Equine-Assisted Occupational Therapy: Increasing
Engagement for Children With Autism
Spectrum Disorder
Cecilia Llambias, Joyce Magill-Evans, Veronica Smith, Sharon Warren
MeSH TERMS
autism spectrum disorder
equine-assisted therapy
occupational therapy
task performance and analysis
Engagement in meaningful activities is essential to development and is often reduced in children with autism
spectrum disorder (ASD) who have limited engagement in activities or relationships. A multiple-baseline
design was used with 7 children with ASD ages 4–8 yr to assess the effect of including a horse in
occupational therapy intervention on task engagement. The children showed improvements in engagement.
Including horses in occupational therapy sessions may be a valuable addition to conventional treatments to
increase task engagement of children with ASD. Factors related to the environment, therapeutic strategies,
and individual participation need to be considered in understanding why this intervention may be effective
and developing a theoretical basis for implementation.
Llambias, C., Magill-Evans, J., Smith, V., & Warren, S. (2016). Equine-assisted occupational therapy: Increasing engagement for children with autism spectrum disorder. American Journal of Occupational Therapy, 70, 7006220040.
http://dx.doi.org/10.5014/ajot.2016.020701
Cecilia Llambias, MScOT, is Graduate Student,
Department of Occupational Therapy, University of Alberta,
Edmonton, Alberta, Canada; llambias@ualberta.ca
Joyce Magill-Evans, PhD, is Professor Emerita,
Department of Occupational Therapy, University of Alberta,
Edmonton, Alberta, Canada.
Veronica Smith, PhD, is Associate Chair, Department
of Educational Psychology, University of Alberta,
Edmonton, Alberta, Canada.
Sharon Warren, PhD, is Professor Emerita, Faculty of
Rehabilitation Medicine, University of Alberta, Edmonton,
Alberta, Canada.
C
hildren with autism spectrum disorder (ASD) have deficits in social interactions as well as restricted interests with stereotyped and repetitive patterns of behavior, core diagnostic features of ASD (American Psychiatric
Association, 2013). These characteristics interfere with their ability to engage in
activities beneficial for development. The duration and quality of engagement—
the “intentional, persistent, active, and focused interaction with the environment, including people and objects” (Watling & Dietz, 2007, p. 576)—differ
from that of children with typical or delayed development (Adamson, Bakeman,
Deckner, & Romski, 2009). Children with ASD spend more time unengaged
and, during their engaged periods, show a higher preference for objects and
solitary play than for people. These behaviors are counterproductive to development because engagement is essential for learning (Patten & Watson, 2011).
In equine-assisted occupational therapy, the variety and novelty of activities
(e.g., saddling, grooming, riding) may engage children with ASD and increase
their purposeful activities.
Identifying activities that engage children with ASD in interaction with
others is essential. Research has reported an increase in social interactions related
to animal-assisted intervention (including horses; Grandin, Fine, & Bowers,
2010; O’Haire, 2013). For centuries, people have interacted with animals to
promote health and well-being (Jorgenson, 1997), laying a foundation for the
management of life experiences. Developing relationships with animals may
give children positive interactions and support and provide psychological and
physical benefits (McCardle, McCune, Griffin, Esposito, & Freund, 2011).
The natural attraction of animals may engage children in animal-related activities,
providing the child with the opportunity for positive, engaged experiences that
can generalize to other environments and persons. However, theory and research
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support for the underlying mechanisms of animal-assisted
intervention are lacking.
Successful interactions with horses may provide important sensory and social stimuli with benefits for psychological,
sensory, motor, communication, and social functioning
(O’Haire, 2013). Research has identified benefits of therapeutic riding for children with ASD, such as increased
social motivation and decreased sensation seeking and
sensitivity (Bass, Duchowny, & Llabre, 2009), fewer
stereotyped behaviors (Gabriels et al., 2012), and improvements in social communication and sensory processing during intervention (Ward, Whalon, Rusnak, Wendell, &
Paschall, 2013). In contrast, Jenkins and DiGennaro
Reed (2013) found no effects for on-task behavior and
responding to others’ initiations for 4 children.
In equine-assisted occupational therapy, the variety and
novelty of activities (e.g., saddling, grooming, riding) may
engage children with ASD and increase their purposeful
activities. Children with ASD have sensory integration or
modulation deficits (Bundy & Murray, 2002). Modulation
allows filtering of irrelevant stimuli and maintenance of an
optimal level of arousal that facilitates attention to environmental demands (Lane, 2002) with longer engagement
in tasks. Strategies to regulate arousal include activities to
stimulate the vestibular and proprioceptive systems (Bundy
& Koomar, 2002). The horse’s gait and speed may stimulate
the vestibular system with either a calming effect by means
of a quiet, unvarying gait or an alerting effect by means of a
fast walk or trot (Lawton-Shirley, 2002). Equine-assisted
occupational therapy may include on-horse activities that
use movement to improve skills and off-horse activities that
engender care and relationship building with the animal.
