Andrea Beetz, Verena Grebe 60 | mup 2|2012|60-71|© Ernst Reinhardt Verlag München Basel, DOI 10.2378/ mup2012.art03e Keywords: therapeutic riding, quality of life, state of mind, children, juveniles, attachment, human-animal relationship The effect of eight sessions of therapeutic riding on the quality of life and state of mind of 28 children with different psychiatric or medical disorders was investigated. Quality of life was assessed before and after the intervention, current state of mind before and after each therapy session. The reports of the children themselves as well as those of the parents showed a significant increase in the child’s quality of life, and an influence of the parent’s attachment status on this effect. Current state of mind was improved after each therapeutic session. The effects were independent from the child’s relationship to animals. Therapeutic riding enhances quality of life and state of mind of children and juveniles with different psychiatric or medical disorders Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … mup 2|2012 | 61 Worldwide up to 20 % of all children and juveniles suffer from disabilities as a result from psychiatric disorders (European Ministerial WHO - Mental Health Conference 2005). This prevalence is also confirmed by the BELLA study carried out by the Robert Koch Institute for Germany, for which all in all 4,000 children and juveniles, age ranging from seven to seventeen, were interviewed from 2003 to 2006. Within the scope of a holistic care approach it is necessary to expand and optimize the range of therapeutic-pedagogical methods. In this respect the value of animal-assisted interventions aiming at improving physical and psychiatric health and quality of life has gained more recognition during the past few years (Nimer / Lundahl 2007; Souter / Miller 2007; Wells 2007, 2009). Therapeutic-pedagogical work with horses within the scope of therapeutic riding and especially hippotherapy is the type of animal-assisted intervention with the longest tradition in Germany (Gäng 2010). Unfortunately, only very few meaningful studies dealing with the effects of therapeutic riding on social-emotional competences or psychiatric health are available (Bass / Duchowny / Llabre 2009; Cawley / Cawley / Retter 1994; Gray / Capella 2009; Trotter 2006). According to Kaiser, Spence, Lavergne and Vanden-Bosch (2004) the generally assumed benefit of all types of therapeutic riding lies in an improvement of the quality of life for individual patients and in supporting their special needs. A study carried out by Davis et al. (2009) documents an improvement of quality of life after ten sessions. Animal-assisted interventions with other animals such as dogs are proven to be capable of having a positive impact on the quality of life of patients suffering from psychiatric disorders as well (Villalta-Gil / Roca / Gonzales et al. 2009). Apart from this global scale of psychiatric and physical health, referring to long-term effects of interventions, contact with animals during only one therapy session can have a positive impact on the emotional state of mind of patients of various age groups suffering from a variety of disorders (e. g. Banks / Banks 2002, 2005; Prothmann / Bienert/ Ettrich 2006). Background of the study presented here was the development of an evaluation concept for horse-assisted therapeutic work carried out by the Animal-assisted Therapy team, a department of the follow-up care centre of the Clinic for children and juveniles in Augsburg (Bunter Kreis Augsburg e. V.). Here, critically ill children as well as children suffering from chronic diseases, e. g. due to premature birth or traumatic experiences, are taken care of. A special requirement of evaluating clinical every-day routine is the wide range of diagnoses (physical, psychiatric social-emotional) and age groups of children and juveniles. Global scales proven and tested for data collection such as well-being and current state of mind as indicators of positive effects of therapeutic riding, were chosen. These indicators are kept general so they can be deployed on patients suffering from a large variety of disorders. Since in animal-assisted interventions, interpersonal contact with the therapist or other patients within a group setting is supplemented by contact with the animal, relationships with animals to one’s own pet at home or pets in general could have an impact on the effect of animal-assisted interventions. Initial studies (e. g. Nagasawa / Kikusui / Onaka / Ohta 2009; Odendaal 2000; Odendaal / Meintjes 2003) indicate a correlation between the attachment to the animal and positive, stressreducing effects through contact with it. Contact with the animal, especially physical contact The generally assumed benefit of all kinds of therapeutic riding lies in the increase of quality of life of individual patients and in advancing their special needs. 