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The Effectiveness of Hippotherapy for Children With Language-Learning Disabilities

Beth L. Macauley The University of Alabama Karla M. Gutierrez Washington State University

This study examined the effectiveness of hippotherapy versus traditional therapy for children with language-learning disabilities. Three boys, ages 9, 10, and 12 years, and their parents independently completed a satisfaction questionnaire at the end of traditional therapy (T1) and again at the end of hippotherapy (T2). A comparison of the responses from T1 and T2 indicated that both the parents and the children reported improvement in speech and language abilities after both therapies. Overall, responses were noticeably higher following hippotherapy, with additional benefits of improved motivation and attention also reported. Hippocrates was the first to describe the benefits of the horse for rehabilitation purposes, calling horseback riding a universal exercise (Riede, 1987). In the time following Hippocrates, medical professionals in Germany, Italy, Austria, and England, as well as eventually the United States, used horses in the rehabilitation of people with disabilities. Today, in the United States, peoples use of horses can be classified into two main categories: equine-assisted activities and equine-assisted therapy. Equine-assisted activities (EAA) are activities centered on the horse in which the purpose is to learn horse-related skills (e.g., riding) and improve a persons quality of life. EAA is a subtype of animal-assisted activities, which can be provided by anyone who receives specialized training and certification (Delta Society, 2002). Equine-assisted therapy (EAT), a subtype of animal-assisted therapy, is the integration of the horse into goal-directed treatment and is provided by licensed therapists (Delta Society, 2002).

Hippotherapy is a specialization of EAT. Hippotherapy means treatment with the help of a horse and is derived from the Greek word hippos, meaning horse (Heine & Benjamin, 2000). The American Hippotherapy Association defines hippotherapy as a physical, occupational, or speech therapy treatment strategy utilizing equine movement (2002). During hippotherapy, the client sits on the horses back and physically accommodates to the three-dimensional movements of the horses walk. The client does not influence the horse; rather, the horses movement influences the rider. Functional riding skills are not taught, and any improvement in the clients quality of life is a secondary benefit (Klimas, 2001). Activities are incorporated within the scope of practice of the therapist to complement the horses movement and help the client move toward meeting his or her treatment goals. Speech language pathologists (SLPs) can receive education and training in EAT through the American Hippotherapy Association and certification through the American Hippotherapy Certification Board. Both physical and psychosocial benefits have been documented or reported from the use of EAT and hippotherapy. The direct physical benefits include improved muscle symmetry (Benda, McGibbon, Grant, & Davis, 2003), postural alignment (Bertoti, 1988), facilitation of normal movement (Glasow, 1985; McGibbon, Andrade, Widener, & Cintas, 1998), improved balance and gait (Haehl, Guiliani, & Lewis, 1999), and improved respiratory and motor control of speech (Macauley & Lombardino, 2004). Psychosocial benefits of EAT and hippotherapy include improvement in self-concept (Beckman, 1992; Cawley, Cawley, & Retter, 1986), locus of 205