Research related to ASD and the use of riding in
occupational therapy is limited to two studies and has
not had a clear theoretical basis. Sams, Fortney, and
Willenbring (2006) compared language use and social
interaction in occupational therapy sessions with and
without llamas for 22 children with ASD (ages 7–13 yr).
Activities occurred both on and off the llamas. Significant
differences were found that favored sessions including
animals. Taylor et al. (2009) investigated the effects of 16
sessions of hippotherapy (use of a horse) on the volition
of 3 children with ASD during video-recorded play sessions. They found positive effects for 2 children.
The current study extends the research with a rigorous
single-case research design. It investigated the effects of
equine-assisted occupational therapy on the engagement of
young children with ASD. The hypothesis was that equineassisted occupational therapy would increase engagement
as earlier defined by Watling and Dietz (2007), including
interactions with objects, the therapist, or the horse.
Method
Participants
Nineteen children with ASD were recruited from a riding
association’s waiting list or through a letter of invitation from
the local autism society. To be included, children had to have
been diagnosed with ASD by a multidisciplinary assessment
team, be 3–8 yr old, understand English, and have had no
riding experiences for ³3 mo before the study. Children
needed to show no aversion to horses (e.g., screaming, running away, refusal to approach) because it would make the
intervention impossible. Exclusion criteria were repeated
aggressive behavior (e.g., hitting, kicking; based on parent
report) or comorbidities (e.g., deafness, blindness, epilepsy)
that could interfere with the intervention.
Interested parents contacted the first author (Cecilia
Llambias). A phone interview was followed by two screening
meetings. The first was a free-play session to determine the
child’s ability to follow directions in English. A second
screening meeting at the equine center ensured the child’s
acceptance of riding a horse. Eleven children did not
participate because they did not complete the screening
process (n 5 8) or were unwilling to ride (n 5 2) or because of concerns about English skills (n 5 1). Data from
1 boy were excluded because of consistently high levels of
engagement during baseline, leaving little room for improvement. The study was approved by the university’s
ethics board, and parents provided written consent.
Information on the 7 participants (3 girls, 4 boys) ages
4 to 8 yr old is provided in Table 1. All names are
pseudonyms. The children’s spoken language level was
classified using Tager-Flusberg et al.’s (2009) criteria:
Phase 1, preverbal (n 5 2); Phase 2, using single words
(n 5 3); Phase 3, using two- to three-word combinations (n 5 1); and Phase 4, using sentences (n 5 1). All
children spoke English at home; 2 children also spoke a
second language. Participants’ cognitive abilities varied.
Three children had not had a cognitive assessment. Six
children had motor delays. Assessment information was
obtained from reports such as individualized education
programs or specialized services (e.g., psychological,
speech) reports completed within the past 2 yr but not
concurrent with the study. Two children also had attention deficit hyperactivity disorder and were on medications
for the disorder. Changes in medications were monitored. All children were in an education setting at least
12–16 hr/wk. Deb, Jen, and Larry attended elementary
school 20 hr/wk, and Juan attended elementary school
full time. In addition, all children had specialized services for 2–4 hr/wk with a speech language pathologist,
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Table 1. Participant Information
Age
Pseudonym (yr, mo)
Cognitive Abilities
TF Communication
Level
Anna
4, 10
4 mo < age (BSID–3–CS)
Phase 2
Cole
5, 8
No report
Phase 2
Deb
5, 1
Unable to test
Phase 1
Jen
5, 1
15-mo delay (BSID–3–CS)
Phase 1
Juana
7, 8
No report
Phase 4
Larrya
5, 5
Phase 3
Qiangb
5, 3
Extremely low (WPPSI–III);
mild delay (ABAS–2)
No report
Phase 2
Note. ABAS–2 5 Adaptive Behavior Assessment System—Second Edition
(Harrison & Oakland, 2003); BSID–3–CS 5 Bayley Scales of Infant and Toddler
Development, Third Edition, Cognitive Scale (Bayley, 2005); Phase 1 5 preverbal;
Phase 2 5 one-word utterances; Phase 3 5 two- to three-word combinations;
Phase 4 5 sentences; TF 5 Tager-Flusberg et al. (2009); WPPSI–III 5 Wechsler
Preschool and Primary Scale of Intelligence–Third Edition (Wechsler, 2004).
a
Attention deficit hyperactivity disorder. bAnxiety, dyspraxia.
physical therapist, occupational therapist, or behavioral
interventionist.
