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Research in Developmental Disabilities 59 (2016) 176185

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Research in Developmental Disabilities

Benets of an experimental program of equestrian therapy


for children with ADHD
Andrs Garca-Gmez a , Marta Rodrguez-Jimnez b, , Elosa Guerrero-Barona b ,
a , Juan Manuel Moreno-Manso b
Jess Carlos Rubio-Jimnez a , Ins Garca-Pena
a
Department of Educational Sciences, Faculty of Teacher Training, University of Extremadura, Campus Universitario, Av. de la
Universidad, s/n, 10071, Cceres, Spain
b
Department of Psychology and Anthropology, Faculty of Education, University of Extremadura, Av. de Elvas, s/n, 06071, Badajoz, Spain

a r t i c l e

i n f o

Article history:
Received 27 April 2016
Received in revised form 1 September 2016
Accepted 1 September 2016
Number of reviews : 2
Keywords:
Adapted riding
ADHD
Quality of life
Personal relationships

a b s t r a c t
Background: Equestrian therapy has been shown to be a useful instrument in the sphere of
the emotional wellbeing and mental health of different population groups.
Aims: To empirically determine the effects of a program of equestrian therapy on quality
of life and various psychosocial variables of a group of 14 pupils diagnosed with Attention
Decit Hyperactivity Disorder (ADHD), aged from 7 to 14 years.
Methods and procedures: A quasi-experimental design, with a pre-test and a post-test, was
implemented with an experimental group and a control group. The program consisted of
24 biweekly sessions, therefore lasting some 3 months. The data acquisition instruments
used were: the Behavior Assessment System for Children (BASC) and an ad-hoc quality
of life questionnaire.
Outcomes and results: The results deriving from the teachers responses and the different
scales of the BASC showed no signicant group differences, but for the experimental group
there was an improvement in the indicator corresponding to interpersonal relationships in
the quality-of-life questionnaire.
Conclusions and implications: It would seem that it is currently possible to recommend
this activity, for this target population, as a sporting activity that provides similar benets
to other physical activities, but which is still far from being able to be recognized as a
therapeutic activity.
2016 Elsevier Ltd. All rights reserved.

What this paper adds?


Previous studies have shown the efcacy of equestrian therapy programs for different aspects in the sphere of mental
health and psychological wellbeing for several population groups; such as, for instance, children and adolescents at risk of
social exclusion. However, research into this same area on those with ADHD is still scarce and the few papers that do exist
have had contradictory results. This work presents research carried out on 14 children diagnosed with ADHD who were

Corresponding author at: Department of Psychology and Anthropology, Faculty of Education, University of Extremadura, Av. de Elvas, s/n, 06071,
Badajoz, Spain.
E-mail addresses: agarcil9@unex.es (A. Garca-Gmez), marta.rodriguez.jimenez@gmail.com, mrodrigumnm@alumnos.unex.es (M. Rodrguez-Jimnez),

eloisa@unex.es (E. Guerrero-Barona), rjjcarlos@gmail.com (J.C. Rubio-Jimnez), inesgape@hotmail.com (I. Garca-Pena),


jmmanso@unex.es (J.M. MorenoManso).
http://dx.doi.org/10.1016/j.ridd.2016.09.003
0891-4222/ 2016 Elsevier Ltd. All rights reserved.

