Download FIVE STEP FORMULA: How to Treat Almost Every Behavior

FIVE STEP FORMULA: How to Treat Almost Every Behavior Problem
Jacqueline Neilson, DVM, DACVB
Portland, Oregon
Introduction:
Behavioral problems in companion animals are a common owner concern and can be
associated with compromised animal welfare and safety issues. If unresolved, behavioral
problems may ultimately lead to dissolution of the human-animal bond and outcomes such as
banishment from the home, relinquishment or euthanasia.
When faced with behavioral problems, owners seek advice from multiple different sources
including the internet, friends, family, trainers, popular media figures and their veterinarian. Of
the sources consulted, the veterinarian is the most qualified to comprehensively evaluate the
animal and give appropriate recommendations. In many states, the veterinary practice act
specifically says that care for the mental and physical health of the animal is under the purview
of licensed veterinarians. That said, within the veterinary profession, there is great variability in
training and individual competence in behavior. Veterinarians often feel overwhelmed by the
cases and scenarios, thereby electing to do nothing. The goal of this lecture is to provide the
basic framework for how to approach treatment for behavioral problems. In the vast majority of
cases, there are five steps to consider. Depending upon your resources, interest and
capabilities, you may elect to simply implement the first two steps or you may elect to pursue all
five. By addressing problematic behaviors in your practice you will help animals, help people
and bond people to your practice.
Step 1: Identify and avoid triggers.
In most behavioral cases, the owners can identify a trigger for their pet’s problematic behavior.
Owners may report that “he is terrified when there is a storm” or “he hates men”. Some
additional questioning can elucidate more details about the triggers (is it all men, or just men
with hats? or, in fact, maybe he reacts undesirably to unfamiliar men and women). Once the
triggers for the problematic behaviors are identified, the first step in treatment is to avoid the
triggers.
There are multiple reasons to avoid triggers including welfare and safety issues. Problematic
behaviors can be dangerous and damaging to the pet, its targets or both. It is imperative to
maintain safety and the physical and emotional well-being of the pet.
Another critical reason to practice trigger avoidance is because of reinforcement. Animals
continue to perform behaviors that are working (rewarding) for them; this occurs through the
process of operant conditioning. Rewards may be in the form of positive reinforcement
(application of something positive) or negative reinforcement (removal of something aversive).
Trigger avoidance serves the important function of stopping the animal from practicing and
being rewarded for performing the undesirable behavior. This “time-off” from practicing the
undesirable behavior also gives the owner an opportunity to work on foundation exercises –
these are the building blocks of establishing a new behavioral response in the pet.
Some owners may be frustrated with this advice saying that avoidance is too passive an
approach to the problem or perhaps is simply catering to the problem pet. It is critical to explain
to these owners that this is a temporary proposition that will prevent further deterioration. In
some cases the owners may discover that the avoidance management technique is so
successful that they will choose to continue to utilize it permanently.
Despite the best efforts at avoidance, there will be situations where the pet exhibits the
undesirable behavior. The best response from the owner in most of these situations is to have
the owner remain calm and simply remove the pet from the situation or the trigger from the pet.
Animals don’t learn well when highly aroused…imagine a child in the midst of a temper tantrum.
This is an opportunity for owners to consider how they could improve their management
strategies to avoid future problematic experiences.
Step 2: Foundation Exercises
The foundation exercises set the stage for predictable, structured interactions and provide
helpful communication tools that can be used in the behavioral modification step of treatment.
The four most important commands that the problem dog should master are: sit/stay, watch me,
go-to spot and u-turn. Depending upon the specific problem, you may elect to work on one or all
of these. The commands are primarily redirection commands – they are designed to give the pet
an alternative activity that may successfully interrupt/redirect an undesirable behavior. The
commands should be mastered in non-distracting circumstances (inside house, in yard, on
walks with no distractions) before they are attempted when the dog is distracted/aroused. Use
of a target hand (treat inside a closed fit) and lure technique makes these relatively easy to
teach and have the pet master.
