Equine Assisted Occupational Therapy for Children with Adhd (Astride): Protocol Development and Preliminary Study

Abstract

Objective

Children with Attention Deficit Hyperactivity Disorder (ADHD) are often referred to Equine-Assisted Services (EAS) for therapy despite lack of validated protocols in the field. This paper reports the development and validation of ASTride (ADHD Skills Therapy): a protocol of Equine-Assisted Occupational Therapy (EAOT) intervention for children aged 6-12 with ADHD. The intervention addresses deficits in cognitive-emotional functions and participation.

Method

Phase one of the intervention development includes theoretical framework and core content based on an in-depth review of existing literature. Subsequently, the intervention protocol was revised by a panel of experts. Phase two includes a pilot study, during which five children diagnosed with ADHD (mean age= 10.40 year, SD 2.966) participated in a 12-week EAOT intervention according to the suggested protocol, with pre- and post-assessments conducted.

Results

Statistically significant improvements were found in executive functions, as reflected in the Behavioral Regulation Index (BRI) total score. Additionally, hope perception and everyday performance improved following the intervention.

Conclusions

Results support the feasibility of ASTride intervention protocol for the improvement of cognitive and emotional functions as well as everyday performance.

Background

Empirical evidence and evidence-based research are fundamental for the validation of clinical practice and promotion of intervention protocols and manuals (Carroll et al., 2002). Though intervention protocols are criticized for limiting therapist flexibility during intervention, they enable a systematic evaluation of therapeutic interventions (Pyatak et al., 2015). To be accepted into clinical practice, an intervention protocol must be well written, valid and reliable.

Carroll et al (2002) suggested viewing a protocol's development as a series of progressive stages where each stage contributes to the next. The use of different stages for protocol development enables the transition of an idea for an intervention into a valid and effective intervention which includes guidelines for practice. Stage one of manual development encompasses intervention techniques, goals, structure, format, a pilot or feasibility test, initial writing, and outcome measures. Stage two consists of controlled clinical trials to evaluate efficacy and differentiate between the proposed intervention protocol and other approaches. Stage three entails studies aimed at integrating the intervention into clinical practice, taking into account therapist training, cost-effectiveness, and its applicability in various settings and formats (Carroll et al., 2002; Pyatak et al., 2015). This article describes the process of developing an Equine-Assisted Occupational Therapy (EAOT) intervention for children aged 6-12 with Attention Deficit Hyperactivity Disorder (ADHD), including Phase 1 and 2, with a planned phase 3 for future research.

ADHD is one of the most common pediatric neurodevelopmental diagnoses. In the United States, approximately 6.4 million children aged 3-17 were diagnosed with ADHD in 2022, with boys experiencing a nearly twofold greater prevalence than girls (The National Survey of Children’s Health, 2023). ADHD is characterized by the presence of inattention, hyperactivity and impulsivity, as well as developmental and chronic impairment of executive functions (EFs) and psychosocial, emotional, and sensory-motor deficits (American Psychiatric Asociation, 2013). Considering the numerous challenges, individuals may also experience reduced participation and difficulties in performing a wide range of daily tasks. Participation is an important part of human development and is defined as involvement in life situations (World Health Organization, 2001). Through participation, we acquire skills and competencies, connect with others in our communities and find purpose and meaning in life. Participation is often used as an outcome measure in Occupational Therapy (OT) practice (Law, 2002). To enable a child with ADHD to participate satisfactorily, treatment must address factors that hinder performance. Occupational therapists focus on assisting individuals in achieving goals in functional activities. OT interventions use everyday life activities, also known as occupations, to promote health and well-being, and enhance participation. This includes involvement in meaningful activities across diferent life domains (AOTA, 2020).

Successful OT interventions for children with ADHD are client-centered and occupation-based. They focus on personal functional goals and include strategy acquisition (Hahn-Markowitz et al., 2017). Although conventional OT approaches show substantial evidence for improving EFs and functional/ academic skills, they do not address psychological dificulties. Conversely, psychological interventions, such as behavioral programs, psychoeducation for parents, and expressive therapies, are not occupation based and do not address strategy acquisition (Pelham & Fabiano, 2008). Existing interventions improve core symptoms, EFs, everyday functions, or emotional symptoms. However, they seldom address the multiple aspects and complexities of ADHD (Hahn-Markowitz et al., 2020). Therefore, an intervention that can incorporate all these elements is imperative.

