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English article: The contribution of Psycho-Educational Vaulting (therapeutic horseback riding) on the psychomotor development of a child with cri-du-chat-syndrom
11
2012
Alexandra Stergiou
Spyridon-Georgios Soulis
Dimitrios Varvarousis
Pinio Christodoulou
Evdoxia Sakellaropoulou
English article: The contribution of Psycho-Educational Vaulting (therapeutic horseback riding) on the psychomotor development of a child with cri-du-chat-syndrom
2_004_2012_001_0013
mup 1|2012|13-23|© Ernst Reinhardt Verlag München Basel, DOI 10.2378/ mup2012.art02e | 13 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi The contribution of Psycho-Educational Vaulting (therapeutic horseback riding) on the psychomotor development of a child with cri-du-chat-syndrome A case study To adopt a training program for a person with “cri-du-chat-syndrome” presents one with many difficulties because of the specific communication disorders, the display of behavioral problems, and the motor-functional abnormalities that characterize the above syndrome. In this particular case study, speech and intelligence of the child are not fully developed, making both communication, and the establishment of social relations, difficult for the child. It is assumed that physical education in combination with appropriate psycho-educational methods and strategies, will contribute positively to the training of these individuals, increasing the level of their mobility and communication with the environment. With respect to this aim, psycho-educational vaulting plays a particularly important role. Keywords: Cri-du-chat-syndrome, psycho-educational vaulting, physical education, psychomotor development 14 | mup 1|2012 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … The Cri-du-chat syndrome is the result of an anomaly of the genetic make-up, the missing of a part of the short arm of the fifth chromosome pair (5p-), to be precise. This is a relatively rare chromosome anomaly, that can be found with a frequency of 1 / 50,000 births. The appearance of children with this syndrome contains communication structures differing from those other children of the same age have. They are accompanied by motor stereotypies, acoustical hypersensitivity, coordination disorders and an obsession with objects. Based on a holistic development profile it can be recognised that Cri-du-Chat syndrome children are able to say what they need and interact with their environment, however, they are limited in their movements (Cornish et al. 1999; Cornish / Pigram 1996). Regarding the syndrome advancement can, apart from classic therapeutic measures, when done via motor skills, yield significant benefits. However, this has hardly been researched on yet. Compiling suitable advancement concepts, considering all peculiarities of people suffering from the Cri-du-chat syndrome and coordinating their methods with the requirements of the individual case, makes a crucial contribution to the development of that specific person. People with Cri-du-chat syndrome have particularly problems with their motor skills. This is why it is required to design the basic conditions and the exercise methods in such a way that the person is encouraged to participate in an active manner to make use of the positive effects of the exercise (Kohler et al. 1998). When deploying a motor skill related advance programme there are usually plenty of problems, which can appear in a variety of behavioural disorders. Among them is the lack of social adaptation, isolation and various stereotype behaviour with these children. Thus, exercises can support the development of these children as well as their successful inclusion. As a result it is required to improve the pedagogical measures of the respective interventions deployed with the advancement of the persons mentioned, so that an advancement via movement can contribute to a comprehensive development (Gallahue 1996). Meanwhile it is a known fact that pedagogical intervention via movement is widely recognized and today is considered a successful pedagogical-therapeutic intervention for children and teenagers suffering from disabilities. It seems to be an important point that there is a correlation between a lack of activity and the occurrence of inappropriate behaviour. This means that the more motor activities are limited the more frequent behavioural disorders occur. One can act on the assumption that the motor activities and encouraging a child in this respect are of special importance. However, the most important thing is to minimise the negative behaviour of persons with Cri-du-chat syndrome to increase the possibilities of an expanded access to their