# Equine-assisted therapy on autistic people

Equine-assisted therapy or equine-assisted therapy on autistic people is a therapy using a mediating horse or pony. A session can take place on foot or on horseback. Equine-assisted therapy is one of the few animal-assisted therapies regularly studied for its effectiveness, and the most popular of all autism therapies.
For a long time, the effect of contact with horses on people with autism has been known only in fragmented terms, through isolated testimonials, such as that of Temple Grandin, a doctor of zootechnics, in her autobiography Emergence: Labeled autistic in 1986. Equine-assisted therapy was popularized by the 2009 book and film The Horse Boy, in which the author describes her autistic son's progress during a trip to Mongolia. Since 2005, various studies have examined the effectiveness of this intervention, which was upgraded from "controversial" to "promising" status in 2007. As the application of equine-assisted therapy to autistic people is recent, these studies remain few and far between.
Equine-assisted therapy offers clinically significant reductions in disability in the areas of communication, perception, attention and emotion regulation. It increases volition, reduces hyperactivity and improves sensory integration in people with autism. In 2016, the scientific community agreed that it was the most effective animal-assisted therapy available to people with autism. Using an animal capable of responding to specific needs, it is not, however, suitable for all autistic people. Furthermore, the sessions are relatively expensive, and require considerable human resources.

## Definition

The horse is the pioneering animal in animal-assisted therapy, and by far the most widely used in this type of intervention. At the same time, equine-assisted therapy is the most popular animal-assisted therapy for autism.
This therapy is described and conceived as a form of care, and not as a leisure activity or learning to ride adapted to autistic people. Its aim is to provide therapeutic assistance. The horse becomes a mediator between the autistic person and the therapist. Ideally, an equine-assisted therapy session should be led by one or more trained therapists, with both solid equestrian skills and experience in supporting people with disabilities.

### Therapeutic areas concerned

Equine-assisted therapy acts on the neuromuscular, relational, perceptive, attentional and emotional levels. The horse stimulates various areas: communication (laughter, speech, etc.), relationships with others, motor behavior, attention, action planning, body awareness, self-confidence, relaxation, emotional regulation and sharing of emotions. The relationship with the horse is highly "sensorial", charged with scents, contact and a variety of sensations, making the equine-assisted therapy session a multi-sensory experience. The kinesthetic stimulation offered by the horse is unique among the animal therapies available to autistic people, since the horse (or pony) is the only mediating animal that can offer it.

### Relationship between horses and autistic people

French equine expert Isabelle Claude believes that the behavior of autistic people is close in some respects to that of the horse, notably in terms of sensory perception, tactile sensitivity, olfactory need and attention to details and micro-signals. She adds that, like the horse, the autistic person is accustomed to expressing their emotional states, particularly their anger. The ASBL Anthe-Anthesis (Belgian national association for therapy with horses) also likens the perception of autistic people to that of horses, in that both are situated in "the world of feeling".
Temple Grandin, an American university professor with autism, likens the behavior of an autistic child to that of a wild horse in the process of being tamed: the reaction to touch and the way in which they are approached are, in her view, very similar. Furthermore, in her book Animals in Translation, she compares the mode of consciousness and thought of animals to that of a so-called "learned" autistic person, asserting that spoken language is not necessary for thought, and that horses, among other animals, use a visual thinking similar to that of certain autistic people.
In her psychology thesis (Université Rennes-II, 2010), Marine Grandgeorge notes that autistic children are generally more spontaneously interested in images of animals, including horses, than in images of objects.

