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Therapeutic Horseback Riding Outcomes of Parent-Identified Goals for Children with Autism Spectrum Disorder: An ABA′ Multiple Case Design Examining Dosing and Generalization to the Home and Community

Margo B. Holm, Department of Occupational Therapy, School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 5012 Forbes Tower, Pittsburgh, PA 15260, USA

Joanne M. Baird, Department of Occupational Therapy, School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 5012 Forbes Tower, Pittsburgh, PA 15260, USA

Young Joo Kim, Department of Occupational Therapy, School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 5012 Forbes Tower, Pittsburgh, PA 15260, USA

Kuwar B. Rajora, Department of Occupational Therapy, School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 5012 Forbes Tower, Pittsburgh, PA 15260, USA

Delma D’Silva, Department of Occupational Therapy, School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 5012 Forbes Tower, Pittsburgh, PA 15260, USA

Lin Podolinsky, Nickers ‘N Neighs, 260 Mountain Trails Lane, Acme, PA 15610, USA

Carla Mazefsky, and Department of Pediatrics, University of Pittsburgh School of Medicine, Webster Hall, Suite 300, 3811 O’Hara Street, Pittsburgh, PA 15213, USA. Department of Psychiatry, University of Pittsburgh School of Medicine, Webster Hall, Suite 300, 3811 O’Hara Street, Pittsburgh, PA 15213, USA

Nancy Minshew Department of Psychiatry, University of Pittsburgh School of Medicine, Webster Hall, Suite 300, 3811 O’Hara Street, Pittsburgh, PA 15213, USA. Department of Neurology, University of Pittsburgh School of Medicine, Webster Hall, Suite 300, 3811 O’Hara Street, Pittsburgh, PA 15213, USA

Correspondence to: Margo B. Holm, [email protected].

Present Address: Y. J. Kim, Integrated Resources, Inc., 4 Ehtel Road, Suite 403B, Edison, NJ 08817, USA Present Address: K. B. Rajora, Kindred Healthcare, CESLC-Hebrew Home, 6121 Montrose Road, Rockville, MD 20852, USA Present Address: D. D’Silva, Kindred Rehab SVCS Inc., DBA Rehab Care, 680 South Fourth Street, Louisville, KY 40202, USA

NIH Public Access Author Manuscript J Autism Dev Disord. Author manuscript; available in PMC 2015 April 01.

Published in final edited form as: J Autism Dev Disord. 2014 April ; 44(4): 937–947. doi:10.1007/s10803-013-1949-x.

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Margo B. Holm: [email protected]

Abstract

We examined whether different doses of therapeutic riding influenced parent-nominated target

behaviors of children with autism spectrum disorder (ASD) (a) during the session (b) at home, and

dosing of 1, 3, and 5 times/week. Three boys with ASD, 6–8 years of age participated, and counts

of target behaviors were collected in each setting and phase of the study. Compared to Baseline,

70 % of the target behaviors were better during Intervention and improvement was retained in 63

% of the behaviors during Withdrawal. Increased doses of therapeutic riding were significant for

magnitude of change, and the effect of the therapeutic riding sessions generalized to home and

community.

Keywords

Autism spectrum disorder; Single subject design; Home; Community

Introduction

While hippotherapy, equine-facilitated psychotherapy, and therapeutic riding have

therapeutic use of horses in common, there are distinct differences. In general, hippotherapy

tends to focus on posture, balance, and mobility. It is usually carried out by physical and

occupational therapists, who consider horseback riding to be a therapeutic modality (All and

Loving 1999). In equine-facilitated psychotherapy, during a riding session, the therapist is

often the instructor, and the presence of the horse is deemed to be therapeutic (Bates 2002;

Masini 2010). The focus of therapeutic riding is broader, and may include physical, social,

learning, sensory, and psychological goals, including the relationship between the rider and

the horse, and is directed by a certified therapeutic riding instructor (All and Loving 1999).

Using a single-subject design methodology, the current study sought to examine the

effectiveness of 3 different doses of therapeutic riding on parent-identified target behaviors

of three boys with autism spectrum disorder (ASD), in three environments: the therapeutic

riding center, the home, and the community.

Previous research on the effectiveness of hippotherapy, equine-facilitated psychotherapy,

and therapeutic riding for children has mostly focused on those with physical (Davis et al.

2009; Drnach et al. 2010; McGibbon et al. 2009; Shurtleff et al. 2009), social/emotional/

behavioral (Bass et al. 2009; Ewing et al. 2007; Schultz et al. 2007), and language/learning

conditions (Kaiser et al. 2006; Macauley and Gutierrez 2004). These studies examined

changes in gait, posture, strength, coordination, self-concept, depression, pain, anxiety, or

quality of life. In most studies, some level of effectiveness was reported, although the

quality of studies varied considerably. Several systematic reviews/ meta-analyses on the

effectiveness of hippotherapy and therapeutic riding were found for children with cerebral

palsy (Snider et al. 2007; Tseng et al. 2013; Whalen and Case-Smith 2012; Zadnikar and

Kastrin 2011). These studies examined outcomes related to gross motor function (Sterba

2007; Whalen and Case-Smith 2012; Snider et al. 2007), asymmetrical activity of the hip

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adductors (Tseng et al. 2013), and postural control and balance (Sterba 2007; Zadnikar and

Kastrin). Two studies found that even a short session (e.g., 8–10 min) could decrease

asymmetrical hip adductor activity significantly and that once a week sessions lasting only

8–10 weeks could yield significant improvements in gross motor function. All studies found

that hippotherapy or therapeutic riding yielded at least short-term positive outcomes on

physical outcome measures for children with cerebral palsy.