Equine-Assisted Services (EAS) and EAOT

The inclusion of animals in interventions for the enhancement of human health, quality of life and participation is an increasingly popular practice. This practice is known as animal-assisted intervention (AAI). AAI is a form of therapy that involves employment of an animal as the fundamental part of a person’s treatment (Kruger & Serpell, 2010). In AAI animals are used as a proxy to promote changes in an individual’s physiological, cognitive, and sociological characteristics (Bass et al., 2009).

Equine-Assisted Services (EAS) are a variety of multimodal and complex activities and therapies designed for the achievement of therapeutic goals through interaction of clients with equines. These interventions vary based on therapeutic goals and therapy provider (Wood et al., 2021). EAOT, a therapy division of EAS, integrates OT approaches with equine surroundings, utilizing the horse as a therapy partner.

Practical and theoretical Approaches incorporated in the intervention protocol

ASTride (ADHD Skills Therapy) intervention is based on the Multi-context approach (Toglia & Katz, 2011), the Cognitive Orientation to Daily Occupation Performance approach (CO-OP) (Polatajko et al., 2001) and Sensory Integration (SI( theory and approach (Ayres, 1972). These OT approaches are used in cognitive rehabilitation and remediation of EF impairments.

The Multi-context approach to cognitive rehabilitation proposes methods for teaching use of strategies across a wide range of meaningful activities, to promote generalization and enhance functional performance. The approach emphasizes the need to directly and explicitly ‘train for transfer’ and the key elements include (a) a focus on strategy, self-generation and training; (b) practice across multiple contexts, and structuring intervention activities so that physical similarity is gradually decreased along a horizontal continuum; (c) an emphasis on metacognitive training; and (d) use of everyday activities that are tailored to a person’s “just right challenge.” Treatment activities are structured to place gradual demands on the ability to apply a strategy to diferent situations, addressing the person, activity, and environment to facilitate performance (Toglia & Katz, 2011).

The CO-OP is a client-centered, performance-based and problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery while placing emphasis on generalization of the acquired skills. It teaches the global strategy Goal-Plan-Do-Check (Polatajko et al., 2001). Basic riding skills such as walking, halting and using reins are implemented using this strategy. Both the Multi-context and the COOP approaches use enabling principles and strategy acquirement. The strategies include the use of extrinsic reinforcements, direct teaching techniques, visuals to supplement task knowledge, decision making through modeling, prompting using physical cues, chaining to learn a sequence of skills, and fading to work toward independence (Halayko et al., 2016). These strategies are incorporated in the EAOT intervention and are used to teach basic riding skills according to each rider's ability. These acquired strategies are transferred to everyday performance after mutual consideration of how they may be transferred and used in everyday activities according to each rider's goals (see examples in table 2).

Table 2.

Intervention protocol

Number of Session and Aim	Means	Session structure	Home assignments
1 Acquaintance with the rider and parents		Baseline assessment and goal setting using the COPM. Introducing the stable environment and the horse, administering safety rules and regulation regarding horse and child. *At the end of each session, EAOT practitioner fills clinical notes regarding each session
2 Acquaintance between rider and horse First riding session	Grooming the horse, tacking and riding it; showering the horse; cleaning stalls; caring for cuts/ wounds.	Discuss the child's functional goals and intervention priorities. Teaching of the global Goal-Plan-Do-Check strategy through basic riding skills: halt, walk, and trot. The child is prompted to verbalize what they want to do (goal), how they’re going to do it (plan), then perform the activity (do). Subsequently, they learn to review and assess their performance (check). Summary of session: review how the global strategy aligns with the child's functional goals.	* In lessons 2-3, child will receive homework assignments. For example: identify one or two activities suitable for practicing the Goal-Plan-Do-Check strategy (doing homework etc.)
3 Basic riding skills acquisition, beginning to work on functional goals.	Grooming the horse, tacking and riding it; showering the horse; cleaning stalls; caring for cuts/ wounds.	Warm up: Choosing the first functional goal. Learning specific strategies according to the specific goal. For example: horse tack is arranged before the session using a checklist to ensure all necessary equipment is present for mounting and riding the horse.	Implementing an inhibition strategy during class when it's not the child's turn to answer the teacher's questions; independently organizing a school backpack with all necessary equipment using a written or pictorial list; employing a calming strategy (such as using a picture, song, or practicing breathing exercises) when feeling angry at home; completing homework assignments while utilizing a checking strategy; and utilizing a fidget or a bouncy band while in class.