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control (Carlson, 1983; Tucker, 1994), affect (Kluewer, 1987), and behavior (Emory, 1992). The studies by Beckman, Carlson, Tucker, Kluewer, and Emory focused specifically on participants with learning disabilities. Dismuke (1981, 1985) was the first to study the use of hippotherapy in speech and language therapy. Twenty-six children with a moderately severe language disorder and learning disabilities participated; 11 children received treatment in the traditional school therapy setting and 15 received treatment through hippotherapy. Results indicated greater improvement in all language measures for participants who received hippotherapy as compared to those receiving treatment in the public school setting. Dismuke stated that the results indicated the value of initiating a multidisciplinary treatment for the handicapped through carefully designed hippotherapy programs and concluded that further research must focus on generating empirical support for the effectiveness of hippotherapy in speechlanguage pathology. Students with learning disabilities comprise 45.2% of the population with disabilities and 5.5% of the total population in prekindergarten through 12th grade, and students with speech or language impairments are the next largest group (U.S. Department of Education, 2002), comprising 17.2% of the population with disabilities and 2.1% of the total population. Furthermore, of the students identified as having learning disabilities, a large portion exhibit a language-learning impairment. Miniutti (1991) estimated the prevalence of students with language-learning disabilities (LLD) among students with learning disabilities was as high as 75%. Recent observations suggest that subtle language deficits associated with learning disabilities may persist into adolescence and young adulthood if the child does not receive appropriate intervention (Lerner, 2000; Mercer, 2000; Wiig & Semel, 1975, 1984). A criterion in many definitions of learning disabilities is the need for special servicesthese children need help if they are to succeed. Therefore, it is important to provide services that will enable children with LLD to excel in life (Lerner, 2000; Mercer, 2000; Wiig & Semel, 1984). Many children with LLD receive treatment for many years. These children may benefit from innovative therapy techniques and environments to enable them to reach their full potential and improve their motivation toward therapy. In addition, children with learning disabilities appear to be at greater risk for experiencing negative emotional affect that, in turn, negatively affects their ability to participate in and respond to therapy (Yasutake & Bryan, 1995). Affect refers to ones emotional state and mood, which, in turn, influences and shapes ones behavior (Fadem, 2004). A negative affect leads to decreased desire to participate, dysphoric mood (feelings of unpleasantness), and increases in the brains chemicals for negative emotions. These chemical changes include secretion of adrenaline, a hormone associated with increased heart rate and the fight-or-flight response, and neuropeptides, a group of neurotransmitters associated with such negative emotions as fear and anger (Young, 2004). Positive affect leads to increased desire to participate, euphoric mood (feelings of

elation), and changes in the brains chemicals for positive mood. These chemical changes include secretion of endorphins, natural opiate chemicals that lead to muscle relaxation and a sense of well-being (Young, 2004). According to Norman (2002), a persons affect changes how the brain processes information in that, if an activity is pleasant, it is easier to do, and if an activity is unpleasant, it is inherently more difficult (Norman, 2002). To facilitate participation, motivation, and attention during a task that is perceived as unpleasant for children with LLD, such as reading a book, a new alternative pleasant task should be initiated, such as reading a book to a dog (Dog day afternoons, 2000). Therefore, it is crucial to investigate the effectiveness of new and innovative treatments that facilitate positive affect for children with learning disabilities. Hippotherapy is one form of treatment that has tremendous potential for children with LLD in that, by its nature, hippotherapy is dynamic and requires the integration of all body systems. The consistent, repetitive movement of the horse stimulates the sensory motor system of the client, giving the nervous system a template from which to build its physical and cognitive responses (Macauley, 2003). The purpose of the present study was to examine the effectiveness of hippotherapy for children with LLD. We hypothesized that children would make more progress toward their speech and language goals and improve their motivation to attend therapy following a block of hippotherapy than they would following a block of traditional clinic-based therapy. Specific research questions addressed included the following: 1. Will children with LLD and their parents report improvement in speech and language abilities following hippotherapy? 2. Will the children and their parents report improvement in the childrens motivation to attend speechlanguage therapy following hippotherapy? 3. Will the children and their parents report improvement in the childrens self-concept following hippotherapy? 4. Is hippotherapy less effective, more effective, or as effective as traditional clinic-based therapy?

METHOD Participants
The participants in this study were three boys, ages 9, 10, and 12 years, with LLD who were receiving traditional speech and language therapy services from the University Program in Communication Disorders (UPCD) Speech and Hearing Clinic in Spokane, Washington. Each participant had been in speechlanguage therapy since the age of 5 and had an individualized education plan (IEP), which included speech language therapy for learning disability, at his school. Results

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from initial testing revealed that each boy had a Clinical Evaluation of Language FundamentalsThird Edition (Semel, Wiig & Secord, 1995) composite score of at least one and a half standard deviations below the mean and a reading level at least two grade levels below his current grade. Each boy had IEP goals and speech therapy goals in auditory comprehension, expressive language, reading, writing, and spelling. All three participants were monolingual English speakers and right handed, with normal hearing between 500 Hz and 4000 Hz. Only the 9-year-old had an additional diagnosis of attention-deficit/hyperactivity disorder (ADHD) and was taking Ritalin at the time of the study.