However, only one study was found on the use of therapeutic riding for children diagnosed

with autism spectrum disorder (ASD) (Bass et al. 2009). Compared to waitlist controls,

children in the riding program showed greater social motivation, sensory seeking, and a

reduction in sedentary behaviors, inattention and distractibility. However, no research has

examined the “dosing” effect of therapeutic riding on parent-identified target behaviors. In

addition, research linking the use of therapeutic riding with parent-identified negative or

positive target behaviors was also lacking, as were studies focused on generalization of the

therapeutic riding session effects to the home or community environments. Therefore, the

current study examined the impact of 3 dosages of therapeutic riding (1, 3, and 5 times/

week) on three parent-identified target behaviors for three boys with ASD, in three

environments: the therapeutic riding center, the home, and the community.

Methods

The study used an ABA’ single subject design, with each phase lasting 4 weeks and the

entire study lasting 12 weeks. Common to education, single subject designs, or N-of 1 trials

are becoming common in medical therapeutics, and allied health because patients serve as

their own controls, variability of response can be seen if the data are graphed, and the

statistical significance of the behavioral change following the Intervention can be calculated

several ways (e.g., mean levels, celeration lines, 2 standard deviation bands, and the more

rigorous C-statistic) (Larson 1990; Lillie et al. 2011; Ottenbacher 1986). Moreover,

depending on the Intervention, data gathered in the Withdrawal phase reflects whether the

effects of the Intervention continue when the Intervention is stopped (i.e., learning has taken

place), or if removal of the Intervention (i.e., a reward, a splint, a technology device) results

in a return to Baseline (control condition) behaviors. In the Baseline (control condition)

phase (A) the 3 participants received their typical 1 session (30–45 min) of therapeutic

riding per week for 4 weeks. In the Intervention phase (B) the participants received either 1

(control dose), 3, or 5 sessions per week (dosing effect). In the Withdrawal phase (A’) all

participants returned to their usual 1 session per week routine. For each participant,

researchers collected data on parent-generated target behaviors during the therapeutic riding

sessions, and parents also collected data on the same target behaviors at home and in the

community (generalization effect). The study was conducted during the months of July (A),

August (B), and September (A’).

Participants

To be eligible for the study, participants had to (a) be diagnosed with ASD by a physician

(b) be between 5 and 13 years of age (c) be available to participate in the Intervention phase

of the study which could require up to 5 days/week riding sessions for 4 weeks (d) be able to

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participate in the therapeutic riding sessions for 12 weeks, and (e) have parents willing to

identify and document target behaviors they wanted increased (positive) or decreased

(negative) in their child. Eight children met 3 of the criteria, and three boys between the ages

of 6 and 8 years met all criteria and participated in the study. Each of the boys had been

riding once a week for approximately 1 year. The three boys were randomized by coin flip

to receive the therapeutic riding Intervention (dosing) for 1 (Participant A; Control dose), 3

(Participant B), or 5 (Participant C) sessions per week. Examples of short-term and long-

term therapeutic riding goals for the three participants are listed in Table 1.

Participant A—Participant A was an 8-year-old boy, who had just completed the 2nd grade. He could read easy sentences, and was also able to do subtraction and addition using

touch math. According to the Kaufman Test of Educational Achievement-Second Edition,

he achieved less than 1.0 grade level for Phonological Awareness, K.2 for Letter and Word

Recognition, K.0 for Match Concepts and Applications, K.4 for Math Computation, 1.0

grade for Reading Comprehension, and less than 1.0 grade for Spelling. No IQ or other

standardized measures were available because of non-compliance with testing. The three

target behaviors identified by his parents were: (1) decrease tensing/ clenching of facial

muscles (2) decrease snapping of fingers, and (3) increase spontaneous communication of

wants/needs.

Participant B—Participant B was a 6-year-old boy, who had completed kindergarten. He had mastered the kindergarten reading list (pre-primer dolch words) and was moving on

with the primer words. He was able to “sound out” simple words phonetically, as well, and

was adding single digits, but not yet subtracting. No IQ or other standardized measures were

available because of non-compliance with testing. The three target behaviors identified by

his parents were: (1) decrease pounding on surfaces with either hand (2) decrease pushing in

nose with either hand, or (3) decrease clapping.