The third theoretical model relies on sensory based principles such as the model of SI. SI theory was developed by A. Jean Ayres (1972) as a neurophysiological approach based on the association between sensory processing and behavior. Sensory processing is defined as the capacity of the central nervous system to regulate and organize the degree, intensity, and nature of an individual's responses to sensory input in a graded and adaptive manner (Miller & Lane, 2000). The sensory systems include the somatosensory, visual, auditory, olfactory, gustatory, vestibular, proprioceptive (James et al., 2011), and interoceptive systems (Mahler, 2015). Impaired sensory processing can result in various learning, developmental, or emotional problems, as well as other disabilities (Ayres, 1972). Sensory based principles focus on sensory input and its continual interaction with motion. Thus, sensory integration plays an important role in EAOT, as riding provides various sensory input, sensory and tactile stimulation, continual motion and subsequent vestibular stimulation (Bracher, 2000).

To date, there are no EAS evidence-based protocols for children with ADHD, despite practitioners’ common referral of these children to EAS. Moreover, no protocol of EAOT for children with ADHD exists, despite preliminary evidence indicating the feasibility of EAOT for children with ADHD. Current evidence discusses the immediate feedback the rider receives from the horse while riding: facilitation of physical and mental self-regulation (Bass et al., 2009; Borgi et al., 2016; So et al., 2017), increased sense of confidence and self-control, and decreased anxiety (Fine, 2019) along with a decrease in other negative emotional symptoms (Bracher, 2000). The horse's movement is found to provide sensory-motor stimuli, thus potentially improving sensory integration (Engel, 1984).

Studies on EAS and ADHD vary significantly in sample size, variables, measurements, session duration, and procedure. Some studies include groundwork, while others focus solely on horseback riding. Despite this heterogeneity, research suggests that 8-32 sessions may lead to a reduction in ADHD symptoms, such as hyperactivity and impulsivity, as well as positively affecting therapeutic relationships, and improving physical, cognitive, social, and emotional functions (Pérez-Gómez et al., 2020). Positive effects of EAS have also been found in domains of body structures and functions, activity, participation, and quality of life (Helmer et al., 2021). Scarce evidence exists for EAOT interventions with ADHD populations, and no current intervention protocol have been found (Helmer and Gilboa, 2021; Pérez-Gómez et al., 2020). Therefore, this paper outlines the process of developing an EAOT intervention for children aged 6-12 with ADHD. Stage 1 and 2 are described, including literature review and manual writing in stage 1, and a feasibility study for implementing the intervention protocol in stage 2.

Method

First validity stage of manual Development – Content

Stage 1 included the development and validation of ASTride−an EAOT intervention program. A literature review including literature for EAS regarding the ADHD population was conducted, as well as a review of theoretical models and frameworks−including the Multi-context approach (Toglia & Katz, 2011), the CO-OP (Polatajko et al., 2001) and SI based principles (Ayres, 1972). The ASTride intervention protocol development was based on literature review and clinical experience. The SPIRIT checklist (2013) was used to ensure complete reporting and transparency (Chan et al., 2013).

Content using an validity experts’ of focus the group intervention protocol

After initial development of ASTride, the intervention protocol was sent to a focus group for feedback. Four OTs specializing in ADHD treatment and four EAS professionals (“experts”) participated in a focus group. OTs were all researchers in the field with a PhD degree in OT with 15-20 years of experience. EAS professionals were all trained as both riding instructors and therapeutic riding instructors with 10-15 years of experience. The focus group reviewed the preliminary intervention protocol and were asked for input regarding the theoretical framework and the intervention’s structure and delivery, including theoretical framework and guidelines for intervention. The review process included 20 questions on a Likert scale from 1 (strongly disagree) to 10 (strongly agree) as well as open questions with suggestions for improvement and comments (see table 1). After receiving the feedback, an analysis of the information was conducted. Intra class correlation coefficient (ICC) test (α =.776). The experts commented on the protocol and requested further examples to better understand the intervention. The intervention protocol was updated accordingly, and more examples were provided. After reviewing the changes, the experts filled the feedback form and ICC test was performed a second time. Alpha Cronbach for agreement level between experts (α =.851) indicated a high level of agreement.

Table 1.