## History

Since the end of the 20th century, there have been consistent but isolated accounts of the benefits that autistic people derive from contact with horses. Temple Grandin testifies to having spent a great deal of time observing horses and cows since childhood. She started riding in the 1960s, realizing that these large animals are often mistreated out of ignorance. Riding and contact with horses calmed her anxieties and hyperactivity, and she testifies that galloping calms her. In France, several therapists work with autistic children using horses or ponies as mediators, including Isabelle Claude since the 1980s in Lorraine, Claudine Pelletier-Milet at her riding hall in La Chapelle-Montligeon since 1999, and Isabelle Chaveneau in Sevrey. In 1989, D. Athy described the case of a horse that had been retired from racing and taken in by a home for autistic children. By caring for and riding the animal, the children's symptoms diminished. At the same time, the horse regained its performance and began racing again, its winnings being used to finance the center, in particular the purchase of other therapy horses for autistic children.
American Hana May Brown publishes a testimonial about a non-verbal autistic child at her therapeutic riding center in Houston, who began to speak and made such progress that schooling became possible. Concordant testimonials led her to officially present horseback riding as a valid therapeutic option for autistic children in 1994. In 1995–1996, Charlotte Daubrée observed five children with autism as part of her veterinary doctorate thesis in Clermont-Ferrand. This work enabled her to observe real progress, but the numbers involved were far too small to draw any conclusions.

### Impact of The horse boy

In 2009, the autobiographical book The horse boy was published in the United States and this bestseller inspired a film. An American father, Rupert Isaacson, testifies that only contact with his old mare calms Rowan, his autistic son. He travels to Mongolia with Rowan, recounting how he establishes communication with his child through horses, travel and shamanism. Since then, he says, Rowan no longer "suffers from the dysfunctions associated with his disorder". The book has been translated into many languages, including French. It is a "convincing plea for equine-assisted therapy", and motivates parents to try this intervention. Isaacson does not use the word cure, but speaks of recovery and healing. Press coverage of the book and film raised the question of whether the company of a horse could help all autistic children. Since then, Isaacson has developed a method of helping autistic children through contact with horses, in Texas.
   "Several children have made capital progress during their passage, some even pronouncing their first words on horseback, to the amazement of their parents."
Commenting on the bestseller of The horse boy, pediatrician Paul A. Offit warns of the lack of studies on the effectiveness of contact with horses, and the temptation to spend large sums on ineffective, poorly supervised therapies.

### First scientific evaluations

In 2005, there was no scientific literature on this intervention, which meant that the scientific community was unable to comment on its effectiveness. In 2008, pediatrician Lisa A. Kurtz listed equine-assisted therapy as one of the "controversial" therapies, noting that some publications supported its efficacy as a complementary therapy. Similarly, in her thesis published in 2008, French veterinary surgeon Laurence Duval-Desnoes considers that "there is very little truly scientific evidence today to show the beneficial effects that an autistic person can derive from contact with an animal. It's more often a question of observations, of isolated facts".
The first scientific assessments of the autistic public were published in 2008 and 2009. According to an article published in The Guardian in February 2012, a growing number of health professionals are recognizing the effectiveness of equine-assisted therapy in helping people with autism. According to French child psychiatrist Dr Laurence Hameury, of the CHRU (Centre hospitalier régional universitaire by its extension in French) de Tours (2017), "therapies including animal mediation are currently in full development, and their benefits are recognized and validated by scientific studies evaluating the results".

## Accessibility and practices

In France, 79.7% of the 232 animal-assisted therapy structures listed in this country offered interventions with autistic children using horses or ponies, in 2014. In 2016, this intervention was described as booming in this country. In 2018, an Indian woman came to France for training to develop equine-assisted therapy with the autistic public in India.
In 2012, according to the French recommendations of the Haute Autorité de santé and the Agence nationale de l'évaluation et de la qualité des établissements et services sociaux et médico-sociaux (French national agency for the evaluation and quality of social and medico-social establishments and services) "activities carried out with animals cannot be considered, in the current state of knowledge, as therapeutic, but constitute practices that can participate in the personal and social development of certain children/adolescents with ASD, according to their centers of interest, if they benefit from specific support".

## Procedure

An equine-assisted therapy session can involve a variety of disorders or disabilities. There are also sessions entirely adapted to the special needs of autistic people. Claudine Pelletier-Milet finds that children's sessions with ponies take place in a joyful, relaxed atmosphere. These sessions can take place on foot or on horseback. The notion of equine-assisted therapy covers both types of intervention. Many autistic people are able to develop quite advanced riding skills during their sessions, so that the latter are often more akin to conventional riding lessons than therapeutic care. A session is also an opportunity to share knowledge about the horse.
According to Isabelle Claude, the sessions most often involve "deficit" autistic children (non-verbal or with numerous behavioral disorders), due to the high demand from families and health professionals, and much more rarely so-called Asperger's autistic people. American Linda Kohanov uses an "emotional message interpretation grid" when working with Asperger's adults. Claudine Pelletier-Milet encourages her patients to anchor themselves in the present moment, and to transcribe the emotions they feel into words.