Design
A multiple-baseline design was selected (Kazdin, 2011) to
test the effects of this novel intervention. It had three
phases: baseline (activities in a play room), intervention
(activities with or related to a horse), and follow-up (same
activities as in baseline in a play room; see Figure 1).
Children received a different number of baseline sessions
(9–11). One feature of the design was the staggered introduction of intervention once data stability (a clear and
stable pattern of the targeted behavior in the absence of
intervention) was observed. Intervention sessions ranged
from 9 to 12 because children whose data were stable first
started intervention earlier, resulting in more intervention
sessions. During intervention, 2 children missed one session
because of medical issues, and sessions were cancelled 1 day
for 4 children because of a blizzard. The study followed
the standards of the single-case documentation developed
by the What Works Clearinghouse (Kratochwill et al.,
2010).
Settings and Procedures
All sessions (baseline, intervention, follow-up) were 45–60
min long. Children spent ³20 min in gross motor (GM),
or physical, activities and 20 min in fine motor (FM), or
cognitive, activities in all sessions in all phases. To assess
the specific contribution of including a horse in occupational therapy sessions, baseline and follow-up sessions
mimicked the basic conditions and activities of the
equine-assisted sessions. Children did activities off (considered FM) and on (considered GM) the horse during
intervention. Therefore, baseline and follow-up sessions
had both GM and FM activities. To mimic the novelty of
Figure 1. Percentage of engagement in activities.
Note. Baseline length is variable, in keeping with a multiple-baseline design;
activities occurred in a playroom. In addition, note the variable length of intervention, which included the horse and horse-related activities. For follow-up,
activities occurred in a playroom. IRD 5 improved rate difference, defined as
the improvement rate of the treatment phase (IRT) minus the improvement rate
of the baseline phase (IRB; Parker, Vannest, & Brown, 2009).
the equine-assisted sessions, a new toy or activity was
offered during baseline and follow-up for GM and FM
sections. One difference between phases was that the
vestibular stimulation provided by the horse during intervention was intentionally modified by the therapist to
regulate the child’s arousal, whereas during baseline and
follow-up, vestibular stimulation (e.g., trampoline, hammock,
or swing) was initiated by the child.
The therapist used evidence-based strategies to promote engagement drawn from behavioral or developmental
approaches during all phases. Strategies included offering
choices (Lough, Rice, & Lough, 2012); gradual reinforcement
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delay; following the child’s lead, using the child’s preferred activities and interests (Boyd, Conroy, Mancil,
Nakao, & Alter, 2007); breaking activities into steps;
verbal support and reinforcement; visual organizers; use
of the Picture Exchange Communication System (Bondy
& Frost, 1993); and grading the sensory stimulation,
such as voice tone and touch to get the child’s attention.
Baseline and follow-up consisted of free play guided
by the first author and took place in a room with mats,
balls, and sport materials for GM activities and toys and
school materials for FM activities. A swing, trampoline,
or hammock was available. Specific activities depended
on the child’s interests and age. GM activities included
jumping, rolling, catching and throwing balls, and sports
such as soccer and basketball. FM activities consisted of
object-oriented play that included cognitive elements and
often occurred at a table (e.g., matching activities, crafts,
play with cars or dolls).
Intervention sessions occurred at the equine center
once a week and were with the first author, an occupational therapy member of the American Hippotherapy
Association (AHA) who is certified as a Professional Association of Therapeutic Horsemanship (PATH) International
therapeutic riding instructor (PATH International, n.d.).
When children were off the horse, she followed procedures for conventional occupational therapy sessions with
inclusion of a horse as the main element of the planned
activities. When children were on the horse, she followed
AHA (2014) guidelines. Activities took place in an outdoor arena for 2 mo until cold weather forced a move to
the indoor arena. Arenas were prepared with cones, poles,
colored buckets, and letters and pictures on the fence or
wall. The unshared outdoor arena provided a quiet environment. The indoor arena was shared with another
program at the opposite end of the arena, which increased
the noise level.
