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My son introduced me

Horses are in my blood

My PATH International Credentials:

Certified Therapeutic Riding Instructor

Advanced Therapeutic Riding Instructor

Equine Specialist in Mental Health & Learning

Certified Mentor

Other Credentials:

Masterson Method Equine Specialist

https://mastersonmethod.com/

I love helping people succeed & grow
More people should know about EAAT!

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Ancient Greece

Documented human-equine relationships

France 1875

First documented proof of horses being used as therapeutic animals

England 1900s

Documented that equines were used therapeutically

1969 Royal Family supported the foundation of the British Riding for the Disabled Association

United States 1969

Developed to implement industry standards to help validate EAAT through PATH International

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Provides credentialing for people who wish to become Equine Assisted Activity and Therapy (EAAT) professionals

www.pathintl.org

873 member centers & 8,000 members worldwide

Serving 69,000 individuals

6,700 are veterans

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Study by The Children's Hospital of Denver

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Study by The Children's Hospital of Denver

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Randomized Controlled Trial of Therapeutic Horseback Riding in Children and Adolescents with Autism Spectrum Disorder

10 weeks

116 participants aged 6-16

Results

Reduced irritability & hyperactivity

Improved social cognition

Increased number of words and new words

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Dr. Robin L. Gabriels, PsyD, Dr. Zhaoxing Pan, PhD, Ms. Briar Dechant, BS, Dr. John A. Agnew, PhD, Ms. Natalie Brim, BA, and Dr. Gary Mesibov, PhD

Abstract

Objective

This study expands previous equine-assisted intervention research by evaluating the effectiveness of therapeutic horseback riding (THR) on self-regulation, socialization, communication, adaptive, and motor behaviors in children with autism spectrum disorder (ASD).

Method

Participants with ASD (ages 6-16 years; N=127) were stratified by nonverbal IQ standard scores (≤ 85 or > 85) and randomized to one of two groups for 10 weeks: THR intervention or a barn activity (BA) control group without horses that employed similar methods. The fidelity of the THR intervention was monitored. Participants were evaluated within one month pre- and post-intervention by raters blind to intervention conditions and unblinded caregiver questionnaires. During the intervention, caregivers rated participants' behaviors weekly.

Results

Intent-to-treat analysis conducted on the 116 participants who completed a baseline assessment (THR n = 58; BA control n = 58) revealed significant improvements in the THR group compared to the control on measures of irritability (primary outcome) ( p=.002; effect size [ES]=.50) and hyperactivity ( p=.001; ES=0.53), beginning by week five of the intervention. Significant improvements in the THR group were also observed on a measure of social cognition ( p=.05, ES=.41) and social communication ( p=.003; ES =.63), along with the total number of words ( p=.01; ES=.54) and new words ( p=.01; ES=.54) spoken during a standardized language sample. Sensitivity analyses adjusting for age, IQ, and per-protocol analyses produced consistent results.

Conclusion

This is the first large-scale randomized, controlled trial demonstrating efficacy of THR for the ASD population, and findings are consistent with previous equine-assisted intervention studies.

Keywords: Autism spectrum disorder, equine-assisted activities and therapies, human-animal interaction, therapeutic horseback riding, social-communication functioning

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder diagnosed based on core impairments in social interaction, communication abilities, and the presence of restricted, repetitive, and stereotyped behaviors and interests. Although these core impairments have a heterogeneous clinical presentation across individuals with ASD, limited joint attention skills (i.e., being aware of and sharing another's focus of attention) appear to be an important issue underlying social-communication symptoms. Improving joint attention skills in the ASD population has been linked to better behavioral regulation, communication skills, and social competence.

Children with ASD exhibit more challenging or inappropriate behaviors than typically developing peers or those diagnosed with other psychopathology. The ASD population has high incidences of stress, anxiety, and depression, along with a variety of other challenges such as irritability, hyperactivity, and problems with sensory processing, dyspraxia, intellectual functioning, adaptive daily living skills, and sleep. Co-occurrence of these issues with core ASD symptoms can present challenging behaviors, often persisting beyond childhood into adolescence and adulthood. Research indicates that care and management of these challenging behaviors contributes to higher rates of stress and greater burden among caregivers of individuals with ASD compared with other special needs populations.

Incorporating animals into the treatment process to decrease problem behaviors and improve functioning has been proposed as a promising area of intervention for these at-risk populations. Evidence for animal-assisted interventions (AAI) is limited; however, including animals in health care settings has been hypothesized to produce sensory-related relaxation experiences that allow children to better manage stressful events and engage in prosocial behaviors. Studies have cited reductions in stress hormone levels (i.e. cortisol) in children with ASD following interactions with service dogs, and also in a general child population following an 11-week equine intervention. The ASD population has a particular need for interventions that target reductions in stress-related maladaptive behaviors and improvements in social-communication functioning.

O'Haire's (2013) comprehensive review of AAIs targeting individuals with ASD identified only 14 empirically-based studies from 1840 to 2011, with interventions that intentionally included a live animal, and reported results. In those studies, results indicated improvements in social interaction communication skills, behaviors, and stress levels, even though intervention methods and types of animals varied (i.e., dogs, guinea pigs, lamas, rabbits, horses). O'Haire (2013) recommended future AAI studies increase methodological rigor by randomizing participants to comparison treatments without animals, employing outcome raters blind to intervention conditions, and replicating methods.

One form of AAI includes Equine-Assisted Activities and Therapies (EAAT). This is a rapidly growing field for special needs populations that involves horses in a therapeutic intervention setting. Since 2009, there has been an increase in EAAT publications citing various methods for working with the ASD population, including therapeutic horseback riding (THR), hippotherapy (HPOT), psychoeducational horseback riding (PER), and EAAT. Although each method offers a different therapeutic focus and type of activity, the inclusion of horses as part of the therapeutic experience is a common thread. THR typically involves riding in small group settings led by a certified THR instructor teaching horsemanship skills targeting therapeutic goals. Hippotherapy is led by an occupational, speech, or physical therapist, and intervention activities use the movement of the horse to target functional outcomes.

