A Systematic Review Interventions for Children With Attention Deficit

Introduction

Attention-arrears/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by the presence of symptoms including inattention, hyperactivity, and impulsivity.¹ ADHD is currently i of the most common pediatric diagnoses. Approximately half dozen.4 million children ages 4–17 years across the United States were diagnosed with ADHD in 2014, with boys experiencing a 2- to 9-fold greater prevalence than girls.²

ADHD is characterized by a developmental and chronic impairment of executive functions (EFs), which are loftier-level cerebral self-management processes often associated with the frontal lobes of the brain. Via dorsal frontostriatal circuits, EFs allow individuals to regulate their behavior, thoughts, and emotions, and thereby enable self-control, goal-directed behavior, response inhibition, interference command, working memory, and prepare shifting.³ Equally these skills are critical for cognitive, social, behavioral, and psychological development,^4,five

ADHD is often further associated with impairment of psychosocial functioning and a wide diversity of daily tasks across the core symptoms.^six,7 These tin can lead to significant difficulties in academic achievements, and in social and personal relationships,⁵ which result in depression self-esteem and reduced quality of life (QoL).⁷ To enable a child with ADHD to participate in daily activities, treatment must address factors that hinder functioning. The current recommendation for the near constructive intervention is a combination of administration-canonical pharmacologic drug medication and/or testify-based psychological and behavioral therapy interventions.^one

The well-nigh common pharmacologic treatment for ADHD is stimulant medication (methylphenidate and amphetamine), which has been shown to reduce symptoms.ⁱ Other nonpharmacologic interventions focus on cognitive preparation of single or multiple domains of EF, such as working memory, inhibition, or cognitive flexibility. These approaches are led by neuroplasticity principles and are based on intensive repetitive preparation and immediate feedback.^8,9 While these approaches address core symptoms such as hyperactivity and inhibition, they exercise not address everyday performance; they therefore cannot be applied to functional tasks.^ten

Behavioral interventions that have been applied successfully to children with ADHD are subject centered and occupation based. They focus on personal functional goals and include strategy acquisition.^11–13 Although these approaches show substantial evidence for improving EFs and functional/bookish skills, they do not address the psychological difficulties that children with ADHD usually feel. The psychological interventions include, for example, behavioral programs, psychoeducation for parents, and expressive therapies.¹⁴ The existing interventions ameliorate core symptoms, EFs, everyday functions, or emotional symptoms. Despite multiple existing interventions, information technology seems that each of them addresses only one specific aspect of ADHD.

Fauna therapy is divers every bit handling in which diverse animals are used to promote therapeutic goals in the physiological, cognitive, psychological, and sociological areas.¹⁵ Specifically, equine-assisted services (EAS), until recently called equine-assisted activities and therapies (EAATs), are a variety of multimodal and complex activities and therapies, designed for achieving therapeutic and other goals through interaction of subjects with equines. These interventions differ from one another by the therapeutic goals and the therapy provider. As complex interventions, EAS involve a number of behaviors required by those receiving and delivering the intervention, which requires a caste of flexibility and tailoring the intervention to a specific individual.¹⁶

EAS interventions are classified into three wide areas of professional work: therapy, learning, or horsemanship. The Therapy partition relates to the broad surface area of therapy as licensed therapy professionals may incorporate horses in v singled-out therapies: counseling, occupational therapy, physical therapy, psychotherapy, and speech-language pathology. These licensed therapy professionals work inside the scope of practice of their particular field of study.¹⁷ It incorporates equine activities and/or the equine environment.¹⁸ Therapeutic goals aim to promote functional outcomes, which may include enhancing participation, promoting QoL, and encouraging social interaction.¹⁹

Rehabilitative goals are related to the patient's needs and the medical professional's standards of practice. Equine-assisted physical therapy (EAPT), formerly named hippotherapy,²⁰ uses equine motility and purposeful manipulation every bit a specific therapeutic tool used by occupational therapy, physical therapy, or speech-linguistic communication therapy professionals to appoint sensory, neuromotor, and cognitive systems and achieve functional goals inside the providers' telescopic of practice as role of their overall handling plans.¹⁷ While riding, the rider is in a country of abiding physical interaction with the horse, responding to the horse's move. Equine-assisted psychotherapy is divers as an interactive process in which a licensed mental health professional working with or as an appropriately credentialed equine professional partners with suitable equine(south) to accost psychotherapy goals set forth by the mental health professional and the customer.²¹

Learning division includes equine-assisted learning (EAL) in education, organizations, and personal development. It is related to the broad surface area of learning, and specially trained or certified professionals may incorporate base activities (east.g., grooming, handling, leading, and observing). These activities may assist participants attain individualized horsemanship skills.¹⁷

Horsemanship division is related to the wide area of horsemanship, and equine professionals may offer four distinct nontherapy services that are adapted from traditional equine disciplines of horseback riding, driving, and vaulting. These include adaptive equestrian sport, adaptive riding or therapeutic riding (TR), driving, and interactive vaulting.^one ⁷ These aim to raise the cognitive, concrete, emotional, and social well-beingness of individuals with special needs, while learning riding skills and caring for a horse. TR treatment is performed during the horseback riding, through creation and development of a connexion between the rider and the horse, and between the rider and the instructor.¹⁹ Since none of the studies in the current systematic review includes horsemanship interventions, except for TR, they are not fully elaborated.