FM activities occurred at a table with chairs in a quiet
area. Well-trained, calm horses were used. The horses were
not consistent between sessions. Off-horse activities involved grooming or feeding the horse, saddling and leading
the horse, art activities (e.g., drawing the horse), and games
related to horses. On-horse activities included playing
games, such as carrying an object from one part of the
arena to the other or grabbing rings. Directed by the first
author, one person led the horse, with two side walkers for
safety. To make intervention similar to baseline, only the
first author talked to the children. Initially, activities were
controlled to promote safety, develop basic riding skills,
and show the children what was and was not allowed (e.g.,
shouting, kicking or biting the horse). After these more
directed sessions, all activities were planned to enhance
engagement. There were opportunities to explore and
show interest, make choices, solve problems, practice skills,
and initiate. The environment promoted play, enjoyment,
and learning and progressed according to each child’s
needs. All children had the same goal of increasing engagement in activities, but strategies differed. Strategies
related to sensory integration helped to regulate arousal
by grading the vestibular stimulation from the horse’s
movements: changes in gait (walk, trot), speed (slow, fast),
and pattern (figures). For example, to increase attention,
trotting was used (vestibular and proprioceptive stimulation).
Follow-up consisted of four free-play sessions for all
children at the same location as baseline and using the
same procedures. We observed whether any effects of equineassisted occupational therapy sessions were sustained for
at least a month after intervention. For all phases, the
order within the sessions varied. Sessions sometimes began
with GM or on-horse activities and sometimes with FM or
off-horse activities.
Outcome Measure
Engagement was defined in keeping with Watling and
Dietz (2007). When the therapist made a request, the
child’s response was coded. If the child responded, interacted with the therapist or horse, or started the requested activity, this behavior was scored as “engaged.” A
child was scored as “not engaged” if he or she ignored the
request or attempts to capture attention, resisted guidance
into the activity, looked away or avoided eye contact,
played alone, had a tantrum or cried, wandered away
from or left the activity or interaction partner (person or
horse), showed stereotyped behaviors (e.g., flapping
hands, flicking fingers, or spinning unrelated to the activity), or stopped or left the activity. The percentage
of time engaged during a randomly selected segment was
the outcome measure. GM activity–on-horse and FM
activity–off-horse percentages were averaged to give a single
value per session. Field notes were recorded and included
notes about the setting (e.g., indoor or outdoor; unusual
circumstances), children’s unusual behavior (positive or
negative), conversations with parents or teachers, materials and activities used, and plans for the next session.
Data Collection and Coding
Digital video recordings captured interactions and verbalizations and were coded by raters (not the first author). A 5-min segment randomly selected (using random
numbers functions) from the first 15 min of each section
(GM activity–on-horse, FM activity–off-horse) of a session was coded. This resulted in two 5-min sections of
video coded per session in all phases. Each 5-min video
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was divided into 5-s intervals using Picture Motion
Browser software (Sony Electronics Inc., Toronto, Ontario, Canada). This interval received a dichotomous code,
engaged or not engaged. If the child was engaged for more
than 5 s, each 5-s interval was coded as engaged. If the
child lost interest, that interval was coded as not engaged.
The percentage of intervals when the child was engaged
was calculated. All segments were scored by the primary
rater with a minimum of 25% scored by a second rater.
Raters were blind to the study purpose but not to
condition (free play, horse) or phase (baseline or followup). To address this potential for bias, inter- and intrarater
reliability were monitored carefully with an emphasis on
adherence to the coding rules. Reliability checks occurred
randomly during all phases. Inter- and intrarater calculations were based on the criteria from Richards, Taylor,
Ramasamy, and Richards (1999). Interrater agreement
was 96.7% (range 5 88%–100%) for occurrence and
nonoccurrence of the behavior. Discrepancies were discussed by the raters to reach consensus. If consensus was
not reached, it was resolved by the first author. Discrepancies were due to rapid behavior changes or unusual
behaviors. Intrarater reliability was assessed over 25% of
the sessions and was 96.7% (range 5 85%–100%).
Implementation Fidelity
The implementation fidelity checklist had 17 items and
ensured that the intervention sessions were the same across
children (e.g., type of prompts, positive feedback, intervention settings, length of GM and FM activities). It also
ensured child safety (e.g., helmet use, side walkers). Sixteen
sessions (2 per child) were selected using the random
numbers function in Excel (2010 version; Microsoft,
Redmond, WA). At least 15 min of each type of activity
(GM and FM) per session were checked. Fidelity was 93%.
Data Analysis
Data were visually analyzed to interpret level, variability,
and trend within phases (Kazdin, 2011). Analysis between
phases consisted of changes in level, trend, variability,
immediacy of effect, proportion of overlap, and consistency of the data from baseline to intervention phases
(Kratochwill et al., 2010). Improved rate difference
(IRD) was calculated to provide an effect size measure
(Parker, Vannest, & Brown, 2009). When interpreting
the IRD, Parker et al. (2009) suggested that small effects
range from 0 to .49, moderate effects range from .50 to
.69, and strong effects are .70 or more. They recommended that confidence intervals (CIs) be set at 95%. CIs
were calculated using WinPEPI software for epidemiologists (Version 11.32; Abramson, 2011).