Though EAAT methods vary, cited improvements with the ASD population overlap across studies, suggesting that some aspect(s) of the human-equine interaction may be important for change. Temple Grandin, an accomplished adult with ASD, asserts that one key element of horseback riding that helped her decrease anxiety-related feelings and behaviors involves the reciprocal/joint attention relationship, or "teamwork," between the rider and the horse (e.g., moving "in sync with the horse's body" and the horse's intuitive sensitivity and responsiveness to the rider) (p. 6). Despite EAAT study variations (i.e., duration, activities, and targeted outcome measures), results include decreases in problem behaviors (e.g., irritability, hyperactivity, stereotypy, inattention, self-injury, and ASD symptom severity) as well as increases in sensory processing, communication, and social skills. Although these EAAT studies offer promising preliminary effects for individuals with ASD, generalizability of these findings are limited by small sample sizes, minimal methods to confirm the ASD diagnosis, and use of potentially biased informants for outcome measures.

The present study builds upon the piloted 10-week THR intervention curriculum conducted by the authors and available from the first author. The objective of this RCT was to evaluate whether the THR could affect significant improvements on measures of self-regulation, communication, social, adaptive, and motor behaviors in children and adolescents diagnosed with ASD. The second, exploratory, aim to evaluate the retention of improvements six months following the THR intervention phase will be reported separately. This study has an elevated level of methodological rigor (i.e., randomized controlled design, use of a well-established standardized ASD diagnostic measure, control group without horses that mirrored THR intervention methods, fidelity measure of the THR intervention, and outcome evaluators blind to participants' intervention condition), and was conducted at an established (30 years) riding center site with "premiere" certification by PATH International, meaning the center adheres to the highest safety and ethical standards in the industry for all living beings involved in the treatment process.

METHOD

Participants

This study was approved by the Institutional Review Board (IRB) at the first author's institution. Participants were recruited using IRB-approved fliers distributed to university-affiliated hospitals, schools, ASD parent support organizations, and community providers. Participants' caregivers were compensated for mileage to study visits.

Participants were included in the study if they met the following criteria: aged 6 to 16 years; met or exceeded the ASD screening cut-off (≥ 15) on the Social Communication Questionnaire (SCQ); had an ASD diagnosis, confirmed by meeting clinical cut-offs for ASD on the Autism Diagnostic Observation Schedule (ADOS) or ADOS-second edition (ADOS-2); had a combined score on the Irritability and Stereotypy subscales of the Aberrant Behavior Checklist-Community (ABC-C) of ≥ 11 and had a Leiter-R Brief nonverbal IQ (NVIQ) standard score of ≥ 40, as established by the pilot. Exclusion criteria included: a previously identified genetic disorder known to be causative of or resulting in a phenotype similar to ASD, a history of medical or behavioral issues making participation dangerous, a history of animal abuse or phobia of horses, more than two hours of EAAT within the past six months, or weight exceeding the riding center's policies to ensure the health and safety of staff and volunteers. In cases with 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. See for the participant flowchart.

Study Design

Interventions

Both 10-week interventions were a minimum of 45 minutes long each session, had two to four 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., use of visual aids, directly praising appropriate behaviors, and using the participant's interest to engage). Every effort was made to maintain the consistency of horses for the THR group and volunteers for the THR and BA control groups.

Therapeutic Horseback Riding Intervention

A certified PATH International advanced therapeutic riding instructor taught all lessons and followed the study manual approach that had a two-part teaching focus: 1) therapeutic riding skills (e.g., mounting, halting, steering, turning, and trotting) and 2) horsemanship skills (e.g., how to lead and care for their horse). Lessons followed a consistent routine presented as a picture schedule: 1) put on riding helmet, 2) wait on the bench, 3) mount horse, 4) riding activities, 5) dismount horse, 6) groom horse, and 7) put away equipment. The riding portion consisted of a warm up activity, skill review, learning a new skill, lesson review, and a cool down activity. After riding, participants led their horses to the tacking area where they learned and practiced un-tacking and grooming skills, and thanked their horses and volunteers.

Behavioral Outcome Measures

Within one month pre-and post-intervention, a battery of assessment measures were conducted to evaluate participants' baseline and post-intervention functioning levels. A consistent caregiver not blinded to the intervention assignment for each participant completed all behavior rating forms before, during, and after the intervention phase. Study assessment personnel were blind to participants' intervention assignment and did not have access to participants' pre-intervention evaluations when conducting post- evaluations.

A speech therapist measured participants' receptive vocabulary using the Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4), norm-referenced and standardized for individuals ages 2 years, 6 months through age 90 years. The PPVT-4 has two parallel forms: form A was used for pre-evaluations, and form B was used for post-evaluations. A five-minute expressive language sample was elicited from participants using the Systematic Analysis of Language Transcripts (SALT), which provides guidelines for eliciting, transcribing, and analyzing language samples from individuals, including those with ASD. An occupational therapist administered the Bruininks-Oseretsky Test of Motor Proficiency-2 nd Ed (BOT-2) (Short Form) and two subscales of the Sensory Integration and Praxis Test (SIPT): Praxis on Verbal Command and Postural Praxis. Participants' adaptive behaviors were evaluated by a study research assistant using the Vineland Adaptive Behavioral Scales - 2 nd Edition, Survey Interview Form (VABS-II) with caregivers.

Caregivers rated participants' irritability, lethargy/social withdrawal, stereotypy, hyperactivity, and inappropriate speech behaviors via the ABC-C. The ABC-C is a 58-item symptom checklist for assessing problem behaviors of children and adults with developmental disabilities in community settings. Extensive psychometric assessment of the ABC-C indicates that its subscales have high internal consistency, adequate reliability, and established validity. In addition, the ABC-C Irritability subscale is an established outcome measure in randomized clinical trials with the ASD population. Caregivers also completed the Social Responsiveness Scale (SRS), which is a 65-item questionnaire that measures the social impairments in ASD on five subscales (Social Awareness, Social Cognition, Social Motivation, Social Communication and Autistic Mannerisms). The SRS has high internal consistency and retest temporal stability in males and females and was used in a previous THR study.

