KNOWLEDGE SUMMARY

Keywords: BEHAVIOUR; FELINE; HIDING BOXES; SENSORY ENRICHMENT; STRESS RELIEF; WELLBEING

Thinking inside the box: do hiding boxes reduce the fear and stress of hospitalised cats?

Leah Foster, DVN, CoP (BVN7.04, 7.08, 7.09), CVN, ATCL^1*

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¹ Eastern Institute of Technology, Hawke's Bay, New Zealand
* Corresponding author email: lf1607@fastmail.com

Vol 10, Issue 4 (2025)
Submitted 18 Sep 2024; Published: 01 Dec 2025
DOI: https://doi.org/10.18849/ve.v10i4.727

PICO question

In hospitalised domestic cats, does the use of hiding boxes compared to no intervention reduce fear and stress?

Clinical bottom line

Category of research

Treatment.

Number and type of study designs reviewed

Five studies were critically reviewed. All five studies were defined by the researchers as randomised control trials.

Strength of evidence

Moderate.

Outcomes reported

Four of the five studies showed moderate evidence that hiding boxes reduce fear and stress in cats, with reduced cat stress scores (CSS) in cats given a hiding box compared to control groups. The hiding box was found more useful in aggressive cats as CSS reduced faster in these groups. Among the three studies that recorded objective physiological stress measures (e.g., temperature, salivary cortisol), two studies showed no statistically significant stress reductions between the hiding box and control groups. Only one study of these three found lower heart rates in hiding box cats, but this may have been influenced by confounding factors.

Conclusion

There is moderate evidence suggesting that the use of hiding boxes in hospitalised cats is associated with reduced stress. The strength of the evidence is considered moderate due to varying limitations (e.g., small sample sizes) in the reviewed studies. Despite these limitations, incorporating a plastic or single-use disposable cardboard hiding box into existing feline-friendly cage environments is recommended for consideration. However, the use of a hiding box should be determined on a case-by-case basis as it may not be suitable for all patients (e.g. critical care patients requiring constant visualisation). High-standard infection control protocols should be applied to ensure the hiding box does not act as a fomite for possible infection transmission.

How to apply this evidence in practice

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.

Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Clinical scenario

You are a veterinary nurse tasked with monitoring and feeding a ward of hospitalised cats. When you enter the ward, the wide-eyed cats hiss and are crouched tensely in their litter trays or burrowing under blankets. It is apparent that the cats are uncomfortable, fearful, and trying to hide so you avoid close contact, resulting in inadequate monitoring of some cats. Other veterinary nurses attempt to handle the cats but are injured as the fractious cats lash out. Due to this, some of the clinic's hospitalised cats cannot be handled, medicated, or undergo the planned diagnostic test or treatment in the timeframe planned. These delays and being under stress may compromise and negatively impact the cat's health. These experiences prompt you to consider other interventions to reduce the cats' stress. You consider whether a hiding box would make a significant difference to their stress levels so decide to review the best evidence on this topic.

The evidence

The search identified five control trials relevant to the PICO question (Klintip et al., 2022; Arrandale & Buckley 2017a; Arrandale & Buckley 2017b; Wright & Baugh, 2018; Dewhurst & Reynolds, 2018). All five trials were stated by the authors as randomised control trials, however three used randomisation methods that were unclear, flawed, or aligned with non-randomised systematic allocation methods (Arrandale & Buckley 2017a; Arrandale & Buckley 2017b; Dewhurst & Reynolds, 2018). Four of the five studies suggested that the use of hiding boxes was associated with reduced stress for cats as evidenced by reduced cat stress scores (CSS) (Klintip et al., 2022; Arrandale & Buckley 2017a; Arrandale & Buckley 2017b; Wright & Baugh, 2018). No other measurements of stress such as salivary cortisol, temperature, or respiration rate, showed significant changes across the studies – except for Arrandale & Buckley (2017b), which found a statistically significant reduction in heart rate, but this could not be replicated in any other study. One study was inconclusive due to major limitations relating to small sample sizes and a flawed methodology (Dewhurst & Reynolds, 2018). Overall, the strength of the evidence was considered moderate as there were varying limitations across all studies (e.g. small sample sizes, short timeframes, unclear randomisation in three studies). However, all studies except Dewhurst & Reynolds (2018) found that hiding boxes were associated with reduced fear and stress.