Questions regarding the protocol for expert group assessment

Question number	Subject	Question	Likert scale
1	Intervention structure	To what extent do you agree with the intervention structure?	1 2 3 4 5
2		To what extent do you agree with the intervention sessions length?	1 2 3 4 5
3	Chosen intervention models	To what extent is using the CO-OP model appropriate?	1 2 3 4 5
4		To what extent is using the SI model appropriate?	1 2 3 4 5
5		To what extent is using the Multicontext model appropriate?	1 2 3 4 5
6	To what extent is the use of each of the following 12 core principles adequate?	Develop awareness to difficulties while riding/working with the horse	1 2 3 4 5
7		Teach executive strategies and transfer from stable to relevant surrounding	1 2 3 4 5
8		Identify a problem and practice problem solving while riding	1 2 3 4 5
9		Reflect the mutual interaction with the horse and transfer the knowledge to interpersonal relationships	1 2 3 4 5
10		Emotional discourse, identify and understand emotions	1 2 3 4 5
11		Promote responsibility by taking care of the horse (ensure that he is fed and clean),	1 2 3 4 5
12		Learn from success (analyze the steps that led to success at the stable and home environment)	1 2 3 4 5
13		Provide vestibular, somatosensory and proprioceptive stimulation while riding the horse	1 2 3 4 5
14		Practice praxis and movement planning (e.g. how to use hand and counter leg simultaneously)	1 2 3 4 5
15		Provide physical activity, releasing endorphins	1 2 3 4 5
16		Promote independence while riding (decreasing verbal instructions gradually)	1 2 3 4 5
17		Exposure to a diverse environment and promote adaptation	1 2 3 4 5
18	To what extent are these questions relevant at the beginning of each session?	From 1-10 how much did you anticipate coming to the session today (1-did not anticipate at all, 10-highly anticipated)	1 2 3 4 5
19		From 1-10, how much progress do you feel you have made (1-no progress at all, 10-the most progress)	1 2 3 4 5
20		To what extent did you enjoy the lesson today? (1-did not enjoy, 10-enjoed the most).	1 2 3 4 5
21	Open questions	Is the protocol clear enough? If not please elaborate	1 2 3 4 5
22		Please indicate three strengths of the protocol
23			Please identify any weaknesses in the protocol and, if possible, provide suggestions for improvement

The proposed ASTride intervention protocol

After analyzing and referring to the feedback for manualizing the ASTride intervention protocol, the following core principles were agreed upon: (1) helping the child develop awareness to difficulties while riding or working with the horse, using guided discovery; (2) teaching and acquiring executive strategies and transferring learned strategies with parental guidance, from the stable to relevant surrounding; (3) identifying a problem and practicing problem-solving; (4) reflecting on the mutual interaction with the horse, understanding that actions affect the horse and vice versa, and transferring that knowledge to interpersonal relationships; (5) engaging in emotional discourse, identifying and understanding emotions; (6) promoting responsibility and care for the horse (ensuring proper grooming and feeding) to foster and improve responsibility; (7) learning from success (analyzing the steps that led to success); (8) providing vestibular, somatosensory, and proprioceptive stimulation while riding the horse; (9) practicing praxis and movement planning (e.g. how to use hand and counter leg simultaneously); (10) engaging in physical activity to release endorphins; (11) promoting independence while riding and gradually reucing verbal instructions; (12) exposing the child to a diverse environment and promoting adaptation to various smells, textures of different horses, and materials such as hay and grain.

The ASTride intervention includes 12 weekly 45-minute sessions conducted by a certified professional. Each treatment session follows a defined structure that includes setting of riding goals; acquaintance with the horse; tacking and preparing for mounting; warm up; and acquisition and practice of skills and strategy and session summary. The summary includes a "planning phase" where the functional goal and its implementation in various environments (home, school, after school curriculum) is discussed. The planning phase takes place with the participaion of the parents and the child, during which decisions are made regarding how and where the goal will be practiced. For example, if the learned strategy involves using a list for preparing the horse, the home assignment might involve preparing and following a list for getting ready in the morning. Parents are guided on how to support and facilitate these assignments (e.g., visual reminders or specific strategies). Consistency is emphasized, requiring that the same parent, or both parents, attend all sessions to facilitate learning and transfer. At the end of each session, the EAOT professional documents the session and completes clinical notes regarding the session. In addition, three questions are presented to the participant:

1. From 1-10 how much did you anticipate coming to the session today (1-did not anticipate at all, 10-highly anticipated).