Results
Figure 1 presents the percentage of time that children were
engaged. Visual analysis suggests that equine-assisted occupational therapy had a strong effect compared with baseline.
Average engagement during baseline was 77.8% (Juan),
76.1% (Cole), 69.9% (Anna), 58.1% (Jen), 56.1% (Deb),
54.7% (Qiang), and 51.8% (Larry). In the intervention
phase, averages ranged from 99.3% (Juan) to 95.5% (Jen).
The smallest increase was 21.0 percentage points (Juan), and
the largest was 46.0 (Larry). It is noteworthy that engagement increased markedly early in the intervention and then
remained at that level throughout. At follow-up, engagement
for all children remained similar to that seen in intervention.
Differences in engagement level from baseline to intervention were clear for all participants. When intervention
was compared with follow-up, Qiang was the only child
with a large drop. He had difficulties with transitions, as is
evident in his first follow-up session. However, he coped
with the change much faster than during baseline, and his
engagement returned to almost intervention levels for the
remainder of follow-up. For the other children, engagement
remained high, indicating that changes were maintained
once intervention was removed.
Regarding baseline trends, there was a decreasing
trend (21.3 to 21.1). The intervention phase trends
had a neutral slope for all children. With the increased
engagement in the intervention phase, this stable level indicates that the children’s engagement was more consistently positive. Follow-up trends were also neutral for all
children except Qiang, who showed an increasing trend
with a return to his intervention level of engagement after
the first follow-up session. There was a strong intervention
effect with an IRD of 100% and 95% CIs [0.90 or 0.91, 1].
Positive effects of the equine-assisted occupational
therapy sessions were reported by parents and in forwarded
teacher’s notes as recorded by the first author. “It is a fact
now: The day after the horse is his best day at school” and
“After the horse session, once he is in the car, he doesn’t
stop talking until he goes to bed” (Qiang’s mom). “I
never saw him so engaged in an activity and so calm as
when he is on the horse” (Larry’s mom). Teachers’ notes
included, “Dear mom, Cole had another great day at
school today. He is much better with transitions, he is
enjoying the activities and having very good mood days,
and he is participating much more. He has become a
happy boy.” Mothers reported that Anna, Qiang, Deb,
Jen, and Larry were talking more, with more initiation of
communication, new words, or longer sentences. Three
teachers came to observe the sessions once changes in
behavior were observed at school.
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According to the field notes, the children showed a
strong preference for some of the hippotherapy activities
and in particular trotting. Once they could balance on the
horse (third session), all the children started to ask to trot
from the time they were seated on the horse. All children
showed signs of enjoyment such as smiles, laughing, or
even singing while trotting. Saddling and feeding the horse
were other preferred activities. These activities were included in the sessions as much as possible.
Discussion
This study continues the process of understanding the
effects of including a horse in occupational therapy interventions (i.e., on-horse and off-horse activities) on the
engagement of young children with ASD. All children
made significant improvements, as indicated by an increased proportion of time engaged in activities during
equine-assisted occupational therapy sessions compared
with baseline. It is interesting that the increase happened
early in the intervention, indicating a good fit of the activity with the child. There was little room for improvement
after the initial response to intervention. Future research
needs to consider what length of intervention is necessary to
ensure ongoing effects on engagement in environments that
do not include a horse and also theoretical explanations for
why immediate effects persisted into the follow-up period.
Several possible explanations for the results need to be
carefully considered to build a theoretical explanation for
why equine-assisted therapy may be effective with children
with ASD. Presence of a horse is one explanation. Our
findings are consistent with the positive effects found in
other studies of therapies incorporating horses for children
with ASD (Bass et al., 2009; Gabriels et al., 2012) and
with the first author’s clinical experience. As Endenburg
and van Lith (2011) suggested, the consistency of positive
effects suggests a real effect, particularly given that the
studies differed in the animal used, therapy approach, or
research method. However, consistent results do not help
in understanding why the intervention worked.
Novelty must also be considered. None of the children
had previously participated in riding or the associated activities. Although something new (new toy, game, activity,
or task) was included in each baseline session, the level of
novelty between baseline and intervention likely still
varied. Many intervention elements were unfamiliar, such
as the smell of the saddle leather, the texture of hay, and
the warmth and movement of the horse’s body. Novelty in
combination with an attraction to the horse may have
increased the children’s engagement. If engagement was
influenced only by novelty, it should have been reduced
after habituation to riding. However, engagement remained high over the 2.5 mo of intervention.
Physical exercise may also positively influence engagement. After physical exercise, brain functions such as
attention, memory, and perceptual and verbal skills improve (Chaddock, Pontifex, Hillman, & Kramer, 2011).