environment (Elliott et al. 1994). “Making use of animals as therapeutic means for improving psychic health you can even find in suggestions made back in 1792.” (Trivedi / Perl 1995, quoted after Klontz et al. 2007, 257). Positive success in treating psychological and physical symptoms with different population layers show when animals are deployed in pedagogictherapeutic intervention. Psycho-educational horse-assisted advancement is such an intervention assisted by animals (Klontz et al. 2007; Brückmann 2006). This method uses the horse as a medium of an advance programme and consists of a combina- Based on a holistic development profile it can be seen that Cri-du- Chat syndrome children are able to say what they need and interact with their environment, however, they are limited in their movements Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … mup 1|2012 | 15 tion of psychomotor movements. It is a method based on personal experience and social learning. Specifically, vaulting and taking care of the horse are used as a concept. The deployment focuses especially on the relationship between the person, the horse and the pedagogue, “on horseback” and “all that has to do with it”. It is an intervention combining the exercise with pedagogical, psychological and psycho-therapeutic principles (Schulz 1999; Spink 1993; Alston 2004). The pedagogic process in which the horse is used as a medium contains motor as well as emotional parts. The motor benefit can be seen in an improvement of the posture, balance, flexibility and the child’s overall performance (Spink 1993; Scott 2005). While walking the movement of man’s pelvis consists of three elements: static-dynamic balance, shifting of the weight and turning (Spink 1993). The walking of the horse moves the rider back and forth and thus creates a back and forth movement of the pelvis. This activates the ability to control the pelvis by using the muscles (flexor and extensor). Apart from that, the horse’s movement activates the rider’s body muscles at his sides, increasing his stability(Sterba et al. 2002). In combination with the rhythmic movement the child’s blood circulation is stimulated (Potter et al. 1994). Additionally, the horse’s rhythmic movements improves the movement of the joints, the shifting of the balance centre as well as posture and balance (Sterba et al. 2002). During the pedagogical measure the vaulting therapist adapts the horse’s steps so that the transmittance of the stimuli improves the person’s sensory functions. These stimuli go through the child’s whole body. This way the improvement, according to Meregillano (2004), has a positive impact on the child’s every-day activities, turning the horse into a means of rehabilitation. The emotional benefit of vaulting shows e. g. in that the child relaxes when sitting on horseback, resulting in stress reduction. This often reduces aggressions which can occur with the child. With the help of psycho-educational vaulting, the child learns also to interact with its co-pupils and environment in an appropriate way. Thus, psychoeducational advancement with the horse has a positive impact on self-esteem and improves social skills. Working with the horse enthuses and delights and encourages the person to participate in this pedagogical process (Alston 2004). A basic principle of psycho-educational horse-assisted advancement is the selective deployment of non-verbal communication between the horse and its rider while being on horseback. The child mainly learns via experiencing, since it gets in tune with the horse’s rhythm and synchronises its movements with those of the horse (Schulz 1999). Establishing relationships to others begins very early, from the very beginning actually, it is non-verbal and is based on movement. Getting more to the point you could say that psycho-educational horse-assisted advancement is a living means to give the child chances and enable learning by allowing it to take initiatives, i. e. to become active itself, and to enable it to interact with its environment. Psycho-motor advancement aims at a physical, psychic and mental development of man (Klüwer 1994). The definition of “psycho-motor“ is the close relationship between movement and psychic experience (Brock 1989). Psycho-motor advancement contains a crucial part of development advancement for handicapped people. Playing is important here. Playing advances emotional as well as cognitive and psycho-motor skills (Jansma 1999). In many cases of children suffering from the Cri-du-chat syndrome they also have psycho-motor disabilities, however, they can vary from child to child. Research done by Cerruti et al. (2000) has shown that despite the mental retardation the