Participant C—Participant C was a 6-year-old boy, who had completed kindergarten. He was able to read above grade level and had excellent spelling test scores too. He could do

simple addition and subtraction. His grade equivalent PIAT scores were: 1.9 for Reading

Recognition, 1.4 for Reading Comprehension, 1.6 for Total Reading, 1.6 for Spelling, and

less than K.0 for Mathematics. The General Information subtest was not scoreable because

of the open-ended question format. The three target behaviors identified by his parents were:

(1) decrease echolalia/scripting (2) decrease mouthing/chewing on fingers/hands and non-

edible objects, and (3) increase verbal demands using 3 or more words.

Standardized Measures of Change

Standardized measures of change were completed four times by the parents, each time with

a look-back period of 1 month: Pre-study (Pre-Baseline), Post-phase A (Baseline), Post-

phase B (Intervention), and Post-phase A’ (Withdrawal) (see Table 2).

Aberrant Behavior Checklist-Community (ABC-C) (Aman and Singh 1994). The ABC-C

was designed to assess behaviors and measure Intervention effects of individuals with

developmental disabilities. The ABC-C (Aman et al. 1985; Brown et al. 2002) consists of 58

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items in five symptom clusters: (1) Irritability, Agitation, Crying (15 items); (2) Lethargy,

Social Withdrawal (16 items); (3) Stereotypic Behavior (7 items); (4) Hyperactivity/

Noncompliance (16 items); and (5) Inappropriate Speech (4 items). Parents were asked to

consider their children’s behaviors for the past month, and rate each item on a 0 to 3 scale (0

= not at all a problem; 3 = the problem is severe in degree). The symptom-cluster subscales

are scored separately and stand alone.

Social Responsiveness Scale (SRS) (Constantino and Gruber 2005). The SRS is designed to

describe and measure the severity of symptoms associated with ASD as they occur in natural

social settings. The SRS consists of 5 scale scores (Social Awareness, Social Cognition,

Social Communication, Social Motivation, and Autistic Mannerisms) and a total score.

Parents were asked to consider their children’s behaviors for the past month (instead of 6

months) and rate each item on a 1–4 scale (1 = not true; 4 = almost always true).

Sensory Profile-Caregiver Questionnaire (SP-CQ) (Dunn 1999). The SP-CG was designed

to allow caregivers to describe the sensory responses of their children. The questionnaire

consists of 125 items grouped into three categories: Sensory Processing, Modulation, and

Behavioral and Emotional Responses (Dunn 1999 p. 1). Within the three categories,

behaviors are further grouped into 14 subcategories (Sensory Processing = 6; Modulation =

5; Behavior and Emotional Response = 3), and ranges of scores for each subcategory are

interpreted as: typical performance (≤1 SD below the national research sample mean),

probable difference (≤2 SD but >1 SD below the national research sample mean), and

definite difference (>2 SD below the national research sample mean). Parents were asked to

consider their children’s behaviors for the past month, and rate each item for the frequency

with which they observed their children exhibit the behaviors on the questionnaire using a 5-

point scale (1 = always, 5 = never). Scores from subcategory items are then transferred to a

9-category factor summary table, and again rated as typical performance, probable

difference or definite difference.

Observed Measures of Change

Data for observed measures of change were collected during the three phases of the study.

Each set of parents identified three target behaviors they wanted to see their child increase

(e.g., verbalization) or decrease (e.g., scripting). Examples of “typical” negative behaviors to

be decreased through participation in the therapeutic riding program included finger licking,

clapping, finger twisting, and body hitting, and pinching. Examples of positive behaviors to

be increased included eye contact, verbalization, and naming of people/items. Each behavior

was clearly defined and each observation of the behavior during a data collection session

counted as 1 observance.

Therapeutic Riding Sessions—The first author and two graduate students videotaped each riding session. Each videotape was reviewed by both graduate students, coded, and

entered into a database. Each “walker” (one on each side of the horse) and the leader also

collected data for one target behavior by moving a bead down a shoelace tied to their belts in

case the video did not capture a behavior. Each session lasted approximately 45 min. Overall

inter-observer reliability was 0.87 % agreement.

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Home—Parents recorded the frequency of each targeted behavior at home (lived-in environment, for 1/2 h for each behavior, 3 times/week. Parents chose the times when the

target behaviors tended to be most prevalent (e.g., getting ready for school, mealtimes, etc.).

At the end of each month, the data sheets were turned into the research team, and the data

were entered into the database.

Community—Parents recorded the frequency of each targeted behavior in a community setting (e.g., church, grocery store, friend’s home) for 1/2 h for each behavior, 3 times/week.

Parents chose the settings and times when the target behaviors tended to be most prevalent.

At the end of each month, the data sheets were turned into the research team, and the data

were entered into the database.

Procedures

The Nickers ‘N Neighs Therapeutic Riding Center, Donegal, PA, was chosen for the study

because the Director had a baccalaureate degree in Equine Facilitated Therapeutics, and was

a Certified and Registered Instructor (Pennsylvania Council on Therapeutic Horsemanship;

The North American Riding for the Handicapped Association). Potential participants were

recruited from Nickers ‘N Neighs. A flyer was distributed to parents of children ages 5–13

who were enrolled in a therapeutic riding program. The flyer included the design of the

study, and the eligibility criteria. The study was approved by the Full Board of the

University of Pittsburgh Institutional Review Board for the Protection of Human Subjects.

