A Residential Treatment Center (RTC) is a facility dedicated to providing therapeutic care to children with complex psychiatric illnesses who are sub-acute in their presentation. The children stay full time at the RTC for several weeks to several months, and receive intensive therapy and consistent monitoring, in order to ensure their safety while providing an immersive therapeutic environment for recovery (Texas Health and Human Services, 2016-2021). In a healthcare system where length of stay (LOS) is considered an important measure of the quality of care provided, RTCs face a unique challenge: to maximize the therapeutic effectiveness of treatment while minimizing the length of stay for patients, specifically in patients diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).
Unfortunately, it has been documented that children with extended psychiatric stays are at risk for re-traumatization due to the negative experiences of being in a psychiatric facility (Hirsch & Steinert, 2019). Common interventions in psychiatric facilities such as restraint and seclusion have an added risk of potentially re-traumatizing pediatric patients (Hirsch & Steinert, 2019). Therefore, the longer a patient is admitted to a psychiatric facility, the greater the risk that the practices of the facility could actually worsen symptoms of trauma, leading to the worsening of symptoms of the psychiatric condition assigned upon admission.
Additionally, the cost of healthcare spending for mental health treatment is rising. Between 2009 and 2019, there has been an estimated $108.8 billion increase of expenditures towards mental health and substance abuse treatment (Substance Abuse and Mental Health Services Administration, 2010-2020). This increase in spending creates a significant burden on not only the economy, but for individual payers as well.
Intervention
Horses, as well as many domesticated animals, have been utilized for medical treatments dating back to the second century (White-Lewis, 2019). Animal assisted therapies have been shown to improve psychosocial, physical and emotional aspects of individuals’ lives (White-Lewis, 2019). Equine-therapy is a specific form of animal-based therapy in which patients learn to ride, train, and care for horses (Garcia-Gomez et al., 2016). Equine therapy has shown effectiveness in improving patients’ overall quality of life as well as reducing symptoms often experienced by patients with PTSD and ADHD.
Interactions with horses, especially riding and caring for horses, has been shown to be an effective therapeutic intervention for children with varying diagnoses (Garcia-Gomez et al., 2016). Equine-assisted therapy (EAT), or equine-facilitated psychotherapy (EFP), typically involves grooming, riding, and practices with the neck-rope of the horse (Shelef et. al, 2019). Therapy with horses has been shown to be effective in improving quality of life in with patients with autism, post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD) (White-Lewis, 2019). Specifically geared towards PTSD, equine-assisted therapy has been shown to increase self-efficacy and self-esteem, and to improve the ability to perform daily tasks (Shelef et. al, 2019). For pediatric patients diagnosed with ADHD, equine-assisted therapy has increased executive functioning, emotion regulation, and overall self-control (Gilboa & Helmer, 2020). In pediatric patients with psychiatric disorders, the greatest predictor for length of stay is the specific diagnosis and the severity of symptoms experienced by each individual (Chakravarthy et al., 2017). This paper aims to determine if equine-assisted therapy, compared to current therapeutic practices, decreases the severity of ADHD symptoms in pediatric patients with an ADHD diagnosis currently admitted to a residential treatment center in San Antonio, Texas over a 12-week treatment program.
As mentioned previously, the length of stay within a psychiatric facility is largely based on diagnosis and severity of symptoms (Chakravarthy et al., 2017). Therefore, evidence that shows a decrease in ADHD related symptoms may potentially decrease overall length of stay in patients suffering from ADHD.
One systematic review, consisting of eight non-controlled prospective studies and 4 randomized controlled trials concluded that equine-therapy seems to improve physiological functions of patients with ADHD including physical fitness and overall brain function (Helmer et al., 2021). One of the specific studies analyzed within this systematic review was a controlled experiment that evaluated ADHD patients’ improvements in symptoms according to the Behavior Assessment System for Children (BASC) scale and a quality-of-life questionnaire (Garcia-Gomez et al., 2016). This study showed that there was a significant difference in the quality-of-life questionnaire results between the equine-therapy group and the control group (Garcia-Gomez et al., 2016).
Furthermore, another study analyzed the executive functioning (assessed by questionnaires) of pediatric patients with ADHD by comparing patients receiving equine-based therapy to a control group which received medication treatment only (Aviv et al., 2020). This study consisted of 123 children who received either 20 weeks of equine-therapy or medication alone treatment. The equine-therapy group demonstrated a significant improvement in the executive functioning of the patients, as well as improved self-esteem as compared to the control group (Aviv et al., 2020). Improving executive functioning and patient self-esteem are essential in patients with ADHD; therefore, this data suggests that improvement in these areas may result in a decrease in severity of ADHD symptoms and potentially decrease overall length of stay within residential treatment facilities. Being that it is not uncommon for patients to remain at a residential treatment facility for six months or more, it would be reasonable to evaluate a 12-week treatment regimen (as evaluated in many of these studies) in the pediatric patients in the residential facility in San Antonio, Texas.
