THE EFFECTS OF EQUINE-ASSISTED THERAPY IN IMPROVING THE PSYCHOSOCIAL FUNCTIONING OF CHILDREN WITH AUTISM

Abstract

The goal of the present study was to examine the effects of short-term equine-assisted therapy as a complementary therapy modality for children with autism spectrum disorders (ASD). There were four children in the study, two boys and two girls from ages 8 to 10 years, with ASD included in this study. All of the children were attending a special education school in Sarajevo, Bosnia and Herzegovina. The equine-assisted therapy sessions took place once a week for a period of 10 weeks. The results of the study revealed positive effects the therapy had in two of the four children as measured by the Autism Treatment Evaluation Checklists (ATEC). The improvement was reported in the domains of speech, socialization, sensory/cognitive awareness and health/behavior. The authors propose a more widely use of this therapeutic modality in the psychoeducational treatment of children with ASD. [PUBLICATION ABSTRACT]

Headnote

Abstract

The goal of the present study was to examine the effects of short-term equine-assisted therapy as a complementary therapy modality for children with autism spectrum disorders (ASD). There were four children in the study, two boys and two girls from ages 8 to 10 years, with ASD included in this study. All of the children were attending a special education school in Sarajevo, Bosnia and Herzegovina. The equineassisted therapy sessions took place once a week for a period of 10 weeks. The results of the study revealed positive effects the therapy had in two of the four children as measured by the Autism Treatment Evaluation Checklists (ATEC). The improvement was reported in the domains of speech, socialization, sensory/ cognitive awareness and health/behavior. The authors propose a more widely use of this therapeutic modality in the psychoeducational treatment of children with ASD.

Key words: autism spectrum disorders, equineassisted therapy, Autism Treatment Evaluation Checklists

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1. Introduction

Autism spectrum disorders (ASD) are developmental disorders characterized by marked abnormal development in three domains: social interaction, communication and restricted repertoire of activities and interests. Age of onset of ASD is before 36 months. ASD include autism, pervasive developmental disorder- not otherwise specified and Asperger disorder. The prevalence of ASD is 6.2 per 1000 (1). Three to five more boys than girls have the disorder (2).

There are many biological treatments, psychoeducational interventions and less traditional or complementary approaches available to remediate the symptoms of ASD. Biological treatments seek to alter physiology or change the underlying processes that result in the symptoms of autism but so far no strong evidence exist to support their efficacy (3). Behavioral interventions are some of the most studied interventions for ASD. Early intensive behavioral interventions have proved to be a very effective approach for young children with ASD (4). A review by Francis offers a detailed description of other psycho-educational programs aimed to remediate symptoms of autism such as the TEACCH, the Picture Exchange Communication System, the Social skills teaching etc (5).

Besides psychoeducational and psychopharmacological approaches to treating the symptoms of autism, there are some less traditional treatment modalities. In this study, we present one such treatment named equineassisted therapy (EAT). EAT is a collective term for therapeutic measures with horses and includes all types of activities besides therapeutic riding (6). The goal of EAT is to promote physical, emotional, cognitive and social growth of the client. Equine assisted therapy relies on the belief that simply being around the horse, grooming and working with the horse has a healing power (7). Psychosocial benefits of EAT include increased motivation, higher self esteem, better concentration and academic performance (8).

There are few studies of the therapeutic effects of EAT for children with ASD. A study by Bass et al. suggested that therapeutic horseback riding is beneficial in improving the social functioning in children with autism (9). That study is particularly important because it tried to eliminate some of the methodological problems common for research in animal assisted therapies through the use of control group and usage of inferential statistics. Given the above mentioned benefits of EAT, it seemed warranted to expand on existing level of knowledge of the efficacy of EAT as a treatment modality in remediation of the ASD symptoms.

The present study examined the effects of equine assisted therapy on psycho-social functioning of four children with autism and intellectual disability as measured by the Autism Treatment Evaluation Checklists (ATEC), whose functional levels vary from mild to severe intellectual disability. Parents of the children completed the Checklist at the beginning of EAT (initial ATEC scores) and at the end of EAT (final ATEC scores). This is a descriptive study in which each child was described as a single case and certain parts of the therapy process are described as well.