Questionnaire
A 21-item client satisfaction questionnaire was used to gather data from all the participants (see Appendix A). The questionnaire was adapted from the UPCD client satisfaction questionnaire. The questionnaire was designed to gather general information on clinician preparedness and therapy activities, as well as specific information on the environment, motivation, and effectiveness of hippotherapy. Two forms of the questionnaire were writtenone for the parents and one for the participants themselves to answer.

quently, the SLP may stand in the middle of the arena and speak through a megaphone or be on a horse, with a horse leader, walking adjacent to the client. During the hippotherapy sessions for this study, the SLP either walked or stood beside the client. Materials can be presented to the client using picture, word, and letter cards; small dry erase boards; and lap desks with pencil and paper. Activities are limited only by the creativity of the therapist. Most activities from a traditional therapy session can be adapted to the hippotherapy environment. The therapy activities during both traditional therapy and the hippotherapy were individually designed to target each childs speech and language goals. Each child had a receptive language, expressive language, reading, and writing goal. Activities done in the traditional setting were adapted to the hippotherapy. Examples of these activities can be found in Appendix B.

RESULTS
A total of six questionnaires were sent to the three children with LLD and their parents after the completion of traditional clinic-based therapy and again after the completion of the hippotherapy. Of the surveys sent, all 12 were completed and returned for a 100% response rate. The responses from the two surveys (T1 and T2) were compared. The average value for each question was determined for the participants and for their parents for T1 and T2.

Procedures
The questionnaires were given to the participants and their parents at the conclusion of traditional clinic-based therapy with the instructions to complete it on the basis of their experiences during the traditional sessions. If the participant was unable to read the questionnaire independently, a parent read it aloud and circled the number response verbalized by the participant. The traditional therapy sessions were 1 hour long, twice a week, during the fall academic semester. After the winter break, the three participants received 6 weeks of hippotherapy. The hippotherapy sessions were 1 hour, twice a week. At the conclusion of the 6 weeks of hippotherapy sessions, the questionnaires were again given to the participants and their parents. The hippotherapy sessions were conducted at Merlin Farms Equestrian Center in Deer Park, Washington, in an enclosed and covered riding arena. A trained therapy horse with the ability to produce a smooth, symmetrical walk was used for all sessions, and experienced equestrians served as horse leaders (controlling the horse by holding on to a lead-rope attached to the horses halter) and side walkers (people who walked beside the client for safety purposes). The SLP was also present during the sessions. During a hippotherapy session, the client sits on the horse, typically on a pad and surcingle (the leather belt that goes around the barrel of the horse to hold the pad firmly in place) or on a saddle. The horse is then led forward at a walk by the horse leader while the side walker walks beside the horse. The client participates in therapy activities with the SLP, who is typically walking in front of the client. Less fre-

Research Question 1
To determine whether the participants and their parents reported improvement in speech and language abilities following hippotherapy, the averages from questions 4, 8, 18, 20, and 21 from the parent questionnaires and the averages from questions 6, 15, 17, 19, and 21 from the participants T2 questionnaires were examined (see Table 1). Responses in the range of 1 to 3 were considered negative (i.e., regression of skills), responses in the range of 4 to 6 were considered no improvement (i.e., maintenance of previously learned skills), and responses in the range of 7 to 10 were considered positive improvement (i.e., active learning and retention of new skills). If a parent circled two numbers, the average of the numbers was used in the calculations (i.e., if a parent circled 8 and 9, then an 8.5 was used). As can be seen in Table 1, all the average scores fell in the 7 to 10 range, and the overall average for the five parent questions was 9.2, indicating that the parents strongly agreed that hippotherapy was effective in improving their childrens speech and language abilities. From the participants questionnaires, two of the responses fell in the 5 to 7 range indicating neutral responses, and three of the average scores fell in the 7 to 10 range indicating agreement. Because the overall average was 8.0 for the five questions, it was determined that, according to the participants, hippotherapy was effective in helping them improve their speech and language skills.