Several characteristics of EAS are believed to address the core symptoms, EFs, emotional aspects, QoL, and daily office among children with ADHD. Data testify that TR and unmounted activities address EFs and core symptoms of attention in children with autism spectrum disorder (ASD)²² as well as transferring of goals to the habitation and customs environment. EAS were also shown to better EFs among children with ASD.²³ As many of these features are also common to ADHD, the authors hypothesized that different EAS could evidence therapeutic to this population as well. Horses increase motivation, while requiring full attention and engagement in the learning state of affairs. It was found that the animal–man emotional relationship promotes changes in the children'southward functioning, including activities of daily living (ADL), and psychological and motor functions.²⁴

The brute–human relationship also evokes attachment behavior,²⁵ along with the reinforcement of positive actions.^23,26 The connexion with an animal provides a sense of confidence, helps decrease anxiety, and is perceived equally a social connexion and relationship with the participant.¹⁹ In addition, one tin can hypothesize that riding the equus caballus and caring for it may provide an ideal learning environs for acquiring cognitive strategies. Information technology is hypothesized that the sensory stimulation of both the ground-level and mounted activities can help to modulate physiological arousal levels, too improving attending and engagement in the activity. The firsthand feedback that the rider receives from the horse enables concrete and mental cocky-regulation.²⁷ Finally, an intervention that includes both horses and riders in various forms can be tailored to address many difficulties nowadays amid children with ADHD.

To date, few studies have systematically examined the effects of the unlike EAS on children and youth with ADHD. Pérez-Gómez et al. have conducted a systematic review aimed to examine the EAS issue in ADHD-diagnosed children, comparison studies of methodological quality and therapeutic protocols.²⁸ This updated systematic review aims to summarize the electric current show supporting the various EAS to improve the core symptoms of children with ADHD in light of the International Nomenclature of Operation, Disability, and Health (ICF).

The specific research questions are as follows: (i) Which body functions and structures, besides as participation limitation and QoL, are successfully addressed by the various EAS among children with ADHD and (two) which EAS have been found successful at ameliorating core symptoms of children with ADHD? The results of the current review volition assistance grade the scientific basis for developing suitable interventions to accost various difficulties presented past children with ADHD, also every bit to determine which EAS are best suited to treat the individual manifestation of ADHD presented by individual subjects. It will besides point future inquiry needed regarding this population.

Methods

Search strategy

This review was conducted according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)²⁹ (PRISMA checklist in Supplementary Appendix SA1). Relevant literature was first identified through electronic searches. A comprehensive and systematic search of relevant databases (PubMed, Cochrane Database, Spider web of Science, and Google Scholar) was conducted to identify original studies published in peer-reviewed journals in English from inception to December 2020, which explored the apply and benefits of EAS for children and youth with ADHD.

A literature search was conducted using medical field of study heading (MeSH) terms and a combination of several keywords (due east.k., "attending" [MeSH] OR "attention deficit disorder with hyperactivity" [MeSH] OR attending deficit AND "therapeutic riding" OR "equine-assisted therapy" OR "hippotherapy" OR "equine-assisted activities and therapies" OR "horseback riding" OR "equine-assisted learning" AND "child" [MeSH] OR child* OR "adolescent" [MeSH]). Since the optimal terminology for services that incorporate equus caballus¹⁷ was published after completing the search, the authors used previous common relevant terms. Farther relevant manufactures were identified by manually searching the references of retrieved manufactures. The complete search strategy of PubMed tin be found in Supplementary Appendix SB2.

Study selection

Two contained investigators (Y.G. and A.H.) assessed report eligibility. The ii reviewers extracted the post-obit parameters from each study: offset author, twelvemonth of publication, study population characteristics, study design, and nature of the EAS (east.g., which EAS information technology was, duration, frequency, goals, and outcome measures). A third reviewer was considered to adjudicate on differences of opinion, but this was not required because a consensus was reached. The studies were also examined to identify and isolate clusters reporting the same information, and then as to avoid the risk of bias.³⁰

The PICOS (participant, intervention, comparison, outcomes, and written report design) framework was used to develop inclusion and exclusion criteria for the review. Inclusion criteria were as follows: participants (a) all participants in the sample were children or adolescents (upwards to 18 years) diagnosed with ADHD; interventions: (b) EAS protocol was described in the research commodity; comparison (c) control groups for interventions were non restricted and studies were considered for inclusion if they used preintervention measures; outcomes (d) studies included outcome measures that can be categorized according to the ICF; and study blueprint (eastward) any written report design was considered for inclusion dependent on whether EAS intervention was carried out.