performance of these children can be improved significantly if intervention takes place already from early childhood. These improve- 16 | mup 1|2012 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … ments achieved with the children show their positive effects also in the adult stage. During psycho-educational horse-assisted advancement the body is trained aiming at getting a better self-assessment and at enabling psycho-motor experience. Psycho-educational vaulting and group activities with horses are a special psycho-motor situation for the person. For a person suffering from psycho-motor disabilities this can have a significant effect on his development, since he gets to know the experience of movement and thus enters into a relationship with the horse. This way psycho-educational horse-assisted advancement enables this person to compensate his disability (Spink 1993; Schulz 1999; Brock 1989; Scott 2005; Horstmann 2010). In Greece, psycho-educational horse-assisted advancement is deployed since 1983 upon the initiative of Aideen Lewis with a group of children from the “Association for protecting Spastics” (the “Etairia Prostasias Spastikon“ is located in Athens and runs a school and a day-care centre for children and adults with cerebral tetraparesis). In 1992, the “Associaiton of psycho-educational horse-assisted advancement“ (SThIE) - a non-profit association based on voluntary work and mainly dealing with social activities. The following case study was carried out at the “Centre of psycho-educational horse-assisted advancement and Hippotherapy“ of Ioannina, since it has been cooperating with SThIE since 2009. This special centre as well as the SThIE are members of the international association FRDI (Federation of Vaulting for the Disabled International). Methods and process of psycho-educational horse-assisted advancement The study describes the deployment and evaluation of an intervention through psycho-educational horseassisted advancement with a ten-year old girl suffering from the Cri-du-chat syndrome. At that time the child attended 2nd form of a state-run special school. It had no active language skills and was only able to articulate herself through screams. It had no siblings, came from a oneparent household and her mother described her as being sensitive and social, but also renitent. According to her mother the child had a sufficient number of social contacts, but gets angry quickly when it doesn’t understand what people want from her or when it doesn’t get immediately what it wants. In these cases it reacts aggressively towards people in its direct proximity. It usually understands what people want her to do and responds accordingly. The child’s stereotypies are moving its head nervously, taking its hand in its mouth, biting other people and having an obsession with various objects. Walking is not very coordinated. Eating is problematic, however, it has an abundant secretion of saliva. It is able to control its bowels and bladder. The child’s clinical data are displayed in table 1 as follows (pattern according to Iyer et al. 1996; Tullu et al. 1998). With the child psycho-educational horse-assisted advancement was deployed, lasting seven months and taking place once per week for 30 minutes. The case study method was chosen since this is a very rare syndrome. Research was based on the method of non-participating observation. For evaluation and the reliability of research findings and in order to avoid the phenomenon of “self-fulfilling prophecy“, two observers were deployed who were not told about the purpose of this research and who were not present during pedagogical discussions afterwards. Before carrying out this study the legal guardian was informed about the purpose of this research and she gave her written approval. All pedagogical interventions were carried out by the same vaulting therapist with the same horse. An observation plan and a recording were deployed (see table 2), dused by both observers with each pedagogical session (Klüwer 1994a). The two observers documented on the basis of the criteria listed in table 2 an average value Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … mup 1|2012 | 17 regarding the girl’s following performance values: “Communication, Concentration, Active participation, Social behaviour, Head movement, Hands in mouth, Screaming, Biting, Correct body posture, Neuro-muscular coordination and Full accomplishment of the tasks“. Another thing to mention is that performance being “very good”, “good”, “moderate” etc. refer to the child’s best possible performance without taking an ageadequate development into account, so that the child’s development was noted down in relation to the duration