A. Garca-Gmez et al. / Research in Developmental Disabilities 59 (2016) 176185

177

given an equestrian therapy program, in two sessions per week over three months. The effects of the program showed null
results in the clinical and psychosocial variables analysed (including the central symptoms of the disorder), as perceived
by the teachers, and a moderate effect on interpersonal relations. This would suggest that equestrian therapy programs are
still far from being recommendable as a therapeutic activity aimed at reducing the problems that these children with ADHD
experience in their daily lives.
1. Introduction
1.1. Attention decit hyperactivity disorder
Attention Decit Hyperactivity Disorder (ADHD) is a mental illness characterized by a pattern of problems of inattention
and/or impulsive hyperactivity. According to the DSM-5 (2013) criteria, it has to be present before the age of 12, has to
occur in two or more different environments, and has to cause clinically signicant impairment in social, academic, or
occupational functioning. Also, according to the prevalence of the symptoms of inattention, hyperactivity, or both, the DSM5 identies three subtypes: the predominantly inattentive subtype, the predominantly impulsive-hyperactive subtype, and
the combined subtype. The prevalence of this disorder is estimated to be between 5.9% and 7.1% of the school-age population
(Willcutt, 2012).
ADHD is commoner in boys than in girls and presents frequent co-morbidities, especially with oppositional deant
disorder (Goulardins, Bilhar, Casella, Nascimento, & Oliveira, 2012). In addition, over 80% of children with ADHD have
behavioral problems (Gargallo, 2005), while 15% (23% of adolescents) suffer from an associated conduct disorder (Faraone,
Biederman, & Monuteaux, 2002). Indeed, one area of research interest is the extent of overlap between ADHD and conduct
disorder. A review by Rubia (2011) of neuro-imaging studies of the pathophysiology underlying the two disorders found
that ADHD is mediated by a cold fronto-striatal-cerebellar dysfunction, but that conduct disorder is mediated by a hot
orbitofrontal-paralimbic dysfunction.
There are associations of ADHD with problems in the social, academic and family spheres of the childs life. Children with
ADHD may experience sustained negative development with problems that continue until adulthood (Cuypers, Ridder, &
Strandheim, 2011; Spencer, Biederman, & Mick, 2007). Data from cross-sectional, retrospective and monitoring studies suggest that children with ADHD are at risk of developing other psychiatric problems in childhood, adolescence and adulthood,
such as substance abuse, mood disorders, anxiety disorders (Spencer et al., 2007), and criminal behavior (Smith & Hung,
2012). Indeed, ADHD is frequently found in juvenile detainees (Colins et al., 2012).
Children with ADHD are likely to be more aggressive than others (Abikoff et al., 2002). This can be explained as being
due to a decit in self-control and behavioral inhibition skills (Gargallo, 2005). Pinto, Presentacin, and Miranda (2011)
state that two areas reported in the literature as being decient in children with ADHD are: a) their resources for facing and
properly resolving conicts, and b) their mechanisms for self-regulating anger. Barkley (2006) also notes problems in their
relationships with parents, teachers and peers, as well as in their academic performance at school. Semrud-Clikeman et al.
(2011) report that a dysfunction in the social environment is often associated with ADHD, and that such problems may be
aggravated when there exists a concomitant depression.
1.2. Equestrian therapy
Interaction with other animals has long been used for the benet of humans. In the 5th century BC, equestrianism was
used therapeutically for the rehabilitation of wounded soldiers. However, it was not until 1960 that horse-riding was used
for this purpose in the U.S.A. (Lentini & Knox, 2009).
Heine distinguishes between classical and modern hippotherapy (Corral & Fernndez, 2011). For that author, classical
hippotherapy is that which takes advantage of the positive effect of the horses movement on the person, and is suitable
for the rehabilitation of neuromuscular, musculoskeletal, and cardiopulmonary problems. Modern hippotherapy, however,
adds a psychological component, and includes objectives of a social, educational, or cognitive nature. In the present work,
the term equestrian therapy is used without any implication of a distinction with modern hippotherapy.
According to Lentini and Knox (2009), some of the features that make horses ideal for use in psychotherapy are that they
provide a calming effect, while requiring complete attention. Their large size allows the rider to explore issues related to
vulnerability and control, while communication with the horse is straightforward, because the animal has no duplicity in
its interaction with the rider. It is a social animal that has evolved to live in a herd, and therefore pays special attention to
details and responds to events that may go unseen by humans.
A child-horse relationship may have positive effects on such qualities as empathy, unconditional acceptance, selfcondence, security, and self-control (Barkley, quoted in Corral & Fernndez, 2011). Moreover, Corral and Fernndez (2011)
note positive social effects, arguing that, during equestrian therapy, children may internalize acceptable ways of expressing
their feelings, ask themselves about what is and what is not appropriate in the horses behavior, and develop motivation
and empathy, which they may later be able to transfer to their relationships with people.
What is more, apart from the intentional benets of the use of horses for rehabilitation with both physical and/or psychological problems, horse-riding is also a sport that involves physical exercise. In this sense, although children with ADHD
develop a greater level of physical activity than their peers who have a typically normal development, it is still insufcient