The post-obit types of studies were excluded: (a) studies with a mixed sample of adults and children; (b) reviews or theoretical articles; (c) instance studies; and (d) studies' full text was not published in English.

Linking to the ICF

The ICF provides a scientific basis for understanding and studying health and health-related states of people, by establishing a common linguistic communication to facilitate communication and data transfer across health professions. The authors followed a 3-footstep procedure for data processing and linking all studies (n = 12) to the ICF every bit follows: [i] extracting study general data—historic period of participants, gender, written report design, and intervention characteristics; [2] identified the outcome measures; and [three] linking the event measures to the advisable ICF domains.³¹

Ii investigators (Y.G. and A.H.) independently linked each measure to the domains of the ICF and a consensus reached by discussion. The ICF domains include the following: (ane) functioning and disability related to the power or inability to perform disquisitional ADL, including body functions (a), body structures (b), activities and participation (c); and (2) contextual factors, including environmental and personal factors (d).³¹

Body functions are described by the ICF as physiological and psychological functions of the torso systems. Body structures are anatomic parts in the human body and their components.³¹ These include neuromusculoskeletal and movement-related functions that relate to motion, and mobility involving joints, bones, reflexes, and muscle function.³¹ Activity is defined as execution of a task or action by an private, while participation is defined equally involvement in a life situation.³¹ Contextual factors include the individual'south background features that are not part of a health condition or health land. They include age, gender, socioeconomic state, lifestyle, habits, educational activity, past and current experience, and other characteristics that may play a function in disability at whatsoever level. Environmental factors brand up the concrete, social, and attitudinal environs in which people live and comport their lives.³¹

The World Wellness Arrangement has conceptualized QoL as an individual's perception of his or her health and health-related domains of well-being.³¹ It can also be defined equally the subjective perception of happiness or satisfaction with life in domains of importance to an individual. In this respect, many researchers equate QoL with functioning, or base their assessments very heavily on participation.³² Despite the link between QoL and participation, QoL was not captured in the current ICF. Yet, because QoL is considered to be an important consequence in the field of kid health^33,34 and is a long-term goal in therapeutic interventions, the authors described QoL findings in the context of EAS for children with ADHD.

Evaluating the report quality and risk of bias

Due to the need for quality control of prove, the authors assessed the risk for bias by using the physiotherapy evidence database (PEDro) calibration³⁵ and the Newcastle–Ottawa Scale (NOS),³⁶ as well equally the Oxford Centre for Evidence-based Medicine (OCEBM).³⁷ Ii independent reviewers (authors Y.G. and A.H.) completed the checklists based on these scales, to prevent the risk of assessor bias. Discrepant scores were resolved by discussion and consensus. Since this review reported the results of merely ten studies, all levels of evidence were included. Assigning lower levels of prove to some studies does not cast doubt, per se, on the validity of the results for the population studied in those particular investigations, but rather raises business organisation for the caste to which bias might touch the generalizability of the findings.³⁸

The PEDro scale rates controlled trials based on random and concealed resource allotment of participants; similarities of the participants at baseline; blinding of subjects; therapists and assessors; dropout rates; the employ of intention-to-care for assay and reporting bespeak measure out; measures of variability; and betwixt-grouping statistical comparisons. A total score out of 10 was derived for each study, based on the number of criteria satisfied. Studies with PEDro scores ≥5 were considered at low take a chance for bias and moderate to loftier methodological quality³⁹ and were included in the analysis. Higher scores indicated better quality of evidence.⁴⁰

The NOS³⁶ was used for assessing the quality and the potential for bias of nonrandomized studies in three areas: participant selection; comparability; and consequence.³⁶ This is i of 2 tools recommended by the Cochrane Collaboration to evaluate the methodological quality of nonrandomized studies³⁰ and provides good functioning with greater ease of use and more specific criteria relating to observational studies.⁴¹ Using the NOS tool, each written report is judged on eight items, categorized into 3 groups: selection of the report groups; comparability of the groups; and ascertainment of either the exposure or outcome of interest for case–command or cohort studies, respectively. The highest quality studies are awarded up to 9 stars. The authors considered studies with nothing to three, four to six, and 7 to nine stars to represent depression, moderate, and high quality, respectively.

