Veterinarian's role in treating behavior problems (Proceedings)

Treating behavior problems

A veterinary visit should be the starting point for each behavior case. The first step would be to rule out any medical factors that might be contributing to the behavioral signs. Diseases of virtually any organ system can cause or contribute to behavior problems. Medical management, including diet or drugs may also be an important part of the diagnosis or treatment program (e.g. food trial to rule out food intolerance). Should the problem persist after medical conditions have been treated (or ruled out), further guidance will need to be provided in the form of behavior counseling, handouts or both. Some cases might be handled by the veterinarian and staff, particularly if the problem is one with which they have expertise and/or resources to guide the client. Rather than focus on the problems that are serious, seen infrequently, require intensive counseling, or have a more guarded prognosis, practitioners might begin by giving advice for more "common" behavior complaints. A good library of books, continuing education and the support of on-line services such as VIN can be an excellent way to begin to expand upon the services provided. Staff can also play an important role in implementing behavior modification techniques.

Those problems that are beyond the expertise of the practitioner can then be referred. The cases most commonly seen by veterinary behaviorists are those that are refractory to previous treatment and either disruptive to the household or potentially dangerous to humans, animals or the pet itself. Aggression is the most common presenting complaint at referral practices, followed by inappropriate elimination, destruction, fears and phobias, excitability, barking and compulsive disorders. Trainers also play an important role in managing normal but undesirable behaviors where the issue is primarily an owner who is unable to teach the pet the appropriate behavior in a particular situation. However, if the problem is beyond the expertise of the veterinarian and is not a training or management issue, the case might best be referred to a behaviorist. Behaviorists are trained in the diagnosis and treatment of behavior problems and should either have a PhD in psychology (applied animal behaviorist) or are veterinarians who have completed the qualifications of a specialty training program (veterinary behaviorist). Although there may be highly competent veterinarians who are available for behavior referrals, the training and expertise of these veterinarians will need to be assessed on an individual basis. Veterinary behaviorists on the other hand, have been certified by the American College of Veterinary Behaviorists and can provide guidance on both the medical and behavioral aspects of diagnosis and treatment.

The behavior consultation

The behavior consultation should begin with a comprehensive review of the history. All medical and behavioral signs should be considered as to how they might be contributing to the problem. By determining the diagnosis, cause, and perpetuating factors, a treatment regime can then be designed that is specific to the problem, pet and household.

The consultation can either take place in the hospital or in the owner's home. Although the home environment provides an opportunity to assess the environment and perhaps even observe the problem itself, it also has its limitations and potential problems. Support staff, products and reading material may not be readily available. The home environment may not be suitable or conducive to a productive and uninterrupted consultation. Travel time, the lack of control over the pet and the possible increased risk of injury can make house calls potentially problematic. Conversely, during in hospital consultations, the home environment will need to be thoroughly described, and might best assessed by having the owner bring a video or make a diagram of the environment listing resting, eating, sleeping, play and problem areas. A detailed description of the problem itself will usually suffice, as it can be impractical, counterproductive and potentially dangerous to try and reproduce or incite the undesirable behavior. Should provocation tests be needed as part of the assessment, the use of the hospital staff and facility would usually be preferred. If the owners can make a videotape or bring pictures of the problem, this can be an invaluable diagnostic tool as well as aid in designing an appropriate treatment program.

Telephone consultations are generally impractical and may be illegal in some jurisdictions since a proper veterinary-client-patient relationship has not been established. Some veterinary behaviorists do however offer telephone or FAX consulting for the veterinarian seeking support and guidance on how to handle a particular case.

Although some practitioners may prefer to assess pets and consult on the problem over the course of a few visits, many behaviorists offer a single consultation and assessment and one or more follow-up consultations either in person or by phone. Hands-on guidance and training advice might then be offered by a staff member or by referral to a trainer.