Statistical Analyses

SAS 9.3 was used for all the analyses. Student t-tests and Chi square tests were used to compare the participants in the BA control group with the participants in THR intervention group for continuous and categorical demographic along with clinical and baseline outcome variables. The primary analyses used a linear mixed effects model (LMM) consisting of the baseline value and the post-evaluations as outcome measures, evaluation time (baseline or post-evaluation) of outcome, group (THR or BA), and their interaction tern as fixed effects and an unstructured covariance. Estimate of the interaction was used to assess the efficacy and test for statistical significance. The primary analysis included any randomized participants (n=116) who had either baseline and/or post-evaluation measure to follow the intent-to-treat (ITT) principle. No data imputation was taken. Sensitivity analysis was used in various ways to reanalyze the outcome found significant from the primary analyses to assess how robust the conclusions were. First, the efficacy was further tested while introducing age, IQ, and gender into the primary model as covariates even if there was no difference between the two groups in these covariates. Second, per-protocol analyses (including participants completing 80% or more of either intervention, n=100) were performed using the same method as the primary analysis. Finally a similar mixed effects model was used to fit the weekly ABC-C data to delineate the time course under which contrasts were used to test the between-group difference in the change from baseline by each week. The potential moderator effect of age, IQ, or gender was respectively examined by the same mixed effects model, with this factor and the three level interaction term of this fact, time, and group as two additional fixed effects. The fidelity of the THR treatment implementation was computed as a percentage of the eight intervention component ratings. Irritability subscale of ABC-C was deemed as the primary outcome. No adjustment for multiple secondary outcome variables was applied.

Power of the Study

This study was primarily powered for efficacy tests to examine whether the THR intervention led to greater improvements on the ABC-C irritability subscale as compared to the BA control after the 10-week intervention. Taking into account active control group, the assumed effect size for this study is smaller than that observed in the pilot. A sample size of 116 with equal group split ensures 80% power at 5% significance to detect the significant efficacy of THR versus the BA control using a linear mixed effects model when the effect size is 0.53 or greater of the standard deviation of the post-intervention change from baseline.

RESULTS

Preliminary Analyses

Of the 144 potential participants screened, 127 (88%) met study inclusion criteria and were enrolled in the trial and randomized (see ). The two randomized groups did not differ at baseline (see ). After the intervention was initiated, four participants dropped from the THR group and seven participants dropped from the BA control group. There were no significant demographic differences between the two groups for dropped participants. One THR and two BA participants reported initiation or discontinuation of medications during the intervention phase.

Table 1

Clinical Outcomes

shows the efficacy of the THR intervention compared to the BA control group for the primary and secondary outcome variables.

Table 2

Self-Regulation (ABC-C)

Participants in the THR group had significantly more improvements from baseline to post-intervention on the ABC-C Irritability subscale score with an effect size of 0.50 ( p=.02). The analysis of the ABC-C weekly data indicated that the two groups were significantly different in the change from baseline beginning by the fifth week of the intervention ().

Similarly, participants in the THR group showed significantly more improvements in the ABC-C Hyperactivity subscale score with an effect size of 0.53 ( p=.01). The time course of the weekly profile of Hyperactivity subscale had a similar pattern as the Irritability subscale with significantly greater improvement in THR group starting at week 5. There was no significant difference between the two groups on the other ABC-C subscales.

The THR group had a greater improvement on the Social Cognition and Communication subscales of the SRS as compared to the BA control group with effect sizes of 0.41 ( p=.05) and 0.63 ( p=.003). There was no significant difference between groups on the other subscales of the SRS.

Although participants in the THR group spoke fewer words at the pre-intervention language assessment, this was not significantly different from the BA control group. However, following the intervention phase, the THR group had a significant increase in the use of different words with an effect size of 0.54 ( p=.01) and spoke more words with an effect size of 0.54 ( p=.01) post-intervention compared to the BA control group.

Other Secondary Outcomes

No statistically significant between-group differences were found with respect to the rest of secondary outcomes, including adaptive (VABS-II) and motor (BOT-2 and SIPT) behaviors, and PPVT-4.

Sensitivity and Moderator Analyses

After adjusting for age, IQ, and gender in the ITT analysis, significantly greater improvements in THR group remained for Irritability (ES=0.51, p=.02), Hyperactivity (ES=0.53, p=.02), Social Communication (ES=0.72, p=.002), number of words spoken, and number of new words (ES=0.52, p=.02), while marginally significant improvement was observed for Social Cognition score (ES=0.52, p=.06). In per-protocol (PP) analysis of participants completing 80% of the intervention (n=52 THR, n=48 BA control), greater improvement in the THR group was also observed for Irritability (ES=0.42, p=.05), Hyperactivity (ES=0.45, p=.04), Social Cognition (ES=0.33, p=.11), Social Communication (ES=0.57, p=.08), number of words spoken (ES=0.55, p=.009), and number of new words (ES=0.56, p=.009), leading to similar conclusions as the primary ITT analysis. No significant moderation effect was found for age, IQ or gender. Of note, co-morbid diagnoses at study entry were obtained by caregiver report and not independently confirmed; therefore, these data were not included in the moderator analyses.

DISCUSSION

This article reports results from a randomized control study of 116 participants diagnosed with ASD (ages 6-16 years) involved in a 10-week THR intervention compared to an activity control group that had no interaction with horses. Results show significant post-intervention improvements in the THR group compared to the BA control on the Irritability and Hyperactivity subscales of the ABC-C beginning by the fifth week of intervention. This finding replicates our pilot study. Compared to the BA control, the THR group also showed significant improvements on the SRS Social Cognition and Communication subscales along with significant improvements in the amount of words and different words spoken during a standard language. The outcomes of this study lend support to findings from previous EAAT studies with the ASD population, suggesting that there is an important active ingredient in the human-equine interaction that can affect positive changes in irritability, hyperactivity, social, and communication behaviors in this population.