All studies were also classified according to their level of evidence by using the nomenclature proposed past OCEBM: a hierarchy of the probable best bear witness, designed so that information technology can be used to find the probable all-time evidence. The OCEBM Levels of Evidence was designed so that in improver to traditional critical appraisal, it can exist used as a heuristic by clinicians and patients to respond clinical questions quickly and without resorting to preappraised sources. Information technology allows to appraise evidence for prevalence, accuracy of diagnostic tests, prognosis, therapeutic effects, rare harms, common harms, and usefulness of (early on) screening. It is divided into five levels of testify, level i the highest and level 5 the lowest.³⁷

Results

Figure 1 shows that the literature search provided a total of 739 manufactures in the electronic databases: PubMed (n = thirteen), Cochrane Library (north = 4), Google Scholar (n = 719), and Web of Science (northward = 3). After discarding duplicate articles, v were excluded because they were written in a language other than English, and 680 were omitted considering they clearly did not meet the inclusion criteria. Post-obit this starting time extraction, 30 manufactures were obtained and reviewed. Briefing proceedings were excluded besides (two). Thus, a final total of 12 articles that met the eligibility criteria were included in this systematic review. The interventions in the included studies are named according to the EAS terminology as used by the authors, about of which use the sometime terminology of EAAT.

FIG. 1. The preferred reporting items for systematic reviews and meta-analyses menstruum diagram.

Table i summarizes all the evidence from included manufactures relating to EAS according to the ICF model and presents the risk for bias and the quality of the testify according to the PEDro or NOS and OCEBM rating scales.

**Table 1. Summary of the Characteristics, Quality Assessment of the Methodology, and Outcomes of the Included Studies (n = 12)**
	Study	EAS intervention	Written report design	Quality assessment	Population	Intervention length	Control grouping	Body functions and structures	Activity and participation	QoL
1	Jang et al.⁴⁶	EAPT and unmounted activities	Prospective, open-label, pre/postal service	NOS 5/9 OCEBM 3	N = twenty Hateful age (years): 8.40 ± 1.85 Diagnosis: ADHD, ADHD and DCD	12 weeks, 24 sessions	No	^Attention via θ/β ratio on electroencephalography was decreased; ^Decrease in inattention/hyperactivity ^*Motor variables: manual dexterity, bilateral coordination, and total motor blended X No significant difference in attentional test	^*Social issues: young, clinginess, non getting along with peers, clumsiness, and preferring to play with younger children
2	Lee et al.⁴⁴	EAPT	Randomized block research	PEDro five/10 OCEBM ii	N = xx Hateful age (years): 11.55 ± 1.85 Diagnosis: ADHD	32 weeks, 32 sessions	N = 19 Mean age (years): 12.28 ± 0.56 Diagnosis: ADHD	^Decrease body fat; ^Brain function: decrease in the activated insular area; Increase in the activated cerebellum area; ^*BDNF levels showed increased tendency
3	Anderson and Meints⁵⁵	TR and unmounted activities	RCT	PEDro: 5/10 OCEBM 2	N = 15 Mean historic period (years): 10 Diagnosis: ASD with ADHD and SMD	v weeks	No		^*Maladaptive behaviors, including internalized, social and external behaviors X Socialization and advice
iv	García-Gómez et al.⁵¹	TR and unmounted activities	Quasiexperimental, randomized pre/post design	PEDro: half dozen/10 OCEBM iii	N = ix Mean historic period (years): 10.65 ± ane.l Diagnosis: ADHD	12 biweekly sessions, 24 session	N = 5 Mean historic period (years): 10.twenty ± 2.38 Diagnosis: ADHD		X Interpersonal relationship	^*QoL and emotional well-beingness
5	Hyun et al.⁵²	EAPT	Prospective trial	NOS four/ix OCEBM three	N = 12 Mean age (years): x.viii ± one.4 Diagnosis: ADHD	4 weeks, 12 session	Due north = 12 Mean historic period (years): ten.3 ± i.2 No ADHD diagnosis	^Cadre symptoms; increased encephalon connectivity ^Improved gait residue
6	Cuypers et al.⁴³	TR	Quasiexperimental pre/mail service design	NOS viii/9 OCEBM three	N = 5 Age (years): 10–11 Diagnosis: ADHD	eight weeks, 16 sessions	No	^*Motor performance	^*Daily life beliefs	^*QoL, Psychic well-being and schoolhouse
7	And then et al.²⁷	TR	Quasiexperimental pre/postal service design	NOS 4/9 OCEBM 3	N = 10 Age (years): 10.iii ± 1.8 Diagnosis: ADHD	four weeks, 8 sessions	N = x Age (years): eleven.2 ± 1.3 No ADHD diagnosis	^*Feet, depression, and attention Ten No improvement in cocky-esteem	10 Overcoming fear and social participation
viii	Lee et al.⁵⁴	EAPT	Quasiexperimental pre/post design	NOS 7/nine OCEBM 3	N = 16, diagnosis ADHD Group1 N = viii, mean age 11.75 ± 1.28 Group two, Due north = viii, mean age 12.00 ± i.51 Group 3: N = vii, mean historic period 11.42 ± 0.98	Group one: 8 sessions of EAAT, eight weeks Group ii: 16 session of EAAT, viii weeks Group 3: 8 session of EAAT +viii session of neurofeedback	No	^*Increase in BDNF
ix	Yoo et al.⁵³	EAPT	Pre/post design	NOS four/9 OCEBM iii	Northward = 10 Historic period (years): 8.3 ± 1.iii Diagnosis: ADHD	12 weeks, biweekly sessions (24 sessions)	No	^*Brain Function: subsequent resting-country functional signal changes in the right precuneus and pars orbitalis clusters
10	Oh et al.⁴⁷	EAPT	RCT	PEDro seven/ten OCEBM ii	N = 34 Age (years): 8.3 ± 1.48	12 weeks, biweekly sessions (24 sessions)	North = 17, pharmacologic treatment	^*Attention, impulsivity, and hyperactivity		^*QoL
11	Gilboa and Helmer⁴⁸	Equine-assisted occupational therapy	Pre/post pattern	NOS five/nine OCEBM 3	N = 25 Historic period (years): 7.viii ± 12.iii	12 weeks, i session per week	No	^*EF	^*Everyday functional goals
12	Aviv et al.⁴⁵	TR	RCT	PEDro: 9/10 OCEBM 3	N = 64 Age (years): ix ± 1.8	20 weeks, ane session per week	Due north = 65 Age (years): 8.95 ± 1.68	^*EF and cocky-esteem		^*QoL