of the pedagogical intervention. Initial objective of this horse-assisted pedagogical intervention was to improve the posture as well as the balance, communication and concentration skills of the child and at the same to reduce its aggression and stereotype behaviour. Apart from that, the goal was also to achieve further development of the body muscles and a better muscle tone to improve the torso’s stability and control. Concrete goals of the psycho-motor intervention with this child were to establish better communication, to increase concentration and performance periods, to encourage her to participate in an active manner, to achieve positive behaviour, to reduce her auto-aggression and to improve her motor skills. A soft blanket with a therapy strap instead of a vaulting saddle was used to improve the transfer of the horse’s body heat and movement to the child and to activate the child’s blood circulation (Sterba et al. 2002). During the first sessions the child was placed without its own participation on horseback by the vaulting therapist. However, during the course of the intervention the child became more and more active itself, achieved through changing the position on horseback: forward position, face-down position, backward position, side position (Sterba et al. 2002). This was done to expose the child to various stimuli through the horse’s movements, so the child was forced to respond. Goal was to develop the torso muscles, to improve the posture and the balance of neuro-muscular coordination (Potter et al. 1994). The torso muscles were strengthened through various exercises such as stopping and making the horse walk as well as repeated exercises during which the child was placed on the horse’s neck and back. Communication, attention and concentration of the child were advanced by making use of various types of tasks. The child had to catch a ball while on horseback, throw it into a basket and choose between several balls. Apart from that, Clinical characteristics Appearance general Charakteristic, piercing and weak scream / similar to the scream of a cat + retarded development + Performance metal handicap + Hypotony + Head Microzephalis + round face - Hypertolerism + Epicanthus + small jaws + sqinting + low-sitting ears - asymmetric face + receding chin + high arched palate + cleft palate - Heart functions Deformities of the heart - hands skin fold - short fingers - short middle hand + shortened fingers + miscellaneous hernia - missing kidney - skeletal difference of finger bones - Table 1: Clinical characteristics of the child 18 | mup 1|2012 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … Table 2: Observation plan and recording Class meeting Criteria Performance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Communication very good good moderate not done Concentration very good good moderate not done active participation very good good moderate not done Social behaviour cooperative indifferent angry isolated Head movement not done little moderate frequently Hands in mouth not done little moderate frequently Screams not done little moderate frequently biting not done little moderate frequently Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … mup 1|2012 | 19 it assisted in taking care of the horse (feeding the animal, assisting leading it, putting on straps snaffles, cleaning). The concept was based on the personal needs and skills of the child as well as on its increasing activity. Sessions were held at the Centre of Therapeutic Vaulting and carried out by a vaulting therapist who was specially trained in psycho-educational horse-assisted advancement. The horse was lead by an experienced assistant in gait by including a change of directions (diagonal, to the side, moving in circles and eights). At the end of each session there was a fast-paced gait to increase the child’s muscle tone. The vaulting therapist walked next to the horse and the child to control the rhythm of the pedagogical process. Apart from that there was an additional assistant on the other side of the horse for the child’s extra safety. The sessions were recorded on video to evaluate the pedagogical interventions later and to adapt the tasks to the child’s needs. The video recordings were also used to document the child’s improvements and progress. Results and discussion During the very first session the child was somewhat afraid of the horse, but it learned very quickly to handle its initial fear. During the course of the intervention it developed very good contact with the horse and was able to express its enthusiasm. Very often it relaxed and became hypotonous, that’s why it was required to remind it of participating in the intervention. When the