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Research Question 2
To determine whether the participants and their parents reported improved motivation to attend therapy following hippotherapy, the averages from questions 6 and 12 from the parent questionnaires and the averages from questions 4, 16, 18, and 20 from the participants T2 questionnaires were ex-

amined. As can be seen in Table 2, all of the parents average scores fell in the 9.5 to 10 range, and the overall average for the two questions was 9.9, indicating that the parents strongly agreed that the participants were very motivated to attend the hippotherapy sessions. From the participants questionnaires, the average scores for the four questions fell in the 9 to 10 range, and the overall

TABLE 1. Reported Improvement in Speech and Language Abilities Following Hippotherapy


Question Parent Responses 4. There were noticeable improvements in my childs ability to communicate following the semester of therapy. 8. My childs ability to communicate in everyday situations is better. 18. I would re-enroll my child in the therapy program. 20. I would refer others for services. 21. Overall satisfaction rating. Overall average Participant Responses 6. My talking and understanding in everyday life is better. 15. My clinician helped me improve my listening skills. 17 . My clinician helped me improve my talking skills. 19. My clinician helped me improve my reading skills. 21. My clinician helped me improve my writing skills. Overall average 6.8 8.8 8.8 8.8 6.8 8.0 5.57 .5 7 .59.5 7 .59.5 7 .59.5 5.57 .5 9.0 8.8 9.5 9.5 9.2 9.2 810 89.5 910 910 99.5 Average Range

TABLE 2. Reported Improvement in Motivation to Attend Therapy Following Hippotherapy


Question Parent Responses 6. My child was motivated to attend the therapy sessions. 12. My child was willing to participate in therapy activities. Overall average Participant Responses 4. I looked forward to coming to therapy. 16. I would come back to therapy for another term. 18. I would tell others to come here for therapy. 20. Overall, I liked therapy. Overall average 9.5 9.5 9.5 9.5 9.5 910 910 910 910 10 9.8 9.9 1010 9.510 Average Range

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average was 9.5, indicating that the participants agreed that they were very motivated to attend the hippotherapy sessions.

Research Question 3
To determine whether the participants and their parents reported improvement in self-concept following hippotherapy, the averages from questions 14 and 16 from the parent questionnaires and the averages from questions 10 and 12 from the participants T2 questionnaires were examined. As can be seen in Table 3, all the average scores fell in the 7.5 to 10 range, and the overall average for the two questions was 8.5, indicating that the parents agreed that hippotherapy improved their childrens self-concept. From the participants questionnaires, the responses fell in the 7 to 10 range, and the overall average was 8.5, indicating that the participants agreed that hippotherapy facilitated improvements in their self-concept.

important, indicating that, according to parents, hippotherapy was more effective than traditional therapy. The differences in the participants responses from T1 and T2 ranged from 1.9 to 6.3, with an average difference of 1.9 (see Table 5 and Figure 2). This average is considered negligible, indicating that the participants believed that traditional therapy and hippotherapy were equally effective.

DISCUSSION
In the parents questionnaire, the questions with differences greater than 4 points between the two therapies were 6, 12, and 14. These are important findings because therapy always runs more smoothly with a willing participant. When a client requires external motivation to participate in the therapy session, valuable time and energy is taken away from the activities and teaching time to motivate the client. If a client has been in therapy for many years, he may be bored and hostile toward the therapy environment, resulting in a negative affect. The child may begin to feel different from his friends because he has to go to therapy, but his friends do not. Many clinicians today are becoming innovative in the therapy session, but the sessions still typically occur in a small room, with or without windows, that has a table and chairs. Results of this study indicate that hippotherapy improves the motivation of the child to attend and participate actively in therapy activities and that improvements in the childs speech and language abilities are not compromised. In this study, each child demonstrated improvements in his speech and language abilities and progressed toward therapy goals. In the participants questionnaires, the questions with differences greater than 4 points between the two therapies were 2, 4, 10, 14, 16, and 20. These are also noticeable results as the answers indicated that the boys looked forward to coming to the hippotherapy sessions, enjoyed the activities, and even talked about their therapy with friends. It is more common for parents to bribe, beg, or cajole their elementary and

Research Question 4
To determine whether hippotherapy is less effective, more effective, or as effective as traditional clinic-based therapy, the averages for each question from T1 and T2 were compared using a paired t test. Results from the parents responses indicated p < 0.000, t = 12.73, df = 21. Results from the participants responses indicated p < 0.002, t = 3.46, df = 21. Furthermore, the differences in each question across T1 and T2 were compared (see Table 4). A difference less than 2 points was considered negligible, a difference between 2 and 4 points was considered important, and a difference greater than 4 points was considered noteworthy. Please note that the same clinicians conducted both the traditional therapy and the hippotherapy sessions. As seen in Table 4, the differences in the parents responses from T1 and T2 ranged from 0.5 to 6.5, with an average difference of 3.3 (see Figure 1). This average is considered

