Community Canine Test	Therapy Dog Test
Vehicle requirements: remaining until release, waiting beside, under control while another dog walks past.	Two handlers get within 10 feet, but dogs should show no more than casual interest in each other and neither dog should go to the other or its handler.	Dog walks past distraction dogs within 2 feet while on trail, sidewalk, hallway, etc.	Dog performs group sit-stay and down-stay; dog and handler meet another dog and dog remains in handler’s control.
Dog stays in relative heel position, calm around traffic, stops when individual comes to halt.	Dog remains in control while walking with handler, but need not be perfectly aligned with handler.	Dog remains under control while handler fills out paperwork, visits with another person.	Dog remains under control at entry table for testing.
Dog waits at door until commanded to enter, waits inside until able to return to heel position.	Dog remains with handler while walking.	Dog enters/exits a doorway or narrow passageway in a controlled manner.	Dog walks through hospital environments without being distracted under control of handler; dog remains at sit, stand, or down stay on command before door to facility.
Dog within “prescribed distance” of individual; ignores public, remaining focused on individual; adjusts to speed changes; readily turns corners without being tugged; maneuvers through tight quarters.	Dog walks through pedestrian traffic under control in public places passing close to at least three people; dog stays at heel during right turn, left turn, and about turn.	Dog walks on loose leash in natural situation, does not pull, makes left and right turns, stops, goes at fast and slow paces;  dog walks on loose leash through a crowd.	Dog moves through people in hallway; dog remains calm upon approach of several people at once; dog makes left and right turn and about-turn after encountering distractions.
Dog responds to recall command on 6-foot lead, does not stray away or seek attention from others or trudge slowly; remains under control and focused on individual; comes within prescribed distance on recall and comes directly to individual.	Handler walks 10 feet from dog, faces the dog and calls it; handlers may use “stay” or “wait” command or simply walk away to put dog in place.	Dog performs recall on 20 foot lead.	Dog commanded to stay and handler moves to end of 20 foot lead, turns around, and on command recalls the dog.
Dog responds promptly to sit command; remains under control around food, not trying to get it and not needing repeated corrections; dog remains composed while shopping cart passes; dog remains at sit-stay while petted by stranger.	Dog accepts friendly stranger without showing resentment or shyness; dog accepts petting from friendly stranger; dog accepts being groomed by evaluator; dog responds to sit and down commands and remains in place on 20-foot lead.	Dog performs sit-stay in group of 3 other people with dogs; handler leaves dog on 20 foot lead, picks up item, returns to dog.	Dog performs sit-stay in group; handlers leave the dogs and move to end of 6 foot leads and wait for evaluator’s command to return to dogs; also a group down-stay; dog is readily accessible for petting by patient; can approach wheelchair.
Dog responds to down command; remains under control around food; remains in control while child approaches (but child should not taunt dog or be overly dramatic)		Dog obeys “leave it” command around food on floor or ground.	Person with walker offers dog a treat, but handler instructs dog to leave it and dog must do so; dog passes food on floor and must walk a straight line and leave it; dog remains calm around playing children.
Dog should remain composed during noise distractions.	Dog should be confident with distractions such as dropping a chair, rolling a crate dolly, having a jogger run in front of the dog, etc.		Dog keeps on straight line walking past distractions, including person on crutches, person running, bicycling, rollerblading; loud noises from dropping something such as can filled with rocks, vacuum cleaner.
Dog is unobtrusive and out of way of patrons and employees in restaurant; dog ignores food and remains quiet.			Dog remains calm in crowds and obeys command to leave food alone.
Dog remains under control when lead is dropped.
Dog taken by another person and dog’s partner can move away without aggression or undue stress.	Another person takes dog and handler goes out of sight for 3 minutes; dog should not bark, whine, or pace unnecessarily.		Helper takes hold of dog’s leash but handler can put dog at stay before; handler moves out of sight; dog can move within confines of lead.
Dog loads into vehicle on command.
Handler praises dog when dog does well; dog consistently relaxed, confident, friendly; partner consistently has dog under control.			Good presentation of handler and dog.

The differences are relatively minor.  ADI looks at dogs getting in and out of vehicles.  This recognizes that a disabled handler is often going to need to be able to get a dog into and out of a car without any physical effort.  People who travel with dogs to any degree will teach them to jump in and out of a vehicle, as I and most people I know have done with our dogs.  There is also an emphasis on going through doors in the ADI test.  People with disabilities may have trouble going through doors, and will need to be confident that, if they cannot go through a door simultaneously with the dog, the dog will catch up or wait for them. I do not know anyone with a therapy dog who has any difficulty with this. 