Quality of included studies

Of the 12 included studies, all were quantitative. Only six out of 12 studies had control groups, and thus, the remaining 6 scored with high risk of bias. The authors establish smashing heterogeneity amid the included studies, in terms of sample sizes, intervention protocol, and study designs, which might issue in high bias from other sources.

Five of the trials were controlled, and therefore rated co-ordinate to the PEDro scale; those scores ranged between 5 and 7 points out of 10 (hateful vi.iv ± 1.67), which reflects moderate-high methodological quality.³⁹ The remaining seven trials were not controlled, and therefore rated according to the NOS. The hateful quality score for the NOS was v.28 ± 1.six, indicating moderate quality on average. Regarding the OCEBM, nine studies were rated at level three/5, while the other three studies were rated at level 2/five.

Outcome measures

The outcomes assessed in the 12 studies together covered all three of the ICF domains: impairments of body structure and function, activity, and participation (Tabular array 2). Of the 34 multiple-detail measures linked to the ICF, the ADHD rating calibration for core symptoms assessment⁴² was the near frequent measure used (four studies, 11.7%), followed by the Clinical Global Impression calibration (three studies, viii.viii%); and functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG) for assessing symptom severity (three studies, 8.viii%).

**Table two. Total Number of Studies Assessing Outcomes Within the Domains and Categories of the International Classification of Functioning, Disability, and Health**
Outcome measures (number of studies using the measure)
Health condition Cadre symptoms assessment: • Attending-arrears/hyperactivity disorder (ADHD) rating scale (four) • Clinical Global Impression (CGI) (3) • Korea Child Behavior Checklist (K-CBCL) (one) • Gordon Diagnostic System (1) • Comprehensive attention test measurement (True cat) (1)
Body functions and structures: • The Behavior Rating Inventory of Executive Part (BRIEF) (2) • The Revised Conners' Parent Rating Scales (1) • Electroencephalogram (EEG) (three) • Body mass alphabetize (BMI) (2) • Cardiorespiratory fitness (1) • Physical force (ane) • Functional magnetic resonance imaging (FMRI) for brain functions (iii) • Tesla Verio MRI scanner (1) • MatScan organisation floor mat (1) • Brain-derived neurotrophic factor (BDNF) (claret test) (ii) • Learning disorder test (1) • Bruininks–Oseretsky test of motor proficiency (BOT-two) (1) • The Modified Function-Neurological assessment (MFNU) (i) • The Motility Assessment Battery for Children (MABC) (1) • The Developmental Coordination Disorder Questionnaire (DCDQ) (2) • Cocky-esteem (3) • The Kid Anxiety scale (1) • The Center for Epidemiological Studies-Depression scale (CES-D) (ane)
Activity and participation • Autism spectrum quotient for children, iv-eleven-ASQ (1) • Autism spectrum quotient for adolescents, 12–fifteen (i) • The Empathizing Quotient parent written report (one) • The Vineland Adaptive Behavior Scale (VABS) (1) • The Behavior Arrangement for Children (BASC) for teachers (1) • Child Behavior Checklist (CBCL) (1) • Canadian Occupational Performance Measure (COPM) (1)
Quality of life • Quality-of-life (QOL) questionnaire (1) • Strength and Difficulties questionnaire (SDQ) (1) • KINDL health-related quality of life questionnaire-for children and parents (1) • Pediatric Quality of Life Inventory (PedsQL) (one)