Behavior problem counseling

During routine office visits, practitioners should allow for a few minutes of behavioral advice within each office visit, and can provide handouts or product demonstrations for minor or emerging problems. For nuisance type problems (e.g. digging, coprophagia) or training advice (play biting, jumping up), a separate visit might be scheduled with one of the veterinarians or staff to provide advice, reading material or product guidance. However, for more serious problems the dog should be examined, any diagnostic tests should be performed, and the client might be provided with a history questionnaire to be completed pending results of the medical workup or a therapeutic trial. The questionnaire helps clients to understand the seriousness of the issue and the amount of time that the consultation will likely require. Behavior consultations should be scheduled in a separate appointment with sufficient time set aside for the particular problem.

The behavior consultation

1. Diagnosis

A veterinary visit should be the starting point for each behavior case since the first step is to rule out any medical factors that might be contributing to the behavioral signs. Diet or drug response trials may be an important part of the diagnosis (e.g. food trial to rule out food intolerance). For behavior cases, the information necessary to make a diagnosis would include a) the history provided by the owner, b) videotape of the problem and c) observing and assessing the pet during the consultation. This information is also critical for developing a treatment plan that is specific to the pet and the household, as well as for determining the prognosis. History forms can be an invaluable means of collecting background information. See forms in Handbook of Behavior Problems of the Dog and Cat or on our website at www.northtorontovets.com. At the consultation, further history will be needed to focus on the specifics of the problem.

When taking a behavioral history it is therefore helpful to begin with a 24 hour day and focus on family interactions. Some problems may be due to normal behaviors that are desirable and acceptable for the pet but not the owners. How does the family spend time with the dog on a regular basis? Does the dog get predictable and adequate opportunities for social and exploratory play? What exactly are the behaviors that the family finds problematic? When and where do they occur? Do the problem behaviors occur with all family members? What have they tried? Have these efforts been successful at all? Has the dog ever responded aggressively to their attempts to stop unwanted behaviors?

2. Prognosis

Owners must be made aware of the risks involved and the limitations on what can realistically be achieved. Unless the possibility of injury or further damage can bee prevented, then it may not be practical to proceed and the pet may need to be removed from the home.

3. Treatment

The treatment program must be tailored to the individual pet. If there is a safety issue, prevention of further injury is the first concern. Therefore, an assessment of the owners, the pet, the problem and the household is not only essential for determining the prognosis but also for developing an effective treatment program. Treatment would include some or all of:

a) Owner education is the first step so that the owner can begin to understand why the pet is exhibiting the behavior, the prognosis, how the environment may need to be modified to prevent further incidents and the basics of normal behavior, learning and behavior modification.

An explanation of why the pet is exhibiting the behavior, and how the owners and stimuli might be influencing the behavior is essential so that further reinforcement and conditioning of the problem can be avoided and so that an appropriate treatment regime can be implemented. The initial approach would generally be to modify the environment as well as the owner's expectations so that further problems can be prevented. This may be a short term remedy, but may also be the best or only practical long term program for some owners and some problems. However, in most cases, when the owners can be educated as to how pet's learn and how behavior can be effectively modified, they can begin to implement the training and behavior modification necessary to improve the problem. In addition, any myths or misconceptions (often related to dominance theory, punishment, spite, and how pets communicate with humans) must first be addressed. What has been previously learned from other trainers, books and resources may need to be reviewed and revised in order that the owners might proceed in the right direction. In general the principle of training and reinforcing appropriate responses and preventing or avoiding inappropriate responses will be the focus of owner education.

b) Environmental management will usually be needed to prevent exposure to the stimulus, to prevent access to where problems might arise, or to provide outlets for expression of the behavior

Not only is it environmental management a means of preventing further recurrence of the problem (i.e. by avoiding or preventing access to the stimuli or by preventing access to areas where problems might arise), it also helps to insure that both the owner and the stimuli do not further reinforce or aggravate the problem. While environmental management is generally a short term approach, it may be the most practical and effective means of controlling some or all of the problem over the long term. Confinement away from the stimulus or the area in which the problem occurs, preventing undesirable responses and modifying the environment to encourage desirable responses are the most common methods of environmental management.

c) Behavior modification will be required in order to change the pet's response to the stimulus to one that is positive and acceptable. This generally involves reward based training, desensitization, counterconditioning and response substitution.

