34 | mup 1|2009|34 - 44| © Ernst Reinhardt Verlag München Basel Ute S. Patrick Green Chimneys is a school and residential facility for Students with socio-emotional disorder, located on the North-East Coast of the United States. Within the past 60 years it has earned an international reputation for its innovative interventions. Animal assisted activities and therapy are fundamental core concepts of treatment and interdisciplinary cooperation is a successful key component. Co-treatment has been especially successful within the hippotherapy treatment. Occupational Therapists and Speech-Language Pathologists work hand in hand, using the multi-sensory qualities of the horse and its unique movement pattern to achieve the students goals in the natural context of the horse barn. Keywords: Occupational therapy, speech and language pathology, interdisciplinary cooperation, hippotherapy, Green Chimneys, animal assisted therapy One Horse Power for success The cooperation between equine assisted Occupational Therapy and Speech Language Pathology Patrick - One Horse Power for success mup 1 |2009 | 35 The Facility When you ask the students at Green Chimney’s school which subject they like best, most of them will say garden or life skills and others might even say that woodshop is their favourite class. The farm and wildlife classes however are without a doubt a hit with every student. Almost everyone has a favourite animal here; the students assist with the daily care and if the day is not going well, oftentimes a walk to the farm is the first thing that comes to the students mind to calm down and feel better. The farm is part of Green Chimneys campus, which produced dairy and crops until the 1940’s. It was bought in 1947 by Dr. Samuel Ross, who transformed it into a boarding school and summer camp. His philosophy has always been to provide opportunities for his students to interact with nature and animals on a daily basis which allows them to gather meaningful experiences. Dr. Ross made it possible to establish the foundation for a vast animal and nature based therapy program, which it is known for internationally today (Beetz 2003, 411 ff). Green Chimneys offers a special education school, a residential treatment center and facility for students with emotional and behavioural difficulties between the ages of 5 and 18. The average length of their stay is usually around two years. In 2008 about 90 boys and girls were placed in the residential treatment facility and center. They attend the therapeutic day school together with around 80 other students from adjacent districts. The therapeutic program is individually created by the students’ treatment team, which includes special education teacher, social services and school psychologists’ and in many cases occupational therapists and speech therapists as well. The Farm Green Chimneys farm is home to approximately 200 animals. From rats, to rabbits, chicken, sheep and pigs; many Picture 1: Philip is ready to go. His speech therapist explains the first activity. farm animals can be visited at the upper barn. The wildlife rehabilitation center gives shelter to owls, hawks, falcons, eagles, deer and even an Andean condor. Oftentimes these wild animals arrive injured at Green Chimneys and trained rehabilitation specialists nurse them back to health with the help of the students. The goal is to release the birds back into the wild, but if they are not capable of returning to their natural habitat they will stay at Green Chimneys wildlife refuge. The adjacent therapeutic riding facility provides a home to horses, ponies and donkeys and is a vital part of the school curriculum. Just like many other animals at Green Chimneys, some of the horses have also been rescued from abusive situations. The story of each individual animal can be very important for the students, since they oftentimes come from a desolate milieu and have experienced abusive situations themselves. The animals’ skill to accept the student the way they are and instinctively react to them, can help to influence the healing process of the traumatized child positively, while self awareness and coping strategies can be improved in reflective and real situations (Levine / Kline 2007). The therapeutic riding center at Green Chimneys provides optimal conditions for a brought equine assisted program by adhering to high quality standards. It is premier accredited by NARHA, an association that oversees facilities in the US, as well as abroad. Horsemanship 36 | mup 1|2009 Patrick - One Horse Power for success classes are one part of the program; farm jobs such as feeding the horses and mucking the stalls, carriage rides with donkeys and fjord ponies, as well as hippotherapy as an occupational and speech therapy method offer a brought treatment approach. The Clientele The majority of students come to Green Chimneys with a history of frustration and unsuccessful school experiences. Classified as students