2. Methods

2.1. Participants

Four children, aged from 8 to 10 years, two boys and two girls, participated in the study. All of the children were diagnosed with autism disorder and all had intellectual disability. The diagnosis of autism was made by mental health professionals (psychiatrists) at the Clinical Center University of Sarajevo according to the International Classification of Diseases, ICD-10 criteria for autism. All children were diagnosed with autism before age of 7 years. According to a psychologist's report, two children were in the range of mild intellectual disability (IQ range 50-70) and two children were in the range of severe intellectual disability (IQ range 20-35). The children were attending a special education school in Sarajevo, Bosnia and Herzegovina. In the school, children were already included in several therapeutic modalities such as speechlanguage therapy, psychomotor rehabilitation and educational programs. Parents of the children gave written consents for their children to participate in equine assisted therapy.

2.2. Instrument

The Autism Treatment Evaluation Checklist (ATEC) was developed in 1999 by Dr. Bernard Rimland and S.M. Edelson in the Autism Research Institute in order to help researchers evaluate the effectiveness of various treatments for children and adults with autism spectrum disorders and to help parents determine if their children benefit from a specific treatment (10). This checklist consists of four subtests: Speech/ Language Communication (14 items), Sociability (20 items), Sensory/Cognitive Awareness (18 items) and Health/Physical/ Behavior (25 items). The internal consistency reliability of the scale is reported to be high (.94 for the Total score). The higher scores on the checklist mean more problematic behavior.

2.3. Procedure

The therapy took place once a week for a period of 10 weeks. Each child's session lasted for about 30 minutes. The authors, occupational therapists with a certificate in equine-assisted psychotherapy, designed the protocol for the therapy and conducted all the sessions themselves. Two teaching assistants and a horse specialist were at the therapy site helping children with mounting and dismounting the horses. The therapy protocol consisted of horsemanship activities, riding and exercises and equine-assisted psychotherapy tasks. Horsemanship activities were aimed at introducing and bonding children with horses through the grooming activities. These activities usually lasted for about 5-10 minutes. Riding and exercises included mounting the horse, riding couple of circles in the arena and doing different kinds of exercises on the horses. This activity lasted for 10 minutes. Equineassisted psychotherapy tasks involved tasks given to the children on the ground. Tasks included getting the horse from one side of the arena to the other side, going with the horse across obstacles etc. The parents of the children were given the ATEC prior to and at the completion of the therapy.

3. Results

3.1. Case description 1

A.S. was an 8 year old girl with a diagnosis of autism and mild intellectual disability. She was diagnosed with autism when she was 6 years old. Her verbal output was very limited, no clear words, responded with speech-like sounds when addressed. Verbal comprehension was much better than verbal expression. No maladaptive behavior such as temper tantrums, screaming, being aggressive was reported for this girl.

In the first therapy session, the girl had a slight fear of the horse. She did not want to approach the horse, but she observed the therapist grooming the horse. She was then offered with a brush and with a teaching assistant she approached the horse. The girl was babbling aloud and laughing while she groomed the horse. Next activity in the session was riding. She was asked to imitate all the moves and exercises of the therapists and she did so constantly laughing and babbling. The last part of the session included tasks on the ground. The girl was asked to lead the horse from one part of the arena to the other. After the therapist gave her a leading rope, she took the horse from one part of the arena to the other. She did not look at the horse while she was leading the horse. By the time last session took place, the girl knew exactly when the therapy day is, she knew the therapy procedure by heart including the exercises on the horse without therapists showing her what to do. According to the results of the ATEC, the girl improved in all four areas, with improvements ranging from 20% in Sensory/Cognitive Awareness to 25% in Speech/ Language/ Communication domain.

3.2. Case description 2

A.C. was a 10 year old boy with very severe symptoms of autism and severe intellectual disability. He had a complete absence of viable speech- his verbal output was limited to random, meaningless or bizarre sounds. Verbal comprehension was very poor, he showed no sign of responding to his name, and did not turn towards the speaker. He did, however, reacted to instructions such as "let's go" by getting up from the seat. The boy showed no interest in toys or in other children and their activities. He reacted severely to any suggested change or uncomfortable situation by screaming, distress, and temper tantrum.

In the first therapy session, when the boy was brought up to the horse, he showed no interest in the horse. He averted his gaze from the horse and did not want to groom the horse. Although he did not show an interest in the horse, the situation was not uncomfortable for him, because he had no negative reactions. Riding activities were much more fun to him. He laughed but could not perform any of the exercises on the horse by imitating the therapists. Activities on the ground could not be performed because the boy did not want to lead the horse even with the therapists' assistance. In the following session, the moment the boy saw the horse he wanted to mount the horse and was opposing everything else. Obviously, he remembered riding activity from the week earlier. By the time last session took place, the therapy protocol could not be fully followed. The boy wanted only to ride the horse, but did not oppose doing exercises on the horse such as lifting arms, imitating the bird etc. (with therapists leading the arms of the child).