TABLE 3. Reported Improvement in Self-Concept Following Hippotherapy


Question Parent Responses 14. My child talked about his/her therapy with his/her friends. 16. My childs self-esteem has improved as a result of therapy. Overall average Participant Responses 10. I talked about what I did in therapy with my friends. 12. I feel better about myself. Overall average 7 .5 9.5 8.5 78 910 8.2 8.8 8.5 7 .59 810 Average Range

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TABLE 4. Parent Responses From Post-Traditional and Post-Hippotherapy Questionnaires


Question 1. Clinician/supervisors were prompt in meeting therapy or diagnostic appointments. 2. The therapy environment was healthy and appealing. 3. The clinician was courteous and concerned in his/her clinical activities. 4. There were noticeable improvements in my childs ability to communicate following the semester of therapy. 5. Communication with the clinician was open, and questions were readily answered. 6. My child was motivated to attend the therapy sessions. 7 . The clinician was interested in my child as an individual and considered his/her special needs. 8. My childs ability to communicate in everyday situations is better. 9. The instructions given to my child were clear and understandable. 10. The clinician helped my child relate the therapy activities to everyday life. 1 1. Therapy tasks were appropriately chosen and well organized. 12. My child was willing to participate in therapy activities. 13. The clinician was well prepared. 14. My child talked about his/her therapy with his/her friends. 15. The clinician was alert and competent in executing the therapy activities. 16. My childs self-esteem has improved as a result of therapy. 17 . Sufficient equipment and materials were available for each session. 18. I would re-enroll my child in the therapy program. 19. The clinician provided helpful emotional support and counseling as needed. 20. I would refer others for services. 21. Overall satisfaction rating. Overall averages
a

Post traditional

Post hippotherapy

Difference

8.3 7 .0 7 .2 6.0 6.7 3.5 7 .2 5.3 6.5 5.0 5.8 4.8 6.7 3.5 5.8 5.5 6.5 5.8 6.5 6.8 6.2 6.0

8.8 8.0 9.8 9.0 10.0 10.0 10.0 8.8 9.5 9.0 9.5 9.8 9.8 8.2 9.8 8.8 9.5 9.5 9.5 9.5 9.2 9.3

0.5 1.0 2.6a 3.0a 3.3a 6.5b 2.8a 3.5a 3.0a 4.0b 3.7a 5.0b 3.1a 4.7b 3.0a 3.3a 3.0a 3.7a 3.0a 2.7a 3.0a 3.3a

Important. bNoteworthy.

middle school children to attend therapy. The children are usually reluctant to talk about their therapy with their peers as it indicates that the child has a problem and may be perceived as different. It is exciting to note that the boys who participated in this study appeared to regard the hippotherapy as something to take pride in and to share with their friends.

Another finding from this study was that the parents reported that their children made greater improvements in speech and language abilities, motivation, and self-concept following hippotherapy when compared to results from traditional clinic-based therapy. Questions 4 and 8 of the parents questionnaire dealt with improvements in speech and

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FIGURE 1. Parent responses from T1 ( *Overall averages.

) and T2 (

). Please refer to Table 4 for the list of questions.

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TABLE 5. Participant Responses From Post-Traditional and Post-Hippotherapy Questionnaires


Question 1. My clinician was on time. 2. The place where I did my therapy was fun. 3. My clinician was nice and paid attention to me. 4. I looked forward to coming to therapy. 5. My clinician answered all my questions. 6. My talking and understanding in everyday life is better. 7 . My clinician was interested in me and appeared to care about me. 8. The therapy activities will help me do better at school. 9. I understood the directions my clinician gave to me. 10. I talked about what I did in therapy with my friends. 1 1. My clinician was well organized. 12. I feel better about myself. 13. My clinician was ready for my sessions. 14. The therapy activities were fun and interesting. 15. My clinician helped me improve my listening skills. 16. I would come back to therapy for another term. 17 . My clinician helped me improve my talking skills. 18. I would tell others to come here for therapy. 19. My clinician helped me improve my reading skills. 20. Overall, I liked therapy. 21. My clinician helped me improve my writing skills. Overall averages
a