62 | mup 2|2012 Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … (Beetz / Kotrschal / Turner / Hediger / Uvnäs- Moberg / Julius 2011), is accompanied by a lower level of the stress hormone cortisol, indicating a reduction of stress. Apart from that, positive interaction with one’s own animal via stroking (Odendaal 2000; Odendaal / Meintjes 2003) or simply eye-contact (Nagasawa / Kikusui / Onaka / Ohta 2009) results in an increase of the level of the attachment hormone oxytocin, usually accompanied by calmness and relaxation. The study is also supposed to determine the relationship with animals based on the attachment theory according to Bowlby (1969). This theory considers a relationship as a behavioural system or an internal working model, in the sense of a pattern about oneself and others within social relationships and expectations and reactions connected with that. According to Julius, Beetz, Turner, Uvnäs-Moberg and Kotrschal (in print, see also Beetz / Kotrschal / Turner / Hediger / Uvnäs-Moberg / Julius 2011) this model can be transferred to man-animal relationships to a large degree. According to the attachment theory, during the first year of one’s life an attachment to one’s parents or the main attachment figure develops, including an emotional-cognitive representation of this relationship in an internal work model. In the ideal case the attachment is secure, i. e. the child trusts its parents and can make use of this contact to get social support in stressful situations (e. g. fear, danger, illness). In the case of an insecure attachment (avoiding or ambivalent), developed through a less supportive, inconsistent behaviour of the parents or even denial, this effect can hardly be found. Apart from that, in case of an untreated attachment trauma (e. g. Vloss, separation, abuse) an attachment disorganisation may be at hand (Main / Solomon 1986), usually significantly affecting contact to the parents to control stress. The parents themselves can cause fear and stress within the child. It has been proven that an insecure or disorganised attachment of the children themselves (Becker-Stoll 2002; Green / Goldwyn 2002) or their parents (e. g. Benoit/ Zeanah / Boucher / Minde 1992; Greenberg / Speltz / Deklyen 1993), is a risk for the psycho-social development of children and juveniles. An insecure or disorganised attachment of one parent is usually associated with less tactfullness and less efficient social support for the child in stressful situations. Objective of the study This study is designed to examine the effects and influential factors of therapeutic riding by looking at a control sample of children and juveniles suffering from various physical and psychiatric disorders. We expect to find positive effects such as an increase of quality of life during intervention and an improvement of the current state of mind during each therapy session. The quality of the relationship of the child to animals and the attachment representation of the parent accompanying the riding therapy session were determined in order to examine his or her influence on the effect of the intervention. Therapeutic Setting The cross-disciplinary Animal-assisted Therapy team consisted by the time of data collection of eleven people, a psychological psychotherapist trained in animalassisted therapy and a hippotherapist among them. Therapy horses were eight ponies and big horses, specially trained for this purpose. A therapy session usually lasts 60 minutes, of which the time in the arena or on the meadow was about 40 minutes. The rest of the time was used to prepare the horse for the therapeutic session together with the client (care, saddling, bridling etc.) or to say good-bye. Contact with the animal, mainly physical contact, is accompanied by stress reduction. Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … mup 2|2012 | 63 Therapeutic sessions differ to a large degree due to influential factors such as weather conditions, current mood of the therapy horses, various therapists, number of children (individual sessions to small groups of up to four children) and differing disorders of the clients. However, what all sessions had in common was establishing a stable and trustful relationship to the therapist as well as the encouragement of selfesteem and joy of life. For instance, exercises for leading the horse, skillfulness and trust as well as riding around obstacles were aiming at this. Although the activities carried out at and with the horse were very individual and often contained elements from hippotherapy as well as from therapeutic pedagogical vaulting, horseassisted work shall be called therapeutic riding from now on. By having contact with the horse the child was emotionally addressed and, through this emotionalisation as well as its trust in the therapist, encouraged to deal with its situation of life, its disorder and fears. On the other hand, interaction with