Riding a horse provides physical demands. Although the
children were having fun, they received the benefits of
physical exercise in an outdoor environment. Such an
environment has positive effects (Ryan et al., 2010) that
promote wellness and are energizing, particularly when
the activity involves social elements and physical exercise
(Frederick & Ryan, 1995).
Another explanation is that the activities may have
addressed the children’s sensory needs. Optimal arousal
allows the child to produce appropriate responses to
environmental demands and therefore more successfully
engage (Bundy & Murray, 2002). Our strategies included
stimulating the vestibular and proprioceptive systems
through the horse’s gait. During baseline, the children
received vestibular stimulation (e.g., on a trampoline)
only if the child selected that activity. The stimulation
came from self-initiated movement and was of short
duration. During the intervention, all children had vestibular stimulation resulting from the tridimensional
movements of the horse at walk. The child was moved up
and down, forward and backward, and from side to side.
The vestibular stimulation provided by the trot was likely
stronger because it was combined with the sensation of
speed and strong proprioceptive and deep touch input
from bouncing on the horse’s back. Children often chose
not to stop the bouncing by gripping the horse with their
legs as they had been taught.
During follow-up, a swing was available and was often
chosen. It may have provided vestibular activity similar to
riding a horse (forward and backward, some up-anddown movement) but was self-driven with less side-toside movement, less proprioceptive input, less deep
touch, and shorter duration. When a child had decreased
attention, we implemented a few minutes of trotting,
which resulted in the child’s being more focused.
Study results suggest that activities in an individualized
setting with the inclusion of an animal that provides
vestibular and proprioceptive stimulation may improve
engagement. The therapist’s responsivity to the child
attempts to engage, physically challenging activities, a
supportive environment, and matching strategies and
stimulation to the child’s needs all seem important but
were not directly measured. Future research needs to
consider these aspects and evaluate these strategies in
other environments such as a playground or school.
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Generalization of Findings
Generalization of the intervention effect was measured in
the playroom during follow-up. Changes in engagement
were maintained during follow-up in the presence of a
familiar adult. The intervention’s social validity was supported by the excellent attendance. During intervention,
parents and teachers often reported changes in the children.
After the study, 5 of the 7 parents registered their children
in riding classes.
Limitations and Future Directions
The study had several limitations. Blinding the raters
to phases was difficult. As with most single-case research
designs, the small sample size limits generalization. The
follow-up period was only 1 mo, which limited understanding of longer term effects. The first author delivered all
sessions over all phases to ensure that changes were not due
to differing adult characteristics. However, increased familiarity with her may have contributed to the results.
Children could not run away or avoid the therapist when
they were on the horse, making it more likely that they
would be engaged. However, the children were also engaged
in the off-horse activities when they could leave. Uniform
standardized assessments of cognition and communication
were not used across children.
Our findings support the benefits reported in other
horse- and animal-based interventions (O’Haire, 2013).
However, the current study needs replication with a
larger and more heterogeneous sample and standardized
assessments of the participants and the outcomes. Controlling for increased familiarity with the adult should be
addressed. Specific aspects of the hippotherapy components need to be evaluated, such as the child’s response
after different types or amounts of vestibular stimulation
and proprioceptive input. Next steps for equine-assisted
occupational therapy include the creation of specific
standardized protocols and manualization of the intervention approach (Smith et al., 2007). These steps will
help researchers and therapists to apply the same conditions and strategies across studies and allow replication.
Work is needed to better understand the theoretical basis
for the intervention.
Implications for Occupational
Therapy Practice
The results of this study have the following applications
for practice:
• To incorporate animals in intervention, occupational
therapy practitioners need to understand the theoretical
basis that links the animal (e.g., horse) with evidencebased therapy because this understanding may greatly
enhance the effective use of the animal.
• The use of animals in therapeutic sessions can be a
strong motivator for children with ASD. However, its
greatest potential comes from combining the attraction of an animal with the strategic selection of techniques from within occupational therapy, such as
those from sensory integration theory.
Conclusion
For young children with ASD, equine-assisted occupational therapy appears to increase engagement in
adult-directed activities. Even though the mechanisms
underlying the changes need further exploration, observations provide some clues to understanding how and why
the changes were produced. It is important to understand
which conditions make these therapies most effective.
