Equine-Assisted Occupational Therapy: Increasing Engagement for Children With Autism Spectrum Disorder

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 ≥3 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 = 8) or were unwilling to ride (n = 2) or because of concerns about English skills (n = 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 = 2); Phase 2, using single words (n = 3); Phase 3, using two- to three-word combinations (n = 1); and Phase 4, using sentences (n = 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, 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).

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Figure 1.

Percentage of engagement in activities.

Settings and Procedures

All sessions (baseline, intervention, follow-up) were 45–60 min long. Children spent ≥20 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 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 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 equine-assisted 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 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 follow-up). 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 = 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 = 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).