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to comply with the established health and dietary criteria. In addition, the hyperactivity associated with the disorder does
not protect them from being overweight (Lin, Yang, & Su, 2013). Thus, the addition of equestrian therapy to the treatment
of these children is also useful as a means to increase their physical activity.
As for other benets of equestrian therapy in children with ADHD, Bender (2011) states that contact with the horse
motivates the child to perform tasks at peak performance. The children learn that they cannot simply impose their will on
the horse. The fact of moving with the swaying of the horse while mounted has a calming effect, and the calming and relaxing
effect of working with the horse lasts for several days.
With respect to the application of equestrian therapy for children with ADHD, the PATH (Professional Association of
Therapeutic Horsemanship) (NARHA, 1997), formerly NARHA, notes the following: the need to set external boundaries and
controls; the establishment of consistent routines that allow the rider to develop a sequential approach to the new scenario;
the potential of using posters with rules and lists of procedures that can serve as visual cues to help the rider organize the
tasks; since the novelty of the stable and other stimuli that are present may be major distractions, it is advisable to tack up
the horse while still in its stall; the strong sensory input provided by the horses movement reinforces the riders corporal
coordination and motor reactions; and the additional teaching techniques of task analysis (breaking long tasks into shorter
segments) and the use of a strong proprioceptive input help to strengthen the riders posture in space and sequencing of
motor tasks.
An exhaustive search of the literature for experimental research into children with ADHD revealed only very few published
studies. That of Cuypers et al. (2011) described the results of a program of equestrian therapy on ve children with ADHD.
There was an improvement in the childrens quality of life, behavior and motor reactions, as reported by their parents and
teachers and by the children themselves. The parents reported an improvement in social contexts, although the children
themselves did not experience any change in their relationships with their peers. In Jang et al. (2015), a group of 20 children
had followed an equestrian therapy program consisting of 20 sessions. A set of variables related with the central symptoms
of ADHD, motor performance and brainwaves through an electroencephalogram were analyzed, and the conclusions stated
that the subjects achieved better social behavior, better manual skills and a reduction in the theta/beta brainwaves related
with ADHD, in addition to a clear reduction in the central symptoms of the disorder. Nevertheless, the authors did not include
a control group in their study.
On the other hand, Lee, Park, and Kim (2015) carried out one of the few studies that exist concerning therapies with horses.
In this work, they evaluate different objective, biological variables. These authors start from the basis that hippotherapy
implies physical activity on the part of the person doing it and that this activity can have a positive effect on the cognition of
those with ADHD. They found that, after 32 weeks of hippotherapy, the body fat of the experimental group of subjects had
been signicantly reduced, while the body fat of the control group subjects had increased. However, no signicant differences
were found in either the brain scans of the two groups or the neurotrophic factor, evaluated through blood samples. The
authors conclude that the evaluated hippotherapy program did not produce signicant changes in the variables related with
the cognitive functions associated with ADHD, so it may be that modications have to be introduced in order to achieve
greater effectiveness.
Despite the sparseness of publications on therapeutic equestrianism for children with ADHD, the effectiveness of such programs is beginning to be demonstrated in other populations, such as at-risk children and adolescents. For instance, McDonald
(2004) describes the results of ve programs carried out in the United States using horses as therapeutic co-facilitators and
enhancers of education in 126 at-risk children and adolescents, understanding as at risk those children and adolescents
with learning problems, behavioral disorders or mental health problems, aged 817 years, and who present a higher probability of developing emotional disorders during their lifetime. Although the joint evaluation of all ve programs yielded
no statistically signicant results, there were signicant ndings in some of the programs when evaluated individually.
Among the variables that beneted were self-esteem, internal locus of control, and a decrease in aggressiveness. Similarly,
Trotter, Chandler, Goodwin-Bond, and Casey (2008) evaluated the effectiveness of equine-assisted counseling in the same
population group, nding a statistically signicant improvement in 5 behavioral areas of the BASC and on the 3 scales of
the Behavior Assessment System for Children Self-Report of Personality (BASC-SRP). This suggested that equine-assisted
counseling is effective in enhancing social behaviors that are positive and in reducing those that are negative.
Based on our review of the literature, and given that there are very few papers of empirical research into the effectiveness
of equestrian therapy in children with ADHD (Busch et al., 2016), our main objective in the present study was to empirically
determine the effects of a program of equestrian therapy on different psychosocial variables in a group of pupils diagnosed
with ADHD.
The following hypotheses were proposed:

1) The program of equestrian therapy will have a positive impact on the ADHD pupils affective, social, and emotional sphere
(aggressiveness, hyperactivity, conduct problems, anxiety, depression, somatization, attention problems, atypicality,
withdrawal, adaptability, social skills).
2) The program of equestrian therapy will have a positive impact on some indicators of the ADHD pupils quality of life.