Results generate hypotheses regarding the role of the human-equine interaction requiring further investigation. One hypothesis is that riding and working together with the horse to engage in therapeutic riding activities involves a nonverbal joint-attention or shared attention experience that may serve a platform for improving behaviors and social-communication skills in children with ASD. This nonverbal communication between the horse and the rider may include the fact that horses constantly mirror and respond to the rider's body language. Also, this shared attention experience may be enhanced by the enormity of the horse combined with the task demand for the rider of maintaining bilateral control and balance. Outcome measures of joint attention skills, including semi-structured play assessments and behavioral observation coding, may be useful considerations for future THR studies. A second hypothesis is that the human-equine experience (i.e., warmth of the horse's body and rhythmic movement of riding the horse) promotes a relaxing context, which may have a calming effect on children with ASD. The impact of THR on reducing stress levels can be explored using objective behavioral observation measures combined with biological measures such as galvanic skin response or salivary cortisol. Physiological measures may provide more accurate assessments of the stress levels in the ASD population, as gathering self-report accounts are challenging in this population.

The study is limited by the fact that several outcomes (i.e., ABC-C, SRS, VABS-II) were measured using non-blinded caregiver report measures, which is a unique confound to this type of intervention research and raises questions as to whether knowledge produced a placebo effect. An additional limitation is the lack of objective observational measures, which are needed to gain further insight into the mechanisms of behavioral changes observed in this study. This study also used broad measures of motor coordination, which limited the ability to detect possible motor-related changes. In order to have a comprehensive assessment of the THR intervention, a study with a placebo group (i.e. no intervention at all) in addition to the BA control group will provide a better insight into the effect of THR. Additional future study considerations include expanding demographic measures to include, for example, a broader measure of intellectual functioning. Finally, no adjustment was made for multiple secondary outcome comparisons in the analysis, as this may have increased the type I error rate. Therefore, caution needs to be taken into account when interpreting the secondary outcome results.

This study further establishes the evidence base supporting EAAT as a viable therapeutic option for children and adolescents with ASD. Further research is warranted to examine if the joint attention and movement experiences are key THR mechanisms to observe behavioral and social-communication improvements in the ASD population.

Acknowledgments

This study was supported by grant R01NR012736 from the National Institute of Nursing Research (R.L.G.). Dr. Pan served as the statistical expert for this research.

The authors gratefully acknowledge the children and families who participated in this study, those who assisted with this project from Children's Hospital Colorado (Laurie Burnside, MSM, CCRC, Tina Farrell, CCC-SLP, Syd Martin, MS, OTR, Shana Holderness, MA, Oren Gordon, BA, and Jessie Lucas, student research assistant), and personnel from the Colorado Therapeutic Riding Center (Amy Shoffner, MSW, PATH International Advanced instructor, Jody Howard, PATH International Advanced Instructor and Registered Evaluator, and Penelope Powell, BA, PATH International Advanced Instructor and Registered Evaluator). The authors also thank PATH International and its former CEO, Kay Green, BA, for disseminating information about this study along with Luitpold Pharmaceuticals and Allen Mann, Director, Luitpold Animal Health, for donating Adequan for study horses. The authors are grateful to Carol Beresford, MD, and Doug Novins, MD, University of Colorado Anschutz Medical Campus for assistance with manuscript preparation.

Footnotes

Disclosure: Dr. Gabriels is a co-author of the book Growing Up With Autism: Working With School-Age Children and Adolescents (Guilford Press), and the book Autism - From Research to Individualized Practice (Jessica Kingsley Publishers), from which she has received royalties. She has received grant funding from the Simons Foundation, Nancy Lurie Marks Family Foundation, MARS/WALTHAM, and the Human-Animal Bond Research Institute (HABRI) Foundation. She has served on the Medical Advisory Board of Professional Association of Therapeutic Horsemanship International and has received honoraria from Spring Harbor Hospital, Portland, ME, Indiana University Neuroscience Center, Indianapolis, IN, and Routledge/Taylor and Francis Group. Dr. Mesibov is the co-author of the book The TEACCH Approach to Autism Spectrum Disorders (Springer Press), from which he has received royalties. Drs. Pan and Agnew, Ms. Dechant, and Ms. Brim report no biomedical financial interests or potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

3. Warreyn P, Van Der Paelt E, Roeyers H. Social-communicative abilities as treatment goals for preschool children with autism spectrum disorder: the importance of imitation, joint attention, and play. Developmental Medicine and Child Neurology. 2014:1-5. [[ PubMed] Google Scholar]

49. SAS Institute Inc., SAS Campus Drive, Cary, North Carolina 27513.

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Randomized Controlled Trial of Therapeutic Horseback Riding in Children and Adolescents With Autism Spectrum Disorder

# data[].attributes.attachment_link.description
Dr. Robin L. Gabriels, PsyD, Dr. Zhaoxing Pan, PhD, Ms. Briar Dechant, BS, Dr. John A. Agnew, PhD, Ms. Natalie Brim, BA, and Dr. Gary Mesibov, PhD This study expands previous equine-assisted intervention research by evaluating the effectiveness of therapeutic horseback riding (THR) on self-regulation, socialization, communication, adaptive, and motor behaviors in children with autism spectrum disorder (ASD).

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Study About EAAT For Individuals With Dementia

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Study About EAAT For Individuals With Dementia

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Influence of an Equine-Assisted Activities Program on Dementia-Specific Quality of Life

8 weeks

9 different activity stations, 1 of which was EAA

6 participants

Results

More positive patterns of time use & emotional well-being

Improved quality of life

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Abstract

Institutional facilities face challenges providing experiences to residents with dementia that promote participation in meaningful activities. Guided by the Lived Environment Life Quality Model, this study investigated associations between 9 different activity situations-one an equine-assisted activities program (EAAP)-and positive, negative, and neutral behavioral indicators of quality of life (QoL) in 6 residents with dementia who expressed an interest in horses. Direct observational data were collected for 4 hours twice weekly over 8 weeks. Using χ ² tests, differences across activity situations were tested. More positive patterns of time use (conversation; χ ² = 44.3, P < .001) and emotional well-being (pleasure; χ ² = 21.8, P = .001) were found in EAAP compared to other activity situations. Further, EAAP was the only activity situation associated with all positive QoL indicators. These findings add to our understanding the importance of providing meaningful activities that promote use of abilities and provide environmental support, for enhancing QoL, especially for institutionalized people with dementia.