with special education needs based on their psycho-pathological and social-emotional difficulties, they oftentimes have a history of failing the regular education system first. Diagnoses’ vary widely from Asperger Syndrome and other disorders on the autism spectrum, to attention deficit disorder with and without hyperactivity, anxiety disorder, bipolar disorder, posttraumatic stress disorder to massive sensory processing disorder and others (Mash / Barkley 2003). Therapy The treatment approach at Green Chimneys takes place in a multiprofessional team and attempts to attend as individual as possible to the student. The unusual setting can assist students to gather multi-sensory experiences, which can improve independence and problem solving skills, as well as enhance their self confidence. The therapeutic approach includes counselling and play therapy, family therapy, social skills groups, psychiatric treatment and medication, speech and occupational therapy and in many cases animal assisted intervention. Adequate staff training in animal assisted interventions is a primary goal at Green Chimneys. In-service training, such as “find your inner farmer” and “the basics of hippotherapy” are provided on a regular basis, introductions for new and interested staff is essential and off-campus training is encouraged and supported. The following paragraph will provide an overview of the occupational and speech therapy approach at Green Chimneys and specifically the cooperation of these professions in the hippotherapy program. Occupational Therapy And Speech / Language Therapy Approximately 60 % of Green Chimneys students receive occupational therapy services and around 50 % receive speech therapy services based on their IEP, the individualized education program. The frequency is usually between once and three times per week and can be in individual or group sessions, depending on the students needs . Both occupational and speech therapists work in designated therapy rooms, as well as in the class rooms and they also facilitate other areas of the school campus, such as the pool, the farm or the gym. The main focus of the o c c up ational therapy approach in a U.S school is to provide assistance and to enable the students to improve their daily performance skills. This includes the promotion of sensory motor skills and psycho-motor skills, as well as to provide strategies to cope with learning disorders and social skill issues. Therefore it is custom at Green Chimneys School that the occupational therapists encourage their students to write name tags for a pig to promote fine motor skills, offer sensory integration therapy in the swing or assist with dressing and self care skills at pool time. The students are also observed and assisted in their classes and their staff is educated on individual strategies, to manifest the carryover of established skills into the students every day routines. S p e e c h t h e ra p y at G re e n C him n ey s promotes the students speech and language development and facilitates the schools resources in a similar fashion. Oral motor exercises might be provided in front of a mirror in the speech department, whereas language comprehension can be promoted Patrick - One Horse Power for success mup 1 |2009 | 37 Picture 2: The sideseat requires good balance and helps to improve postural control. This position also improves the studenttherapist bond. while studying a recipe in the life skills class. The speech therapist educates staff about strategies to improve speech production, grammar or comprehension skills. A crossover between occupational and speech therapy is inevitable and cooperation is common practice. Both professions benefit from discussion and exchange regarding the students’ abilities and issues, to provide adequate and effective treatment. Hippotherapy The Anglo-American hippotherapy approach differs from the approach in German speaking countries as it is not only a physical therapy intervention, but it can also be an occupational and speech therapy intervention (Engel / MacKinnon 2 0 0 7 ) . T h e A m e r i c a n H i p p o t h e r a p y Association (AHA) describes hippotherapy as an integrated intervention strategy imbedded in the individual treatment plan, which utilizes the horses’ movement specifically for its therapeutic benefits. The movement pattern of the horse is multi-dimensional, rhythmical and repetitive, which can improve the short term sensorymotor learning effect. Variations in tasks and positions on the horse, as well as adjustment of speed and change of direction, challenge the clients’ motor reactions and therefore can help to facilitate a long term motor learning effect (Shumway-Cook / Woollacott 2001). Not only sensorymotor skills are addressed during the dynamic interaction between client, therapist and horse, but also cognitive-perceptive and psychosocial skill components, which are essential performance skills for the client to