After reviewing the study with each set of parents, and obtaining informed consent, the first

author, the Center Director and the parents identified 3 observable target behaviors for each

participant. Operational definitions for each behavior were then generated. Directions for

data collection at home and in the community were reviewed with each set of parents, who

were then provided with a notebook of data collection forms and measures to be completed

prior to Baseline, and immediately following each phase using a look-back period of 1

month. C-statistics were chosen for data analysis because they are more rigorous than

celeration line graphics.

The instructors were certified in therapeutic horsemanship, set overall goals with the family

and the student (see sample goals, Table 1), and had lesson plans for each session. Each

session began with grooming of the horse, emphasizing touch, naming of parts, and

following directions given by the instructor. During the riding session, students were

accompanied by a leader (who lead the horse around the indoor track), and two trained

walkers (persons who walked on either side of the horse and placed their forearms across

each of the child’s legs to ensure student safety, or provide cues to the student). The

instructor stood in the center of the arena and guided the lesson, by giving directions to the

student. The students wear appropriate clothing such as helmets for their physical protection.

All riding activities take place on the stable grounds in a controlled environment and follow

a pre-planned sequence to meet the therapeutic riding program goals and objectives.

Standardized test data were analyzed using descriptive statistics, and then converted to the

performance level indicator. Observed measures consisted of frequency counts, and were

entered into excel to be analyzed using the C-statistic (Ottenbacher 1986), which yields a Z

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score. Inter-rater reliability was calculated for the two research assistants for 25 % of their

observations, and confirmed by the principal investigator.

Results

Standardized Measures of Change

Screening with the Childhood Autism Rating Scale (CARS; Schopler et al. 1988) indicated

that all three boys were “mildly-moderately autistic.” On the repeated standardized measures

of change, the participants showed little variation in behaviors from Pre-Baseline to Post-

Baseline to Post-Intervention to Post-Withdrawal. On the ABC-C, parent-rated behaviors of

all three boys ranged from the 60th to the 98th percentile across phases. On the SRS, all but

one T-score of parent-rated behaviors ranged above 60, indicating mild to severe social

impairment. On the SP-CQ, parent-rated sensory indicators tended to remain stable, with

each participant being rated as “typical performance” during all phases of the study for low

endurance/tone, sensory sensitivity, and sedentary factors. Participants A and B were also

rated as “typical performance” in all phases for emotionally reactive, and Participant B for

poor registration. In contrast, Participants A and C were rated as “definite difference” for

sensory seeking, and Participant C for fine motor/perceptual (see Table 3).

Observed Measures of Change

Participant A (Control Dose, 1 Time/Week)

Tenses/clenches facial muscles: Although the behavior increased during the riding sessions compared to Baseline it decreased at home and in the community during Intervention and

during Withdrawal. The change in the behavior in the community, from Baseline to

Withdrawal, was significant (see Table 4).

Snapping fingers: Again, compared to Baseline, the behavior increased during the riding sessions, and decreased at home during Intervention and during Withdrawal. In the

community, compared to Baseline, the behavior decreased significantly during the

Intervention, but increased significantly during Withdrawal (see Table 4).

Spontaneous verbal communication of wants/needs; any number of words: Compared to Baseline, the behavior increased during Intervention and Withdrawal during riding

sessions, at home, and in the community. Significant changes occurred during riding

sessions from Baseline to Intervention, and at home from Baseline to Withdrawal (see Table

4); however, because increases in verbalization were observed during Baseline and the data

were autocorrelated (data were already increasing in a linear path), it is not clear that the

changes were due to the Intervention alone.

Participant B (Dose = 3 Times/Week)

Pounding on surfaces with either hand: While riding, compared to Baseline, the behavior increased significantly during Intervention, but there was no change from Baseline to

Withdrawal. Compared to Baseline, the behavior decreased at home and decreased

significantly in the community during Intervention and Withdrawal. However, because

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decreases in the behavior were observed during Baseline and the data were autocorrelated, it

is not clear that the changes were due to the Intervention alone (see Table 5).

Pushing in nose with either hand: Compared to Baseline, during Intervention and Withdrawal the behavior decreased during riding sessions, at home, and in the community,

and the decrease from Baseline to Intervention in the community was significant (see Table

5).

Clapping: For both during riding sessions and at home, compared to Baseline, the behavior increased during Intervention and Withdrawal. However, only the increase during

Intervention riding sessions was significant. In the community, compared to Baseline, the

behavior decreased during Intervention and Withdrawal (see Table 5).

Participant C (Dose = 5 Times/Week)

Echolalia/scripting—Compared to Baseline, the behavior increased while riding during Intervention (significant) and Withdrawal (significant). Likewise, compared to Baseline the

behavior increased at home during Intervention (significant) and Withdrawal and in the

community during Intervention and Withdrawal (significant) (see Table 6).