Potential Significance of the VA’s Approach to Emotional Support Animals

The VA provides a table regarding the distinctions between service dogs and emotional support dogs, indicating that, although emotional support dogs qualify for accommodations in housing and air travel, they do not qualify for entry into places of public accommodation.  The table is reproduced below:

	Service Dog	Emotional Support Dog
General Definition	A dog that is individually trained to perform work or tasks for the benefit of a person with a disability.	A dog that provides comfort or support for a person with a disability, but does not have any individualized training to perform work or tasks.
Reasonable Accommodation in Housing?	Yes. Housing provider may ask for documentation that owner has a disability and there is a disability-related need for a service animal.	Yes. Housing provider may ask for documentation that owner has a disability and there is a disability-related need for an emotional support animal.
Reasonable Accommodation in Places of Public Accommodation and Public Entities?	Yes. Public accommodations and public entities may not ask for documentation, but can ask if the animal is a service animal and what it is trained to do.	No.
Reasonable Accommodation for airline travel?	Yes. Airline may ask whether the animal is a service animal and what it is trained to do.	Yes. Airline may ask for a signed note from a licensed mental health professional, not more than 1 year old, that states that owner has a psychiatric disability and a disability-related need for an emotional support animal.

While this may be a serviceable summary of the general requirements of the Departments of Justice, Transportation, and Housing and Urban Development, it must be noted that the definitions of those agencies make no mention, and would often be inconsistent with the tests that the VA is using to qualify service and emotional support animals.  The VA knows this.  An article posted on a VA website states that:

"One assistance dog advocacy organization, Assistance Dogs International (ADI), has promoted definitions of assistance dog and service dog that are widely cited and accepted by many service dog trainers, but the definitions are not universally used among laypeople or healthcare personnel nor are they aligned with definitions that appear in Federal or state laws." L. Parenti, A. Foreman, B.J. Meade, and O. Wirth (2013). A Revised Taxonomy of Assistance Animals. Journal of Rehabilitation Research & Development, 50(6), 745-756. 

So why was this table included in a Sources Sought/Request for Information? It may have been a way of indicating to prospective emotional support dog providers that they should not expect that dogs they supply would qualify for the access that service dogs receive.  This raises the question, however, of what exactly the VA may be planning for emotional support dogs that are used by veterans with PTSD. A VA webpage on “Dogs and PTSD” also describes the difference between the two types of specialized dogs, but says that generally “a regular pet can be an emotional support dog if a mental health provider writes a letter saying that the owner has a mental health condition or disability and needs the dog’s help for his or her health or treatment.”  Certainly this does not suggest the level of training or obedience required for an AKC Community Canine. 

Is it possible that the VA is considering a change in policy that would allow emotional support dogs to live with veterans in VA or VA-supported facilities, but only if the dogs have a level of training that will avoid their becoming problems for VA administrators?  Could emotional support dogs travel in buses and vans that serve VA hospitals?  Would emotional support dogs have access to VA hospitals where therapy dogs are already being used? 

An even bigger question involves the U.S. Army.  As I have noted before, the Army and the VA have always seemed to be joined at the hip with regard to service dog policies. A major source of pain for enlisted Army personnel with service dogs trained for PTSD has been that the Army has put a ban on dogs for PTSD, stating in Army Directive 2013-01, signed by Secretary of the Army John McHugh, that the “psychological service dogs are not considered service dogs” by the Army.  If the VA is considering recognizing emotional support dogs, will the Army also take this step?  If so, could soldiers live on base with emotional support dogs, and perhaps fly them on military transports?  Presumably they would not be able to take them into base canteens, on the analogy to the ADA requirements with regard to service animals, but even this is not clear. 

Conclusion

Is the idea of using an American Kennel Club standard to determine qualification of an emotional support animal a good one?  It has the advantage of being readily available, and the AKC website says that the cost includes a $20 processing fee.  Test-giving organizations may also charge a fee for conducting the test.  AKC Approved CGC Evaluators administer the test.  When I and Chloe took our therapy dog test, we had such an Evaluator, who was also a therapy dog tester. AKC evaluators will not be hard to come by anywhere in the U.S.  In my case, though going back over five years, the Evaluator charged nothing for the CGC aspect of the test beyond what was forwarded to the AKC, which then sent me and Chloe a certificate. 