Conclusion
Due to the growing concern of polypharmacy within the psychiatric field, non-pharmacologic interventions such as equine-therapy require significant consideration and research regarding their overall effectiveness. Should more research demonstrate that equine-therapy is an effective treatment option for children with ADHD, there is potential for improving overall quality of life, and decreasing the severity of ADHD symptoms. With more manageable symptomatology, children can spend less time admitted to psychiatric facilities, which reduces the risk for re-traumatization as well as limiting the financial burden that can impact treatment. When prescribing and referring patients to specific treatment models, nurse practitioners need to be aware of the risks of treatment, such as re-traumatization, as well as potential barriers to treatment, such as financial burden. One systematic review, which included nine separate articles based in equine therapy concluded that further research with higher methodological quality needs to be considered before the effectiveness of equine-therapy can be fully understood (Perez-Gomez et al., 2021). This highlights the importance of further research to better understand the potential benefits that equine-assisted therapy may have in improving the overall quality of life of patients suffering from ADHD and potentially decrease their overall length of stay within psychiatric facilities.
References
Aviv, T.-li M., Katz, Y. J., & Berant, E. (2020). The contribution of therapeutic horseback riding to the improvement of executive functions and self-esteem among children with ADHD. Journal of Attention Disorders, 25(12), 1743–1753. https://doi.org/10.1177/1087054720925898
Chakravarthy, B., Yang, A., Ogbu, U., Kim, C., Iqbal, A., Haight, J., Anderson, C., DiMassa, G., Bruckner, T., Bhargava, R., Schreiber, M., & Lotfipour, S. (2017). Determinants of pediatric psychiatry length of stay in 2 urban emergency departments. Pediatric Emergency Care, 33(9), 613–619. https://doi.org/10.1097/pec.0000000000000509
Children’s mental health residential treatment center project. Texas Health and Human Services. (n.d.). Retrieved November 5, 2021, from https://www.hhs.texas.gov/services/mental-health-substance-use/childrens-mental-health/childrens-mental-health-residential-treatment-center-project#:~:text=The%20average%20length%20of%20time,Help%20Through%20the%20RTC%20Project%3F.
García-Gómez, A., Rodríguez-Jiménez, M., Guerrero-Barona, E., Rubio-Jiménez, J. C., García-Peña, I., & Moreno-Manso, J. M. (2016). Benefits of an experimental program of equestrian therapy for children with ADHD. Research in Developmental Disabilities, 59, 176–185. https://doi.org/10.1016/j.ridd.2016.09.003
Gilboa, Y., & Helmer, A. (2020). Self-management intervention for attention and executive functions using equine-assisted occupational therapy among children aged 6–14 diagnosed with attention deficit/hyperactivity disorder. The Journal of Alternative and Complementary Medicine, 26(3), 239–246. https://doi.org/10.1089/acm.2019.0374
Helmer, A., Wechsler, T., & Gilboa, Y. (2021). Equine-assisted services for children with attention-deficit/hyperactivity disorder: A systematic review. The Journal of Alternative and Complementary Medicine. https://doi.org/10.1089/acm.2020.0482
Hirsch, S., & Steinert, T. (2019). Measures to avoid coercion in psychiatry and their efficacy. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0336
Pérez‐Gómez, J., Amigo‐Gamero, H., Collado‐Mateo, D., Barrios‐Fernandez, S., Muñoz‐Bermejo, L., Garcia‐Gordillo, M. Á., Carlos‐Vivas, J., & Adsuar, J. C. (2021). Equine‐assisted activities and therapies in children with attention‐deficit/hyperactivity disorder: A systematic review. Journal of Psychiatric and Mental Health Nursing. https://doi.org/10.1111/jpm.12710
Shelef, A., Brafman, D., Rosing, T., Weizman, A., Stryjer, R., & Barak, Y. (2019). Equine assisted therapy for patients with post-traumatic stress disorder: A case series study. Military Medicine, 184(9-10), 394–399. https://doi.org/10.1093/milmed/usz036
White‐Lewis, S. (2019). Equine‐assisted therapies using horses as healers: A concept analysis. Nursing Open, 7(1), 58–67. https://doi.org/10.1002/nop2.377
Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
| Citation
Complete Scholarly Article following APA |
Purpose | Design and
Strength /Level of Evidence |
Sample participants/ volunteers | Measurement(s) if used in the study or report
If qualitative may not have instrument If reports of data collected may not have instrument. |
Results/ Conclusions/ Recommendations |
| Aviv, T.-li M., Katz, Y. J., & Berant, E. (2020). The contribution of therapeutic horseback riding to the improvement of executive functions and self-esteem among children with ADHD. Journal of Attention Disorders, 25(12), 1743–1753. https://doi.org/10.1177/1087054720925898 | The purpose of this study was to evaluate the effectiveness of equine therapy on executive functioning (EF) of children with Attention-Deficit Hyperactivity Disorder (ADHD) in Isreal.