Introduction

To help shape an individual's last chapter of their biography in meaningful and positive ways,1,2 recent health-care efforts have recognized the importance of not only providing quality care for residents of long-term care (LTC) facilities but also striving to optimize their quality of life (QoL).3-5 In response to this shift in health care, a variety of nonpharmacological approaches have evolved. Nonpharmacological, environment-based approaches that incorporate animals are referred to as animal-assisted interactions (AAIs). Animal-assisted interactions are often structured time periods that incorporate animals to promote a person's mental, physical, social, and emotional functioning.6

A recent systematic mapping review found that animal-assisted therapies in LTC facilities may help to enhance the QoL of older adults with Alzheimer's disease and other dementias, referred to simply as "dementia" in this article.7 Although not without methodological weaknesses, the 10 studies included in this review offered evidence that therapies that incorporate dogs may help LTC residents with dementia occupy time in diverse ways, use their existing capacities in meaningful activities, and experience heightened emotional well-being. This article reports on a study of an equine-assisted activities program (EAAP) that was guided by the same conceptual model that directed the mapping review, the Lived Environment Life Quality (LELQ) Model.8

The LELQ Model was derived from and based upon a wide body of research pertaining to environmental influences on dementia-specific elements of QoL. One primary domain of the model, the lived environment, contains the subdomains of the caregiving microsystem, the person with dementia, and an environmental press.

The caregiving microsystem is understood to consist of the amount and quality of opportunities for engagement that are provided to LTC residents with dementia and the physical and social environmental supports of their engagement in those opportunities. This subdomain draws attention to the concept of activity situations. Defined, activity situations are "bouts of time that are readily recognizable because they routinely happen at designated times of a day in specific facilities."9 Staff and administrators of facilities determine the time frames, the purpose, and the format of these activity situations. Examples of activity situations may include meal or snack times in large dining rooms, television times, activity groups such as music and news time, and even a community-based, EAAP.

Although people with dementia experience declines in cognitive and other functional abilities, their innate needs for engagement in meaningful activities remain.10 The person with dementia subdomain captures an individual's occupational profile. Humans "derive meaning in their lives through what they do."11 The ability to "do" is shaped by an individual's preferences, needs and desires, habits, retained capacities-whether physical, cognitive, sensory, perceptual, or social-as well as by the surroundings in which the individual is exposed. Thus, an occupational profile refers to all characteristics that can influence the residents' motivations to engage in some activities over others.12

These 2 lived environment subdomains are operationalized in a transactional manner. That is, the daily experiences of residents with dementia are presumed to be influenced by the fit of the systems of care experienced by LTC residents with dementia (caregiving microsystem) and who those residents are as occupational beings (the person with dementia)-a function of an environmental press. The term, environmental press, refers to the interaction of any context, physical, social, and interpersonal environmental stimuli13 that "serves to elicit or press toward the expression of some behaviors and suppression of others."1 The environmental press of the interaction between the resident with dementia and specific activity situations can be observed based on the 3 QoL subdomains of the model: (1) time use or how people with dementia occupy their time, (2) ability to function or the quality of a person's functioning attuned to the dementia stage, and (3) relative being or the person's emotional experiences. Altogether, the LELQ Model suggests that environmental presses of activity situations may have immediate influences on QoL. Furthermore, the environmental presses may range from occupationally enlivening to occupationally deadening experiences; in other words, residents who are surrounded by an environment that understands and is responsive to their needs, wants, and desires, will undoubtedly use their time more effectively by maintaining engagement in desired activities. However, residents who are in unreceptive environments in which caregivers or staff do not value their preferences, needs or existing capacities, may experience, an occupationally deadening environmental press.

To experience occupationally enlivening environmental presses, adults with dementia may benefit from interacting in activity situations that they find value and meaning in.11 Evidence also suggests that traveling off site to other therapeutic contexts to engage with animals may promote positive QoL experiences.7,14 Thus, the purpose of our study was to investigate associations between positive, neutral, and negative indicators of QoL expressed by LTC residents with dementia during different activity situations, one of which was an EAAP. The following research question was asked:

Methods

Research Approach

Findings reported in this article were based on a mixed method, case study design. Yin15 described the case study as a design that can include both quantitative and qualitative methods to deliberately "focus on a single phenomenon while understanding its real-world, dynamic context." The case consisted of a small group of residents with dementia from an LTC facility that expressed interest in participating in the EAAP. To address the research question, this article reports quantitative findings from the larger mixed methods study.

Selection and Description of Study Sites

This study occurred at 2 study sites located in Northern Colorado. A for-profit LTC facility that provides full memory care services to residents with dementia was selected. This facility resembles a home-like community that emphasizes residents' preferences by offering a variety of daily activity opportunities. In addition, a nonprofit therapeutic riding center that established the EAAP in 2011 to help promote physical and psychosocial benefits for older adults with dementia was chosen. This therapeutic riding center was chosen as a site for the study based on its established dementia-specific program and accreditation as a PATH Intl. Premier Accredited Center, the highest level of accreditation possible for therapeutic riding centers. This accreditation ensures that centers are abiding by industry standards in administration, safety, and equine-assisted interactions (see PATH Intl. website for details on standards and accreditation process).

Participants

After approvals from the study sites and by the institutional review board were obtained, a convenience sample of 8 residents from the LTC facility participated in the study. Residents were identified through a 2-stage screening process. A brief in-person meeting with an administrator from the LTC facility identified residents who met the following inclusion criteria: (1) age of 45 years or older, (2) ability to ambulate with minimal assistance from a caregiver (by walking or wheelchair), (3) stable regimen of medications (including psychotropic medications), (4) diagnosed with mild-moderate stage dementia, (5) resident at the facility for 4 weeks or longer prior to the study, (6) not allergic to horses, and (7) English speaking. The second stage was a critical step in the study in that it allowed the researchers to understand what activities mattered most to the previously identified residents. For this study, researchers were particularly interested in exploring resident interactions during an EAAP in comparison to other activity situations in the LTC facility. Therefore, the administrator from the LTC facility identified residents who had an interest in or experience with horses.

During this study, LTC staff invited the 8 identified residents to a variety of activity situations, including the EAAP. Of note, resident involvement in every activity situation was voluntary. Residents and proxy (primary caregiver) consents were obtained. Participation in the study was voluntary and the residents could withdraw from the study at any time.