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2. Method
2.1. Participants
The initial sample consisted of 18 pupils aged from 7 to 14 years, of whom 12 were male (66.67%). In the population of
children with ADHD, the ratio is 3 boys for 1 girl (Staller & Faraone, 2006), so girls were over-represented in our sample.
The subjects were randomly assigned to the two groups. However, during the information gathering process, the volunteer
collaborators returned some questionnaires not fully completed, so the data from the study refers to 9 subjects in the
experimental group (mean age: 10.65 1.50) and 5 subjects in the control group (mean age: 10.20 2.38).
All of the participants had been diagnosed with ADHD through clinical diagnosis carried out by a neuro-pediatrician, in
accordance with the diagnostic criteria DSM-IV-TR (2000). We also took into account the fact that the symptoms should
be clearly recognizable in the school environment, through interviews with the tutors. We also asked them to inform us
of any change in the medication of the children during the period of the intervention; however, no parents informed us
of any such changes. In addition, a signed consent had been obtained from the childrens legal representatives, as well
as a medical certicate. All the participants resided in the Autonomous Community of Extremadura (Spain) and attended
different, ordinary schools in urban settings. No exclusion criteria were applied other than when there was some medical
condition that advised against the intervention.
2.2. Instruments
To evaluate the impact of the independent variable (intervention program) on the dependent variables in our study
(psychosocial variables and quality of life), the two instruments described in the following subsections were used.
2.2.1. Behavioral assessment system for children
For a complete and comprehensive evaluation of various psychosocial variables, we used the Behavioral Assessment
System for Children (BASC; Reynolds & Kamphaus, 1992) in its Spanish version, published by Gonzlez, Fernndez, Prez, and
Santamara (2004).
The BASC is a multi-dimensional and multi-method system that evaluates a number of variables in the social, adaptive, and clinical sphere. It is designed to be applied to children and adolescents aged from 3 to 18 years. It consists of
the following components: two assessment scales (one for parents and one for teachers), a self-rating personality scale, a
structured history of development and a pupil observation system. It also includes both positive (adaptive) and negative
(clinical) dimensions. The teacher-rating (BASC-T) questionnaires were used in this study. The scales measured by the BASCT are: aggressiveness, hyperactivity, conduct problems, anxiety, depression, somatization, attention problems, atypicality,
withdrawal, adaptability, leadership, social skills, learning problems and study skills. Each item was scored from A to D,
where A corresponds to never, B to sometimes, C t o frequently, and D to almost always. The scores are interpreted
in negative (clinical) dimensions as follows: T-scores between 40 and 60 are considered normal, between 60 and 70 are in
the risk range, and over 70 are clinically signicant. The scores are interpreted in positive (adaptive) dimensions as follows:
T-scores between 40 and 60 are considered normal, between 30 and 40 are in the risk range, and less than 30 are clinically
signicant.
According to Reynolds and Kamphaus (1992), each component of the BASC is individually a valid and reliable instrument.
The Spanish adaptation has similarly appropriate psychometric properties (Gonzlez et al., 2004). For reliability, it has high
internal consistency coefcients for all the scales, ranging from 0.70 to 0.80.
2.2.2. Quality-of-life questionnaire
An ad-hoc questionnaire was used to assess quality of life. This questionnaire was based on the model of Schalock
and Verdugo (2002) and was administered to the parents of both the experimental and control groups. It covers seven
of the models eight basic quality of life dimensions (physical wellbeing, emotional wellbeing, interpersonal relationships,
social inclusion, personal development, material wellbeing, and self-determination), with the indicators that were most
appropriate for our study. The eighth dimension of the model referring to the knowledge and exercise of human and legal
rights was excluded from the questionnaire since, because of the participants age, it was considered that the intervention
program would not have any effects on the said rights. To prepare and validate the instrument, inter-rater validation was
applied using a consensus procedure with a group of experts in the area of special educational needs. The indices of reliability
were acceptable, with = 0.641.
2.3. Procedure
Firstly, after obtaining the signed consent of the parents or teachers, the verbal consent of the participants, and a medical
certicate, participants were randomly allocated to control and experimental groups.
Secondly, the participants were evaluated by their teachers (BASC-T). Then, before beginning the sessions with horses,
two training sessions were held for the riding instructors who would participate in the program. In these sessions, the
main characteristics of children with ADHD were explained. Similarly, different sessions were scheduled with the parents