Post traditional 9.5 3.7 8.2 3.2 9.3 8.7 9.0 9.3 9.3 3.2 8.3 9.3 9.3 4.5 7 .7 3.8 5.0 9.3 8.3 3.8 6.3 7 .1

Post hippotherapy 9.7 9.7 9.5 9.5 9.5 6.8 9.7 7 .5 9.5 7 .5 9.5 9.5 9.5 9.5 8.8 9.5 8.8 9.5 8.8 9.5 6.8 9.0

Difference 0.2 6.0b 1.3 6.3b 0.2 1.9 0.7 1.8 0.2 4.3b 1.2 0.2 0.2 5.0b 1.1 5.7b 3.8a 0.2 0.5 5.7b 0.5 1.9

Important. bNoteworthy.

language abilities. In response to Question 4, there was a 3-point increase from traditional therapy to hippotherapy. Parents felt that their children made greater progress following the hippotherapy program than they did following the traditional program. The parents also reported that their childrens ability to communicate in everyday situations was better following the hippotherapy than it was following the traditional therapy. In contrast to their parents, the participants responses indicated that they believed their speech and language abilities in everyday life improved more following the traditional therapy than the hippotherapy. These responses may indicate that during traditional therapy, the child is focused on the paper and pencil tasks or listening and talking activities that target his speech and lan-

guage goals so the child is more aware of what he is doing the difficulty, the repetition, and the monotony of the tasks. The child is conscious that the tasks relate to his language deficits. In contrast, the activities during the hippotherapy sessions targeted the childs speech and language goals, but in a new, exciting, and different way. As a result, the childs attention was on the fact that he is on a horse in an arena (although not in charge of the horseduring hippotherapy session, the horse is controlled by a horse-leader) and not on the therapy tasks themselves. Therefore, the children may not have been aware that the activities in which they were participating targeted their speech and language deficits and were not as aware of the relationship between the therapy activities and their talking in everyday life.

213

FIGURE 2. Participant responses from T1 ( *Overall averages.

) and T2 (

). Please refer to Table 5 for the list of questions.

The results of this pilot study showed that, with a small number of participants, hippotherapy was successful. We acknowledge that the parents may have responded positively to hippotherapy because of its novelty, as well as the inherent influence of the researchers expectations during survey-based research. Future research should examine this therapy tool with greater numbers of subjects in other geographic locations to improve external validity. Research into the effectiveness and efficiency of hippotherapy as a treatment tool for clients with communication disorders other than LLD also is needed. We would like to encourage SLPs, especially those with equestrian skills, to complete continuing education courses in hippotherapy and to begin integrating hippotherapy into their practice. ABOUT THE AUTHORS
Beth L. Macauley, PhD, CCC-SLP, HPCS, is an assistant professor in communicative disorders at the University of Alabama. Her research interests are neurogenic communication disorders and equineassisted therapy with special emphasis in hippotherapy. Karla M. Gutierrez, MS, is working in Winnipeg, Manitoba, Canada.

AUTHORS NOTES
The authors would like to thank Joyce Morgan, Mellissa Morgan, Shawn Macauley, and Merlin Farms Equestrian Center, Deer Park, Washington, for their assistance with this project. This research was supported by a grant from the Edward R. Meyer Fund, Washington State University, Pullman, WA.

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APPENDIX A

Parent Questionnaire
Please circle the number to the right of the question that best fits your response. Strongly Disagree 1. Clinician/supervisors were prompt in meeting therapy or diagnostic appointments. 2. The therapy environment was healthy and appealing. 3. The clinician was courteous and concerned in his/her clinical activities. 4. There were noticeable improvements in my childs ability to communicate following the semester of therapy. 5. Communication with the clinician was open, and questions were readily answered. 6. My child was motivated to attend the therapy sessions. 7. The clinician was interested in my child as an individual and considered his/her special needs. 8. My childs ability to communicate in everyday situations is better. 9. The instructions given to my child were clear and understandable. 10. The clinician helped my child relate the therapy activities to everyday life. 11. Therapy tasks were appropriately chosen and well organized. 12. My child was willing to participate in therapy activities. 13. The clinician was well prepared. 14. My child talked about his/her therapy with his/her friends. 15. The clinician was alert and competent in executing the therapy activities. 16. My childs self-esteem has improved as a result of therapy. 17. Sufficient equipment and materials were available for each session. 18. I would re-enroll my child in the therapy program. 19. The clinician provided helpful emotional support and counseling as needed. 20. I would refer others for services. 21. Overall satisfaction rating. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Neutral 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 Strongly Agree 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

Participant Questionnaire
Please circle the number to the right of the question that best fits your response. Strongly Disagree 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Neutral 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 Strongly Agree 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10
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1. 2. 3. 4. 5. 6.