Equine-Assisted Activities Program (EAAP) Description

Staff from the LTC assisted each resident onto the facility's bus to attend the EAAP 1 time each week for a total of 8 weeks. Residents were accompanied to each session by 1 or 2 LTC staff members. Once the bus arrived at the therapeutic riding center, staff and volunteers from the therapeutic riding center helped residents off the bus and guided them into the covered arena to sit in chairs until activities started.

Therapeutic riding center staff partnered with 3 trained horses and 1 pony to provide the EAAP. A 14-year-old and 18-year-old mare provided riding activities. A 21-year-old mare was designated for grooming activities and a 15-year-old mare pony interacted with residents sitting in chairs to provide a petting opportunity.

Two-certified therapeutic riding instructors provided the EAAP. Therapeutic riding instructors are trained to conduct safe and basic equestrian lessons to people with disabilities.16 There was typically a 3:1 staff and volunteer to resident ratio. Before interacting with the horses, volunteers and staff helped the residents put on helmets for safety. Residents were then approached individually and given the choice to ride, groom and pet a horse, or stay seated and observe others' involvement in activities. Residents who expressed interest in riding were escorted by volunteers up a handicap accessible ramp. The therapeutic riding instructors then provided tactile and verbal cueing to help the resident mount the horse. While on the horse, residents were accompanied by 2 volunteers who served as side walkers for safety, and the therapeutic riding instructor directed activities at a walk such as riding over ground poles or through cones. Riding lasted approximately 15 minutes to avoid fatigue and overstimulation. Residents who completed groundwork activities such as petting and grooming were also guided by at least 1 volunteer. The entire session lasted an hour in the morning, approximately 10 to 11 am. After the session, each resident was escorted back to the facility's bus parked outside of the arena to travel back to the LTC facility with their staff.

Data Gathering

Data were collected using a modified version of the Activity in Context and Time (ACT) Table 1). This computer-assisted, real-time, direct observational instrument was developed and has been described by Wood.17 The ACT includes a domain of routine activity situations that represent environmental correlates of QoL, in addition to 2 domains related to QoL: time use and apparent affect. Nine activity situations were observed during this study: downtime, television, meals/snacks, games, jokes and riddles, music group, bus time, physical therapy, and EAAP. Measures of time use as QoL indicators specifically relate to gaze, position and movement, conversation, and participation in activity. Two time use subdomains, gaze and participation, contained modifier groups or factors that described the observed behaviors in more detail. For gaze, the direction of the gaze, if observed, was coded as either single (eg, engaged gaze with horse) or multiple (eg, engaged gaze with horse and person). For participation, details of what the residents were doing were coded as either simple (eg, groom horse) or complex (eg, groom and pet horse).

Modified Activity in Context and Time.

Measures of apparent affect, or more broadly, emotional well-being as QoL indicators specifically relate to agitation and apparent affect. Agitation refers to problem behaviors such as agitation, behavioral distress, and resistance to care. Measures of apparent affect as QoL indicators were derived from Lawton et al's Apparent Affect Rating Scale.18 See Appendix A for coding guide and definitions. Because the ACT's measures were established based on "grounding the ACT in credible and relevant scholarship," the instrument demonstrates content and construct validity.17 Its 2 QoL domains contain optimal codes or codes that suggest more favorable QoL in the moment ( Table 1). For instance, specifically related to gaze, an engaged gaze, wherein the participant is visually oriented to an object, person, or event, is considered optimal in comparison to eyes closed or unengaged gaze wherein participants stare blankly into space.

Using Noldus, an observer software system,19 hand-held computers were programmed with each of the exhaustive and mutually exclusive ACT subdomains and an instantaneous sampling strategy. An instantaneous sampling strategy was chosen to capture the sequence of direct observations at regular intervals of time. One complete observation was collected on each resident and their involvement in chosen activity situations every 10 minutes over 4 hours, from 9 am to1 pm. An example of one observation completed between 9:00 and 9:10 am of a man having breakfast at LTC facility could be as follows: activity situation, meals and snacks; gaze-engaged gaze; position and movement sitting; conversation, no participation in conversation; activity, participation in eating and drinking; and apparent affect, no affective expression is apparent. Observations were captured on 2 different days: on Thursdays, residents were observed during a range of activity situations at the LTC facility and on Fridays, residents were observed at the LTC facility and the therapeutic riding center.

Two researchers underwent extensive training in the use of the ACT to ensure interobserver reliability. Approximately 8 days consisting of 32 hours of preliminary behavioral observations of the residents with dementia at the therapeutic riding center were recorded. These field experiences allowed the researchers to record observations of the included residents in this study, compare each other's results, and discuss disagreements to better understand each other's use of the tool. After these field experiences were completed, researchers checked their precision and consistency of applying the ACT using the reliability function in Noldus. Weighted κ coefficients for interobserver reliability across all domains of the ACT were calculated and ranged from .92 to .96, indicating substantial agreement. Once trained, the 2 researchers collected observations for the final 4 weeks of EAAP. During observations, researchers did not engage with residents.

Data Analysis

All data were uploaded into Noldus and then exported into SPSS Version 22.0 for statistical analysis. The overall objective of this study was to investigate whether the activity situations (ie, all other LTC activity situations or EAAP) were related to the QoL indicators. Descriptive statistics included frequencies and proportions. Frequencies represent the number of times a value for a QoL subdomain was observed. Proportions represent the share of one value for each QoL subdomain response in relation to the subdomain whole. In addition to these descriptive statistics, χ ² test was selected to discern which activity situation induced a significant response in terms of resident's behavior. Routine activity situations were dichotomized as (1) all other LTC activity situations and (2) EAAP. The 6 ACT subdomains were nominal or dichotomous. Raw data were checked for outliers and missing values. Missing values were imputed using a listwise deletion. Once all missing values were imputed, the data set resulted in 3554 active cases, which is a "large-scale sample" in any statistical exercise. Results were considered statistically significant at P < .05.

Post hoc analyses were also investigated for the 2 subdomains that contained modifier groups, gaze and participation. These data were summarized as proportions using the pivot table tool function in Microsoft Excel.