Nigh ICF upshot measures were used to assess body function and structures (52.9%), while fewer (20.5%) were used for activity and participation, including social behavior and maladaptive beliefs, and QoL. Only a few of the measures covered nigh of the ICF components, including trunk functions, activity and participation, environmental and personal factors. The content of measures differed significantly in their representation of the ICF capacity in all components. As some researchers included comorbidity, some outcome measures referred to other diagnoses such as ASD. Where instruments contained subscales and several items, these were individually assigned to the relevant category (Table ii). Contextual factors were not assessed separately.

Using the ICF as a framework, the codes and categories inside wellness and wellness-related domains relevant to ADHD were commencement identified. Second, the outcomes assessed in the ten retrieved studies were mapped to the relevant domains and categories of the ICF (Fig. 2).

FIG. 2. — FIG. ii. ICF wellness-related domains relevant for ADHD identified during the study. ADHD, attending-deficit/hyperactivity disorder; BDNF, claret–brain-derived neurotrophic factor; EF, executive part; ICF, International Nomenclature of Performance, Disability, and Health.

Effects of various EAS on body part and structures

EAS were found to be beneficial among children with ADHD with respect to the following trunk functions and structures:

Mental function

TR (due north = 4) and EAPT (n = 6) studies have shown that riding offers an opportunity for success that raises global mental functions such as self-confidence, self-esteem, and motivation.^27,43–45 In addition, EAPT studies (n = 3) showed an improvement in specific mental office. For example, a significant increase was institute in retentiveness functions of the left bilateral heart frontal cortex, correct bilateral eye frontal cortex, and left precentral cortex.⁴⁴ Improvements were found in specific core symptoms, including hyperactivity, impulsivity, and inattention using the ADAD rating calibration,^46,47 yet, one report showed no improvement in the attentional test.

Studies used equine-assisted Occupational Therapy (OT) and TR, institute improvement in EFs, especially in monitoring, working memory, and initiation.^45,48 These two studies used the Behavior Rating Inventory of Executive Function ⁴⁹ a valid questionnaire for EF assessment among children with ADHD.⁵⁰ However, another TR study, which included unmounted activities and riding, found zero results in core symptoms' improvement.⁵¹

Neuromusculoskeletal and movement-related functions

A study with five children ages 10–11 years participating in 16 sessions found an improvement in motor performance.⁴³

Metabolic functions

One study assessed the result of 32 TR sessions and found a decrease in body fat in insular areas.⁴⁴

Nervous system functions

The influence of EAS on the nervous system was demonstrated in five studies using iii dissimilar objective result measures (e.g., fMRI, EEG, and blood testing).^{27,44,46,52,53} Claret–encephalon derived neurotrophic factor (BDNF) plays a key role in nerve-cell dopamine receptors, which is thought to affect core symptoms in ADHD. In a report including 16 children that lasted 16 sessions of combined EAPT and neurofeedback training, a meaning increment was found in the BDNF level in the research group, which may point brain role improvement.⁵⁴ Another study showed similar results afterward 32 sessions without neurofeedback using a control grouping.⁴⁴ fMRI was used in 3 studies and demonstrated decreased activity in the right precentral cortex, where more neurotransmitter activation is found,^50,52 in add-on, cerebellum activation was increased afterwards EAPT.⁴⁴

Effects of EAS on activity and participation

EAS (n = four) have been found to enable participation in activities in the following domains:

Interpersonal interactions and relationships

In that location is evidence of social behavior and participation comeback post-obit EAPT among children with ADHD. Social behavior traits targeted for improvement included young behavior, clinginess, not getting along with peers, awkwardness, and preferring to play with younger children.⁴⁶ A study that included TR and unmounted activities reported significant changes in maladaptive behavior, which decreased afterwards half-dozen sessions of three h each. Significant improvement in empathy was also found. In addition, another study, which likewise incorporated unmounted activities and TR sessions, institute moderate improvement in interpersonal relationships.⁵¹ All the same, another study found no improvement in socialization and advice skills later a five-week TR and unmounted activities.⁵⁵

Regarding social role behavior, an improvement was found in emotional symptoms and conduct problems relative to before the TR.⁴³ It is important to mention that some results have been reported by teachers and some by parents and thus have the take chances of bias as they do not hold both reports.