### Walking sessions

Equine-assisted therapy sessions usually begin on foot, away from the animal. The autistic person then creates an emotional bridge with the animal by grooming and touching it. Sessions on foot are used to work on cognition, attention and social skills. Sandrine Willems recounts having witnessed a case where an autistic child unable to wash himself learned to do so, presumably by grooming his horse during the on-foot equine-assisted therapy sessions.

### Mounted sessions

During mounted sessions, the horse's movement is used to work on mobility. They can involve the therapist and up to three other people for individual intervention: one person to guide the horse, the therapist to move the rider and give instructions, and two people on the horse's sides to prevent falls resulting from loss of balance.

## Advantages and disadvantages

Animal-assisted therapy involves an animal that already shares a long history with human beings. Psycho-pedagogue Jean-Pierre Juhel recommends horses for all autistic people, including those diagnosed with Asperger's syndrome. While autistic children have difficult contact with peers and adults, they readily accept and seek contact with horses. The autistic person generally testifies to feeling a profound sense of well-being during these sessions. According to Amélie Tsaag Valren, the therapeutic setting is not compulsory to feel the benefits of horses. Tactile contact with these animals (or even their simple observation) can be enough to remedy the anxiety that autistic people often experience. On the other hand, France's EgaliTED collective is hostile to this intervention, which it classifies as "psychic care", calling it "a pony pompously renamed 'equine-assisted therapy".

### Advantages

According to Merope Pavlides, among autism interventions, equine-assisted therapy has many advantages and few disadvantages. The effectiveness of contact with the horse depends largely on its non-judgmental nature. The horse's presence creates a feeling of trust, whereas human relationships create stress, for fear of being judged. Therapist Claudine Pelletier-Milet believes that the horse's effectiveness as a therapeutic partner stems largely from the fact that it does not talk, is non-judgmental, non-intrusive or demanding: she describes it as a "simple, honest and consistent" animal. In their book on behavioral approaches to autism, Ron Leaf, John McEachin and Mitchell Taubman believe that "making contact with a massive animal, such as a horse, and maneuvering it successfully, brings a sense of self-actualization for the individual", although they add that there is a lack of data to back this up. The herd behavior of the horse means that these animals have a natural tendency to follow each other, which avoids having to hold them all the time. Temple Grandin focuses on the horse's movements, which create an imbalance that the autistic person has to compensate for, leading to work on body posture.
Laurence Duval-Desnoes points out that the size of the horse "makes it possible to work with subjects whose reactions are unpredictable, who may become violent and strike the animal; indeed, it is rare for a child or even an adult to hurt a horse with their bare hands", all the more so as the animals chosen for therapy are generally chosen for their calm temperament. She adds that the position of the horse's eyes, far apart from each other, can be reassuring for autistic people, who don't like to be approached and looked at head-on. The Belgian association Anthesis emphasizes the horse's ability to decipher body language, and its sensitivity to voice intonation. This constitutes "an important therapeutic potential for work with autistic children".

### Limits and disadvantages

Contact with horses does have its limits. Temple Grandin admits "painfully" that observing and then understanding how animals feel has not helped her to better understand human relationships. What's more, the attention to detail shown by non-deficit autistic people can lead to anger and even regression if a change is made in the course of the equine-assisted therapy session. Another difficulty lies in the cost of this intervention, which is one of the most expensive among the therapies offered to autistic people. In the United States, the cost is annually around $ 5 000 per person.
The very large size of a horse can cause anxiety for the person, "as soon as you have to approach it or ride on it". There is a risk of knocks, falls or wound infection when working with the animal, as well as a risk of allergy (frequent) or zoonosis (very few cases reported). In a few cases, the presence of the animal can generate human behavioral disorders: phobia, "excessive attachment", vulnerability to the animal's death. The horse itself may experience stress due to the behavioral inconsistencies of the person being cared for, or even be the victim of abuse.
In France, this practice is not regulated, the only registered profession being that of equine technician, and this can lead to abuse.