2. From 1-10, how much progress do you feel you have made (1-no progress at all, 10-the most progress).

3. From 1-10, to what extent did you enjoy the lesson today? (1-did not enjoy, 10-highly enjoyed).

In ASTride, functional goals measuring occupational performance are discussed and trained during the sessions using learned strategies. Participants are intially taught a global problem-solving strategy− inspired by the CO-OP approach−for strategy and skill acquisition. Tis global strategy can then be applied when the therapist is not present (e.g., at home) to support improvement in occupational performance. The intervention is designed for one-on-one instruction and allows for flexibility to meet each participant's needs, with the aim of gradually reducing instruction and increasing independence over time. It is assumed that as independence increases, participants will be able to implement learned strategies and transfer their skills to other environments. An example of a 12-week intervention process is described in table 2. A full manual of the intervention can be obtained from the authors.

Second Development stage of – Predictive intervention validity protocol

Participants

The second stage aimed to examine the efficacy of the ASTride intervention among children aged 6-12 years with ADHD through a feasibility study. The study comprised of a convenience sample of 5 participants (mean age= 10.40 years, SD 2.96) diagnosed with ADHD by a pediatric neurologist (See table 3). Seven participants were approached and two declined due to scheduling issues. Participants were referred to EAS at Yehuda Mountain stable, Israel, and underwent 12 weeks of EAOT intervention according to the ASTride intervention protocol. Inclusion criteria included: (1) children between 6 and 12 years of age; (2) diagnosis of ADHD from a medical professional based on DSM-5 criteria, with or without medication (e.g., psychostimulant medication); (3) general doctors' approval and referral for participation in EAS. Exclusion criteria included: (1) moderate to severe cognitive impairment; (2) neurological disorders (e.g., epilepsy); (3) children with additional developmental disorders (e.g., Autism, Cerebral Palsy); (4) children who will begin new medication treatment or change existing treatment during intervention; (5) children with severe sensory loss (e.g., blindness).

Table 3.

Sociodemographic Participant Characteristics

Participants
n (%)		Characteristic
		Gender
4 (80)		Male
1 (20)		Female
		Medication
3 (60)		Yes
2 (40)		No
		Residency
1 (20)		City
3 (60)		Community
1 (20)		Town
Range	M (SD)
6-13	10 (2.96)	Age (in years)
35-43	38 (2.94)	Mother Age (year)
36-43	39 (3)	Father Age, (year)
15-20	17 (1.94)	Mother education, (year)
12-24	15 (5.19)	Father education, (year)

Note. N=5. Participants were on average 10.40 years old (SD=2.96) M=mean; SD=standard deviation

Procedure

After obtaining ethical approval from Tel-Aviv university IRB ethical committee (number 0003949-3), relevant participants were approached to participate in the study. Once the consent form was signed by child and parents, participants were asked to complete a baseline assessment which included the The Tower of Hanoi Test (TOH) (Lezak et al., 2004), the Behavior Rating Inventory of Executive Function (BRIEF), the Hebrew adaptation of The Children’s Hope Scale (Law, 2002; Snyder, 2002; Snyder et al., 1997), the Child Performance Skill Questionnaire (PSQ) (Bart et al., 2010) and the Canadian Occupational Performance Measure (COPM) (Law et al., 2014). After the baseline assessment, participants went through 12 weeks of EAOT intervention according to the ASTride intervention protocol. At the end of the intervention, participants completed a post-intervention assessment which included all the measures used in the pre-intervention assessment. Assessments were administered by a research assistant blinded to the participant’s stage in the intervention.

Measures

EFs

The Tower of Hanoi Test (TOH) (Lezak et al., 2004) was used to assess EFs. The test requires moving differently sized disks across three pegs according to a picture depicting the goal layout, aiming to do so as quickly and with as few moves as possible. The TOH is a non-verbal spatial perception test that measures EFs. It requires generation of a multistep sequence of moves and strategy selection while inhibiting incorrect moves (Ahonniska et al., 2000). The TOH test has been used with children and teenagers to assess EFs (Tottori et al., 2019) as well as with children with ADHD. It comprises two scales; (a) Duration of completion of the assignment and (b) Number of moves performed in order to complete the assignment. Test-retest reliability was reported as .81 for the total score (Ahonniska et al., 2000). In this study, the measurement scales included the number of moves and the time taken by participants to complete the test.