the horse allowed for a positive distraction from the disease and experiencing joy of life and well-being. Method Through a pre-post-design effects of eight sessions of therapeutic riding (within a period of twelve weeks due to holidays) on the quality of life (KINDL) of the children and juveniles were examined. Apart from that, before and after each therapy session the current state of mind (Basler-state-scale) was determined. What was done as well was collecting data on the relationship with animals (FERT) and the attachment representation (APP) with the parent accompanying the children as influencing variables before the study. KINDL questionnaire (Ravens-Sieberer/ Bullinger 1998) The KINDL questionnaire is a validated, standardised tool with good psychometric properties (Ravens-Sieberer 1998), collecting health-related quality of life of healthy and ill children and juveniles. There are three self-evaluating versions for various age groups: Kiddy KINDL for children from four to seven, Kid KINDL for children from eight to twelve, and Kiddo KINDL for juveniles aged thirteen to sixteen. Apart from that, there are two peer evaluation versions for parents available, Kiddy KINDL for parents of children from four to seven years of age, and KINDL for parents of juveniles from eight to sixteen. The two versions Kid KINDL and Kiddo KINDL, the answer categories of which have five stages and only differ in terms of age adequate wording, were merged for the purpose of this study (Kid and Kiddo KINDL). Using 24 Likert-scaled items, six dimensions were queried: physical well-being, self-esteem, family, friends and functionality in every-day life. Basler State Scale (BBS, Hobi 1985) DThe Basler state scale is a standardised and validated method for collecting data on the subjective state of mind and is suitable for progress monitoring for therapy evaluation. The questionnaire records four items each with five answer alternatives spread across four subscales vitality, vigilance, intra-psychic balance and social extraversion. Since in a pre-test the original version was too much for the younger children in our study in terms of understanding as well as time consumption for two query sessions per session (pre / post) ), a short version was developed for children under the age of eleven, asking about the most important item of each area (item selection made by the authors). By getting in contact with the horse the child is emotionally addressed and thus encouraged, also through its trust in the therapist, to deal with its life situation, its disease and fears. 64 | mup 2|2012 Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … Questionnaire on experience with animals (FERT, Beetz / Ascione 2004 ) The questionnaire on experience with animals is the German version of the ARQ-Animal Relations Questionnaire (Beetz / Ascione 2004). FERT’s part one collects demographic data as well as data on current and past animal possession. The second part was compiled based on the Inventory of Parent and Peer Attachment by Armsden and Greenberg (1987). The 21 items are held in a general form, so they are also suitable for people who never had an animal or who currently do not have one. For animal owners the questions always refer to their own pets. Subscales Trust (six items), Communication (seven items), Alienation (seven items) as well as the overall scale Attachment (seventeen items) are calculated (Cronbach’s Alpha: overall scale Attachment =.90; Trust =.85; Communication =.87; Alienation =.65; Beetz / Mayr / Reiter 2007). Each item is answered on a five-staged Likert scale (1 = not true at all, 5 = very true). Adult Attachment Projective (AAP, George / Pettem / West 1998) Adult Attachment Projective (George / Pettem / West 1998; George West 2001) Adult Attachment Projective (George / Pettem / West 1998; George West 2001) is a projective method for evaluating the attachment representation with adults. The test persons are asked to tell a brief story on eight pictures each, representing an attachment-relevant situation. The transcripts of these stories are evaluated based on indicators of warding processes, untreated attachment traumata and secure attachment by a reliable coder. Integrating these results allows for allocating attachment representations: secure, avoiding / reserved, involved or disorganised (Buchheim / Strauß 2002). Control sample 28 children, fourteen girls and fourteen boys, taken from a patient pool at the children’s hospital and the Kinder- und Jugendpsychiatrie Augsburg. The age of the examined children was between six and sixteen years with an average age of 9.61. Since the tools are not suitable for children suffering from mental disabilities, these patients were not considered in this study. The examined control sample was heterogeneous in terms of their disorders, however, it reflects the usual patient pool of the therapeutic facility. Table 1 shows the