Piloting an Enhanced Protocol of Occupational Therapy in an Equine Environment for Youth With Autism
Condition: Autism Spectrum Disorder
MeSH terms: Autistic Disorder; Autism Spectrum Disorder
Study type: Interventional

Summary: 
      The purpose of this study is to learn about occupational therapy for youth with autism in a
      traditional clinic environment, and in an equine environment. 20 youth with autism will
      participate in 10 weeks of occupational therapy in a clinic environment, followed by 10 weeks
      of occupational therapy in an equine environment. Caregivers will complete online surveys
      about their child's behavior. Occupational therapists and other stakeholders will provide
      feedback about the interventions. The therapy sessions that involve horses will be
      videotaped, and a researcher will look at the behaviors of the horses involved in the
      intervention. We will use the results of this study to improve the quality of both
      interventions.
    

Detailed description: 
      The purpose of this study is to assess the feasibility, acceptability, and preliminary
      efficacy of occupational therapy in an equine environment (OTEE) for youth with autism. As a
      feasibility study, this study aims to accomplish several key development tasks. Specifically,
      this study aims to:

        1. Create a safe, feasible, and manualized control group that controls for non-animal
           critical elements of the OTEE intervention

        2. Assess welfare of the therapy horses that are integrated into the OTEE intervention

        3. Enhance the OTEE manual by increasing standardization, while still allowing for
           individualization

      Design. We will implement a longitudinal design, where caregivers will complete outcomes
      measures at 1)pre-test, 2) after their child participates in 10 weeks of occupational therapy
      in a clinic environment and 3) after 10 weeks of occupational therapy in an equine
      environment.

      Participants. Youth with ASD will be screened for inclusion in a 2-part process that includes
      1) an online survey and 2) virtual screening visit using Microsoft Teams. After completing 10
      weeks of occupational therapy in a clinic environment, youth will then participate in an
      additional screening visit and re-evaluation for OTEE to ensure they a) are able to mount and
      ride a horse (with assistance) for 10 minutes while following safety rules, and b) meet all
      PATH Intl criteria for participation in equine-assisted services. Twenty youth with autism
      and their caregivers will be enrolled in the study. Occupational therapists that deliver the
      interventions and other stakeholders (i.e. program coordinators, etc.) will also be asked to
      be research participants.

      Occupational Therapy Evaluation. Each youth and caregiver will participate in an occupational
      therapy evaluation at Temple Grandin Equine Center (or virtually, depending on COVID
      guidelines in 2021) that include an occupational profile, semi-structured interview, social
      skills checklist, and collaborative goal setting. Therapists and caregivers will jointly
      determine three goals for each youth with autism in the domains of self-regulation, social
      communication, or social play.

      Occupational Therapy in a Clinic (Control Group). The occupational therapy in a clinic
      environment will occur at Temple Grandin Equine Center on CSU's foothills campus. We will
      recruit occupational therapists to deliver the intervention who a) are licensed and
      registered occupational therapists, and b) have at least 1-year of experience providing
      occupational therapy to youth with autism. Included therapists will receive 5 hours of
      training before each 10-week intervention session, as well as participate in 1-hour case
      conferences every other week throughout the 10 week intervention session.

      Youth with autism will be paired into dyads based on social communication and self-regulation
      abilities. Dyads will attend 10 weekly 60-minute sessions of occupational therapy that follow
      a general structure: greeting, activities in a play room, parent debrief, and goodbyes.
      Therapists will design intervention activities based on the following critical elements:
      direct instruction of goal behavior; activities in the playroom that elicit the goal
      behavior; positive reinforcement of goal behaviors; use of behavioral techniques to scaffold
      goal performance.

      Hearts and Horses Screening Visit and Re-evaluation. Each youth will attend an additional
      screening visit for the second portion of the study, to ensure they can safely ride a horse
      with assistance and meet all medical and behavioral standards set forth by PATH Intl for
      participation in equine-assisted services. Caregivers will be asked to bring the Hearts and
      Horse enrollment packet, that includes physician signature that the youth can ride a horse.
      Then, youth will ride a horse for 15 minutes. Finally, caregivers and youth will participate
      in re-evaluations with an occupational therapist, to update or set new goals for 10 weeks of
      OTEE.

