CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For consumers on the autism spectrum, does supplementing with alternative treatments, when compared to using only traditional treatments and therapies, improve overall quality of treatment and daily life functions? Bass, M. M., Duchowny, C. A., Llabre, M. M. (2009). The effect of therapeutic horsebackriding on social functioning in children with autism. Journal of Autism Developmental Disorder, 39, 1261 1267. http://dx.doi.org/10.1007/s10803-009-0734-3 CLINICAL BOTTOM LINE: With the increasing prevalence of autism spectrum disorders (ASDs), families and caregivers are trying a variety of treatments to enhance their child s quality of life. However, it is easy for families to be overwhelmed by the vast amount of alternative and complimentary treatments available. Many families are currently obtaining their information by word of mouth (Wong, 2008). Although this strategy is useful in sharing ideas, it does not provide families with important information, such as possible side effects, effectiveness, and available research. This research study is one of the first to evaluate the effect of therapeutic horseback riding intervention with the ASD population. Its results indicate potential use of this alternative intervention for positive changes in the areas of social functioning, sensory processing, directed attention, and focusing ability. It specifically examined the effects of horseback riding in comparison to maladaptive behaviors for children with ASD as an alternative to generic forms of therapy to provide an alternative route for receiving kinesthetic stimulation. Therapeutic horseback riding sessions included mounting and dismounting, exercises, riding skills, mounting games, and horsemanship activities. The control was put on a waitlist for the duration of the study, and it is believed that they received this intervention after the study was completed. The study provides results that lead to a positive alternative treatment to ASD. Results are significant in that treatment effects were all statistically significant for the 4 subscales of sensory seeking, inattention/distractibility, sensory sensitivity, and sedentary (p <.001). Its results indicate potential use of this alternative intervention for positive changes in the areas of social functioning, sensory processing, directed attention, and focusing ability. A limitation to this study was that it used data from previously reported hippotherapy to guide this study. In addition, the authors conclude 1
that although this researched method of intervention may be beneficial, more research is needed to further assess its therapeutic effects. With the data collected from this study and from its cited references, occupational therapists can provide a source of evidence in support of equine services for children with ASD, if parents are seeking alternative treatment approaches. RESEARCH OBJECTIVE(S) List study objectives. To evaluate the effects of therapeutic horseback riding on social functioning in children with autism (p. 1261). DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Randomized pretest and posttest trials Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. This study evaluated previous research about hippotherapy and investigated the effects of animal-assisted therapy vs. traditional therapy and used it to guide their study. SAMPLE SELECTION How were subjects selected to participate? Please describe. A total of 34 children with an ASD diagnosis were recruited from the Agency of Persons with Disabilities and from the University of Miami s Center for Autism Related Disabilities. Inclusion Criteria Participants must have a medical diagnosis of autism spectrum disorder according to the DSM IV TR standards. Medical approval from physician. Parental consent to participate in intervention. Exclusion Criteria Previous exposure to equine-assisted activities. SAMPLE CHARACTERISTICS N = 34 # Dropouts 0 2
# Male 29 # Female 5 Ethnicity NR Disease/disability diagnosis ASD Check appropriate : <20/study 20 50/study 51 100/study 101 149/study 150 200/study INTERVENTION(S) AND CONTROL GROUPS Add s, if necessary. Group 1 Brief Description Setting The experimental included 17 male participants and 2 females, ranging from age 5 to 10 years. Participants in this received the intervention for free. Pretest measures were given to parents of this to establish a data baseline. All members of this participated in a 12-week therapeutic horseback riding program. The program consisted of the child interacting with the horse to complete these learn the following information: Mounting and dismounting Exercises Riding skills Mounted games Horsemanship activities. After the 12-week intervention, parents completed a posttest questionnaire to evaluate the effects of the intervention. Good Hope Equestrian Training Center (GHETC) in a rural Florida area. Who Delivered? Administrative staff at GHETC. Frequency? Duration? Once weekly; sessions were 1 hour long. 12 weeks. Group 2 Brief Description The control included 12 male participants and 3 females, ranging from age 4 to 10 years. Participants in this received the intervention for free. Pretest measures were given to parents of this to establish a data baseline. All members of this continued conventional therapies for the 12-week program. After the 12-week intervention, parents completed a posttest questionnaire to evaluate any changes. 3
Setting Who Delivered? Frequency? Duration? Participants in this continued conventional treatment at various locations. NR NR 12 weeks. Intervention Biases: Circle yes or no and explain, if needed. Contamination Co-intervention Timing Site Use of different therapists to provide intervention This study does not specify who specifically delivered each treatment but indicated a mix of administrative staff at GHETC. MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. Social Responsive Scale (SRS) that is a 65-item questionnaire which measures the severity of autism spectrum disorder symptoms (p. 1263). Item subscales include Social Awareness, Social Cognition, Social Communication, Social Motivation, and Autistic Mannerisms. High overall reliability (α =.97) was reported in this study. Reliability: Yes. High retest stability for males and females (r =.85 and r =.77) Validity: NR Frequency: Completed by the parents before and after the 12-week intervention program. Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. 4
Sensory Profile (SP) is a 125-item questionnaire completed by parents or teachers. It uses a 5-point Likert scale to evaluate overall social functioning, including sensory processing, modulation, behavioral, and emotional responses. Reliability: NR Validity: NR in this study, but internal consistency ranged from.47 to.91 Frequency: Completed by the parents before and after the 12-week intervention program. Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. Evaluators were aware of participants diagnosis. Recall or memory bias. Circle yes or no, and if yes, explain. RESULTS List results of outcomes relevant to answering the focused question. Include statistical significance where appropriate (p < 0.05). Include effect size, if reported. The experimental demonstrated significant results when using the SP with p <.01 while the control only slightly showed improvement with p =.101 No significant interaction for fine motor/perceptual scores (p >.05) Interaction effects for 4 out of 5 subscales were significant, with Sensory Seeking, Attention and Distractibility, Sensory Sensitivity, and Sedentary all scoring p <.01. Treatment effects were all statistically significant for the 4 subscales of Sensory Seeking, Inattention/Distractibility, Sensory Sensitivity, and Sedentary (p <.001) SRS overall scores for the experimental were significant (p =.038). No significant interactions were found in the Social Cognition and Social Awareness subscales. Follow-up to significant interaction showed that the experimental means significantly increased (p =.017). Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. 5
Were appropriate analytic methods used? Circle yes or no, and if no, explain. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. Tables displayed clear and concise results. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. Participants in this study demonstrated improved social motivation and sensory sensitivity, directed attention, as well as decreased inattention and distractibility when compared to the control that did not participate in the hippotherapy program (p.1266). Furthermore, this study provides findings that hippotherapy may be an effective treatment method for children with ASD; however, further research is needed to examine its therapeutic effects. This high-level study demonstrates good rigor and reliability for those with an ASD diagnosis. Overall, this study sets a good beginning for the direction of future equine research as an occupational therapy treatment modality for ASD. References Wong, V. C. N. (2008). Use of complementary and alternative medicine (CAM) in Autism Spectrum Disorder (ASD): Comparison of Chinese and Western culture (Part A). Journal of Autism and Developmental Disorders, 39, 454 463. http://dx.doi.org/10.1007/s10803-008-0644-9 This work is based on the evidence-based literature review completed by Hannah Doody, OTS, and Carmela Battaglia, PhD, OTR/L, Faculty Advisor, Keuka College. CAP Worksheet adapted from Critical Review Form Quantitative Studies, copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 6