Mouthing/chewing fingers/hands and non-edible objects—Although the behavior decreased significantly during Intervention compared to Baseline during the riding sessions,

the behavior increased from Baseline to Withdrawal. However, compared to Baseline the

behavior decreased at home during Intervention (significant) and Withdrawal (significant)

and in the community during Intervention and Withdrawal (significant) (sees Table 6).

Verbal demands of 3 words or more—Compared to Baseline, the behavior increased significantly during Intervention and Withdrawal during the riding sessions, and increased in

the home and community during Intervention. It also increased significantly at home during

Withdrawal, but the increase in the community during Withdrawal was not significant (see

Table 6).

Goal-Free Evaluation of Change

At the end of the study, each set of parents was interviewed again and asked if they had

noticed any changes in their child during the study beyond the identified target behaviors.

Each set of parents identified several common behaviors that they perceived as improving

during the Intervention phase of the study, and continuing into the Withdrawal phase: (1)

increased overall verbalization (2) increased ability to follow directions (3) improved

physical strength and coordination, and (4) increased ability to respond to the rhythm of

their horses’ movements.

Discussion

The current study examined the impact of 3 doses of therapeutic riding [1 time/week

(Control dose), 3 times/week, and 5 times/week] on parent-identified target behaviors of

three boys with ASD. In addition, we examined whether changes in behavior occurred

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during therapeutic riding sessions and if there was any carryover into the home and the

community.

At first glance, dosing of therapeutic riding did not seem to have an obvious effect on the

parent-identified targeted behaviors. In fact, Participant A showed improvement in 13/18

behaviors across the phases and environments; Participant B showed improvement in 12/18

behaviors; and Participant C showed improvement in only 11/18 behaviors. However, the

statistical significance of the changes (magnitude) did vary based on dosage, with changes

for the better and for the worse. For Participant A, 5/18 changes were significant: 4 were

significantly better and 1 was significantly worse. For Participant B, 5/18 changes were

significant: 3 were significantly better and 2 were significantly worse. For Participant C,

11/18 changes were significant: 7 were significantly better and 4 were significantly worse.

Therefore, although increasing the dosage of weekly therapeutic riding sessions did not

seem to impact the number of positive behavioral changes, it did impact the magnitude of

those changes—primarily for the better.

We also sought to examine whether the target behaviors changed for the positive during the

riding sessions, and if the benefits of the therapeutic riding sessions carried over to the home

and community. For changes during the riding session between phases (A–B; B-A’), 2/3

behaviors each for Participants A and B changed for the worse or remained the same and 1/3

behaviors changed for the better, whereas 1/3 behaviors of Participant C changed for the

worse, and 2/3 changed for the better. In contrast, even though some behaviors changed for

the worse in each phase during the riding sessions, the impact of the riding sessions on the

target behaviors in the home and community were uniformly positive. Of the 6 potential

changes (3 behaviors × 2 phases), positive changes in the home and the community for

Participant A were 6/6 and 5/6 respectively; for Participant B, the positive changes were 4/6

and 6/6 respectively, and; for Participant C, the positive changes were 4/6 for both home and

community. Therefore, even though the target behaviors often exacerbated with the

excitement during the therapeutic riding sessions, the carryover of the session effect on the

target behaviors in the home and community was positive.

However, there were few changes in the standardized measures over the 3 months of the

study. Each of the boys was scored as “mildly-moderately autistic” on the CARS at the

beginning of the study. On the ABC-C measure, all three boys were scored lowest on the

irritability scale, but all other scales were more indicative of severe symptoms. Likewise, for

the SRS, most of the T-scores for each time period were in the severe range. Perhaps the

CARS level of “mildly-moderately” versus severely autistic is associated with the number of

scales on which the boys were scored as having “typical performance” for their ages in

regard to sensory processing. According to the results of the SP-CQ throughout the study,

for Participant A, four scales were rated as typical; for Participant B, seven scales; and for

Participant C, three scales. Compared to the research norming sample, all three boys were

typical for low endurance/tone, sensory sensitivity, and being sedentary. Two of the boys

were also typical for emotionally reactive, and one boy for both oral sensory sensitivity and

the fine motor/perceptual factors. Participants A and C were rated as having a “definite

difference” in sensory processing from the research norming sample for two and three

scales, respectively. Given that sensory issues are often thought to be a hallmark of children

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diagnosed with ASD, “typical performance” in multiple factors of the SP-CQ was not

surprising (Dunn, 1999), although those factors where there was a definite difference were

consistent with ASD: sensory seeking, inattention/distractibility, poor registration, and fine

motor/perceptual.