Summary of the evidence

Arrandale & Buckley (2017a)

Towels versus hides: Which are best at reducing acute stress in the newly hospitalised domestic cat (Felis sylvestris catus)?

Aim: To identify whether towels over a cage or a box provided within a cage were better at reducing stress in the newly hospitalised cat.

 

Arrandale & Buckley (2017b)

The use of hides to reduce acute stress in the newly hospitalised domestic cat (Felis sylvestris catus)

Aim: To identify if newly hospitalised cats would both use a hide, and show a reduction in stress levels when one was provided.

 

Dewhurst & Reynolds (2018)

Does the Feline Fort^® reduce stress in feline inpatients within a veterinary surgery and is it any better than a cardboard box or no hideaway at all?

Aim: To compare the use of the Feline Fort to a disposable cardboard box, and also to assess whether having any hideaway at all reduced stress compared to having no hideaway at all within veterinary practice.

 

Klintip et al. (2022)

First study on stress evaluation and reduction in hospitalized cats after neutering surgery

Aim: To evaluate stress in hospitalised cats after neutering surgery using cat stress score (CSS) and salivary cortisol levels, including the impact of providing a hiding box (B) and/or administering a pheromone product to reduce stress.

 

Wright & Baugh (2018)

Effectiveness of providing a box, or partially covering the cage front, on reducing cat stress

Aim: To investigate whether providing hospitalised cats with either a box or a partial towel cover to the front of the cage reduced stress levels, and whether each of these methods was sufficient in providing hiding opportunity.

 

Appraisal, application and reflection

This Knowledge Summary aimed to identify whether the use of a hiding box as compared to no intervention is associated with reduced fear, stress, or anxiety for hospitalised cats. Hence, studies conducted in animal shelters were excluded during the search as these findings may have been influenced by other factors and are less relevant to clinical practice. Any studies conducted prior to 1 Jan 2015 were excluded to ensure only the most recent research relevant to today's veterinary practice were included.

Five studies relating to the PICO question were obtained (Klintip et al., 2022; Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Dewhurst & Reynolds, 2018; Wright & Baugh, 2018). All studies were primary research control trials. All five studies were defined by researchers as randomised. However, three of these studies had flawed group allocation methods and it was unclear if this was truly random or systematic allocation methods were used (Arrandale & Buckley., 2017a; Arrandale & Buckley., 2017b; Dewhurst & Reynolds, 2018). The researchers stated they allocated cats to the control group, hide group and/or other group “randomly, by the order of admission” (Arrandale & Buckley, 2017a; Dewhurst & Reynolds, 2018). However, this is reminiscent of systematic allocation, rather than true randomisation, which may have introduced confounding factors and bias.

Dewhurst & Reynolds (2018) found no link between reduced stress and the use of hides. However, these findings were inconclusive due to major limitations such as small sample sizes, oversimplified stress measurement tools, no baseline measurements, confounding factors (e.g. cage size of hideaway groups larger than Control Group), unclear randomisation methods, and a short study timeframe.

Klintip et al. (2022) had a more robust study design, clear randomisation, and utilised a wide range of objective and physiological stress markers. Klintip et al. (2022) also demeanour-scored the cats to determine the efficacy of hiding boxes in ‘aggressive’ cats versus ‘friendly’ cats. This study concluded that hiding boxes have a stress-reducing effect on both friendly and aggressive cats (Klintip et al., 2022).