The Behavior Rating Inventory of Executive Function (BRIEF) (Gioia et al., 2000) is an 86-item standardized ecological rating scale filled out by parents, designed to reflect the neuropsychological constructs of EFs for children aged 5–18. The BRIEF comprises eight scales: Inhibit (10 items), Shift (8 items), Emotional Control (10 items), Initiate (8 items), Working Memory (10 items), Plan–Organize (12 items), Organization of Materials (6 items), and Monitor (8 items). Additionally, two indexes can be calculated: the Behavior Rating Index (BRI), derived from the sum of scores on the Inhibit, Shift, and Emotional Control scales, and the Metacognitive Index (MI), calculated from the sum of scores on the Initiate, Working Memory, Plan–Organize, Organization of Materials, and Monitor scales. The total score, the Global Executive Composite (GEC), is the sum of scores of all eight scales. Items are rated on a Likert scale 1-3 (1=never, 2 =sometimes, 3=often). Raw scores are converted to t scores, with 65 or more considered clinically impaired (standard deviation = 10) (Gioia et al., 2000; Hahn-Markowitz et al., 2017). Internal consistency, test–retest reliability (r = .72-.84), discriminant validity, and convergent and concurrent validity was established for children with ADHD (Hahn-Markowitz et al., 2017; Mccandless & O'Laughlin, 2007). The BRIEF was found to be valid for identification, description and measurement of EFs among children with ADHD (Mark Mahone et al., 2002). In our study sample, high internal reliability was found for the BRI scale (α=.93), MI scale (α=.9) and for the GEC total score (α=.96). Internal reliability for the rest of the subscale was found moderate to high with Inhibition (α=.94); Shift (α=.51); Emotional control (α=.95); Initiate (α=.73); Working memory (α=.77); Plan (α=.85); Organization of materials (α=.93) and Monitor (α=.53).

Performance skills

The Child Performance Skill Questionnaire (PSQ) (Bart et al., 2010) is a parental questionnaire designed to assess three skill domains: motor, process, and communication. The term ‘‘performance skill’’ refers to the observed performance of the child when engaged in different activities (Mimouni-Bloch et al., 2016). The PSQ consists of 35 items. Parents are asked to rate how each item describes their child on a scale from 1 (‘‘does not describe my child at all’’) to 6 (‘‘describes my child very much’’), with a higher score indicating stronger performance skills. Total scores are calculated for each individual scale: the Motor skills scale (9 items), Organizational skills scale (16 items), and Communication skills scale (10 items). Good internal reliability (α = .84-.92) has been reported, and convergent and divergent validities are well-established (Bart et al., 2010; Mimouni-Bloch et al., 2016). In this study, the internal reliability of the PSQ total score was found to be high (α=.90), as well as the internal reliability of the subscales: Motor skills (α=.88), Organizational skills (α=.90), and Communication skills (α=.87).

Cognitive-emotional functions

The Hebrew adaptation of The Children’s Hope Scale (Law, 2002; Snyder, 2002; Snyder et al., 1997). The questionnaire consists of 6 statements to which participants respond on a 6-point Likert-type scale ranging from 1 (none of the time) to 6 (all of the time). There are three agency items (e.g., “I think I am doing pretty well”) and three pathway items (e.g., “I can think of many ways to get things in life”). A total score of all items is calculated into an overall scale to indicate change. The Hebrew version was translated and found to have internal consistency of α= .80 for its overall scale (Moran et al., 2014). In this study, a Cronbach alpha of .77 was found for the questionnaire.

Occupational Performance

The Canadian Occupational Performance Measure (COPM) (Law et al., 2014) is a standardized, client-centered tool designed for use by OTs to detect self-perceived changes in occupational performance problems over time in children over the age of 5. The COPM refers to the client's roles and expectations and can be used as a measurement for treatment outcomes and objectives pre- and post-intervention. Moreover, the COPM facilitates goal setting with the client based on their preferences. Each chosen treatment goal in the COPM is evaluated across three scales: level of Importance, Performance, and Satisfaction, all rated on a visual analogue scale from 1 to 10. Intervention efficacy is determined by a change of at least two points on the 1-10 scale between pre and post intervention. The COPM is well validated, reliable (test–retest reliability = .80 for Performance scale over 1–2 weeks), and standardized. It has been employed as an outcome measure for clients with ADHD in various studies (Bosch et al., 2005; Hahn-Markowitz et al., 2011). In this study, the treating OT collaborated with the parents and the child to establish goals.

Data analysis

Statistical analysis was performed using SPSS statistical software Version 27.0, with statistical significance set at p < .05. Descriptive statistics were used for the demographic data. Wilcoxson test was used for comparison of children’s scores on the TOH, BRIEF and the HOPE questionnaire pre- and post-intervention.