Of the nine target behaviors, one behavior involved verbal stereotypy (e.g., echolalia), six

involved physical stereotypy (e.g., mouthing objects, pushing in nose), and two involved

spontaneous verbalization. Of all the target behaviors, it was spontaneous verbalization that

consistently increased between phases (A to B; A to A’) and each setting (riding, home, and

community). Increased verbal communication was also mentioned by all three sets of

parents during the goal-free evaluation at the end of the study. For each boy, communication

with the instructor was a therapeutic riding goal, and this mostly consisted of verbalizing to

the instructor what he wanted to do (e.g., trot, canter). The therapeutic riding instructor also

required the boys to follow directions for the planned lesson first, before granting choices,

and if the boys did not verbalize the choice accurately (e.g., 3 or more words), then the horse

would stand still until they did. All parents reported consistent increases in verbalization at

home and in the community over the Intervention and Withdrawal phases of the study.

Likewise, for the same phases, all parents also reported that their boys improved at

following directions at home and in the community, and associated it with the clear cause-

effect linkage the boys experienced during their riding sessions: they had to follow the

instructor’s directions if they wanted the horse to move, trot, or canter, which all of the boys

enjoyed.

Changes in physical core strength and coordination were two other positive outcomes of the

therapeutic riding program reported by parents, including improved abilities to sit up straight

on the horse for a greater proportion of the session, manage the reins better, and stand up in

the stirrups. Parents also commented on how their boys had learned to adjust their postures

in response to their horse’s gait and rhythm, even if it was only to avoid a “bumpy” ride!

Although they had not been target behaviors for any of the boys, each boy had “physical”

goals as part of their therapeutic riding program.

Only two studies have been published on the use of therapeutic horseback riding for children

with ASD (Bass et al. 2009; Wuang et al. 2010), and one study simulated horseback riding

by using a gymnastic metal “horse” (Wuang et al. 2010). Bass et al. (2009) compared the

social interactions of children with ASD who participated in a 12-h, 12-week therapeutic

riding program versus those on a wait-list. They found that the social motivation scale of the

SRS increased significantly for the children in the experimental group, as did four factors of

the SP-CQ: sensory seeking, inattention/distractibility, sensory sensitivity, and sedentary. In

contrast, our participants did not show meaningful changes over the phases of the 12-week

study for the SRS, or for the sensory seeking and inattention/distractibility factors of the SP-

CQ. However, our participants scored in the “typical performance” range for sensory

sensitivity and sedentary factors across all phases of the study, with little room for

improvement. Wuang et al. (2010) administered a 40-h, 40-week protocol using a crossover

design with the experimental group receiving 21-h sessions/week on the simulated “horse” +

traditional occupational therapy. The control group received traditional occupational therapy

only, with conditions reversed at the 20-week point, and measures taken at weeks 1–2 (T1),

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weeks 23–24 (T2), and week 44 (T3). Because Wuang et al. (2010) focused on the specific

gross and fine motor skills of the Bruininks–Osteresky Test of Motor Proficiency (BOTMP;

Bruininks 1978), and the Test of Sensory Integration Function (TSIF; Lin 2004),

comparison of results is more difficult, especially since neither test is a parent report, but

rather a therapist administered tool. Also, participants in the Waung et al. received 40 h of

riding and 40 h of occupational therapy, whereas our Intervention consisted of either 4, 12,

or 20 h of therapeutic riding at the most. Waung et al. found significant effect sizes for all

BOTMP and TSIF items, for both the experimental and the control conditions at T2 and T3,

although the effect sizes were larger for the experimental condition. Our participants’

parents also reported that their children demonstrated improved strength and coordination as

well as the ability to respond to the rhythm of the horses’ movements, both of which could

be categorized under the rubric of motor proficiency.

As with all studies, our study had limitations. Although the study met all criteria for a well-

designed single subject study (Horner et al. 2005; Kazdin 2011), it still had only three

subjects, and generalization becomes more limited to the inclusion criteria, demographics,

and clinical characteristics of each of our participants. Also, the parents were not masked to

the general purpose of the study, and also served as data collectors for target behaviors in the

home and community. Because each of the participants had ridden once a week for about 1

year, they had already mastered any fear associated with approaching, grooming or riding a

horse. Future studies should include larger samples, and gather more data on the impact of

confounding factors during each phase of the study. The use of a goal-free evaluation can

provide further evidence of the parents’ perceived positive outcomes of a therapeutic riding

program for children with ASD when it is conducted by a certified and registered instructor.

This study sought to fill in gaps on previous therapeutic riding studies of children with ASD

by including parent-identified target behaviors, dosing, and generalization of effect to the

home and community. Of the 27 target goals (3 per boy × 3 settings × 3 boys), 70 % of goals

were better during Intervention compared to Baseline, and 63 % of goals remained better

during Withdrawal compared to Baseline. Dosing of therapeutic riding was associated

positively with the magnitude of changes in target behaviors, but not the number of

behavioral changes. Additionally, even though target behaviors worsened during the

excitement of the riding sessions, the effect of the sessions generalized positively to the

home and community for physical stereotypy behaviors and spontaneous verbalization, but

not for verbal stereotypy behaviors. Single subject design was an effective, yet intense,

method of establishing evidence for an Intervention that has the potential to increase positive

behaviors and reduce negative behaviors in children with ASD.