According to the parents' report, the boy made a slight progress in the domains of socialization and sensory/cognitive awareness, and a slight deterioration in behavior (Table 1).

3.3. Case description 3

E.I. was a 9 year old girl with autism and mild intellectual disability. Of all the children in the therapy, she had the best verbal expression. She used simple words and phrases, could make her needs known, but still showed some weakness such as echolalia, jargon and invented words. Verbal comprehension was well developed, she understood complex, two or more instruction demands. She reacted severely to the changes in routine and to the obstacles she could not come across by crying and auto-aggressive behavior.

From the first therapy session, the girl showed strong interest in the horse. She herself took a brush and started to groom the horse. She was repeating everything the therapists were saying about the horse, e.g. the name of the horse, how horses like to be clean etc. She enjoyed riding activity and did all the exercises she was asked to do on the horse. The girl performed ground task of leading the horse using the words such as "let's go". That was an excellent example of using an appropriate phrase for problem solving. By the time the last session took place, the girl was totally independent in all the activities according to the therapy protocol with minimum therapists' supervision.

According to the parents' report on ATEC, the girl improved significantly in all of the domains assessed. The improvement ranged from 11% in the domain of Health/Behavior to the 30% in the domain of socialization (Table 1).

3.4. Case description 4

M.D. was a 10 year old boy with severe symptoms of autism and severe intellectual disability. He had a complete absence of viable speech. He understood basic words such us "come, give, take". The boy had no interest in toys or to play with other children. No meaningful eye contact. The boy had no observable response to other people, an apparent unawareness of other children and adults. The child demonstrated extreme autoaggressive behavior.

From the first therapeutic session to the last, the child was uninterested in the therapeutic activities. What is more, the child was aggressive towards the horse and the therapy had to be discontinued for safety reasons after seven sessions.

4. Discussion

There are many benefits of the equine assisted therapy. This study aimed to determine if there were any benefits of the equine assisted therapy based on the functioning of four children with autism as measured by the Autism Treatment Evaluation Checklist. The current study revealed mixed results. In two children, A.S. and E.I., there was an obvious and large improvement in three of the four areas assessed according to the parents' reports. No changes or minimal changes were reported for the Health/Physical/Behavior Domain. The probable reason for this is that these two children already had a very favorable initial score on ATEC which in turn left little space for an improvement. The other two children, A.C. and M.D. showed minimal or no improvement with one child deteriorating in the area of behavior. Because the changes were minimal (on 1 item) they could be attributed to the measurement error between the initial and final evaluation. A caution should be made in interpreting these results as the children who did improve significantly had a much better baseline scores on ATEC than did the children who did not improve. Baseline scores obviously played an important role as predictors of the successfulness of the therapy.

All the children included in the therapy besides having autism had an intellectual disability as well. It is widely recognized that intellectual disability makes the prognosis of autism poor (11). Two children who did not improve substantially after the therapy were in the range of severe intellectual disability and had very severe symptoms of autism. It is likely that the severity of autistic symptoms and child's preferences might serve as a good predictor of the successfulness of equine assisted therapy.

Case description design did not allow any statistical tests to be performed. Other limitations of the study include small number of cases so the results can not be generalized to all children with autism. Lastly, reports made by parents are subjective in nature, so it is hard to tell if the effects reported are genuine. On the other hand, one clear advantage of single-case research studies is that the participants serve as their own control, whereas in group design there is often greater variability between the participants (12). In this study we used a case description with parent ratings at two points in time, namely at the beginning of treatment and at the end of treatment. To further validate these results it is necessary to do a follow-up study to see whether the benefits of EAT are long-lasting.

5. Conclusion

It is certain that equine-assisted therapy holds future in treating the children with ASD and should be used as a complementary therapy to other educational, behavioral and biological therapies. Not all children with ASD will benefit from EAT. Prior to the implementation of EAT, as in any other therapy, it is important to assess the children and note their likes and dislikes, and according to their preferences to make individual program of therapy. Therapists need to individualize EAT and help each child grow with the assistance of the horses.

References

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