successfully interact with his environment (Jerosch-Herold et al. 2004). Occupational Therapy interventions on horseback mainly target the promotion of gross and fine-motor skills, sensory processing skills, attention and concentration skills, as well as the improvement of other cognitive skills. The horse barn enables the therapist to create a therapeutic environment and activities in the least restrictive way possible and at the same time provide an opportunity for the client to engage in a meaningful occupation (Engel / MacKinnon 2007, 6 ff). Speech therapy intervention on horseback a d d r e s s e s m a i n l y t h e p h o n o l o g i c a l development (Speech development) of the client. The movement of the horse positively influences the skeletal static of the body, the muscle tone of the respiratory system and the outer skeletal muscle groups of the trunk, which regulate postural control (Saatweber 2003). At the same time the oral-facial muscle tone can be regulated and therefore speech production can be facilitated. Language development can also be addressed by incorporating the multi-sensory and motivating context of the environment into the treatment session . Language comprehension, vocabulary and grammar can improve in this enriching setting. Hippotherapy At Green Chimneys In 2008, Green Chimneys was home to 17 horses, 4 miniature Shetland ponies and 2 donkeys. 38 | mup 1|2009 Patrick - One Horse Power for success Approximately 12-14 horses work in the riding classes and about seven also participate in the hippotherapy program. Two horses are trained in ground-driving and are on schedule three to four times per week. The other five horses are lead by a trained volunteer or intern. The occupational therapist chooses the horses according to the students needs, considering size, quality of gait and character. Tack usually consists of a pad or bareback pad, which is equipped with a girth and stirrup rings, which provides the option to attach stirrups when needed. Since the leader is in charge of the horse during the session, the horse is lead by halter and lead rope or wears a bridle when ground driven. The students, who participate in the h i p p o t h e ra py p r o g ra m , a r e s e l e c t e d considering various reasons. Oftentimes the student lacks adequate attention skills and sensory processing difficulties, as well as sensory motor delays often occur along with the inability to stay focused in class. While the horse carries the student passively; specific interventions stimulate, train and saturate the students’ sensory systems and a basis for efficient learning can be established. Learning disabilities are also addressed, eg. using the rhythmical movement of the horse to facilitate counting etc. The horses midline is concrete and helps the student to differentiate right and left and the position on the horse can assist with the determination of proper preposition. The selection criteria depend on the physical skills of the rider and possible contraindications. Green Chimneys has a full service health and wellness center that keeps track of all medical records and obtains release forms for the students that allow them to participate in equine activities on and off the horse. The occupational therapist only treats the students with a physician’s prescription and when in doubt, discusses the intervention specifically with the physician. Every student who receives occupational and / or speech therapy at Green Chimneys is thoroughly evaluated, before the hippotherapy treatment plan is implemented. In 2008 14 students participated in weekly hippotherapy sessions; eight exclusively as part of their occupational therapy treatment and six in co-treatment with a speech therapist. Internal trainings for horse handlers and side-walkers are offered on a regular basis, to practice safety procedures and review barn rules. Standards provided by NARHA are reviewed and implemented. The cooperation between occupational Picture3: Hand‘s off and backwards this position improves and promotes coordination and communication skills in a playful way. Patrick - One Horse Power for success mup 1 |2009 | 39 therapy and speech therapy at Green Chimneys has proven itself as productive and efficient. The fundamental idea of the co-treatment is to sync the students’ individual goals from an occupational and speech therapy perspective. It needs to be considered that these goals may be addressed parallel by both professions. Some goals may be closely related and others may have components which can build upon each other. The interrelated cooperation of both professions enables the student to gain long-term success within his performance skills; such as the ability to maintain adequate respiratory capacity and improved postural control to sing with his peers or speak loudly in front of his class. The practical implementation of the cooperation between occupational and speech therapy includes the