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and other collaborators, explaining the basic guidelines for handling horses and the prevention practices that were to be
observed at all times.
Thirdly, after these sessions, we proceeded to implement the intervention program.
2.4. Intervention program
The three-month intervention program consisted of twice-weekly sessions (a total of 24 sessions) of three-quarters of an
hour each, with groups of 4 pupils. The practical sessions in which the pupils of the experimental group participated were
held in the Monfrage Equestrian Centre of Cceres, which has over fteen years experience of training young riders.
Before the start of these contact sessions with a horse, two informative meetings were held with the monitors, in which
an ADHD specialist informed them of the subjects basic characteristics, what their needs are, and what aspects should
be taken into account when interacting with them. Similarly, another two informative meetings were held in which the
monitors informed the parents and other collaborators in the sessions about the basic characteristics of handling horses and
what preventive practices should be followed at all times.
After these initial informative meetings, the program sessions themselves were initiated. Each session consisted of three
phases, forming a continuum of the central riding activity. This pattern was based on that used by Bass, Duchowny and
Llabre (2009), which was designed and implemented by instructors with PATH International (Professional Association of
Therapeutic Horsemanship International, formerly NARHA) training.
1) The rst phase corresponded to activities prior to mounting preparing the equipment and the horse.
2) The second phase corresponded to mounting and riding. In the rst sessions, each pupil was helped by a monitor leading
the horse with a halter.
3) The third phase corresponded to learning to round off the work with the horse: dismount, bring in the horse, gather and
put away the equipment and say goodbye to horses and monitors.
During the intervention program, the participants of the control group did not attend the riding center, but went on with
their routine daily activities in the home, since the equestrian therapy sessions took place outside school hours. During this
period, neither the parents nor the professionals informed of signicant variations in any of the participants daily activities
from either group, such as therapeutic interventions under the psychologists and specialized educational support at the
schools. Once the intervention program had nished, the participants in the control group were invited to ride recreationally
for ve sessions with the riding instructors.
2.5. Data analysis
Both descriptive and inferential statistics were used to analyze the results. Non-parametric tests were used for the
hypothesis test due to the small sample size. To be precise, the Mann Whitney U test was used to study the intergroup
differences as a result of the intervention. The measurements of the size of the effect (Cohen d) were added, as the reduced
sample size made its use advisable. The interpretation of the results was subject to the commonly accepted values: a score
of less than 0.2 indicates no effect, a score of between 0.2 and 0.5 indicates a small effect, between 0.5 and 0.8 indicates a
moderate effect, while a score of over 0.8 indicates an ample effect. The statistical analyses were carried out using the SSPS,
version 19, applying a condence interval of 95%.
3. Results
3.1. BASC
Table 1 lists the results for each of the scales, comparing the pre-test and both the experimental and control groups. It
can be seen that there are no signicant differences between the two groups at the start of the intervention. Nevertheless,
the groups are not equivalent since the values at the outset for both groups are not equal, as can be seen in the magnitude
of the effect of the differences in some of the test dimensions.
Table 2 lists the results for each of the scales, comparing the post-test and both the experimental and control groups. As
can be seen, after the program, there are still no signicant differences between the groups.
Given that the groups are not equivalent, we have calculated the differences in the scores obtained by both groups
between the post-test and the pre-test, obtaining an indicator of the gain in each of the variables analyzed at the end of
the treatment. Table 3 shows that the effect of the treatment on the studied variables is, in all the dimensions, small or
unappreciable. A small deterioration can be seen in the clinical variables of both groups, those of the experimental group
being slightly less. That means that the intervention program permits a slight attenuation in the deterioration of the clinical
variables, but this effect is small. Furthermore, in the variables that measure the adjustment, there is a positive increment
in both groups, that of the experimental group being slightly larger. Nevertheless, the observed effect in these adjustment
variables as a whole is also small.