      OTEE Intervention (Intervention group). The OTEE intervention will occur at Hearts and Horses
      Therapeutic Riding Center. The occupational therapists who will deliver the intervention are
      licensed and registered, have completed training by the American Hippotherapy Association,
      are PATH Intl registered instructors, and have experience delivering occupational therapy in
      an equine environment to youth with autism. Included therapists will receive 5 hours of
      training before each 10-week intervention session, as well as participate in 1-hour case
      conferences every other week throughout the 10-week intervention session.

      Youth with autism will be paired into dyads based on social communication and self-regulation
      abilities. Dyads will attend 10 weekly 60-minute sessions of OTEE. Sessions follow a general
      structure: greetings, activities with horses, parent debrief, goodbyes. Therapists design
      intervention activities based on these critical elements: a) incorporation of horses to
      optimize attention and engagement (includes use of equine movement to facilitate optimal
      arousal) b) direct instruction of goal behavior, c) activities with horses that elicit the
      goal behavior, d) positive reinforcement of goal behaviors, and e) use of behavioral
      techniques to scaffold goal performance.

      Equine Welfare. OTEE sessions will be videotaped. Noldus software will be used to analyze
      equine behaviors using an applied ethogram, a behavioral scoring system in horses
      incorporated in equine-assisted services that determines the presence or absence of stress.

      Fidelity. Dr. Peters will rate the fidelity of 25% of intervention and control sessions.
      Therapists will also provide self-ratings of fidelity for 20% of intervention and control
      sessions.

      Outcome Measures. All youth/caregiver outcome measures will be collected three times: once
      before occupational therapy in a clinic environment, once before OTEE, and once after OTEE.
      Caregivers will be asked to complete online surveys that include the following assessments:
      Aberrant Behavior Checklist- Community (ABC-C) irritability and hyperactivity sub-scales,
      Social Responsiveness Scale Second Edition (SRS-2), Pediatric Evaluation of Disability
      Inventory Computer Adaptive Test for Autism Spectrum Disorders (PEDICAT-ASD), Emotional
      Dysregulation Inventory (EDI), and World Health Organization Quality of Life- Brief
      (WHOQOL-Brief). After each 10-week session, an occupational therapist blinded to treatment
      condition will call each caregiver and conduct a semi-structured interview in order to rate
      the child's performance on occupational performance goals using goal attainment scaling
      methods.

      Therapists will be asked to fill out feedback forms every other week during case conferences,
      to gather immediate feedback on intervention delivery. After the evaluations/re-evaluations,
      therapists will be asked to complete a short survey about the feasibility and acceptability
      of the evaluations. At the conclusion of each 10-week session, therapists and other
      stakeholders (i.e. program coordinator, etc.) will be asked to complete short surveys about
      intervention acceptability, as well as attend a 1-hour audiotaped focus group to gather
      feedback on the intervention manual.

      Data Analysis. To assess feasibility and acceptability, we will calculate rates of
      attendance, attrition, fidelity, assessment completion, safety events, and satisfaction. We
      will conduct content analysis of focus group and feedback form data to inform intervention
      and control manual revisions. Preliminary efficacy will be assessed using appropriate
      parametric or non-parametric statistics.
    

Intervention name(s): Occupational Therapy in an Equine Environment; Occupational Therapy in a Clinic (OTC)
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 10 weeks of occupational therapy in an equine environment aimed at improving individual goals related to self-regulation, social communication, and play; 10 weeks of occupational therapy in a clinic aimed at improving individual goals related to self-regulation, social communication, and play
Other intervention name(s): OTEE-HORSPLAY
Intervention model: Single Group Assignment
Intervention model description: All participants will receive 10 weeks of occupational therapy in a clinic, followed by occupational therapy in an equine environment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: occupational therapy; equine-assisted services; hippotherapy