speech therapist as a side-walker and co-therapist. The occupational therapist obtained additional training and certification through AHA and NARHA and is responsible for the preparation, such as choosing the therapy horse, setting up of the arena etc., and the implementation of the therapy session, as well as for the safety of the student, the horse and the team. Coordination of the session is discussed previously and adjustments are discussed throughout the session. Distractions are reduced to a minimum and clear instructions regarding speed, direction and assistance for the student are continuously provided by the occupational therapist. The therapists discuss position changes of the student, which are guided and adjusted by the occupational therapist to provide optimal input for the student. Progress and possible regression is evaluated after every hippotherapy session and adequate strategies are developed to improve the students’ performance on the horse. The efforts to provide an equine assisted therapy session is comparably greater to conventional treatment sessions, but the benefits and progression that can be concluded from the experiences to date make the effort worthwhile. The case study in the following paragraph will explain the cooperation between occupational and speech therapy at Green Chimneys practically. C a s e Study P hilip P hilip ( n a m e changed) is nine years old. At five years old he was referred by the social service department to Green Chimneys and for the past year he has been placed with a foster family. He receives occupational and speech therapy three times per week, one time per week as a 30 minute hippotherapy session in co-treatment with his speech therapist. P hilip pre s e nts with d ela y s in his sensory motor development and therefore lacks adequate body awareness, sensory p r o c e s s i n g s k i l l s a n d m u s c l e t o n e regulation. These deficits are caused by insufficient development of his basic senses (proprioception, vestibular and tactile) which could be linked to his experiences in early childhood. Philip’s protective reactions are not adequately developed and persistent primitive reflexes can still be triggered, which interferes with proper gross motor coordination. His visual perceptual and visual motor skills are not developed age appropriately as well. Socially and emotionally it is difficult for Philip to tolerate frustrating situations and the initiation of adequate social interaction is often difficult for him. It is extremely challenging for him to interpret social behaviours appropriately and therefore is often exposed to stress triggers, such as when a classmate accidentally bumps into his chair and Philip feels that his space was invaded on purpose. Philip is very impulsive and it is extremely difficult for him to stay focused on school tasks, since he is easily 40 | mup 1|2009 Patrick - One Horse Power for success overwhelmed by visual and tactile stimuli that he can’t process properly. Philip also lacks adequate communication and speech skills, especially in word finding, grammar and vocabulary. His speech production is also delayed and he has difficult with certain consonant sequences, since adequate muscle regulation and control is necessary to produce them. Philip is an engaged and interested boy, who loves to be physically active. He enjoys working in 1: 1 situations and it becomes increasingly easy for him to work on puzzles, games or handwriting assignments. Philip likes to help take care of the animals in the barn. He loves mucking the stalls and has learned to manoeuvre the wheelbarrow safely. He enjoys grooming the animals and to assist at feeding time. Tasks are easier for him to manage when they are predictable and when he has the chance to experience the activity with his own hands. He benefits from routines and sequences which help him to orientate himself in the situation. Philip has met several different horses throughout his hippotherapy sessions. Pappy, a 24 year old Arabian mix gelding is lead by a horse handler during the hippotherapy session and mostly works with Philip. Spadi is a 10 year old Icelandic pony who works well ground driven. Philip has no preference for a certain horse and he engages openly and interested with all of them. Even though he has not ridden every horse in the Table 1: Occupational and Speech Therapy Goals Therapy Goals Occupational Therapy Within 12 weeks Philip will be able to…: 1. OT: imitate 5 body poses per session correctly (with 90 % success) 2. OT: improve his bilateral upper extremity strength, by repeating 4-8 exercises without fatigue(with 90 % success) 3. OT: stabilize his left upper extremity while his right upper extremity is used dynamically (e. g. writing, puzzle etc.) (with 80 % success) 4. OT: visually detect and follow letters, objects or pictures from left to right or from up to down (with 80 % success) 5. OT: identify 3 sensory diet strategies and to