Results

Eight residents were deemed potentially eligible for the study through the screening process. Of those, 2 did not participate due to exclusion for nonattendance. Two residents failed to attend the EAAP for more than 2 consecutive weeks: 1 resident experienced health problems not associated with the EAAP and staff at the LTC considered the other resident unsafe to partake in the program due to his lack of safety awareness. The mean age of residents was 83.3 years, range of 71 to 95 years. The 6 residents who participated in all 8 sessions of EAAP were Caucasian, 4 were female, and 5 were characterized as being in the moderate stage of dementia. All residents had had previous experience with horses, therapeutic horseback riding, or both.

There were no significant differences observed between the EAAP and all other LTC activity situations in the subdomains of gaze (χ ² = 3.0, P = .227), position and movement (χ ² = 4.1; P = .246), and agitation (χ ² = 2.4, P = .123). Statistically significant associations were found between the EAAP in comparison to all other LTC activity situations in 2 QoL subdomains, conversation (χ ² = 44.3, P < .001) and apparent affect (χ ² = 21.8, P = .001) ( Table 2).

Time Use Domain

In the time use subdomain, gaze, higher proportions of the optimal QoL indicator of engaged gaze were observed during EAAP (99%) compared to all other activity situations combined (94%). Post hoc analysis revealed that a multiple engaged gaze was greater (23%) in EAAP compared to all other LTC activity situations. Of these multiple engaged gaze observations, 74% recognized attention to a person and a horse. In the time use subdomain, position and movement, higher proportions of the optimal QoL indicator of walking were observed during EAAP (15%) compared to all other activity situations combined (8%). Thus, a trend toward higher levels of general alertness and a greater proclivity to use the physical capacities necessary for walking during EAAP was observed. However, these differences were not statistically significant.

In the time use subdomain, conversation, higher proportions of the optimal QoL indicator, yes-conversation, were observed during EAAP (60%) compared to all other activity situations (24%). Thus EAAP, which included a rich social environment involving multiple residents, volunteers, and therapeutic riding instructors, as well as horses, was significantly associated with the highest frequencies of social interaction and communication.

In the time use subdomain, participation, higher proportions of the optimal QoL indicator, yes-participation, were observed in all other activity situations (38%) compared to EAAP (16%). However, post hoc analysis revealed that the highest proportion of complex participation was observed in EAAP. Half (50%) of all observations of yes-participation during EAAP were complex (eg, riding a horse while singing a song) in comparison to the activity situations with the second and third highest frequencies of complex participation: music groups wherein 45% of all yes-participation observations were complex, and bus rides wherein 5% of all yes-participation observations were complex. Hence, in addition to being attentive to the environment, walking or talking, multiple activity-related behaviors were most often concurrently observed during EAAP, suggesting that this activity situation may have prompted participants' use of a variety of functional abilities.

Emotional Well-being Domain

In the emotional well-being subdomain, agitation, higher proportions of the optimal QoL indicator of no agitation were observed during EAAP compared to all other LTC activity situations, yet these differences were not statistically significant. In the emotional well-being subdomain, apparent affect, however, the optimal QoL indicator of pleasure was significantly more frequently observed during the EAAP compared to all other activity situations. These findings suggest that both the EAAP did not elicit undue stress or upset in participants and the experience of the program was comparatively enjoyable to them.

Discussion

Residents in this study were observed to be able to converse, maintain an engaged gaze, walk, participate in relatively complex activities, and evidence pleasure, all positive dementia-specific indicators of QoL. When compared with other routine activity situations in their LTC facility, these optimal QoL indicators were most frequently observed during EAAP. The EAAP appeared to offer an occupationally enlivening environmental press as described in the LELQ Model. Altogether, findings suggest that the EAAP may be an effective nonpharmacological approach for eliciting favorable QoL experiences for institutionalized adults with dementia with an interest in or experience with horses or therapeutic riding contexts. Next, aspects of the EAAP are related to the caregiving microsystem and person with dementia subdomains of the LELQ Model to illuminate active ingredients that may have contributed to the good fit or match between the resident's adaptive behavior, affect, and the environmental context of the EAAP.

Lived Environment: Caregiving Microsystem

The LELQ Model suggests that aspects of the social and physical environment in a resident's lived environment may promote occupational opportunities that contribute to enlivening presses.8 Social environmental factors may have contributed to occupationally enlivening presses. Residents experience challenges with language and thus find it difficult to express themselves as dementia progresses. Studies have demonstrated that animals stimulate positive social interactions20 and provide older adults a way to communicate their feelings.21 Another study reflected on the role of animals as "emotional mediators" and "catalysts" for positive interactions. The increased communication, multiple engagement, and pleasure during the EAAP suggest that residents were empowered to make connections with both people and horses involved in the activities.

Although our study did not assess the effects of contact with nature, physical environmental aspects of the therapeutic riding center may have positively shaped the residents' QoL experiences. For many people, connecting with nature contributes to their sense of QoL. This sense is robustly articulated through the biophilia hypothesis,22 which asserts an inherent human need to affiliate with nature. The direct contact with nature in this study may have evoked a mental and physical appreciation associated with the heightened engagement and complex participation. This affinity to nature may perhaps be linked with a sense of "being away."23 Research studies have revealed that being outdoors, away from institutionalized and other urban type settings, has positively influenced affective states.23 Duggan et al24 exposed the connection between outdoor environments and health for people with dementia. Specifically, they found that people in the early stage of dementia valued being outdoors for exercise, fresh air, and emotional well-being. Likewise, Rappe et al21 shared the restorative effects of being in direct contact with nature for older adults with dementia residing in LTC; the more the people were presented opportunities to be outdoors, the stronger the associations were with positive self-rated health.

Lived Environment: Person With Dementia

The LELQ Model suggests that the care approach should take into consideration the retained capacities, preferences and needs, and occupational history of the person with dementia to positively influence QoL experiences. Many studies support and emphasize that meaningful activity should pertain to one's life roles and interests as a means for fostering fulfilment and emotional well-being.8,10,25 Correspondingly, the Continuity Theory of Aging 26 suggests that defining personality characteristics become more prominent with age and those that maintain their preferred roles throughout life will experience a desirable QoL. In similar fashion, Albert and colleagues27 highlighted the variability in activity and affect, that is, not all activities are going to "tap" into the same past memories for every person. Indeed, Chung10 found a significant association between well-being and participation in activities that were considered, from the participants in that study, as enjoyable. This study, which intentionally selected residents with an interest in horses or the therapeutic riding context, similarly found that these individuals demonstrated high levels of positive QoL indicators during the EAAP. These findings may reflect the integration of the residents' personal experiences of meaning and interconnections to past valued activities.