The populations used in all five studies were cats undergoing neutering surgery. It is important to note that these studies did not research the use of hides in cats hospitalised for other health conditions, non-elective procedures, or in cats with behavioural disorders. Two studies used treatment groups with similar numbers of females and males (Arrandale & Buckley, 2017b; Wright & Baugh, 2018). However, two studies had more males than females (Arrandale & Buckley, 2017a; Dewhurst & Reynolds, 2018) and one study had more females than males (Klintip et al., 2022). This may have introduced a minor confounding factor in these studies as male and female cats can exhibit different stress responses or behavioural patterns (Tateo et al., 2021). Across the five studies, the median age of participants was between 6 months and 1 year old. All studies, except for Klintip et al. (2022), measured the cats’ stress during the preoperative phase, when the cats were awaiting their surgery (before premedications were given). Klintip et al. (2022) was the study that differed as the cats’ stress was measured for up to seven days after surgery.

All five studies had several limitations. Small sample sizes, unclear group randomisation methods, confounding factors, and short timeframes of measurement (most studies ranged from 20–60 minutes) were a recurring issue. These short timeframes may have caused the cumulative effects of stress to be overlooked, and potentially missed the full impact of the treatments. Four of the five studies had small sample sizes, ranging from 21–45 cats (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Wright & Baugh, 2018; Dewhurst & Reynolds, 2018). Klintip et al (2022) had the largest sample size with 80 cats. However, the studies all had relatively small sample sizes compared to a recent study on hiding boxes in shelter cats, which involved 179 cats (Wojtaś et al, 2024). Hence, the reviewed studies may have faced challenges with statistical analysis, increased risk of Type II errors (potentially seen in Dewhurst & Reynolds (2018)), and increased variability due to individual differences among cats (such as personality, prior clinic experience, and personal preferences) (Mesquita et al., 2012; Cartlidge, 2020). However, conducting studies with larger sample sizes in veterinary clinics can be challenging due to constraints such as limited space, resources, and time.

All five studies also used a between-group design methodology rather than a within-subject design. If used, the within-subject design could have reduced variability due to individual cat characteristics, making it easier to attribute stress reductions directly to the interventions (Sedgwick, 2014; Wright & Baugh, 2018). However, it is not always possible to conduct a within-subject crossover study in veterinary research due to ethical and welfare considerations (Adami et al., 2023). Some studies also had minor confounding factors (Arrandale & Buckley, 2017a) had changing noise levels in the study environment), issues with stress measurements (Klintip et al., 2022) did not take cortisol samples every day), and lack of pilot studies conducted prior (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Dewhurst & Reynold, 2018; Buckley & Mansbridge, 2017). In four of the five studies it was also not stated whether the allocation of interventions or cats into cage locations was randomised (Klintip et al., 2022; Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Dewhurst & Reynolds, 2018). Only one study clearly described that both the allocation of cats to treatment groups and the allocation of interventions to cage locations were randomised (Wright & Baugh, 2018). In studies where all interventions (control, hides, and others) were housed in the same room it would have been prudent to randomise interventions to cage locations to reduce bias and confounding factors.

Overall, however, these limitations are mitigated by the fact that four of the five studies (Klintip et al., 2022; Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Wright & Baugh, 2018) showed that hides are associated with reduced feline stress. This consistency across four different studies strengthens the overall conclusions.

Though each study had limitations, there were strengths in each study too. All studies had control groups, the interventions were well-implemented, and care was taken to minimise confounding factors as much as possible in the busy clinical setting. The study designs were undertaken by veterinary staff in an ethical and considerate manner using non-invasive or low-invasive measurement techniques.

The type and material of the hiding boxes used in the five studies varied. Three studies used cardboard boxes (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Dewhurst & Reynolds, 2018), one used a plastic box (Wright & Baugh, 2018), another used the plastic Feline Fort^® (Dewhurst & Reynolds, 2018), and one study did not describe the material of the box (Klintip et al., 2022). While the focus of this paper is largely on determining the behavioural implications of using a hiding box for cats hospitalised in a veterinary clinic, the biosecurity risks and considerations for hygiene must also be considered. Dewhurst & Reynolds (2018) was the only study to mention cleaning procedures for their hiding boxes, noting that the plastic Feline Fort^® was cleaned before each use and the cardboard box was disposed and replaced for the next participant.