A. Garca-Gmez et al. / Research in Developmental Disabilities 59 (2016) 176185

181

Table 1
BASC-T pre-test: Control Group versus Experimental Group. Mann-Whitney test for two independent samples.
Variables Test

Test statistics

Clinical

M SD Experimental n = 9

M SD Control n = 5

sig

d Cohen

Aggressiveness
Hyperactivity
Conduct problems
Attention problems
Learning problems
Atypicality
Depression
Anxiety
Withdrawal
Somatization
Internalizing problems
Externalizing problems
School problems

54.89 14.62
59.22 12.97
56.22 18.90
59.89 11.23
59.33 12.83
67.78 23.31
62.67 14.27
56.67 12.35
55.00 11.43
58.11 14.77
61.78 15.08
57.33 15.85
60.44 15.85

57.00 15.65
54.40 10.09
54.60 10.92
58.00 12.02
55.80 9.47
59.60 15.24
53.60 15.35
50.20 11.64
63.60 21.22
47.20 5.93
50.60 11.12
56.20 12.55
57.20 10.33

20.5
18
30
20
19
18.5
14.5
16
16
10.5
12.5
22
18.5

0.26
0.60
0.33
0.33
0.46
0.53
0.10
0.88
0.87
0.16
0.13
0.06
0.53

0.78
0.54
0.73
0.73
0.63
0.59
0.28
0.37
0.38
0.10
0.18
0.94
0.59

0.14
0.32
0.18
0.17
0.25
0.29
0.05
0.48
0.87
0.08
0.07
0.03
0.28

Variables Test

Test Statistics

Adaptive

M SD Experimental

M SD Control

sig

d Cohen

Study skills
Social skills
Leadership
Adaptive skills

43.78 9.24
47.11 8.08
46.56 7.46
44.44 6.76

40.60 5.27
40.60 14.50
43.60 10.13
40.80 14.46

16
17
20
21

0.87
0.73
0.33
0.20

0.38
0.46
0.73
0.84

0.47
0.40
0.18
0.10

Table 2
BASC-T post-test: Control Group versus Experimental Group. Mann-Whitney test f for two independent samples.
Variables Test

Test statistics

Clinical

M SD Experimental n = 9

M SD Control n = 5

sig

d Cohen

Aggressiveness
Hyperactivity
Conduct problems
Attention problems
Learning problems
Atypicality
Depression
Anxiety
Withdrawal
Somatization
Internalizing problems
Externalizing problems
School problems

57.22 17.92
58.88 12.40
55.11 11.25
59.88 9.76
59.66 12.99
65.11 24.24
63.66 17.83
57.66 11.53
57.22 10.80
63.11 21.88
64.33 16.46
58.00 14.56
60.77 11.79

58.60 20.77
55.40 14.08
55.40 15.07
57.20 12.27
55.80 9.20
59.20 14.92
59.60 23.29
49.60 10.13
64.80 20.87
49.20 12.85
53.60 17.16
57.40 18.74
56.80 9.80

21.5
16.5
22
20.5
20.5
20
16.5
15.5
17
13.5
13.5
22
18

0.13
0.804
0.06
0.26
0.26
0.33
0.80
0.94
0.73
1.21
1.20
0.06
1.20

0.89
0.42
0.94
0.78
0.78
0.73
0.42
0.34
0.46
0.22
0.23
0.94
0.54

0.07
0.44
0.03
0.14
0.14
0.17
0.44
0.52
0.40
0.68
0.67
0.03
0.67

Variables Test

Test Statistics

Adaptive

M SD Experimental

M SD Control

sig

d Cohen

Study skills
Social skills
Leadership
Adaptive skills

45.55 10.53
49.44 10.54
49.00 5.38
48.00 8.20

42.60 6.30
41.80 14.28
45.20 9.95
43.00 13.45

13.5
17
17
16.5

1.20
0.73
0.74
0.80

0.22
0.46
0.45
0.42

0.68
0.40
0.40
0.43

A visual impression of the whole can be obtained from Fig. 1, which shows the lines of the pre-test and the post-test in
both groups. It can be seen that they are not equivalent, but that the lines of the tests are parallel in both groups.
Thus, given that there are no signicant differences and that the amplitude of the mean effects are also small, added to
the fact that the sample size is also small, it cannot be afrmed that our program of equestrian therapies has a signicant
and wide-ranging effect on the variables studied.

3.2. Quality of life


As can be seen in Table 4, the Mann-Whitney test for independent samples showed a signicant difference (p = 0.033)
between the experimental and control groups in the second dimension, corresponding to interpersonal relationships. However, no signicant differences were found in the other dimensions, either individually or in the total.