Results

EFs

Improvement in EFs, as evidenced by the TOH test, was found to be statistically significant between pre- and post-intervention. Specifically, statistical significance was observed in the number of moves scale, with a significant decrease in the number of moves required for solution post-intervention (see table 4). The time measure did not show statistical significance, as illustrated in table 4.

Table 4.

Comparison of pre-post change according to The Tower of Hanoi test and BRI index (N=5)

p	z	Post Session	Post Session	Pre Session	Pre Session
		Interquartile range	Median	Interquartile range	Median	Measure
0.893	0.13	60	66.40	99.9	67.86	Hanoi (seconds) time
0.043	2.02	2	11	3.5	15.4	Hanoi moves
0.109	1.604	65	8.5	65	1.604	Inhibition
0.257	1.134	67	11.5	67	1.134	Shift
0.109	1.604	65	8.5	65	1.604	Emotional control
0.043	2.023	43.5	64	12	69	BRI
0.4160	0.813	17	59	17	59	Initiate
0.342	0.948	19.5	56	10	67	Working memory
0.500	0.674	5.5	49	45	69	Plan/ organize
0.109	1.604	20	52	20.5	52	Organization of materials
0.141	1.473	11.5	54	19.5	54	Monitor
0.225	1.214	20	53	17	66	MI
0.104	1.625	18.5	57	14	63	GEC total

With the exception of participant 1, all participants demonstrated a similar pattern of improvement in the BRIEF scales assessing EFs; scores decreased post-intervention, although not significantly. Only the BRI index (comprising inhibition, shift, and emotional control scales) showed statistical significance post-intervention compared to pre-intervention. The MI index and its comprising scales (including Initiate, Working memory, plan/organize, monitor and the total scale GEC) did not show significant improvement. See table 4.

Performance skills

No significant differences were observed between pre- and post-intervention in the PSQ scales, including motor, organizational, and communication scales. Despite the lack of statistical significance, some improvement in organizational skills was noted. See table 5.

Table 5.

Comparison of pre-post change according to the HOPE, and PSQ questionnaires (N=5)

p	z	Post intervention	Post intervention	Pre intervention	Pre intervention
		Interquartile range	Median	Interquartile range	Median	Measure
0.686	0.405	1.34	5.00	1.23	5.56	Motor skills
0.465	0.730	1.65	3.75	2.88	3.38	Organization skills
0.223	1.219	1.35	4.70	1.45	4.50	Communication skills
0.465	0.730	0.79	4.63	1.36	4.37	Total PSQ
0.43	2.023	7	32.8	9	23.6	Hope

Cognitive-emotional functions

Hope score was found to be statistically significant at post-intervention in comparison to pre-intervention, as illustrated in table 5.

Occupational performance

The COPM measure was used to determine treatment goals with child and parent at baseline, pre-intervention. Goals were set in different life areas of everyday living and reflected occupational performance. We observed improvements in occupational performance and satisfaction, as rated by parents and children using the COPM, particularly in the areas of school performance, self-care, and leisure. Most participants demonstrated post-intervention improvements in satisfaction and performance across the majority of functional goals, with a 2-point change indicative of improvement (see figure 1).

Figure 1.

COPM results Pre- and Post-intervention of all participants

Discussion

The purpose of this article is to illustrate the process of developing and feasibility testing of ASTride, an EAOT intervention protocol for children aged 6-12 with ADHD. The intervention protocol was developed by OT experts in ADHD and EAS professionals. Previous studies on EAS and ADHD show considerable diversity in intervention protocols. This diversity complicates the assessment of intervention effectiveness and the identification of characteristics for evidence-based interventions (Helmer et al., 2021). The objective of this protocol is to establish a cohesive and valid framework applicable to EAS practitioners working with the ADHD population. Pilot data from this study shows potential improvements in ADHD outcomes post intervention.

Phase two of development included administering the intervention according to the intervention protocol in a pilot study conducted by a licensed OT and EAS professional. Results show feasibility for using the ASTride intervention protocol for children with ADHD, as improvement was found in cognitive and emotional functions as well as in everyday performance.