The studies varied greatly in their chosen feline stress measurements. One study utilised salivary cortisol, bodyweight, and food intake as stress markers (Klintip et al., 2022). Another measured the presence of hide-seeking behaviours (frequent repositioning into corners or burrowing under blankets) (Wright & Baugh, 2018). Two studies measured the cats’ heart rates, respiration rates, and body temperatures (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b). However, all five studies utilised a cat stress score (CSS) system to measure behavioural signs of stress. Interestingly, in all studies where they were measured, objective physiological stress measurements showed no statistically significant differences between control and hiding box groups. Only in one study out of the two that measured heart rate found a statistically significantly lower heart rate in the Hiding Box Group (Arrandale & Buckley, 2017b). However, Arrandale & Buckley (2017a) stated that this may be due to confounding factors. Additionally, four of the five studies recorded each cat’s usage and interaction with the hiding box (Klintip et al., 2022; Arrandale & Buckley, 2017b; Wright & Baugh, 2018; Dewhurst & Reynolds, 2018). Three studies concluded that cats were likely to use the box if it was provided and preferred to hide inside the box (Arrandale & Buckley, 2017a, Arrandale & Buckley, 2017b; Dewhurst & Reynolds, 2018).

All five studies utilised the Kessler & Turner (1997) CSS, except Dewhurst & Reynolds (2018) who simplified and modified it. The Kessler & Turner (1997) CSS is a non-invasive subjective behavioural assessment tool used to measure stress levels in cats.  This CSS system has been used reliably to measure feline stress in shelter environments (Hirsch et al, 2021; Vojtkovská et al., 2020; Van der Leij et al., 2019). However, research shows that cat stress scoring is currently underutilised in the veterinary clinic setting (Hill, 2023).

Interestingly, in the four studies that utilised the unmodified Kessler & Turner (1997) CSS, evidence of reduced stress in cats with hiding boxes was found (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Klintip et al., 2022; Wright & Baugh, 2018). This again suggests that the Kessler & Turner (1997) CSS system is a reliable method to measure behavioural signs of stress in felines (Vojtkovská et al., 2020; Hirsch et al, 2021; Van der Leij et al., 2019). Notably, in the four studies using the unmodified Kessler & Turner CSS, behavioural stress signs reduced with the use of hides but measurable physiological stress changes could not be consistently identified. This may have been that studies’ limited sample sizes, confounding factors (e.g. removing cats from cages and handling during measurement) or the specific physiological stress measurements used in these studies were not ideal. Also, behavioural indicators may be more reliable and sensitive for short-term studies, whereas physiological changes may take longer to manifest and were likely missed in short study timeframes (Arrandale & Buckley, 2017b; Hirsch et al. 2021). Notably, this Knowledge Summary raises questions about the relationship between behaviour and physiology in cats under stress, as it was found that outward behaviours do not always correspond with measurable physiological changes. It is also important to note that the reliance on subjective observations in these studies means that while consistent evidence of stress reduction was found, there is potential for bias or interpretational differences.

Fear/stress in animals is defined as a physiological and behavioural adaptive response to threatening stimuli (Riemer et al., 2021; Lloyd, 2017). Physiologically, the hypothalamic-pituitary-adrenal axis is activated, releasing cortisol, and increasing heart rate, temperature, blood pressure and other bodily functions (Riemer et al., 2021). Behaviourally, the animal may display a ‘fight, flight, or freeze’ response to avoid or cope with the threat (Riemer et al., 2021). A cat’s stress response can range from mild signs of stress (e.g. mildly tense body) to extreme panic and terror (e.g. yowling) (Lloyd, 2017; Kessler & Turner, 1997).