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Table 3
Analysis of the differences between the post-test less the pre-test of the experimental and control groups.
Variables

Test statistics

Clinical

Experi.group Postest pretest

Group control Postest pretest

Sig.

d Cohen

Aggressiveness
Hyperactivity
Conduct problems
Attention problems
Learning problems
Atypicality
Depression
Anxiety
Withdrawal
Somatization
Internalizing problems
Externalizing problems
School problems
Mean Clinical

2.33
0.33
1.11
0.00
0.33
2.66
1.00
1.00
2.22
5.00
2.55
0.66
0.33
0.87

1.60
1.00
0.80
0.80
0.00
0.40
6.00
0.60
1.20
2.00
3.00
1.20
0.40
1.12

0.20
0.67
0.06
0.33
0.54
0.94
0.75
0.53
0.53
0.06
0.06
0.06
0.06

0.84
0.50
0.94
0.73
0.58
0.34
0.45
0.59
0.59
0.94
0.94
0.94
0.94

0.10
0.36
0.03
0.17
0.29
0.52
0.40
0.29
0.29
0.03
0.03
0.03
0.03

Variables

Test statistics

Adaptive

Experi.group Postest - pretest

Group control Postest - pretest

Sig.

d Cohen

Study skills
Social skills
Leadership
Adaptive skills
Mean Adaptive

1.77
2.33
2.44
3.55
2.52

2.00
1.20
1.60
2.20
1.75

-0.47
-0.6
-0.06
-0.46

0.63
0.54
0.94
0.64

0.25
0.32
0.03
0.25

a
b

An increase in the value of the clinical variable means a worse outcome.


An increase in the value of the adaptive variable means a better outcome.

Fig. 1. Graphics with the scores of the pre-test and the post-test of both the experimental and control groups.

4. Discussion
The aim of this study was to determine the effects of an equestrian therapy program on a series of psychosocial variables
and the quality of life of a group of pupils diagnosed with ADHD.
We could nd no previous studies that have used the BASC battery to establish the efcacy of an equestrian therapy
program in children with ADHD. However, studies with other population groups, such as those of Trotter et al. (2008), who

A. Garca-Gmez et al. / Research in Developmental Disabilities 59 (2016) 176185

183

Table 4
Quality of life in the experimental group versus the control group: Mann-Whitney test for independent samples.
Dimensions

Sig.

d Cohen

Emotional well-being
Interpersonal relationships
Personal development
Physical well-being
Self-determination
Social inclusion
Familial well-being
Total quality-of-life