Acknowledgments

This study could not have been implemented without an anonymous Grant to the University of Pittsburgh, Department of Occupational Therapy, the participation of the parents and boys, and the therapeutic riding staff of Nickers ‘n Neighs Therapeutic Riding Center.

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Table 1

Examples of therapeutic riding goals for students in the study

Physical

The student will learn to canter

The student will learn to post the trot

The student will learn the rhythm of the trot

The student will learn to balance independently at the trot

The student will learn to keep an upright neutral position at the trot

The student will learn to keep an upright neutral position with his leg underneath him at the trot

The student will learn two point positions

The student will learn to balance through transitions

The student will learn to transition between two-point and posting trot

The student will learn to hold onto the saddle for canter transitions

Emotional/behavioral

The student will become more comfortable with the horse

The student will learn to groom his horse

The student will learn to touch his horse appropriately

The student will learn the body parts of the horse

The student will follow directions upon being first asked with no additional prompts

Cognitive

The student will develop communication systems with the horse and instructor

The student will learn to use his leg aids

The student will learn to use his rein aids

The student will learn to use sentences to interact with the instructor

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S po

nt an

eo us

v er

ba l

co m

m un

ic at

io n

of w

an ts

/n ee

ds ;

an y

nu m

be r

of w

or ds

id in

g 5.

13 (

4. 70

) 22

.2 5

(1 0.

41 )

B et

te r

3 .3

6 S ig

5. 13

( 4.

70 )

47 .1

3 (3

0. 59

) B

et te

r 1 .4

8 n s

om e

12 .7

5 (9

.2 0)

14 .2

5 (9

.7 0)

B et

te r

0 .7

6 n s

12 .7

5 (9

.2 0)

21 .5

8 (9

.6 9)

B et

te r

2 .1

0 S ig

om m

un it

y 5.

92 (

3. 92

) 8.

50 (

6. 57

) B

et te

r 0.

32 ns

5. 92

( 3.

92 )

10 .6

7 (7

.8 0)

B et

te r

− 1.

05 ns

P ha

se A

= B

as el

in e;

P ha

se B

= I

nt er

ve nt

io n;

P ha

se A

’ =

W it

hd ra

w al

; S

IG =

s ig

ni fi

ca nc

e; S

ig =

s ig

ni fi

ca nt

; ns

= n

ot s

ig ni

fi ca

nt ;

It al

ic iz

ed =

d at

a w

er e

au to

co rr

el at

J Autism Dev Disord. Author manuscript; available in PMC 2015 April 01.

N IH

-P A

A u th

o r M

a n u scrip

t N

IH -P

A A

u th

o r M

a n u scrip

t N

IH -P

A A

u th

o r M

a n u scrip

Holm et al. Page 19

T a b

le 5

S um

m ar

y of

o bs

er ve

d m

ea su

re s

of c

ha ng

e fo

r pa

rt ic

ip an

t B

: m

ea n

le ve

ls a

nd C

-s ta

ti st

ic s

P ar

ti ci

p an

t B

C h

an ge

s p

h as

e A

t o

p h

as e

B C

h an

ge s

p h

as e

A t

o p

h as

e A

’

T ar

ge t

b eh

av io

rs P

h as

e A

P h

as e

B C

h an

ge ?

C -s

ta ti

st ic

P h

as e

A P

h as

e A

’ C

h an

ge ?

C -s

ta ti

st ic

M (

S D

) M

( S

D )

Z S

co re

S IG

M (

S D

) M

( S

D )

Z S

co re

S IG

P ou

nd in

g on

s ur

fa ce

id in

g 0.

00 (

0. 00

) 0.

86 (

1. 68

) W

or se

2. 89

S ig

0. 00

( 0.

00 )

0. 00

( 0.

00 )

N o

ch an

ge –

–

om e

23 .1

6 (2

4. 88

) 2.

50 (

2. 24

) B

et te

r 1.

48 ns

23 .1

6 (2

4. 88

) 1.

00 (

2. 89

) B

et te

r 1.

61 ns

om m

un it

y 9.

58 (

11 .1

6) 1.

08 (

1. 44

) B

et te

r 3 .3

1 S ig

9. 58

( 11

.1 6)

0. 17

( 0.

58 )

B et

te r

3 .4

2 S ig

P us

hi ng

i n

no se

id in

g 0.

50 (

0. 75

) 0.

29 (

0. 46

) B

et te

r 1.

41 ns

0. 50

( 0.

75 )

0. 13

( 0.

35 )

B et

te r

1. 13

om e

4. 17

( 4.

04 )

2. 83

( 2.

12 )

B et

te r

− 0.

44 ns

4. 17

( 4.

04 )

2. 92

( 2.

81 )

B et

te r

0. 13

om m

un it

y 4.

83 (

4. 69

) 1.

33 (

1. 07

) B

et te

r 2.

07 S

ig 4.

83 (

4. 69

) 2.

92 (

2. 81

) B

et te

r 1.

54 ns

C la

pp in

id in

g 0.