The veterinary clinic environment can be highly stressful for cats. Firstly, they must travel to the clinic which can be a stressful event for owner and cat (Caney et al., 2022). Once the cat arrives in the clinic, they are faced with an unfamiliar environment and possible separation from their owner, which can trigger negative emotions (Taylor et al., 2022). These compounding stressors leads to a concept known as ‘stressor stacking’, where stressors accumulate during preparation for the veterinary visit at home, and continue during admission, physical examination, treatment, hospitalisation, and even once the cat has returned home (Taylor et al., 2022). This is a real challenge for caring for feline in-patients as described in the clinical scenario outlined above. The increasing physiological and behavioural stress of the patient can lead to misleading clinical findings, prolonged recoveries, difficult handling for staff (and possible injuries), treatment delays, and ultimately compromise feline health and wellbeing (Taylor et al., 2022; Lloyd, 2017; Riemer et al., 2021).

The evidence reviewed in this Knowledge Summary suggests that in domestic cats hospitalised in the veterinary clinic, the use of hiding boxes compared to no intervention is associated with reduced stress. Four of the five studies found that the use of a hiding box as compared to no intervention was associated with reduced stress (Klintip et al., 2022; Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Wright & Baugh, 2018).

It is well-acknowledged that cats have an instinct to hide when faced with stress-inducing stimuli.  Therefore, hiding boxes may help reduce stress for cats by giving them a sense of security, control, and comfort (Taylor et al., 2022). They may also limit the awareness of environmental triggers (e.g. disrupting sightlines of other cats). It is also thought that allowing an animal to display normal behaviours can help minimise negative emotions or promote positive ones (Taylor et al., 2022). This concept was supported by Wright & Baugh (2018) which found a link between cats in the Control Group exhibiting hide-seeking behaviours (e.g. burrowing under newspaper or positioning into cage corners) and having higher CSS. Wright & Baugh (2018) also observed that the Control Group cats spent an average 34% of the 60-minute timeframe exhibiting hide-seeking behaviours whereas the Hiding Box group cats spent less time (an average of 2% of the 60-minute timeframe) exhibiting hide-seeking behaviours.

Therefore, after reviewing the evidence, it is recommended that veterinary clinics consider providing each cat with a hiding box in addition to the normal feline cage environment (e.g. bedding, litter trays, food/water bowls.). Specifically, this can be done using a plastic box, plastic bucket, cat carrier, or single-use modified cardboard box (Taylor et al., 2022; Lloyd, 2017). It is imperative that the boxes are clean, large enough to fit comfortably within the cage, feline-friendly and that there are no sharp sides that may harm patients. It is important to note that in all five studies there was no hiding box groups where increased stress was observed (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Klintip et al., 2022; Wright & Baugh, 2018 ;Dewhurst & Reynolds, 2018). However, when providing hiding boxes to feline patients it is always prudent to observe the patient and consider whether the intervention is having the desired effect (Wright & Baugh, 2018).

The material choice of the hiding box may impact the ease of cleaning and efficacy of disinfection. It is known porous materials (such as cardboard) are more difficult to clean and disinfect and may act as a fomite for disease or infection transmission if reused (Stull et al, 2018). Hence, hiding boxes made from cardboard should be disposed after use. Non-porous materials (such as some plastics) are easier to clean and disinfect so can be reused (Traverse & Aceto, 2022). Taylor et al. (2022) states that cat ward cages should contain non-permeable and easy to disinfect materials such as laminated or moulded plastic. It is imperative that high-standard infection control and hygiene protocols are undertaken whenever using hiding boxes, just as with other veterinary clinic environments, equipment, and surfaces.