This is a much less radical degree of privatization than has occurred with service dogs under VA and Army rules, and could be justified in contexts where an emotional support animal must be firmly in a handler’s control.  There is the additional policy question of whether some greater access to public accommodations and public transportation should be granted a dog with such a high degree of control by a handler, though without specifically individualized training for a disability.  This would require a major policy shift by the Department of Justice, however, and seems unlikely.  Still, it has to be acknowledged that the VA, whether seeking to or not, has brought forth a new idea that might provide a mechanism for dealing with the problem of bogus service animals in public accommodations and transportation.  

There is another policy question that must be asked.  If the VA thinks that testing can qualify dogs to be either service or emotional support dogs, why does the agency not insist that ADI open up its Public Access Test to non-members?  The test would seem to be sufficiently similar to the AKC tests that it could be administered by AKC Evaluators or other neutral testers.  Testing would not need to be restricted to dogs trained by ADI organizations, which would significantly expand the potential sources of service dogs for veterans.  Alternatively, the VA and the Army could ask the AKC to develop a public access test for service dogs, taking into account issues appropriate for service animals, such as getting into and out of cars and going through doors separately from handlers. Solutions exist to the current bottleneck created by VA and Army policies.  It is only a matter of making the effort to find and implement them.   

But I have expressed optimism that the VA and the Army would take intelligent directions in their canine policies before, only to be disappointed, so I advise readers to remain skeptical.  

Thanks to Michael Arnold and Leigh Anne Novak for suggestions that vastly improved this piece.    

Additional Notes.  It has been brought to my attention that, on September 23, 2013, Senator Charles Schumer of New York requested an update on the VA study of service dogs for veterans. He stated: "I feel strongly that the VA should provide service dogs to eligible Veterans with PTSD."  This undoubtedly increased the pressure on the VA to do something, but it does not explain why emotional support animals are suddenly in the picture.  

Someone suggested to me, I think with some degree of cynicism, that the VA may accept that psychiatric service dogs are really only emotional support animals, i.e., that it is impossible to individually train a dog to do work or tasks for a non-physical disability.  While I prefer to believe that this level of ignorance does not control thinking inside of the VA, neither can I rule it out.   

An anonymous commenter below correctly refers to the Clinical Trials site maintained by NIH with reference to the study discussed above.  The site contains several pages devote to a study that is labeled: Can Service Dogs Improve Activity and Quality of Life in Veterans with PTSD? (SDPTSD).  The description of the clinical trial defines an emotional support dog as one "that has earned AKC Good Canine Citizen certification and provides emotional support and comfort to the Veteran."  Curiously, the definition of service dog does not mention ADI, saying only that this is "an assistance dog specifically trained to perform tasks that are specific to the person's disability and has public access privileges."  The final clause presumably refers to the access rules of the Department of Justice.  Why ADI is not mentioned here is not stated. 

Law on Facility Dogs as Aids to Vulnerable Witnesses Continues to Develop

An adult man, Douglas, is retarded but able to hold down a job.  He meets the girl next door, Alesha Lair, who soon moves in with him, and moves in three members of her family as well.  Alesha begins to drain Douglas’s bank accounts and max out his credit cards on presents for her family and friends, including another boyfriend, Timothy Dye.  She sets up an apartment using more of Douglas’s money, then moves out.  But she hadn’t taken everything, so Timothy comes back to get what’s left from Douglas.  He enters the house when Douglas is there and takes things despite Douglas’s protests.  The next day, when Douglas is at work, Dye again returns and takes everything left of any value, leaving the door open as he leaves.  Finally the law gets involved.  Alesha pleads guilty to theft in the first degree with the aggravating circumstance that Douglas is a vulnerable victim.  Timothy Dye fights the charge and is prosecuted.

Douglas has trouble facing Timothy in court and asks to be able to come to the witness stand with a “facility dog” named Ellie. The trial court allows it.  A Washington State Appellate court affirms.  Now the Supreme Court of the State of Washington has also affirmed, making this one of the most important cases in this developing area of the law.   

To know more, read the article below on the website of the Animal Legal and Historical Center of Michigan State University.  Use of facility dogs is an important trend, but I fear that some courts are not being careful to limit the prejudice that might be involved.  I have no sympathy for people like Alesha Lair and Timothy Dye—the facts speak for themselves—but courts should attempt to limit the impact of the presence of the dog as much as possible.  The innocence of the dog must not become proof of the victim’s honesty.  The dog is a way to let the victim to tell his side of the story in a setting that is, for many victims, terrifying, but the dog should not by its mere presence establish that what the victim says is true.  Certain precautions to limit the impact the presence of the animal might have should be considered by courts in these cases.

Recent Cases on the Use of Facility Dogs by Witnesses While Testifying (originally written in 2012 and updated periodically since then).