The other foundation exercise is a fundamental change in the way the owner engages with their
pet. This is often called the “nothing in life for free” program. In most homes, the owner has
gotten into the habit of asking the dog to do a command prior to receiving food (treats or meals)
but aside from that situation, there is very little owner initiated structured interactions. Structure
and predictability can be a very important for animals, especially those that suffer from anxiety.
For pets that will need redirection away from triggers, practice makes perfect…practicing having
the pet look to the owner for cues about what to do in non-challenging situations will establish a
pattern of behavior that can be translated into more challenging situations. This program is
integrated into everyday life and all interactions with the pet. It is not to be done during a
“special training session” but instead is a fundamental and long-term change in the way owners
interact with their pet. The basic principle is that each time an owner wants to interact with their
pet, they should first ask the pet to do a command. These exercises are not about forcing a dog
to respond - it a simple request and, if completed correctly, compliance is rewarded.
Commands should be given in a soft, calm voice – commands should not be shouted or
repeated. It is simply done by saying the pet’s name, then the command, then pausing and
giving the pet a chance to respond. Owners should only use commands that their pet knows:
for some pets that have a limited obedience repertoire may use the sit command frequently. For
others, they will have a larger repertoire of commands to select from: sit, down, shake, watch
me, etc. Non-compliance is not rewarded, the dog is ignored for non-compliance for several
seconds; if the owner wishes, they can give another command, once the period of
disengagement has passed. It is important that the human involved in these interactions
remains calm, controlled and patient.
Step 3: Products
There are many different products on the market that can be useful in certain cases to augment
the treatment process. While not comprehensive, the following chart has some product
categories to consider in behavioral cases.
Product Category
Leashes
Patient Category
On-leash reactivity
Collars
On-leash
reactivity/pulling
On leash
reactivity/pulling
Harnesses
Muzzles
Aggression
Crates/Baby Gates
Multiple
Calming Cap®
Body Wraps
Anxiety during car
travel
Anxiety
Food Puzzle Toys
Separation Anxiety
Pheromones
Anxiety
Nutraceuticals
Mutliple
Recommendation
No retractable leashes instead use a flat
nylon or leather 4-6’ leash
Use a head collar instead of a neck collar
Use a front attachment harness instead of
a harness that attaches to leash on
back/shoulder area
Basket muzzles are generally preferred
since pets can wear for extended periods,
if needed. Acclimation should be gradual
and positive in nature.
Once acclimated to a crate or area it can
be used as a way to safely contain a pet.
Blocking visual stimuli can help relieve
anxiety in some pets.
The swaddling effect may help to reduce
anxiety.
Provide tasty treats inside puzzle toys at
departures.
Various forms (spray/diffuser/collar) can be
used to help reduce anxiety; DAP® (name
is changing to Adaptil®) has published
multiple controlled clinical trials showing
efficacy over placebo.
Research individual products and
companies prior to implementation; many
products lack good controlled clinical trials.
Check for contraindications with other
medications.
Step 4: Behavioral Modification
The principles of learning theory demonstrate that there are multiple ways to alter a specific
behavior. For example, if you wanted to stop a dog from barking at passing cars you may be
able to employ operant based conditioning (punishments or rewards), classical conditioning,
flooding or desensitization techniques, among others. That said, from a clinical perspective,
there are techniques which are generally better options for average pet owners to employ. As
veterinarians one of our goals is to “do no harm” so selecting the techniques with the least risk
and that protect the welfare of the animal is important. Therefore in the majority of cases, a
process of desensitization and counter-conditioning or simply classical counter-conditioning is
recommended.
Desensitization:
Sensitization is the increase in responsiveness to a given stimulus. Therefore desensitization
refers to the opposite - a decrease in responsiveness to a given stimulus. With dogs and cats
we are usually trying to reduce the reactivity of the animal to certain stimuli such as fireworks,
other animals, people, etc. Therefore we are trying to desensitize the pet to particular triggers
identified in step 1 of this process. In behavior modification usually we apply “systematic”
desensitization – this implies that a gradient approach will be taken to the desensitization
process. The reason for selecting this systematic approach is that it prevents the animal from
experiencing further undesirable emotions/behavior. The goal is to start pet exposure to the
trigger stimuli below the threshold for undesirable behavior; you want the pet to be calm and
relaxed in the context of exposure to the stimuli.