In some cases, the use of a hiding box may be inappropriate for some cats. For example, some patients may require continual clear visualisation for monitoring. Additionally, animals with fears of hiding boxes or small spaces should not be provided with one. Therefore, it is recommended that a hiding box is added to a standardised cage set-up protocol, with practitioners deciding whether to use it or not as they assess each individual case. It is also important to note that the use of hiding boxes has not been well researched for use in unwell patients or patients with behavioural disorders, so their use in these specific situations is currently unclear. Alternatively, the hiding box could be reserved for more anxious or aggressive cats in the clinic. Klintip et al. (2022) proved that hiding boxes were more effective in cats with an ‘aggressive’ demeanor as these cats showed a faster stress reduction than the ‘friendly’ cats.

Three out of the five studies support the use of a hiding box to reduce stress in the preoperative phase (when the patient was awaiting surgery but had not been given premedications), so it is specifically recommended to be used at this time (Arrandale & Buckley, 2017a; Arrandale & Buckley, 2017b; Wright & Baugh, 2018). Only one study researched the use of a hiding box for a longer-term period of 8 days (Klintip et al., 2022). While the box proved useful in reducing CSS over that time, this shows there is currently limited evidence supporting their use in longer-term hospitalised patients (Klintip et al. 2022). It should also be mentioned that all studies focused on cats undergoing neutering surgery so naturally they had younger patients as their participants. Hence, the findings of these studies are more representative of this age group.

Applying this evidence has few barriers as hiding boxes are more affordable, easily stored and are non-invasive. However, there may be some challenges associated with making changes to usual clinic protocols, and it can be difficult to ensure the box fits comfortably inside cages. Dewhurst & Reynolds (2018) found that hiding boxes the same size as the Feline Fort^® (39 cm x 41 cm x 30 cm) could not fit inside their standard size kennels (55 cm x 70 cm x 55 cm) alongside food/water bowls, litter trays, and resting spaces.

Currently, studies on the use of hiding boxes in clinical settings are limited and have small sample sizes, so further studies are required to strengthen and refine their use. Future research could involve randomised control trials with larger sample sizes, clearer randomisation, minimised confounding factors, targeted sample populations (e.g. unwell cats, anxious cats), and longer timeframes. Also, future studies could utilise additional non-invasive measurements/biomarkers of feline stress, such as blood pressure, infrared thermography, faecal glucocorticoid metabolite, or other cortisol measurements (e.g. salivary, urinary, or hair cortisol), which have been utilised in similar studies focusing on shelter cats (McCobb et al., 2005; Ellis et al., 2021; Klintip et al., 2022; Wojtaś et al., 2024;). As discussed, Klintip et al. (2022) used cortisol to measure stress. However, the salivary cortisol samples were collected irregularly, only three cats were chosen for sampling from each group (containing 10 cats), and the timing of sample testing was inadequate (Klintip et al., 2022).

Notably, the use of hiding boxes has been recently recommended in the 2022 International Society of Feline Medicine and the American Association of Feline Practitioners Cat Friendly Veterinary Environment Guidelines consensus source which is used to inform evidence-based practice (Taylor et al., 2022). Interestingly, however, these guidelines only cited studies conducted in shelter cats when describing hiding box recommendations. Therefore, this Knowledge Summary intends to help clarify the efficacy and use of hiding boxes in veterinary practice.

Methodology

Search Strategy

 

Exclusion / Inclusion Criteria

 

Search Outcome

 

Acknowledgements

I would like to thank to Jennifer Hamlin for her constant encouragement and mentorship. Thank you also to the editors and peer reviewers of Veterinary Evidence who gave up their time to make this paper the best it could be. I would also like to thank my family, particularly my sister, who were fantastic sounding boards during the writing of this paper. Primarily though, I must heartfully acknowledge my two best friends, my precious beloved furbaby G, and my beautiful king J, who are the reason for everything.

ORCiD

Leah Foster: https://orcid.org/0009-0005-5875-5558

Conflict of Interest

The author declares no conflicts of interest.

Use of artificial intelligence

The author declares that no generative artificial intelligence (AI) tools were used in the writing of this manuscript. All content, interpretations, and conclusions were produced entirely by the author without AI assistance.

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