In the ADHD population, there was comeback in self-regulating beliefs after TR sessions⁴⁴ and in the behavioral inhibition system,⁵³ also equally improvement in occupational performance and occupation-based goals after equine-assisted OT. The functional goals were related to education (e.g., doing homework independently), self-care (e.g., performing morning time routine on time), and leisure and socializing (e.g., engaging in a soccer game with friends in the afternoon).⁴⁸ In another report, statistically significant comeback was found in feet and depression measures, equally well as learning disorder comeback following TR sessions.²⁷

Contextual factors

The EAS take identify in the physical surroundings of the stable: a nonconventional treatment surround that might encourage therapeutic engagement. By involving animals and instructors, who are non perceived as a part of the medical or clinical world, the stigma of treatment is removed.⁵⁶ In this review, nevertheless, no research was found examining the specific effect of various EAS on other personal factors.

An important and unique issue relevant for EAS is the safeness of the intervention in the stable surroundings. Six studies reported safety considerations taken in advance to prevent adverse events. They specified safety equipment supplies for riders such as helmets and harnesses and prophylactic education, as well equally the use of proper trained horse adequate for the EAS intervention.^{27,44,47,52,54,55} No safety events have been reported in all included studies.

Quality of life

The authors found that despite the importance of QoL as an consequence measure, the impact of EAS on QoL was tested in only four studies using unlike outcome measures, which might increase bias.^43,45,47,51 The intervention included TR and EAPT, demonstrating that all 3 tin enhance QoL aspects. An improved QoL was reported both by children and parents in 2 studies.^43,45

Discussion

This systematic review summarizes the literature, namely, 12 peer-reviewed studies that met the inclusion criteria, which investigated the effectiveness of using EAS, defined broadly as diverse interventions incorporating horses for children diagnosed with ADHD, using the ICF concepts and terms. Using the ICF, information technology is possible to describe important and meaningful aspects of function and intervention outcomes amongst children with ADHD. It is easy to understand why these domains and factors play such important roles in the potential outcome of whatever wellness intervention.

Most of the studies that the authors examined investigated the effects of various EAS on trunk structures and functions, with an accent on the motor, sensory, and psychological areas. These studies are based on bottom-up rehabilitation approaches, which human activity on the distal physical level and aim at influencing the cardinal nervous system.⁵⁷ These are believed to exist prerequisites to successful occupational performance or functioning.⁵⁸ Some of the studies addressed activeness and participation, and QoL.

Birthday, the reviewed studies showed moderate methodological quality, while v studies demonstrated moderate-high methodological quality. Studies showed mostly positive outcomes, which back up the utilise of dissimilar EAS for promoting trunk functions and participation among children with ADHD. The current results shows that EAPT studies had greater influence in terms of trunk functions and structures, especially comeback in specific mental functions,^44,46,47,53 even in distant environments outside the stable.⁴⁸

It is hypothesized that the outcome of the interventions on body function and structures derives from ii chief sources. Get-go, the riding itself provides unique sensory input and encourages motor response during the motility.⁵⁹ The horse'southward pelvic movement during its walking pace has a rhythmic three-dimensional step that mimics the movement of the human being pelvis, and therefore, it provides the same course of motor, sensory, and proprioceptive input that is received during the homo walking gait.^44,lx–63 The passenger must learn how to adjust his or her body and align it with the horse's body.

Second, riding requires the rider to calm his/her senses and pay attention, to succeed in giving the correct body signals for asking to walk, run, or halt; otherwise, the equus caballus will non perform the task the rider requires. It is likewise assumed that when riding is performed on different terrains and in varying rhythms (walking, running, and cantering), it requires focus on matching the range of attending to the different activities; it therefore helps to amend the attention span.⁶⁴ In terms of body function, nevertheless, studies regarding the furnishings of EAS on cognition, intellectual processes, temperament, and other nonphysical functions are still needed.

EAS are also causeless to promote participation through various psychological benefits.⁶⁵ These improvements have been plant in most TR interventions, incorporating unmounted activities (currently classified as EAL) with the horses, rather than solely riding them.^27,43 TR has been shown to ameliorate social interactions, maladaptive behaviors, and interpersonal relationships.^51,55

There are several hypotheses regarding the mechanisms of EAS in promoting participation. First is the interaction that occurs in the stable, both with the horse-riding instructor and with other riders. The relationship established between the rider and the horse is an important aspect in the riding procedure. Information technology is causeless that bonding with the equus caballus makes allowances for the rider's difficulties in a nonjudgmental context.²⁵ The second is the set of tools and skills that the passenger acquires during the intervention that can be transferred to other contexts and interactions exterior the stable. Some show has shown generalization of treatment outcomes following EAS to the habitation and community environments, as well every bit to the classroom.

