CRITICALLY APPRAISED PAPER (CAP) Gabriels, R. L., Pan, Z., Dechant, B., Agnew, J. A., Brim, N., & Mesibov, G. (2015). Randomized controlled trial of therapeutic horseback riding in children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 541 549. https://doi.org/10.1016/j.jaac.2015.04.007 CLINICAL BOTTOM LINE This randomized controlled trial study provides preliminary evidence that a 10-week equineassisted activity intervention supported significant improvements in irritability and hyperactivity among children and adolescents diagnosed with autism spectrum disorder (ASD). Additionally, compared with the control group, the intervention group showed significant improvements in social cognition and communication, along with an increase in the number of words and different words spoken. This study was a randomized controlled trial and provides Level I evidence. The strength of this study is an asset, and the statistically significant outcomes of this study further support the positive effects derived from human equine interaction as well as the study s internal validity. Although this interaction requires further investigation, the nonverbal joint attention may serve as a platform for improving behaviors and social communication skills among children and adolescents with ASD. Also, the human equine interaction promotes a calming effect by providing warmth from the horse s body and rhythmical movement from riding. Although the outcomes of this study are promising, the practicality of the intervention is in question. Practitioners may find it difficult to implement because of the need to locate a specific therapeutic riding center that is certified by the Professional Association of Therapeutic Horsemanship (PATH) International to deliver this type of intervention. Moreover, the intervention more than likely is not covered through insurance. These factors affect the study s external validity. The study limitations included the use of nonblinded caregiver report measures, a lack of objective observational measures regarding behavioral changes, the inability to detect possible motor-related changes, and the lack of information about whether the participants were receiving other services during the study. Additionally, because ASD presents differently for each client, there is no guarantee that equine-assisted activities will benefit all clients or that all clients will develop a personal interest in equine-related activities. However, if the client finds equine-assisted activities to be enjoyable, occupational therapy practitioners can use the benefits from this emerging practice setting and apply them to 1
traditional practice settings. For example, the practitioner might have the client talk about or complete activities centered on horses and riding in therapy if this provides a source of motivation. They could then work with the resulting decreased irritability and hyperactivity to increase the client s focus and attention to task. RESEARCH OBJECTIVE(S) To evaluate the efficacy of therapeutic horseback riding (THR) on self-regulation, socialization, communication, adaptive, and motor behaviors among children with ASD DESIGN TYPE AND LEVEL OF EVIDENCE Level I, randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? The participants were recruited through institutional review board approved fliers distributed to university-affiliated hospitals, schools, ASD parent support organizations, and community providers. Inclusion criteria: Participants Were 6 16 years old; Met or exceeded the ASD screening cutoff ( 15) on the Social Communication Questionnaire; Had an ASD diagnosis, confirmed by meeting clinical cutoffs for ASD on the Autism Diagnostic Observation Schedule or the second edition of that measure; Had a combined score on the Irritability and Stereotypic Behavior subscales of the Aberrant Behavior Checklist Community (ABC C) of 11 or higher; and Had a Leiter-R Brief Nonverbal IQ standard score of 40 or higher. Exclusion criteria: 2
Individuals were excluded if they had A previously identified genetic disorder known to be causative of or result in a phenotype similar to ASD; A history of medical or behavioral issues that would make participation dangerous; A history of animal abuse or a phobia of horses; More than 2 hours of equine-assisted activities and therapies within the past 6 months; or Weight exceeding the riding center s policies to ensure the health and safety of staff and volunteers. Additionally, if there was more than one child with ASD in a family, only the first sibling who qualified for the study was included, to avoid duplication of caregiver reporting styles. PARTICIPANT CHARACTERISTICS N= 116 #/ % Male: 101/(87%) #/ % Female: 15/(13%) Ethnicity: Latino or Hispanic: 21 Native American or Alaska Native: 3 Asian: 4 Black or African American: 1 Hawaiian or Pacific Islander: 1 Caucasian: 92 Multiracial: 7 Other: 5 Missing data: 3 Disease/disability diagnosis: ASD INTERVENTION AND CONTROL GROUPS Group 1: THR intervention 3
Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Each session had 2 4 participants, had equine-related information content, assigned at least one volunteer to each participant, and used behavioral teaching methods commonly used for the ASD population (e.g., using visual aids, directly praising appropriate behaviors, and using the participant s interest to engage). There was a two-part teaching focus in THR: Therapeutic riding skills (e.g., mounting, halting, steering, turning, and trotting), and Horsemanship skills (e.g., how to lead and care for their horse). The lessons followed a consistent routine presented as a picture schedule: Put on a riding helmet Wait on the bench Mount the horse Participate in riding activities Dismount the horse Groom the horse Put away equipment. The riding portion consisted of a warm-up activity, skill review, introduction of a new skill, lesson review, and a cool-down activity. After riding, participants led their horse to the tacking area, where they learned and practiced untacking and grooming skills and thanked their horse and volunteers. 49 boys and 9 girls The intervention took place at Colorado Therapeutic Riding Center, an established (30 years) riding center site with premiere certification by PATH International. A certified PATH International advanced therapeutic riding instructor taught all lessons. Each session was a minimum of 45 minutes. 10 weeks Group 2: Barn activity (BA) control intervention 4
Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Each session had 2 4 participants, had equine-related information content, assigned at least one volunteer to each participant, and used behavioral teaching methods commonly used for the ASD population (e.g., using visual aids, directly praising appropriate behaviors, and using the participant s interest to engage). Participants in the BA control intervention had no contact with horses. However, a life-sized stuffed horse was an integral part of teaching horsemanship skills. 52 boys and 6 girls The intervention took place at Colorado Therapeutic Riding Center, an established (30 years) riding center site with premiere certification by PATH International. The BA group was co-led by a therapeutic riding instructor and a master s-level therapist who had expertise working with and modifying curriculums for children with ASD. Each session was a minimum of 45 minutes. 10 weeks INTERVENTION BIASES Contamination: NO Although the BA control group did not have any contact with horses, their activities were still equine centered. The interventionists used a life-size stuffed horse to teach horsemanship skills. Also, participants in the BA control group were offered two free riding lessons at the conclusion of the study. Co-intervention: Given participants diagnosis of ASD and their age (6 16) years old, it is possible that the participants were receiving other services. The authors did not identify whether the participants were receiving other services, which is a great limitation of this article. Timing of intervention: NO Both the THR intervention and the BA control group were conducted at the same time. Site of intervention: 5
NO Both the THR intervention and the BA control group were conducted at the same riding center. Use of different therapists to provide intervention: A certified PATH International advanced therapeutic riding instructor taught all lessons in the THR intervention group, and the BA control group was coled by a THR instructor and a master s-level therapist. Baseline equality: NO The authors indicated that the two randomized groups did not differ at baseline assessment (N = 116), and there were no significant demographic differences despite 4 participants dropping from the THR intervention group and 7 participants dropping from the BA control group after baseline assessment. MEASURES AND OUTCOMES (Only on measures relevant to occupational therapy practice) Measure 1: Self-regulation Name/type of measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? ABC C The Irritability, Lethargy/Social Withdrawal, Stereotypy, Hyperactivity, and Inappropriate Speech Behaviors subscales were assessed. Not Reported Not Reported The Irritability and Hyperactivity subscales of the ABC C were assessed within 1 month pre- and postintervention and during each week of sessions. The other subscales were measured within 1 month pre- and postintervention. Measure 2: Social measure Name/type of measure used: What outcome is measured? SRS The Social Awareness, Social Cognition, Social Motivation, Social Communication, and Autistic Mannerisms subscales were assessed. 6
Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Not Reported Not Reported The SRS was measured within 1 month pre- and postintervention. Measure 3: Motor, praxis, and adaptive behaviors Name/type of measure used: Bruininks Oseretsky Test of Motor Proficiency (2nd ed.; BOT-2), Sensory Integration and Praxis Test (SIPT), and Vineland Adaptive Behavioral Scales (2nd ed.; VABS-II) What outcome is measured? The BOT-2 measured motor skills. The SIPT measured the Praxis on Verbal Command and Postural Praxis subscales. The VABS-II measured adaptive behaviors. Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? NO Not Reported NO Not Reported The secondary outcomes were measured within 1 month pre- and postintervention. MEASUREMENT BIASES Were the evaluators blind to treatment status? The assessment personnel were blind to the participants intervention assignments and did not have access to preintervention evaluations when conducting postintervention evaluations. However, the ABC C and the SRS forms were completed by the caregivers and thus were not blind. For all other measures, the evaluators were blind. Was there recall or memory bias? 7
NR This was not indicated in the study. RESULTS According to the authors, there were significant improvements starting in Week 5 in the THR group, compared with the BA control group, on measures of irritability (effect size [ES] = 0.50, p =.02) and hyperactivity (ES = 0.53, p =.01). Significant improvements in the THR group were also observed for social cognition (ES = 0.41, p =.05) and social communication (ES = 0.63, p =.003). The study did not report statistically significant findings between groups on motor (ES = 0.24, p =.26), praxis on verbal command (ES = 0.04, p =.85), postural praxis (ES = 0.35, p =.10), or adaptive behaviors (ES = 0.11, p =.64). Was this study adequately powered (large enough to show a difference)? Although the effect size of this study was smaller than the pilot study and the study was primarily powered for efficacy tests, it was still adequately powered at 80%, and statistically significant results were indicated. Were the analysis methods appropriate? The authors used Student t tests and chi-square tests to compare the participants in the two groups, and the primary analyses used a linear mixedeffects model. Were statistics appropriately reported (in written or table format)? The statistics were reported both in written and in table formats. Was participant dropout less than 20% in total sample and balanced between groups? YES NO According to the authors, of the 144 potential participants screened, 127 (88%) met study inclusion criteria and were enrolled in the trial and randomized. The two randomized groups did not differ at baseline. After the intervention was initiated, 4 participants dropped from the THR intervention and 7 participants dropped from the BA group, bringing the participant dropout rate to 8.6%. Per the authors, there were no significant demographic differences between the two groups for dropped participants. What are the overall study limitations? 8
The authors suggested that one limitation was the inclusion of several outcomes that were measured with nonblinded caregiver report measures, which might have caused a placebo effect. Another limitation was the lack of objective observational measures regarding behavioral changes. Additionally, the study s use of broad measures of motor coordination limited the ability to detect possible motor-related changes. Last, the authors did not indicate whether the participants were involved in other services during the study, which should be addressed in future considerations. The authors recommended that for a comprehensive assessment of the THR intervention, future researchers should conduct a study with a placebo group (i.e., no intervention at all) in addition to the BA control group. This would provide better insight into the effect of the THR intervention. Future researchers might expand demographic measures to include a broader measure of intellectual functioning. They might also make adjustments for multiple secondary outcome comparisons, because this might have increased the Type I ( false positive ) error rate. CONCLUSION This study further establishes the evidence base supporting equine-assisted activities and therapies as a viable therapeutic option for children and adolescents with ASD. Further research is warranted to examine whether the joint attention and movement experiences are key THR mechanisms to observe behavioral and social communication improvements in the ASD population. This work is based on the evidence-based literature review completed by Jennifer M. Lee and Myka Winder, OTD, OTR/L, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 9