allocation of disorders based on the diagnostic criteria of DSM-IV-TR (American Psychiatric Association 2000). Written approval for the adult and the children participating in the study was obtained from the adults themselves and the children’s respective legal guardians. AAP was carried out with the parent dealing most with the children’s therapies, all in all four fathers and 22 mothers (two refused to participate). Educational background of the parents was heterogeneous and covered a range from O-levels to university degrees. All in all, the meaningfulness of this study is, due to the lack of a control group, the heterogeneity of the control sample and the limited number of participants, restricted. Due to the urgent need of children a waiting control group was not justifiable from an ethical point of view, and a control group, supported by a different form of therapy, was not available on location. This is Table 1: Distribution of disorders of the study participants sorted by gender Girls Boys Affective disorders 3 2 Anxiety disorders 8 4 Eating disorders 2 1 Disorders regarding attention, activity and social behaviour 0 6 Tic disorders 0 1 Other disorders with little children, during childhood and adolescence 1 0 Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … mup 2|2012 | 65 why it is hard to control whether observed effects are caused only by therapeutic intervention or by specific aspects of therapeutic riding. Results State of mind before and after therapy sessions (BBS) - Self-assessment of children / juveniles A comparison of the mental state of mind of children who have answered the four-item short version (age < 11 years) and those who have filled out the longer original BBS version, did not show any significant differences with none of the five scales at any given time (therapy session one to eight, before / after) The age was not correlated with the state of mind at any given data point. This is why the data on the state of mind of all children were analysed together (N = 28). Looking at the four subscales vigilance, vitality, intra-psychic balance and social extraversion as well as overall state of mind, in the mean there are almost always positive changes during a therapy session, also across all therapy sessions. An exception was the vigilance in therapy session four, which was slightly decreased, looking at the average value. The value (overall scale) for the state of mind increased on average during each therapy session. The difference between post and pre measuring was biggest during the first therapy session (M = 2.9, SD = 4.2, Max = 14.0, Min: −5.6), and smallest during the third therapy session (M = 0.9, SD = 4.1, Max = 14.0, Min: −4.2). As expected, the improvement of the state of mind was just as low during the final therapy session (M = 1.1, SD = 2.9 Max = 8.4, Min = −4.2), since the imminent ending of a therapy very popular among children and saying good-bye to therapists and horses usually affects the state of mind. Despite the mentioned results, a variance analysis with repeated measurements of the change (difference) of the overall state of mind in each therapy session (first to eight) shows now significant influence (Greenhouse-Geisser: F = 1.522, p = 189) of the number of the therapy session on the change of the state of mind. Summarising the eight therapy sessions, the picture of measuring the state of mind before and after eight sessions is as follows (see ill. 1): Variance analysis with repeated measurement shows a significant improvement of Vitality (F = 4.216, p = .050), Vigilance (F = 10.247, p = .003), Intra-psychic Balance (F = 9.735, p = .004) as well as Overall State of mind (F = 11.826, p = .002) across all therapy sessions and a tendency for Social Extraversion (F = 4.064, p = .054). A comparison of girls and boys regarding a change of state of mind through therapeutic riding during sessions showed a significant difference with Social Extraversion, but not with the other subscales and the BBS overall scale. Boys (difference: M = 0.727) showed, compared with girls, (difference: M = −0.063) a significant improvement of Social Extraversion through intervention with the horse in an average across all therapy sessions (T-Test: T = −2.640, p =.014). Quality of life (KINDL questionnaire) - Self assessment of the children Due to missing questionnaires at the time of the intervention we shall go into detail in the data of the following analyses of seven children under the age of eight (Kiddy KINDL) and sixteen more children age ranging between eight and sixteen (Kid and Kiddo-KINDL - will be evaluated together due to similar values). During self-assessment the children under the age of eight showed a significant improvement of their quality of life regarding their fam- After each therapy session the girls and boys felt more balanced, more vital and all in all better. After the session, boys were more open for friendly contact with others. 