Interaction with an animal, novelty and variation, the
strategies used, the vestibular stimulation, and the environment may all play an important role. This study
emphasizes that it is not only the animal itself but also the
selection of specific techniques and strategies in combination with the attraction and the features of the animal
that may make equine-assisted occupational therapy a
successful alternative intervention tool. s
Acknowledgments
The Autism Society of Edmonton and the Autism Research Center provided funding. We thank the children
and their families, the board and instructors of the equestrian
center, and the volunteers whose presence and collaboration
were invaluable. We thank Steve Mackenzie from the
American Hippotherapy Association for his contribution.
This study has been registered at ClinicalTrials.gov (Registration No. NCT02714101).
References
Abramson, J. H. (2011). WINPEPI updated: Computer programs for epidemiologists, and their teaching potential.
Epidemiologic Perspectives and Innovations: EP1I, 8, 1.
http://dx.doi.org/10.1186/1742-5573-8-1
Adamson, L. B., Bakeman, R., Deckner, D. F., & Romski, M.
(2009). Joint engagement and the emergence of language
in children with autism and Down syndrome. Journal of
Autism and Developmental Disorders, 39, 84–96. http://dx.
doi.org/10.1007/s10803-008-0601-7
American Hippotherapy Association. (2014). Level I hippotherapy treatment principles. Retrieved from http://www.
americanhippotherapyassociation.org/cirriculum/leveli-hippotherapy-treatment-principles/
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/ on 11/23/2016 Terms of Use: http://AOTA.org/terms
7006220040p7
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The
effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism and Developmental Disorders, 39, 1261–1267. http://dx.doi.org/
10.1007/s10803-009-0734-3
Bayley, N. (2005). Bayley Scales of Infant and Toddler Development, Third Edition. London: Pearson Assessment.
Bondy, A. S., & Frost, L. A. (1993). Mands across the water: A
report on the application of the picture-exchange communication system in Peru. Behavior Analyst, 16, 123–128.
Boyd, B. A., Conroy, M. A., Mancil, G. R., Nakao, T., &
Alter, P. J. (2007). Effects of circumscribed interests on
the social behaviors of children with autism spectrum
disorders. Journal of Autism and Developmental Disorders, 37, 1550–1561. http://dx.doi.org/10.1007/s10803006-0286-8
Bundy, A., & Koomar, J. (2002). Orchestrating intervention:
The art of practice. In A. C. Bundy (Ed.), Sensory integration, theory and practice (2nd ed., pp. 242–259). Philadelphia: F. A. Davis.
Bundy, A., & Murray, E. (2002). Sensory integration: A. Jean
Ayres’ theory revisited. In A. C. Bundy (Ed.), Sensory integration, theory and practice (2nd ed., pp. 3–33). Philadelphia: F. A. Davis.
Chaddock, L., Pontifex, M. B., Hillman, C. H., & Kramer,
A. F. (2011). A review of the relation of aerobic fitness and
physical activity to brain structure and function in children.
Journal of the International Neuropsychological Society, 17,
975–985. http://dx.doi.org/10.1017/S1355617711000567
Endenburg, N., & van Lith, H. A. (2011). The influence
of animals on the development of children. Veterinary
Journal, 190, 208–214. http://dx.doi.org/10.1016/j.tvjl.2010.
11.020
Frederick, C. M., & Ryan, R. M. (1995). Self-determination in
sport: A review using cognitive evaluation theory. International Journal of Sport Psychology, 26, 5–23.
Gabriels, R. L., Agnew, J. A., Holt, K. D., Shoffner, A., Zhaoxing, P., & Ruzzano, S. (2012). Pilot study measuring the
effects of therapeutic horseback riding on school-age children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 6, 578–588. http://
dx.doi.org/10.1016/j.rasd.2011.09.007
Grandin, T., Fine, A. H., & Bowers, C. M. (2010). The use of
therapy animals with individuals with autism spectrum
disorders. In A. Fine (Ed.), Handbook on animal-assisted
therapy (3rd ed., pp. 247–264). San Diego, CA: Elsevier.
http://dx.doi.org/10.1016/B978-0-12-381453-1.10013-3
Harrison, P., & Oakland, T. (2003). Adaptive Behavior Assessment System–Second Edition. San Antonio: Harcourt
Assessment.
Jenkins, S. R., & DiGennaro Reed, F. D. (2013). An experimental analysis of the effects of therapeutic horseback riding on the behavior of children with autism. Research in
Autism Spectrum Disorders, 7, 721–740. http://dx.doi.org/
10.1016/j.rasd.2013.02.008
Jorgenson, J. (1997). Therapeutic use of companion animals in
health care. Image: The Journal of Nursing Scholarship, 29,
249–254. http://dx.doi.org/10.1111/j.1547-5069.1997.
tb00993.x
Kazdin, A. E. (2011). Single-case research designs: Methods for
clinical and applied settings (2nd ed.). New York: Oxford
University Press.