The ASTride intervention, according to the developed intervention protocol, has demonstrated improvement in the core symptoms of ADHD. Children with ADHD often present deficits in cognitive functions, including deficits in EFs. Results of the intervention show an improvement in the TOH test, as participants were able to perform the task with less moves post-intervention. The TOH test requires planning, strategy selection, and maintaining the tasks' goal in working memory. Therefore, it may be assumed that post-intervention participants improved their ability to select an effective strategy for executing the task and making correct moves while inhibiting incorrect ones (Ahonniska et al., 2000). It may be that the strategies discussed and practiced during sessions, as well as transferring to and implementing in daily tasks, contributed to the improvement in EF’s. For example, learning to tack a horse using a pictorial list while ensuring that each item on the list was checked off. This facilitated inhibition throughout the task, as well as practice in working memory, which were later transferred to getting organized in the morning using a pictorial list of morning routine (requiring the use of these EFs).

Consistent with the findings of the TOH test, we observed improved inhibition as indicated by the BRI scale of the BRIEF questionnaire, which includes the inhibition, shifting and emotional control subscales of EFs. It is plausible that this improvement in inhibition also led to enhanced emotional regulation, resulting from a better ability to inhibit and select appropriate coping strategies. Riding a horse requires continual inhibition and control of muscle movements to prevent falling and achieve succeful riding. Riders must demonstrate the ability to plan and select the appropriate strategy for walking, running, and steering the horse. Immediate feedback is received from the horse’s body, reflecting its position and posture, which necessitates regulation and inhibition while riding (Bass et al., 2009; Borgi et al., 2016; So et al., 2017). While improvement was documented in other BRIEF scales, it did not reach statistical significance. A larger sample size may reveal greater improvements in these scales.

Although not reaching statistical significance, minor improvements in organizational skills were observed, as indicated by the PSQ. Activity analysis reveals that organizational skills are essential for working in a stable environment, where participants must groom and tack the horse and prepare it for riding. Furthermore, during riding, participants must plan, steer, and consider other horses in the arena, all of which require organizational skills of both body and mind. Therefore, a larger study with a larger sample size should be conducted to assess the contribution of ASTride to organizational skills.

Corroborating the findings presented by the BRIEF, improvements in the emotional aspect were observed, indicated by the Hope questionnaire; post-intervention participants reported higher levels of hope. It is presumed that children with ADHD, owing to their developmental challenges, typically exhibit lower levels of hope compared to their peers without ADHD, primarily due to various deficits impacting their daily lives (Einav & Margalit, 2022). Hope plays a crucial role in the ability to set meaningful goals, identify specific ways to reach these goals, and plan effective ways to overcome obstacles along the way (Einav & Margalit, 2022). Higher levels of hope may also contribute to better utilization of cognitive functions such as planning, shifting, inhibiting, and regulating. Hopeful beliefs held by parents and children are considered protective factors that aid in coping with deficits and achieving goals in life (Shiri et al., 2014). Riding also offers appropriate levels of challenge, allowing riders to feel capable and gain a sense of mastery and success (Martin et al., 2017) which contributes to their sense of hopefulness.

In addition to improvements in body functions, ASTride intervention protocol has demonstrated improvement in everyday performance, as evidenced by the COPM, wherein learned strategies were effectively applied to functional objectives. The ability to transfer learning from one situation to another is one of the challenges of therapeutic interventions (Toglia et al., 2010). It is hypothesized that learning a strategy within a meaningful activity provides a greater opportunity for transfer, especially when using everyday activities tailored to a person’s “just right challenge” (Toglia et al., 2010). In this study, all participants were taught strategies and riding skills according to their personal ability while participating in a meaningful activity: horseback riding. All participants demonstrated motivation for riding and caring for their horses while participating in the intervention and were persistent in attending the sessions and practicing their homework assignments. The ASTride intervention protocol guides participants in selecting their goals alongside their parents, ensuring that these goals align with individual preferences and significance. Subsequently, the protocol aids in guiding both participants and their parents in transferring the acquired strategies to various other settings. Improvement in participant’s cognitive functions and perception of hope may have facilitated greater transferability as well.

Implication for Occupational Therapy Practice

This study has found feasibility for the use of ASTride−an EAOT intervention protocol for children with ADHD−along with preliminary results supporting the intervention protocol. This intervention may have the potential to benefit children with ADHD.

Conclusion and Limitations

This study has found feasibility for the use of ASTride-an EAOT intervention for children with ADHD-along with preliminary results supporting the intervention efficacy. Further research evaluating the efficacy of this intervention is still needed−as a future stage 3, including a controlled study. This study included a small convenience sample. To better assess the ASTride intervention protocol, future studies should use an RCT method with a larger sample size along with a control group, with outcomes carefully considered due to the above limitations.