child senses someone was walking next to it it often behaved passively and did not try to get active by itself. Apart from that, at the beginning it either bowed forward on the horse’s neck or backwards on its back and refused to sit straight again. Initial difficulties were significantly reduced so that from the ninth session on the child was able to sit straight on horseback on its own. When giving up the correct posture it was able to increase its sitting posture under the supervision of the Class meeting Criteria Performance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 correct body posture upright regression to the side with support unstable neuromusculare coordination very good good moderate not there complete fulfilment of tasks yes with support no 20 | mup 1|2012 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … vaulting therapist without the help of the assistant walking on the other side of the horse. Additionally, from the ninth session on it actively participated in taking care of the horse, in cleaning it as well as in attaching the strap. From the 28th session on it fed the horse on its own and lead it in walking pace without letting go of the reins. At the beginning it sat on horseback and allowed changes of its posture only in a passive manner, however, during the course of the intervention, especially from the 21st session on, it participated actively in all processes. Cooperation with the horse and the vaulting therapist was very rare at first, but with constant verbal support the child participated more and more. As the intervention progressed, it responded better and better to the various tasks and was able to increase its concentration periods and improved its communication. The stereotypies such as moving its head to the left and right, putting its hands in its mouth and biting have decreased significantly. Now it only screams when things become too much for her or when something does not please her, but only in a very low voice. In addition, it has learned to make new movements, to recognise noises and to deal with its fear. However, the most important thing is that the child has gained additional social skills, since it has learned to follow instructions, to stick to rules and to cooperate with the horse and the vaulting therapist. It also watched other children who were at the same place and enjoyed when the environment changed. Apart from the neurological-motor functions which were trained, improvements in its social-emotional, cognitive and language skills were able to be observed. Psycho-educational horse-assisted advancement as part of a pedagogical-therapeutic intervention thus turns out to be an all in all suitable pedagogical intervention, supporting the rehabilitation of children suffering from the Cri-duchat syndrome. It is obvious that this is a positive psycho-pedagogical process able to successfully support Cri-du-chat syndrome children in their development. Literature ■ Alston, A. J. (2004): Therapeutic Riding: An Educational Tool for Children with Disabilities as Viewed by Parents. Journal of Southern Agricultural Education Research 54, 113-123 ■ Brock, J. B. (1989): Therapy on horseback, Psychomotor and psychological change in physically disabled adults. Dissertation research. Universität Ioannina ■ Brückmann, J. (2006): Tiergestützte Therapie bei Kindern mit Lern- und Verhaltensauffälligkeiten. GRIN, München ■ Cerruti, M. P., Guala, A., Pastore, G., Pozzo, G., Dagna, B. F., Pierluigi, M. (2000): Psychomotor development in cri du chat syndrome. Clin Genet 57, 459-461 ■ Cornish, K. M., Cross, G., Green, A., Willatt, L., Bradshaw, J. M. (1999): A neuropsychologicalgenetic profile of atypical cri du chat syndrome: implications for prognosis. J Med Genet 36, 567-570 ■ Cornish, K. M., Pigram, J. (1996): Developmental and behavioural characteristics in Cri-du-chat syndrome. Archives of Disease in Childhood 75, 448-450 ■ Elliott, R. O., Dobbin, A. R., Rose, G. D., Soper, H. V. (1994): Vigorous, aerobic exercise versus general motor training activities: effects on maladaptive and stereotypic behaviors of adults with both autism and mental retardation. Autism Dev Disord 24, 565-576 ■ Gallahue, D. L. (1996): Developmental Physical Education for Today’s Children. Brown Benchmark, Dubuque IA ■ Horstmann, M. (2010): Heilpädagogisches Reiten als Entwicklungsförderung für Kinder mit psychomotorischen Auffälligkeiten: Ergebnisse einer Interventionsstudie. Peter Lang, Frankfurt ■ Iyer, S. L., Duraiswamy, A. A., Kher, A. S., Joshi, S. S., Bharucha, B. A., Kanade, S. S. (1996): Cri du chat syndrome. J Postgrad Med 42, 86-88 The concept takes the personal needs and the child’s increasing self-activity into account. Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … mup 1|2012 | 21 The authors Alexandra Stergiou 2003 training to become a sports teacher at Athens university, 2010 Mcs of Special Pedagogics at Ioannina university, since 2008 chairwoman of the Center of Therapeutic Vaulting and Hippotherapy in Ioannina (Greece) Dr. Spyridon-Georgios Soulis Assistant professor of special pedagogics at Ioannina university (Greece), studied pedagogics and theology in Greece, studied therapeutic pedagogics with a Cologne scholarship, dissertation in the field of therapeutic pedagogics, since 1998 professor of Special Pedagogics at Ioannina university, assistant professor in Special Pedagogics at Ioannina teacher education facility Dr. Dimitrios Varvarousis 1996 studied Medicine and the Medical Faculty of the University of Thessalonikis, 2007 orthopedic surgeon, 2010 PhD at Athens university, since 2007 at the sports and rehabilitation clinic at Ioannina university clinic Pinio Christodoulou 1991 studies in Pedagogics at Patra university, since 2008 additional studies in Special Pedagogics at Ioannina university, IKY scholarship, since 2002 kindergarten teacher at a specialpedagogical kindergarten in Agrinio Dr. Evdoxia Sakellaropoulou studied Pedagogics and Theology, school inspector for primary schools in Ioannina, dissertation in the area of multi-cultural education Lucia Kessler-Kakoulidi 1977 degree in Music in Therapeutic Rhythmics at the Academy of Music, working as a music therapist at special schools in Germany and at Athens university (teacher education facility), publications in Greece and Germany 22 | mup 1|2012 Stergiou, Soulis, Varvarousis, Christodoulou, Sakellaropoulou, Kessler-Kakoulidi - The contribution … ■ Meregillano, G. (2004): Hippotherapy. Phys Med Rehabil Clin N Am. 15, 843-854 ■ Potter, J. T., Evans J. W., Nolt Jr, B. H. (1994): Therapeutic horseback riding. Journal of the American Veterinary Association 204, 131-134 ■ Schulz, M. (1999): Remedial and psychomotor aspects of the human movement and its development: A theoretical approach to developmental riding. Scientific and Educational Journal of Therapeutic Riding 7, 44-57 ■ Scott, N. (2005): Special Needs, Special Horses: A Guide to the Benefits of Therapeutic Riding. Denton, TX: University of North Texas Press ■ Spink, J. (1993): Developmental Riding Therapy. A Team approach to Assessment and Treatment. Therapy Skill Builders, Tucson ■ Sterba, J. A., Rogers, B. T., France, A. P., Vokes, D. A. (2002): Horseback riding in children with cerebral palsy: Effect on gross motor function. Developmental Medicine & Child Neurology 44, 301-308 ■ Trivedi, L., Perl, J. (1995): Animal facilitated counseling in the elementary school: A literature review and practical considerations. Elementary School Guidance & Counseling 29, 223-233 ■ Tullu, M. S., Muranjan, M. N., Sharma, S. V., Sahu, D. R., Swami, S. R., Deshmukh, C. T., Bharucha B. A. (1998): Cri-du-chat syndrome: clinical profile and prenatal diagnosis. J Postgrad Med 44, 101-104 Addresses of the authors Alexandra Stergiou · Centre for Therapeutic Vaulting and Hippotherapy, Ioannina (Greece) · asterg@cc.uoi.gr Dr. Spyridon-Georgios Soulis · University of Ioannina Pedagogical Faculty, P.T.D.E 45333 Ionnina Greece · ssoulis@cc.uoi.gr Dr. Dimitrios Varvarousis · University hospital for Medicine and Rehabilitation, University of Ioannina (Greece) dvarvar@otenet.gr Pinio Christodoulou · University of Ioannina (Greece) Pedagogical Faculty · xripinio@gmail.com Dr. Evdoxia Sakellaropoulou · School inspector for primary schools in the district of Ioannina (Greece) esakellarop@gmail.com Lucia Kessler-Kakoulidi · “Maraslio“ teacher education facility Pedagogical faculty at the National and Kapodistriako university Athens (Greece) · luciakessler@gmail.com ■ Jansma, P. (1999): Psychomotor Domain Training and Serious Disabilities. University press of America ■ Klontz, B. T., Bivens, A., Leinart, D., Klontz, T. (2007): The Effectiveness of Equine-Assisted Experiential Therapy: Results of an Open Clinical Trial. Society and Animals 15, 257-267 ■ Klüwer, B. (1994 a): Psychomotoric movement: Observation in Hippotherapy. Featuring selected proceedings from the 8th International Therapeutic Riding Congress. Scientific Journal, The Federation of Riding for the Disabled International, 47-56 ■ Klüwer, B. (1994 b): Die Förderung motorischer Fähigkeiten von Kindern und Jugendlichen durch therapeutisches Reiten und Voltigieren. GRIN, München ■ Kohler, F. W., Anthony, L. J., Steighner, S. A., Hoyson, M. (1998): Teaching social interaction skills in the integrated preschool: An examination of naturalistic tactics. Topics in Early Childhood. Special Education 21, 93-103