It is prudent to review what you mean by calm/relaxed behavior. This requires a basic short
course in dog body postures. Eye contact with the owners is stressed, if the dog’s eyes are
darting around, the dog isn’t relaxed. If the dog has very wide eyes it probably isn’t relaxed.
Instruct the owners to observe the tension of the dog’s muscles – they should be relaxed, not
tensed. Lip licking, yawning and grooming can be other signs of conflict/distress. Of course, full
body tremors are consistent with anxiety. Panting dogs may just be hot or it can be a sign of
distress/anxiety. One method of helping the owners recognize and reward the appropriate
behavior is to have them watch their dogs breathing patterns. A slow respiratory rate is usually
associated with calm behavior.
With success at low level intensity exposures, the intensity of the trigger stimulus is gradually
increased. There are many ways to modify and then gradually increase intensity of stimuli.
These are termed gradients and can include volume, distance, height, size, color, etc. While we
strive for a gradient exposure, with almost all cases there are unpredictable/uncontrollable
events that result in an unexpected exposure at a higher intensity. In these cases the owners
are instructed to try to give the pet appropriate direction (they may surprise you and do well) and
remove the pet from the situation. Treatment success is achieved when the pet learns to
handle the full intensity stimulus.
Counterconditioning
Counterconditioning is conditioning the animal to behave in a way that is counter to its current
behavior/emotional state. This can be done in association with desensitization or can be a
stand-alone approach. The most typical way to do this is to provide an animal with a
pleasurable experience when it is exposed to the problematic stimuli. For example, for the
firework phobic dog, toss the dog treats every time there is a bang. If you are employing
counterconditioning along with desensitization, the low level recording of a bang can be paired
with a treat delivery. Instead of having the animal respond in a neutral or negative way to the
stimuli, we can condition the animal to respond in a very positive emotional state (bang=treats).
Step 5: Drug Therapy
Is the Condition a Candidate for Drug Therapy?
The most straightforward answer to this question, “is there a drug to treat the condition?”, is the
availability of FDA approved drugs to treat the diagnosed condition. FDA approved drugs exist
for two behavioral diagnosis: Canine Separation Anxiety and Canine Cognitive Dysfunction
Syndrome. Drugs FDA approved to treat canine separation anxiety when used in conjunction
with a behavioral modification program include: Clomicalm® (clomipramine) and Reconcile®
(fluoxetine). The FDA approved drug to treat Canine Cognitive Dysfunction Syndrome is
Anipryl® (selegiline). Other than these three drugs, all drug therapy is off-label use and this fact
should be brought to the attention of the owner and noted in the medical record. Despite the
fact that other behavioral drugs lack FDA approval, a combination of clinical experience and
studies are available to guide your dispensing decisions. In the literature drug therapy has been
documented in the treatment of the following conditions:



Anxiety related conditions: Fear aggression, Conflict Aggression, Generalized Anxiety
Disorder, Noise Phobias, Separation Anxiety
Urine Marking
Compulsive Disorders
Is the Patient a Candidate for Drug Therapy?
Multiple factors may impact the question is the patient is a candidate for drug therapy. First and
foremost is the pet healthy enough to metabolize and excrete the medication successfully?
The pharmacokinetic profile of each drug will vary although for most drugs we are interested in
liver and kidney function. If is physical examination is normal, a CBC and chemistry profile is
suggested as a minimal data base prior to instituting drug therapy. Thyroid values may be
impacted by drug therapy (average reduction of free T4 by ED of 30% in dogs post
clomipramine administration) so if you want to explore pet thyroid status, you should run these
tests in advance of implementing behavioral drug therapy.