0.04
2.13
0.00
0.16
0.54
0.47
0.62
0.63

0.63
0.03*
1.00
0.87
0.58
0.63
0.53
0.52

0.02
1.38
0
0.08
0.29
0.25
0.25
0.34

applied an equine-assisted counseling program to children and adolescents at risk of social exclusion, found improvements
in several behavioral areas reported by the parents and the children themselves, as measured with the abovementioned
assessment tool. Nevertheless, this study used the scale for parents and the self-reporting scale for the children, but not the
scale for teachers. In our work, the scale for teachers does not show signicant differences as a consequence of the effect of
our program. In this sense, it is interesting to point out that some of the variables used with the BASC battery concern some
of the central symptoms of ADHD, such as hyperactivity or problems of attention and behavior.
One aspect of particular interest is that we have not found any effect on one of the central symptoms of ADHD: hyperactivity. In this sense, the positive effects that Cuypers et al. (2011) found after the application of a program of equestrian
therapy with ve ADHD children could be due to the fact that the children learnt appropriate behavior patterns in the tasks
they performed with the horses. In those tasks, they had to avoid impulsive, uncontrolled behavior, excessive activity, etc.,
which could endanger them. This established limits. In the study of Cuypers et al. (2011), however, the parents were present
during the hippotherapy sessions, and it was they who informed of a signicant reduction in this symptom. For their part,
the teachers did not observe important improvements. In our case, however, we have only considered the replies given by
the teachers. In this respect, it should be taken into account that it could be more complicated for the teachers to observe
gains, as they have to deal with several pupils at the same time, which makes it hard for them to observe individual pupils.
Another possibility is that the greatest effects are present immediately after the therapy, or that the children have difculties
in generalizing the newly learnt conduct in the hippotherapy sessions and extrapolating that conduct to different scenarios
or different people, such as the school context or the gure of the teacher. In any case, this lack of an impact on the central
symptoms of the disorder (in this case, the problems of inattention) is also supported by the work of Lee et al. (2015), in
which no signicant differences are found in the brain images of the regions related to the attention processes of a group of
subjects practicing hippotherapy.
As for quality of life, and unlike the ndings of Cuypers et al. (2011), our results did not show the therapy leading to
any improvement in the overall quality of life. This may reect the differences in the instruments used in the two studies.
However, in both our study and that of Cuypers et al. (2011), the parents reported an improvement in their childrens
social relationships. As noted above, difculties with peers constitute one of the main problems experienced by children
with ADHD. Trotter et al. (2008), in a study of children and adolescents at risk of social exclusion, found that working with
horses was effective in reducing negative social behaviors and enhancing those that are positive. We agree with Taylors
interpretation (cited by Corral & Fernndez, 2011), which stated that children see the horse as a social being, thus allowing
an easy generalization of behaviors learnt when interacting with the horse to their peer relationships. Another possible
explanation could be that indicated by Cuypers et al. (2011), who point out that it is the childrens self-condence and
self-esteem that are favoured after the therapy with horses, and that this would nally lead to a greater perception of
social skills by both parents and peers. In this sense, the hippotherapy provides the children with a sense of domination, as
they see themselves as being capable of handling such a large animal. This, in turn, could have a positive impact on their
self-condence and self-esteem. In addition, the horse is a social animal that responds to signs that are not perceived by
humans.
As for the limitations of our work; rstly, the sample size makes any extrapolation of the results difcult; secondly,
as previously pointed out, it is possible that the limitations of the BASC results could be because it was the teachers and
not the parents who were responsible for evaluating the improvements after the therapy. In fact, the parents did report a
signicant improvement in their childrens social relations in the questionnaire about quality of life. In any case, the results
could highlight certain difculties in generalizing the gains (if any should exist) to different contexts from those in which
the interventions took place. It would therefore be interesting to incorporate a series of activities aimed at transferring
what has been learnt, such as the establishment of routines that could later be incorporated into class work, training in selfinstruction during hippotherapy sessions, or even the incorporation, whenever possible, of elements characteristic of school
contexts (such as the teachers themselves or school work). Another interesting aspect could be to take various measures to
evaluate the impact of the programs, as it may not be immediately after the intervention when the greatest gains occur, but
following a process of assimilation on the childs part of the new ways to behave, or once the new behavior patterns had
been sufciently reinforced. In addition, the low number of questionnaires returned by the teachers of the control group
should be taken into account. This may have been because they did not observe any changes in their pupils over the time the
intervention lasted, or that the end of the intervention coincided with the end of the school year, a time when the teachers

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have a great many tasks to carry out. For future work, we would recommend carrying out a prior informative session to
make them aware of the importance of completing the questionnaires, or that the end of the therapy should not coincide
with the end of the school year.
To conclude, and in relation with the aims of our work, it could be pointed out that, although the effectiveness of the
therapy has been demonstrated for some symptoms of this disorder, such as hyperactivity (Cuypers et al., 2011), a better
social behavior, better manual skills, and a reduction in the theta/beta waves related to ADHD (Jang et al., 2015), other
works, such as our own or that of Lee et al. (2015), do not seem to point in that direction. Thus, more studies are needed to
support our results and to conrm the usefulness of the equestrian therapy as an instrument for improvement in students
diagnosed with ADHD. For the moment, it would seem that this activity could be recommended for this specic population
as a sporting activity that brings benets which are common to other physical activities of a low or medium intensity, but
that we are still far from being able to recommend it as a therapeutic activity.
5. Conclusions
This work analyses the inuence of an equestrian therapy program on different aspects related with the mental health,
emotional wellbeing and quality of life of students diagnosed as suffering from ADHD. The results do not show signicant
gains in the variables analysed, as perceived by teachers. On the other hand, the parents do report a moderate effect on the
childrens interpersonal relations. Thus, we are still far from being able to recommend it as a therapeutic activity aimed at
helping these children to lessen the difculties they experience in their daily lives.
Acknowledgments
This work was carried out between 2009 and 2013, and forms part of a broader, regional-scale, research project being
undertaken by the GRESPE Research Group in the University of Extremadura. The study was supported by FEDER funds
through the Regional Government of Extremadura for the research program PRI09A111.
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