25 (

0. 71

) 10

.7 1

(1 2.

46 )

W or

se 1.

93 S

ig 0.

25 (

0. 71

) 1.

13 (

1. 64

) W

or se

0. 74

om e

5. 75

( 6.

32 )

7. 08

( 6.

29 )

W or

se −

1. 31

ns 5.

75 (

6. 32

) 8.

42 (

8. 21

) W

or se

0. 48

om m

un it

y 6.

58 (

3. 55

) 5.

58 (

3. 34

) B

et te

r −

0. 64

ns 6.

58 (

3. 55

) 5.

92 (

3. 68

) B

et te

r −

0. 38

P ha

se A

= B

as el

in e;

P ha

se B

= I

nt er

ve nt

io n;

P ha

se A

’ =

W it

hd ra

w al

; S

IG =

s ig

ni fi

ca nc

e; S

ig =

s ig

ni fi

ca nt

; ns

= n

ot s

ig ni

fi ca

nt ;

It al

ic iz

ed =

d at

a w

er e

au to

co rr

el at

J Autism Dev Disord. Author manuscript; available in PMC 2015 April 01.

N IH

-P A

A u th

o r M

a n u scrip

t N

IH -P

A A

u th

o r M

a n u scrip

t N

IH -P

A A

u th

o r M

a n u scrip

Holm et al. Page 20

T a b

le 6

S um

m ar

y of

o bs

er ve

d m

ea su

re s

of c

ha ng

e fo

r pa

rt ic

ip an

t C

: m

ea n

le ve

ls a

nd C

-s ta

ti st

ic s

P ar

ti ci

p an

t C

C h

an ge

s P

h as

e A

t o

P h

as e

B C

h an

ge s

P h

as e

A t

o P

h as

e A

’

T ar

ge t

b eh

av io

rs P

h as

e A

P h

as e

B C

h an

ge ?

C -s

ta ti

st ic

P h

as e

A P

h as

e A

’ C

h an

ge ?

C -s

ta ti

st ic

M (

S D

) M

( S

D )

Z S

co re

S IG

M (

S D

) M

( S

D )

Z S

co re

S IG

E ch

ol al

ia /s

cr ip

ti ng

id in

g 16

.1 3

(7 .5

1) 34

.0 0

(1 5.

26 )

W or

se 2.

75 S

ig 16

.1 3

(7 .5

1) 51

.8 6

(1 5.

29 )

W or

se 1.

87 S

om e

13 .5

0 (3

.5 5)

15 .0

8 (4

.1 0)

W or

se 2.

00 S

ig 13

.5 0

(3 .5

5) 16

.4 1

(4 .5

4) W

or se

0. 69

om m

un it

y 10

.3 3

(3 .6

7) 13

.9 1

(5 .1

6) W

or se

1. 12

ns 10

.3 3

(3 .6

7) 13

.0 0

(3 .1

0) W

or se

2. 07

S ig

M ou

th in

g fi

ng er

s/ ha

nd s

an d

ob je

ct s

id in

g 18

.1 3

(1 0.

41 )

6. 78

( 6.

17 )

B et

te r

2. 93

S ig

18 .1

3 (1

0. 41

) 21

.8 8

(3 3.

80 )

W or

se −

0. 61

om e

8. 08

( 5.

23 )

3. 75

( 2.

70 )

B et

te r

1. 86

S ig

8. 08

( 5.

23 )

1. 75

( 1.

48 )

B et

te r

2. 64

S ig

om m

un it

y 6.

58 (

4. 76

) 2.

92 (

2. 78

) B

et te

r 1.

44 ns

6. 58

( 4.

76 )

0. 17

( 0.

58 )

B et

te r

2. 71

S ig

V er

ba l

de m

an ds

o f

3 w

or ds

o r

m or

id in

g 4.

25 (

4. 17

) 19

.5 (

11 .2

6) B

et te

r 4.

93 S

ig 4.

25 (

4. 17

) 20

.5 0

(1 2.

50 )

B et

te r

2. 00

S ig

om e

3. 42

( 0.

90 )

4. 08

( 0.

99 )

B et

te r

− 0.

68 ns

3. 42

( 0.

90 )

5. 83

( 1.

70 )

B et

te r

2. 85

S ig

om m

un it

y 3.

17 (

1. 47

) 4.

08 (

2. 19

) B

et te

r 1.

04 ns

3. 17

( 1.

47 )

5. 92

( 2.

61 )

B et

te r

0. 81

P ha

se A

= B

as el

in e;

P ha

se B

= I

nt er

ve nt

io n;

P ha

se A

’ =

W it

hd ra

w al

; S

IG =

s ig

ni fi

ca nc

e; S

ig =

s ig

ni fi

ca nt

; ns

= n

ot s

ig ni

fi ca

nt ;

It al

ic iz

ed =

d at

a w

er e

au to

co rr

el at

J Autism Dev Disord. Author manuscript; available in PMC 2015 April 01.

Small Project

Therapeutic horseback riding outcomes.pdf

intructions.PNG