66 | mup 2|2012 Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … ily (Wilcoxon test: Z = −2.365, p =.018) and the general function level (Z = −2.277, p =.023) after the intervention period, whereas there was a tendency towards an increase of quality of life across all areas. During self-assessment the children and juveniles from the age of eight years (Kid and Kiddo KINDL) showed a significant improvement across all areas of quality of life except for “Friends” after the end of the intervention compared with the data point before the intervention. The gender of the child showed no significant connection with the change of quality of life (Mann-Whitney-U- Test, difference pre-post test). Quality of life (KINDL questionnaire) - Peer assessment through parents In evaluating the quality of life of the children through their parents the data of all children independent from their age were analysed together due to the comparability of the questionnaire. Also here there were significant improvements on all scales (Wilcoxon test), independent from the child’s gender (Mann-Whitney-U-Test, difference pre-post test). Relation to animals (FERT) The children gave an average value of M = 3.65 (possible scale values min = 1.0, Max = 5, average value = 3) in Table 2: Quality of life before (t1) and after (t2) intervention, Kid & Kiddo-KINDL (children from the age of eight) Average value t1 Average value t2 Wilcoxon test Z Wilcoxon test p Physical well-being 3.51 4.12 −2.085 .037 Mental well-being 3.61 4.25 −2.258 .024 Self-esteem 3.00 3.45 −2.543 .011 Family 3.54 4.27 −3.202 .001 Friends 3.63 3.89 −1.578 .115 Functionality in every-day life 3.60 3.94 −2.578 .010 6,50 6,00 5,50 5,00 4,50 4,00 soc. Extraversion Vitality Vigilance Intra-ps. Balance Overall mental state pre post Ill. 1: Average value of state of mind (BBS) before and after therapy sessions, average of all therapy sessions of all children / juveniles Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … mup 2|2012 | 67 FERT regarding a good and trustful relation with their own pets or animals in general (subscales Trust: M = 4.2, SD = 0.67, Alienation: M = 1.8, SD = 0.81, Communication: M = 3.3, SD = 1.26). Attachment to animals had no significant connection with the change of state of mind during therapy sessions or the change of quality of life across all eight therapy sessions (Spearman’s Rho). Attachment representation of the parent (APP) A secure attachment representation could only be found with eight (31 %) of the 26 examined parents, while one parent (4 %) showed an insecure-involved attachment, eight (31 %) had an insecure-avoiding attachment, and nine (35 %) showed an attachment disorganisation. Variance analyses with repeated measurements were carried out to examine the dependency of the change of the children’s quality of life (selfevaluation of children older than eight years) from the attachment pattern of the parent involved in the therapy. The trend was (p > .10) that children of parents with a secure attachment (N = 8) compared with parents with a disorganised attachment (N = 9) showed a clearer improvement of family-related quality of life (feeling comfortable within the family etc.) (Posthoc Tuckey-HSD-Test: p =.074). This is remarkable since children of parents with a secure-attachment had, on average, higher values already before the intervention than the ones of insecureavoiding and disorganised-attached parents. The coherence of quality of life before therapy and the parent’s attachment status became significant in terms of Friends (ANOVA F = 5.204, p = .041). It was highest with children of secureattached parents (M = 3.63), followed by children of avoiding-attached parents (M = 3.49) and disorganised-attached parents (M = 2.28). Posthoc test (Tuckey-HSD) showed that children of disorganised-attached parents indicated significantly worse friend-related quality of life before the beginning of the therapy than the ones of secure- (p = .022) and insecure-avoiding attached parents (p = .041). Discussion These results indicate that therapeutic riding can lead to an improvement of the state of mind of children and juveniles suffering from various disorders right after the therapy session. This effect is kept across the intervention progress of eight sessions, i. e. the “horse effect” does not get weaker during that period. Only with boys, not with girls, social extraversion has increased during individual therapy sessions. Apart from these short-term effects of therapeutic riding, changes in quality of life Table 3: Quality of life before (t1) and after (t2) intervention, parents questionnaire Average value t1 Average value t2 Wilcoxon test Z Wilcoxon test p Physical well-being 3.51 4.12 −3.304 .001 Mental well-being 3.61 4.25 −3.621 .000 Self-esteem 3.00 3.45 −3.450 .001 Family 3.54 4.27 −2.699 .007 Friends 3.63 3.89 −2.759 .006 Functionality in every-day life 