implement them adequately in his school day (e. g. brushing, jumping, swinging etc.) (with 90 % success) 6. OT: to use his rules adequately when interacting with others (80 % success) Speech Therapy Within 12 weeks Philip will be able to …: 1. ST: use all simple syllables and word sequences correctly throughout the session (95 % success) 2. ST: identify and use all multi-syllable and consonant sequences (e. g. heli-cop-ter) correctly (95 % success) 3. ST: improve his grammar by using simple rules and to expand his answers in a simple context (95 % success) Hippotherapy Within 12 weeks Philip will be able to…: 4&6 OT / 1,2,3 ST: name and follow all rules of the barn and for the process of mounting and dismounting (90 % success) 1, 2, 3, 6 OT / 1,2 ST: demonstrate 5-7 warm-up exercises while counting to 10 with the rhythm of the horses steps (90 % success) 1, 3, 4, 5, 6 OT / 1, 2, 3 ST: maintain his balance in side seat with minimal assist while identifying various objects / pictures and naming them in a sentence (90 % success) 2, 3, 4, 5, 6 OT / 1, 2, 3 ST: alternate between unilateral grabs and prone prop position in backwards position on the horse while playing a Q&A game (90 % success) 2, 3, 4, 5 OT / 1, 2, 3 ST: pass / throw a weighted ring from right to left in forward or backward position while building sentences in the context of the environment (90 % success) Patrick - One Horse Power for success mup 1 |2009 | 41 Picture 4: Saying thank you with a big hug - Philip embraces the horse with his whole body and smells his warm mane before ending the session. barn, he does know all their names. He is always motivated to come to his hippotherapy session and is already excited on Mondays about his session the next day. The occupational therapist, as well as the speech therapist initially consider the students strength and weaknesses. In Philips case it is important to offer him ritualized routines and gradual introduction to new skills to improve his competencies and offer him control that makes him feel safe and secure. New activities are always multisensory and include sensory motor, cognitive and communication components. In 2008 Philip has been working on the goals demonstrated in table 1 for his occupational and speech therapy treatment and the goals for his hippotherapy treatment derived from these general treatment goals. They are set for approximately 12 weeks and the progress is documented by both therapists after each session separately. Both therapists convene on a regular basis to discuss progression or regression. Table 2 offers an example of a treatment session to obtain a better understanding of the process during interdisciplinary cooperation. Future Ideas And Reflection On Interdisciplinary Hippotherapy At Green Chimneys The qualities a horse can offer are in many ways unique and very valuable for the therapist. The horse motivates the student to pay attention, to be able to use their own body successfully and to improve their overall skills. These skills are extremely important to the students at Green Chimneys, since it is oftentimes very difficult for them to stay focused in class, to perceive their own body properly and perform coordinated tasks. Many of the students also lack the ability to built trust and they often don’t feel the need to take responsibility for another being or themselves. The sensory-motor and psychomotor skills that a rider needs to stay on the horse can be implemented beautifully and the rich and stimulating environment offers many topics for meaningful communication. The cooperation between Occupational and Speech Therapy with the individual student offers the opportunity to review his performance from two perspectives. The fact that both therapists experience the same concrete situation can enable them to reflect and discuss constructively. The student also has the advantage of missing one half hour per week less during their academics class, which can promote better participation and reduces absences for the student. It is desired to continue and improve the hippotherapy program at Green Chimneys School and the cooperation between Occupational and Speech Therapy will have its place in these efforts. Thank you to Julia A. Malanga, Speech Therapist, for her support in this article. 