It is worth noting that these effects were found in interventions applied by licensed therapeutic professionals.^48,66 Third, EAS are perceived as a sport and not equally a therapy procedure.⁶⁷ Riding enables the rider to perform a normative leisure activity, where the individual can express him/herself freely. It serves as a motivational stimulus to "forego" treatment. This held true amidst participants with psychopathologies, too equally children and adults with ASD, where social motivation, social interaction, and communication skills were enhanced following the intervention.^22,56,64

Regarding QoL, it is assumed that improving body functions and structures will amend participation in meaningful life areas, which will positively influence the individual's QoL.⁵⁸ Only three studies accept shown improvement in QoL and well-being post-obit EAS amidst children with ADHD.^43,47,51 Interestingly, these studies included EAPT and TR combining riding and unmounted activities. Those results are nevertheless in line with others that assessed the impact of EAS on QoL amid children with cerebral palsy and intellectual disability.^68,69

All interventions included under the definition of EAS safely comprise both provider and horse and sometimes involve significant others (e.thousand., parents, teachers). Complex interventions such as these require multiple interacting components that must be addressed in a single intervention session. Every bit can exist seen in this review, the unique intervention components (due east.one thousand., horse, environment, unmounted activities) take been shown to have some benefits in diverse areas, especially when performed by certified professionals and while combining unmounted activities.

Each intervention showed specific improvement in unlike components according to the ICF. For example, EAPT was found to be effective in improving body function (e.m., specific mental functions) and TR in action and participation (e.g., social behavior). It should be mentioned that some studies take shown no improvement in attention,⁴⁶ self-esteem, and socialization.^27,55 These results might be explained by the fact that the TR and EAL were not performed by a licensed therapist. In addition, the authors hypothesized that these results might also relate to the combining of unmounted activities and less riding fourth dimension on the horse.

Farther research is needed to address the mechanisms of alter involved in the diverse intervention characteristics. This cognition will be helpful in developing specific modality of goal-directed interventions that can be tailored to each child. Studies that will evaluate the long-term effects and influence of EAS on QoL and participation in daily life of children with ADHD through diverse contexts are needed likewise. In improver, combining objective with subjective unremarkably used outcome measures can heighten the validity of intervention and enable replication.

Limitations

While the existing evidence is from research studies, potential biases in evidence might take influenced the results. The PEDro Scale and NOS assessments have been shown to have acceptable levels of psychometric backdrop.^70,71 The NOS has the potential for more limited ability to observe bias in the examined studies, specially in the areas of pick of appropriate written report blueprint, statistical analysis, reporting, and generalizability of results.⁷² It is important to note that assigning lower levels of evidence to some studies does not cast doubt, per se, on the validity of the results for the populations studied in those particular investigations but rather raises business concern about the degree to which bias might bear upon the generalizability of the findings.

Moreover, the authors excluded briefing proceedings and abstracts, potentially resulting in publication bias since the proportion of studies with null findings is likely greater in those presented at conferences merely not published, compared with those published in peer-reviewed journals.^xxx Another potential for bias was the option of articles written in English language only, while inquiry in other languages were excluded, equally virtually studies have been done outside the United States or not-English-speaking countries such every bit Korea,^{27,44,46,47,52,53} Spain,^51,55 and Iran.⁷³

Furthermore, the definition of each EAS intervention and attribution to each methodology (therapy, horsemanship) seemed to be unclear at times. In addition, most studies had no unified protocol inside their treatment modality (e.g., TR, EAPT), and therefore, no precise fashion to replicate those measures and outcomes. Almost studies did not specify the exact grade of handling (i.east., the number of sessions needed, group versus individual intervention, the type of horse in terms of conformation and character), only only gave full general outlines of performance. These limitations might restrict the generalizability of the findings.

Conclusion

Over the past 20 years, just 12 studies were found evaluating EAS among children and adolescents with ADHD. Nearly research has shown the positive effect of EAS in terms of body structures and functions, activity and participation, besides equally QoL. Specifically, it has been found to improve the cadre symptoms of ADHD, such as hyperactivity, impulsivity, and inattention, especially during EAPT sessions and interventions.^46,48,53,74 Positive changes were besides seen in participation, peculiarly in social integration during TR session and unmounted activities with the horses.^46,55 However, despite the research and show gathered on the effectiveness of various EAS among children with ADHD, there is yet a long fashion to go until solid verification is established.

Future studies that will examine dissimilar EAS can be valuable to promote the understanding of unique mechanisms of change inside each handling modality. This volition permit us to found a meliorate-suited and tailored intervention for each individual. Understanding the significant of a multimechanism and complex intervention is also crucial for setting handling goals and outcomes. Within the existing studies, almost of the samples were small and the criteria for the various impairments were inconsistent. Hence, larger RCTs are required to confirm the current evidence and provide more information on EAS outcomes for children with ADHD.

Author Disclosure Statement

No competing financial interests exist.

Funding Data

The work submission is the authors'. This review did not receive whatever specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SB2

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Source: https://www.liebertpub.com/doi/10.1089/acm.2020.0482