## Scientific evaluations of effectiveness

Standardized scientific evaluation of equine-assisted therapy applied to autism is hampered by the heterogeneity of Autism Spectrum Disorders, and the impossibility of evaluating sufficiently large samples due to material constraints. In addition, the studies carried out present methodological weaknesses. On the scale of scientific validation of complementary therapies for autism established by Gardner T. Umbarger in 2007, distinguishing between recommended, promising, emerging and non-recommended therapies, equine-assisted therapy is considered "promising", meaning that at least 4 studies of acceptable quality and 2 of high quality are evaluating its results. A review of the scientific literature was devoted to pet therapy for people with autism in 2012. It concluded that the results were unanimously positive, despite the studies' weaknesses, highlighting the need to pursue this research more rigorously.
The first evaluations were carried out on a wide range of disabled children. It wasn't until 2008 that the American Alexandra Dingman published the first study devoted to the specific case of autistic children brought into contact with horses. In 2009, 19 children with ASD and 15 control children were followed for 12 weeks. The conclusion was that "autistic children exposed to equine-assisted therapy showed greater sensory seeking, sensory sensitivity, social motivation, and less inattention, distraction, and sedentary behaviors". Research carried out on 16 children aged 2 to 14 receiving one session of horse therapy per week for 10 weeks, in Texas, led to "significant improvement" and the same conclusion, in 2010. A study published the same year involved 60 children followed for 20 weeks. They showed improved motor control and sensory integration.
In 2011, a study was published on 24 children with ASD, assessed using a global autism symptom severity scale. It concluded that these "results suggest that children with ASD benefit from assisted equestrian activities". In 2012, a preliminary study looked at 42 participants diagnosed with autism spectrum disorder, aged 6 to 16, during their 10 weekly lessons, along with 16 controls. They showed "significant improvements on measures of irritability, lethargy, stereotyped behaviors, hyperactivity, expressive language skills, motor skills, and motor and verbal planning skills", as well as "significant improvements in self-regulatory behaviors". The study suggests that these improvements are linked to equine-assisted therapy, and that the movement created by the animal leads to a positive effect on motor skills. In 2013, the American Occupational Therapy Association studied six children with ASD, aged 5 to 12, during 12 horse therapy sessions of 45 minutes each. It concludes that equine-assisted therapy has a positive influence on children with ASD, and can be a useful therapeutic tool for this population. Postural sway decreased significantly post-intervention. Significant improvements were also observed in global adaptive behaviors, leisure demand and social interactions.
Research conducted at the University of Washington in 2014 also concludes that equine-assisted therapy "can significantly improve balance, social responsiveness and other life events". To address the lack of comparative studies, 13 children with ASD participate in 9 weeks of equine-assisted therapy, and are compared to 12 children cared for by non-equine social programs. Parents noted significant physical, emotional and social improvement in their child after the first 6 weeks, superior to that of children participating in the non-equine program.
A study of six children in Joué-lès-Tours, France, found "clear improvement from the very first session" in communication, development, and motor, emotional and perceptual regulation. The children seemed calmed, became aware of the effect of their actions on the pony, and sought interaction. A 16-week program investigated the willingness of three autistic children, revealing an increase in willingness over time. This preliminary evidence shows that "improved willpower may be an important and underestimated benefit of equine-assisted therapy for children with autism". The potential of horse therapy for women may also be underestimated, as many girls and women with Asperger's have horses as a special area of interest, but are deterred from riding in a riding hall because of social relationships with other girls or teenagers. Indeed, riding is notoriously more popular with girls, who are more interested in contact with animals than boys.
In 2016, according to a review of the available scientific literature, there is a consensus that equine-assisted therapy is the most useful animal therapy for people with autism.
Equine-assisted therapy may not be effective for all people with autism. In a study of four children in Bosnia-Herzegovina, only two experienced positive effects. Similarly, in the areas of fine motor skills, social cognition and social awareness, research has so far (2011) shown no significant results.