3.60 3.94 −3.541 .000 68 | mup 2|2012 Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … could be observed during the intervention period. While with the small group of children under the age of eight only positive changes regarding family-related quality of life were significant, improvements in all areas of quality of life showed with older children and juveniles according to self-evaluation, except regarding their circle of friends. Peer evaluation made by a parent documented an improvement in all areas, also regarding family, friends, functionality in every-day life, but also self-esteem, psychiatric and physical well-being. Both taken together emphasise the positive value of therapeutic riding on the quality of life of children and juveniles suffering from various disorders. Due to the fact that post measurement was only made once after therapy, no statement can be made regarding the stability of positive changes beyond the actual therapy period. Since it is of interest whether a relatively brief intervention period can yield positive changes, more post-tests should be made in future research projects. The positive effects of therapeutic riding came to the fore independent from a positive relation to one’s own animal or animals in general. The fact that the children in average stated to have a very close relationship with animals confirms the findings of another study on stressregulating effects a dog has on children during a social stress test (Beetz et al. 2011). Also in that study made with more than 80 pupils the children in average reported about a close and trustful relationship to their own pets. So, animal-assisted interventions are of interest for and can be deployed with a large number of children and juveniles if no other reasons for exclusion exist (allergies, other diseases). The statistical significance of the attachment status, only with an effect by trend, of the accompanying parent regarding changes of quality of life during intervention could have mainly been caused by the small size of the group (secure eight/ disorganised nine). Still daring to interpret this tendency, an attachment disorganisation of the parent involved in therapy could be considered an inhibiting factor for improving the quality of life through therapeutic riding. The high percentage of parents with attachment disorganisation does not surprise looking at the children’s disorders, since these are often associated with the children’s psycho-social disorders. Analysis of the quality of life before the beginning of the therapy dependent on the attachment status of the parent emphasises the negative impact of insecure, but mainly disorganised attachment on a child’s state of mind. A systemic approach in the therapy of the child considering the disorganised attachment of the child, could contribute to the positive effect of therapies on the quality of life, well-being and maybe the support of the child’s symptoms. All in all, the results indicate a positive effect of therapeutic riding on the current state of mind and the quality of life of children and juveniles suffering from various psychiatric and physical disorders. This means that already a relatively small number of therapeutic riding sessions can have a positive effect on clients, whereas no statement can be made on the stability of these effects. Apart from that, results indicate that therapeutic riding can contribute to the state of mind and the quality of life of clients with a large range of disorders, which can often be found in reality. Research needs to be done regarding underlying mechanisms leading to these positive psychological effects. Not much known is about this. Test collecting data on psychological and psychophysiological mechanisms as well as their interplay, would make a significant contribution to the understanding and optimisation of therapeutic work with horses. Credits We would like to express our gratitude to Mrs Schuler and the Bunter Kreis Augsburg e. V. for supporting us in carrying out this study. We would also like to thank the supervisor of the final thesis of Mrs Grebe, Prof. Dr. H. Beetz, Grebe - Therapeutic riding enhances quality of life and state of mind of children … mup 2|2012 | 69 Häcker, Bergische Universität Wuppertal, and the Forschungskreis Heimtiere in der Gesellschaft für die Unterstützung der Forschungsgruppe Mensch & Tier at the Institut für Pädagogik, Prof. Dr. E. Liebau, Erlangen university, this project was supervised by. Literature ■ American Psychiatric Association (APA) (2000): Diagnostic and Statistical Manual of Mental Disorders. IV. Text revision (DSM-IV-TR). American Psychiatric Association, Washington D.C. ■ Armsden, G. C., Greenberg, M. T. (1987): The Inventory of Parent and Peer Attachment: Relationships to well-being in adolescence. Journal of Youth and Adolescence 16 (5), 427-454 ■ Banks, M. 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