The specifics of learning and behavior modification are discussed more extensively in the notes on preventive counseling and the specific behavior problems such as fear aggression, separation anxiety and fighting between household cats. As mentioned, the initial plan is to implement a program in which problems can be entirely prevented, safety can be insured, and control can be achieved with reward based training. Training the pet to reliably exhibit those behaviors which will be needed for exposure exercises is the first step in retraining. Behavior management devices such as a clicker, target for training, leash and head halter or muzzle, as well as the use of medications may be needed concurrently to most safely and effectively manage the problem. For most dogs, training should focus on training and shaping settled responses in the absence of stimuli, with the goal of teaching these responses during exposure exercises. A settled sit / focus, down / stay, mat or crate exercise, loose leash walk, turn away or back out, and come (especially if the pet is to be off leash) are the most important behaviors on which to focus. Drop or give may also be necessary for pets that are possessive. Identifying all rewards and saving them exclusively for training will accelerate learning (predictable rewards) and will increase motivation (if they are withheld except for training).

Once the owner can reliably get the target behaviors indoors and outdoors, the next step is to progress to new environments and more distractions. The owners should focus on environments where problems arise and progress to situations where the dog is increasingly more distracted, excited or aroused but not fearful or aggressive (such as greeting familiar people or dogs). If the owner can successfully calm the dog with commands in these environments, it might then be possible to begin controlled exposure exercises to muted or modified levels of the stimulus (desensitization) at or below the behavioral threshold. Each exposure should then be paired with favored rewards which have been saved exclusively for exposure associations, until the pet's emotional response to the stimulus is positive (counterconditioning) and the behavioral response is acceptable for greeting (response substitution). Once a positive association and desirable behaviour can be achieved, then the owner can progress to gradually more intense stimuli. However, if the owner is anxious or fearful, the stimulus shows any fear or aggression or the pet cannot be calmed and reinforced, the problem will be further aggravated.

d) Behavior management products that might aid in the management of behavior problems including avoidance devices, anti-chew deterrents, bark control collars, head halters and muzzles.

A head halter serves to communicate the owner's intentions by prompting the dog to achieve the desired response, while release of tension indicates to the dog that the desired behaviour has been achieved (negative reinforcement). At the same time the owner can remain calm and safety can be insured since a pull on the leash can close the mouth or turn the head away from the stimulus and toward the owner. Products that prong or shock may suppress behaviour but do not help to achieve desirable responses and may exacerbate conditioned fear or anxiety. A muzzle can help to insure safety, while at the same time test the pet's response to potentially threatening stimuli. A leash and body harness might be used during walks if the pet begins to pull or lunge ahead but does not control the mouth, muzzle and head position. Targets and clickers provide additional tools to implement reward based training techniques. A calming cap can also be used to partially reduce visibility which might help reduce fear or help the dog to focus on the owner rather than the stimulus. Devices are also available that interrupt the undesirable behavior (e.g. spray, sound or ultrasonic), or that keep pets away from problem areas (e.g. spray or noise avoidance devices). However, while they may help to prevent or stop what is undesirable, they may be counterproductive when attempting to reinforce what is desirable.

e) Surgery: For dogs and cats exhibiting sexually dimorphic behaviors such as mounting, roaming, urine marking, and some forms of intraspecific aggression, castration may reduce the hormonal effects on the behavior. Spaying may reduce heat-associated behaviors including marking.

f) Medical therapy– Drugs and natural alternatives might also be indicated to reduce fear or arousal or to normalize neurotransmitter turnover and receptor function. Drugs or natural products may also help to improve trainability; help the owner to achieve a more immediate or greater level of success; and may provide increased safety especially during the initial stages of a behavior modification program. These are discussed in further detail in the drug therapy notes.

4. Follow-up

Every consultation should have a follow-up assessment to review and modify the treatment program based on outcome, as well as to determine the success of the consultation.