My clinicians were on time. The place where I did my therapy was fun. My clinician was nice and paid attention to me. I looked forward to coming to therapy. My clinician answered all my questions. My talking and understanding in everyday life is better.

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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

My clinician was interested in me and appeared to care about me. The therapy activities will help me do better at school. I understood the directions my clinician gave me. I talked about what I did in therapy with my friends. My clinician was well organized. I feel better about myself. My clinician was ready for my sessions. The therapy activities were fun and interesting. My clinician helped me improve my listening skills. I would come back to therapy for another term. My clinician helped me improve my talking skills. I would tell others to come here for therapy. My clinician helped me improve my reading skills. Overall, I liked therapy. My clinician helped me improve my writing skills.

Strongly Disagree 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Neutral 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7

Strongly Agree 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10 8 9 10

APPENDIX B: SAMPLE ACTIVITIES FROM TRADITIONAL THERAPY AND HIPPOTHERAPY Example 1


Goal: Improve auditory comprehension. Task: Listen to a story; repeat main points of story; answer questions about details. Traditional Therapy: The client walks around room as the clinician tells a story. At the end of the story, the clinician asks the client to retell the story. The client retells the story while continuing to walk around the room and has to tell the next part of the story as he or she passes by a corner. The client then continues to walk in circles, serpentines, or around chairs and answers the clinicians questions about the story. Hippotherapy: The client walks around the indoor arena on horseback, with a horse leader leading the horse and a side walker on the ground beside the client for safety purposes, while the clinician tells a story. The client retells the story while continuing to walk around the arena and has to tell the next part of the story as he or she passes by a cone on the ground. The client continues to walk in circles, serpentines, around cones, and over poles while he or she answers the clinicians questions about the story.

Example 2
Goal: Improve phonological awareness. Task: Determine the first, middle, or end sound of different words. Traditional Therapy: The client sits at a table and listens to the words said by the clinician. The client then writes the correct letter or group of letters (e.g., th) that fits the instructions (first, middle, or end sound) on a piece of paper or chalkboard. An alternative strategy would be to post the letters around the room and have the client walk to the correct sound following each presentation or group of words. Hippotherapy: The client walks around the indoor arena on horseback, with a horse leader leading the horse, and listens to the words said by the clinician. Before each word, the clinician says, first, middle, or end sound. After hearing the word, the client writes the letters that make up the chosen sound on a small white board in his or her lap. An alternative strategy would be to post the different sounds around the perimeter of the arena and have the client ride to the correct sound following each presentation or group of words.
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Example 3
Goal: Increase sentence complexity. Task: When given two or more words, the client will use them correctly in the same sentence. Traditional Therapy: The client sits at a table and listens to the words said by the clinician. The client then writes or says a sentence using the given words. For example, the clinician says, or, tomorrow, and client responds, Tom is coming over today or tomorrow. Hippotherapy: The client walks around the indoor arena on horseback, with a horse leader leading the horse, while listening to words given by the clinician. The client then writes a sentence on a white board he or she is holding or says a sentence to the clinician using the given words and the given sentence type.

Example 4
Goal: Improve spelling ability. Task: Spell given words following discussion on specific spelling rules. Traditional Therapy: The client spells the word given by the clinician while jumping from one lily pad (piece of green paper on the floor) to another, one letter per lily pad. Hippotherapy: The client spells the word given by the clinician while his horse walks over ground poles (long poles used to make jumps that are set on the ground rather than in a jump). The client must say one letter per step over a ground pole. If the client makes an error, the horse stops and cannot keep walking until the error is fixed. To increase or decrease difficulty, the horse can walk faster or slower and the poles could be placed closer together or farther apart.

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