The use of psychotropic medications in animals may pose an ethical dilemma for some people
(veterinarians and/or owners). The guidelines used by the author to contemplate/initiate drug
therapy include:



behavioral modification alone cannot control the problem
the animal’s welfare is compromised
the drug can facilitate the behavioral modification process (risk/benefit analysis)
What is the best drug therapy for a specific patient?
Event vs. Daily Drug Therapy
The first consideration is if the pet needs the medication on an intermittent basis or if the pet
needs the medication on a routine basis. If triggers can be identified for the undesirable
behavior and those triggers are rare and predictable then intermittent/event drug therapy may
be appropriate. If the triggers are more ubiquitous and/or unpredictable, then routine/daily
therapy may be most appropriate. In cases with profound, unavoidable anxiety that need
immediate relief but you also anticipate will need chronic drug therapy, you can use event drugs
temporarily (2-4 weeks) at the onset of treatment with a daily medication.
Contraindications with other medications should be considered. Once again, these may vary
based upon the drugs and the drug label should be consulted for full information.
Other medication contraindications or warnings include drugs that significantly alter the
cytochrome P450 (CYP) enzyme system. The CYP is a large and diverse group of enzymes
and they are the major enzymes in drug metabolism, accounting for ~75% of total drug
metabolism. The activity of the various CYP enzymes can be altered by drugs/herbal
supplements, their enzyme activity either increased or decreased. The change in the CYP
enzyme activity can then affect the metabolism and clearance of other drugs/substances. For
example, if one drug inhibits the CYP-mediated metabolism of another drug, the second drug
may accumulate within the body to toxic levels. It is understandable that drugs with a narrow
therapeutic range or safety margin are the most susceptible to serious consequences
from CYP effects. Unfortunately, there is not always available data on the CYP effects of
drugs in dogs and cats and extrapolation from human data is not necessarily accurate. That
said, for pets on multiple medications CYP data should be investigated and, if available and
significant, consider dosage adjustments or choosing drugs that do not interact with the CYP
system.
Assess Drug Efficacy/Terminating Drug Therapy
 The expectation of the medication should be to attenuate the clinical signs, rarely do
drug alone resolve all clinical signs.
 Owners should be advised to create and maintain a log so they can track frequency and
intensity of behavioral problems.
 Event drug efficacy is evident shortly after medicating, therefore owners will know almost
immediately after instituting therapy if it is helping. Use of event drugs may continue
intermittently, as needed
 If daily drug therapy is used as part of the treatment plan, this type of medication is
typically given for months, or until the animal’s behavior has stabilized at a satisfactory
point for at least 2 months. Then termination of drug therapy can be attempted. This can
be done with abrupt cessation or a weaning process by halving the dose weekly over a
2-4 week period. If termination of drug therapy results in relapse of clinical signs, then
drug therapy can be reinstituted. Some animals require long term therapy for control of
problem behavior. In those cases annual or semi-annual physical examinations and
bloodwork (CBC, chemistry panel) are suggested for monitoring.
Conclusion:
The 5-Step Formula is intended to be a framework for a treatment approach for clinical
behavioral problems but not a substitute for individual case assessment and therapy. The five
steps are:
1)
2)
3)
4)
5)
Identify and Avoid Triggers
Foundation Exercises
Products
Behavioral Modification
Drug Therapy
Even if you are only comfortable instituting the first two steps for any given patient, these can
help set the patient up for additional referral therapy and ultimate treatment success.
References/Suggested Reading
Horwitz D, Mills, SM eds. BSAVA Manual of Canine and Feline Behavioural Medicine 2nd
Edition, BSAVA, Glouschester, England, 2009.
Horwitz D, Neilson J Blackwell’s 5 Minute Veterinary Consult: Canine and Feline Behavior.
Blackwell Publishing. Iowa, 2007.
Landsberg G, Hunthausen W and Ackerman L. Handbook of Behavior Problems of the Dog
and Cat. Saunders 2nd Edition Philadelphia 2003
Houpt, KA; Virga V. eds. The Veterinary Clinics of North America. Update on Clinical Veterinary
Behavior. Philadelphia: W.B Saunders Company Vol. 33, No. 2; 2003