Kratochwill, T. R., Hitchcock, J., Horner, R. H., Levin, J. R.,
Odom, S. L., Rindskopf, D. M., & Shadish, W. R. (2010).
Single-case design technical documentation. Retrieved from
http://ies.ed.gov/ncee/wwc/documentsum.aspx?sid5229
Lane, S. J. (2002). Sensory modulation. In A. C. Bundy (Ed.),
Sensory integration, theory and practice (2nd ed., pp.
101–120). Philadelphia: F. A. Davis.
Lawton-Shirley, N. (2002). Hippotherapy. In A. C. Bundy
(Ed.), Sensory integration, theory and practice (2nd ed.,
pp. 351–353). Philadelphia: F. A. Davis.
Lough, C. L., Rice, M. S., & Lough, L. G. (2012). Choice as a
strategy to enhance engagement in a colouring task in
children with autism spectrum disorders. Occupational
Therapy International, 19, 204–211. http://dx.doi.org/
10.1002/oti.1337
McCardle, P., McCune, S., Griffin, J. A., Esposito, L., &
Freund, L. S. (2011). Animals in our lives: Human–animal
interaction in family, community, and therapeutic settings.
Baltimore: Brookes.
O’Haire, M. E. (2013). Animal-assisted intervention for autism
spectrum disorder: A systematic literature review. Journal of
Autism and Developmental Disorders, 43, 1606–1622. http://
dx.doi.org/10.1007/s10803-012-1707-5
Parker, R. I., Vannest, K. J., & Brown, L. (2009). The improvement rate difference for single-case research. Exceptional Children, 75, 135–150. http://dx.doi.org/10.1177/
001440290907500201
Patten, E., & Watson, L. R. (2011). Interventions targeting
attention in young children with autism. American Journal
of Speech-Language Pathology, 20, 60–69. http://dx.doi.org/
10.1044/1058-0360
Professional Association of Therapeutic Horsemanship International. (n.d.). Learn about therapeutic riding. Retrieved
from http://www.pathintl.org/resources-education/resources/
eaat/198-learn-about-therapeutic-riding
Richards, S. B., Taylor, R. L., Ramasamy, R., & Richards,
R. Y. (1999). Single subject research. London: Singular
Publishing Group.
Ryan, R. M., Weinstein, N., Bernstein, J., Brown, K. W.,
Mistretta, L., & Gagné, M. (2010). Vitalizing effects of being
outdoors and in nature. Journal of Environmental Psychology,
30, 159–168. http://dx.doi.org/10.1016/j.jenvp.2009.10.009
Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating animals for children with
autism: A pilot investigation. American Journal of Occupational Therapy, 60, 268–274. http://dx.doi.org/10.5014/
ajot.60.3.268
Smith, T., Scahill, L., Dawson, G., Guthrie, D., Lord, C.,
Odom, S., . . . Wagner, A. (2007). Designing research
studies on psychosocial interventions in autism. Journal
of Autism and Developmental Disorders, 37, 354–366.
http://dx.doi.org/10.1007/s10803-006-0173-3
7006220040p8
Downloaded From: http://ajot.aota.org/ on 11/23/2016 Terms of Use: http://AOTA.org/terms
November/December 2016, Volume 70, Number 6
Tager-Flusberg, H., Rogers, S., Cooper, J., Landa, R., Lord,
C., Paul, R., . . . Yoder, P. (2009). Defining spoken language benchmarks and selecting measures of expressive
language development for young children with autism
spectrum disorders. Journal of Speech, Language, and Hearing Research, 52, 643–652. http://dx.doi.org/10.1044/
1092-4388(2009/08-0136)
Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill,
S. M., Ciukaj, M. D., & Gehman, M. (2009). Volitional
change in children with autism: A single-case design study
of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192–200. http://dx.
doi.org/10.1080/01642120902859287
Ward, S. C., Whalon, K., Rusnak, K., Wendell, K., &
Paschall, N. (2013). The association between therapeutic
horseback riding and the social communication and sensory reactions of children with autism. Journal of Autism
and Developmental Disorders, 43, 2190–2198. http://dx.
doi.org/10.1007/s10803-013-1773-3
Watling, R. L., & Dietz, J. (2007). Immediate effect of Ayres’s
sensory integration–based occupational therapy intervention on children with autism spectrum disorders. American
Journal of Occupational Therapy, 61, 574–583. http://dx.
doi.org/10.5014/ajot.61.5.574
Wechsler, D. (2004). WPPSI–III administration and scoring
manual. Sydney: Harcourt Assessment.
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/ on 11/23/2016 Terms of Use: http://AOTA.org/terms
7006220040p9