42 | mup 1|2009 Patrick - One Horse Power for success Table 2: Example for a typical Hippotherapy session Phase Horse Philip (P.) Occupational Therapist (OT) Speech Therapist (ST) Material/ Equipment Initial Contact Ready-Standing with horse handler in arena Greets horse and handler Greets horse and handler Greets horse and handler Introduction Ritual and mounting Standing - Names rules - Mounts with minimal assist after placing mounting block properly Visual & tactile cues to place mounting block Assists with reviewing rules Assist with mounting Asks about barn and mounting rules Refers to right and left discrimination Assists OT with mounting Mounting block Working phase Standing - Answers questions Responds when ready Instructs team in terms of direction, speed and assist for P. Explains activity Assists with instructions Warm-up activities in forward position Walking on lead rope in figure 8 through the whole arena and then serpentines along the long side Manages activity while counting to 10 Activity 1: arms up sideways, the vertically stretched up and then crossed, hands on shoulders Activity 2: “walk with your hands on mane” Activity 3: both hands on horses back Counts with P. - Provides actively assist for grammar and vocabulary Stand for change of position Changes position from forward to side seat as independent as possible Names body parts and right/ left sides Explains new activities Activity 4: change position while naming sides and body parts Provides actively assist for grammar and vocabulary Patrick - One Horse Power for success mup 1 |2009 | 43 Phase Horse Philip (P.) Occupational Therapist (OT) Speech Therapist (ST) Material/ Equipment Activities in side seat Walking on lead rope around the whole arena (P. facing to center of arena) and if possible reduce to a 10 meter circle (to increase balance challenge for P.) Rides in side seat, maintaining balance and regulating muscle tone to maintain postural control Focus on dialogue with ST and comments on animal pictures OT (off side) facilitates proper position of pelvis to increase postural control Instructs horse handler and ST regarding direction and speed Activity 5: establishes sentences and dialogue with P. according to animal pictures ST assist with minimal hold lower extremities Initiates a Q&A game about horses (e. g. How does the frog move? The frog jumps. How does the horse move? The horse walks. etc. Animal - Pictures Activities in backwards position Stand for position change Changes position from side seat to backwards as independent as possible Explains new activity Activity.6: Assist with change of position Establishes topics with P. concerning his environment and the game, passes a ring back, following the example of the OT Ring - Walking on lead ope around the whole arena and changes direction through diagonal, optional large figure to improve P. vestibular system Walk-halt sequences to improve postural control in P. Prone prop at walk, alternating between unilateral grasp and bilateral prone prop, passing ring back and forth between OT and ST Explains Act.7: passing ring back and forth to improve tone regulation and attention skills Assist with communication between ST and P. Closing ritual Halts - Waits for instruction and returns to forward position Initiates end of session Ends communication game with P. Standing - Leans forward to hug the horse and give thanks Assists verbally with ritual Assists verbally with ritual Exit sequence Standing - Dismounts as independent as possible and says goodbye to horse and team Reflects on session Assists verbally and tactilely with dismount Reflects on session Says good bye to student Reflects on session Provides overview of next session and returns P. to class 44 | mup 1|2009 Patrick - One Horse Power for success Ute S. Patrick Bc (NL), OTR / L, since 1999 Occupational Therapist. Trained in Münster (D) and Heerlen (NL). Studied Hippotherapy in the US. Since 2007 at Green Chimneys School. Address: Ute S. Patrick · Green Chimneys Childrens Services · 400 Doansburg Road · Brewster · NY 10509 USA Ute.s.patrick@gmail.com The author Bibliographical references Beetz, A. (2003): Green Chimneys - Ein Vorbild ■ für tiergestützte Therapie mit Kindern und Jugendlichen. In: Olbrich, E., Otterstedt, C. (Hrsg.): Menschen brauchen Tiere. Grundlagen und Praxis der tiergestützten Pädagogik und Therapie. Kosmos Verlag, Stuttgart, 411-418 Engel, B. T., MacKinnon, J. R. (2007): Enhancing ■ Human Occupation through Hippotherapy. A guide for Occupational Therapy. AOTA Press, Bethseda, MDJerosch-Herold, C., Marotzki, U., Hack, B., ■ Weber, P. (2004): Konzeptionelle Modelle für die ergotherapeutische Praxis. 2. Auflage. Springer, Berlin Levine, P. A., Kline, M. (2007): Trauma through ■ a Childs eyes. Awakening the ordinary Miracle of healing. Infancy through adolescence. North Atlantic Books, Berkely, CA. Mash, E. J., Barkley, R. A. (2003): Child Psycho- ■ pathology. 2. Auflage. Guilford, New York, NY Saatweber, M. (2003): Grundzüge der Stimm-, ■ Sprech- und Sprachtherapie nach Schlaffhorst- Andersen. In: Böhme, G. (Hrsg.): Sprach-, Sprech-, Stimm- und Schluckstörungen. Band 2 Therapie. 4. Auflage, Elsevier, Urban & Fischer Verlag, München, 163-176 Shumway-Cook, A., Woollacott, M. H. (2001): ■ Motor Control. Theory and Applications. 2. Auflage. Lippincott Williams & Wilkins, Philadelphia Links American Hippotherapy Association: ■ www.americanhippotherapyassociation.org (8.12.2008) Green Chimneys Childrens Services: ■ www. greenchimneys.org (8.12.2008) North American Riding for the Handicapped ■ Association, Inc.: www.narha.org (8.12.2008)