Implications for Practice

The routine activity situations that characterized the residents' daily life during this study may be key in understanding contributing factors of QoL. An important benefit of living in institutionalized settings such as a LTC setting is being able to participate in a variety of activity situations. Across all observations of activity situations, the greatest number of optimal QoL indicators was observed in the EAAP; when the LTC activity situations are viewed altogether, the residents' time use and emotional well-being express lower QoL experiences.

Similar to findings from Wood et al, the variations in environmental presses generated from the observed activity situations in this study specify further that, "simply surrounding residents with activities insure neither their meaningful time use nor their remaining functional capacities will be tapped or optimally maintained."9 Therefore, this study raises questions about organizing and giving shape to activity situations outside the institutional walls that attend to physical, social, and interpersonal determinants of dementia-specific QoL. Findings underscore the ability of an EAAP to provide activities that have potential for occupational engagement, performance, and emotional vitality. Namely, adequate support, both physical and social, and attention to individual residents were routinely observed; these strategies align with Kitwood's concept of being person centered28 and Mezey's concept of abilities focused care,29 2 approaches highly valued in dementia care. To ensure that these 2 critical concepts are integrated into dementia care, findings from this study suggest that residents would benefit from facilities developing life-history forms to capture residents' previous occupations, preferred nickname, leisure interests, behavior and coping styles, and even past experiences with animals and nature. By integrating these forms into practice, staff would be better equipped to provide more effective care and better understand the interactions between the residents and their surrounding environment.

Limitations and Future Research Directions

Residents were selected using a convenience sampling approach, which lends itself to a biased sample. Although using an instantaneous sampling approach provided a more manageable data set, the predetermined time intervals may have caused the researchers to miss some resident behaviors. As with most observational research, we did not attempt to control confounding variables that may have influenced the residents' behaviors such as changes in volunteers during the EAAP or outdoor temperatures. Observers were also not blinded to the study's hypothesis. Neither did this exploratory study establish cause and effect relationships between activity situations and indicators of QoL.

With these limitations noted, this study adds evidence to the sparse literature on AAIs for institutionalized adults with dementia. Owing to the early scientific development and complex nature of AAIs, in particular for the dementia population,7 findings from this study suggest that future research should focus on expanding, evaluating, and implementing EAAPs. The authors are developing a manuscript with the qualitative findings from this study to comprehensively describe each component of the EAAP. Further, to establish the empirical basis of complex approaches, Craig et al30 suggests that researchers identify and develop theory. Accordingly, these quantitative and qualitative findings will by synthesized to inform the development of a logic model, which is warranted to guide program development for the dementia population.31 Once this foundational work has been established, future research should investigate comparison conditions that could include other community-based outings and specific EAAP elements such as mounted activities and groundwork.

Conclusion

LTC residents with dementia experience a challenging lifestyle. Not only do they struggle with a progressive condition, but environmental factors may further compromise their QoL. Many LTC facilities recognize the need to understand how their care efforts affect residents. This study offered evidence that a nonpharmacological approach, EAAP, provided safe and largely enjoyable opportunities to LTC residents with dementia. Furthermore, these opportunities appeared to help residents tap into and use a wide range of their existing capacities, interact intentionally with people and horses, and engage in more complex, multilayered activities than typical in their LTC facility. Researching the influence of activity situations on residents' QoL may provide health professionals with greater understandings of the needs and preferences of the residents and enable those professionals to provide more alternative nonpharmacological approaches. This study offers support that EAAPs present as a fruitful opportunity to paint a more holistic picture that encompasses the transactional nature of environmental and personal factors in pursuit of positively influencing QoL for people with dementia residing in LTC.

Appendix A

Table

Acknowledgments

This manuscript is based on and expands upon a dissertation conducted by the first author. The authors would like to express sincere thanks for the participation and assistance of the residents. With permission, we acknowledge the Temple Grandin Equine Center, Seven Lakes Memory Care, Hearts and Horses Therapeutic Riding Center, and Rebecca Lassell and Sarah Busselman for their incredibly generous support to the research.

Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Carl and Caroline Swanson Foundation.

ORCID iD
Beth Fields, PhD, OTR/L http://orcid.org/0000-0002-8192-7144

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# data[].attributes.attachment_link.title
Influence of an Equine-Assisted Activities Program on Dementia-Specific Quality of Life - Beth Fields, Jason Bruemmer, Gene Gloeckner, Wendy Wood, 2018

# data[].attributes.attachment_link.description
Abstract Institutional facilities face challenges providing experiences to residents with dementia that promote participation in meaningful activities. Guided by the Lived Environment Life Quality Model, this study investigated associations between 9 different activity situations-one an equine-assisted activities program (EAAP)-and positive, negative, and neutral behavioral indicators of quality of life (QoL) in 6 residents with dementia who expressed an interest in horses.

# data[].attributes.headline
My Future Endeavor:   Equisol~ Living in The Moment

# data[].attributes.subject
My Future Endeavor:   Equisol~ Living in The Moment

# data[].attributes.body
Through mindful practices with equine partners, experience awareness, stress reduction and a greater sense of balance and alignment to allow your genuine soul to shine

# data[].attributes.headline
Common Conditions That May Benefit From EAAT

# data[].attributes.subject
Common Conditions That May Benefit From EAAT

# data[].attributes.body
Autism Spectrum Disorder

Developmental Delay

Anxiety

Depression

Post Traumatic Stress Disorder

Multiple Sclerosis

Muscular Distrophy

Cerebral Palsy

Parkinson's Disese

Alzheimer’s Disease

Attention Deficit Hyperactivity Disorder /Attention Deficit Disorder

Oppositional Defiance Disorder

# data[].attributes.body
Individuals with physical, cognitive, emotional disabilities

Youth at risk

Veterans

Seniors with Alzheimer's and other forms of dementia

Anyone