|
Cross- sectional Survey; (Level II) | This study surveyed 123 Israeli children diagnosed with ADHD. All participants had no other psychiatric diagnoses, and were all receiving medication as treatment for ADHD. | This study utilized surveys regarding hyperactivity, attentiveness and oppositional behaviors, filled out by the children’s mothers | Therapeutic horseback riding improves executive functioning in children with ADH, and also increased their self-esteem |
| Chakravarthy, B., Yang, A., Ogbu, U., Kim, C., Iqbal, A., Haight, J., Anderson, C., DiMassa, G., Bruckner, T., Bhargava, R., Schreiber, M., & Lotfipour, S. (2017). Determinants of pediatric psychiatry length of stay in 2 urban emergency departments. Pediatric Emergency Care, 33(9), 613–619. https://doi.org/10.1097/pec.0000000000000509 | The purpose of this study was to evaluate the factors that lead to longer lengths of stay in pediatric patients with psychiatric diagnoses. | Cross-sectional
Study; (Level II) |
This study had 939 participants between the ages of 3 years and 17 years old, presenting to one of two urban emergency departments. | A retroactive chart review was performed with the intention of determining the factors that are related to increased length of stay for pediatric patients with psychiatric diagnoses. | This study found that diagnosis was the primary determinant of length of stay. Children with psychotic disorders, suicide attempts or suicidal ideation had longer lengths of stay than children with other diagnoses. |
| García-Gómez, A., Rodríguez-Jiménez, M., Guerrero-Barona, E., Rubio-Jiménez, J. C., García-Peña, I., & Moreno-Manso, J. M. (2016). Benefits of an experimental program of equestrian therapy for children with ADHD. Research in Developmental Disabilities, 59, 176–185. https://doi.org/10.1016/j.ridd.2016.09.003 | The purpose of this study was to empirically evaluate equine therapy as a potential therapeutic resource for children with ADHD. | Quasi-experimental | (N= 14) Fourteen total children aged 7-14 years with an ADHD diagnosis, 9 in the experimental group and 5 in the control group. | A Behavioral Assessment Survey for Children (BASC) was completed for each child, consisting of two portions: one for the teacher and one for the parents. | While this study found benefits to implementing equine therapy for children with ADHD, they found the benefit to be more closely aligned with the benefits of physical exercise than with therapy. |
| Gilboa, Y., & Helmer, A. (2020). Self-management intervention for attention and executive functions using equine-assisted occupational therapy among children aged 6–14 diagnosed with attention deficit/hyperactivity disorder. The Journal of Alternative and Complementary Medicine, 26(3), 239–246. https://doi.org/10.1089/acm.2019.0374 | This study aimed to evaluate the effectiveness of self-management intervention for attention and executive functions via equine-assisted occupational therapy (STABLE-OT)
|
Cross-sectional survey; (level II)
|
(N=25) 25 children ages 6-14 years old with ADHD diagnoses
|
Using The Behavior Rating Inventory of Executive Function (BRIEF) and the Canadian Occupational Performance Measure (COPM), the researchers were measuring changes in the executive function of participants | Equine-assisted therapy provided a significant increase in executive function in children with ADHD. |
| Helmer, A., Wechsler, T., & Gilboa, Y. (2021). Equine-assisted services for children with attention-deficit/hyperactivity disorder: A systematic review. The Journal of Alternative and Complementary Medicine. https://doi.org/10.1089/acm.2020.0482 | A systemic review was performed to evaluate the current research on Equine-assisted therapy. This review was aimed to evaluate the current evidence to determine if Equine-assisted therapy would be a valuable point of study | Systematic Review of 4 RCTs and 8 noncontrolled studies (Level I) | Twelve articles were found. Of that 12, eight studies were noncontrolled prospective studies and 4 were randomized controlled trials. | Researchers reviewed electronic databases from inception to December 2020 in order to find articles regarding EAT as treatment for pediatric ADHD | There is preliminary evidence that equine-assisted therapy can promote physiologic systems in children with ADHD; however, more evidence is needed to support that EAT can improve participation and quality of life for children with ADHD. |
| Hirsch, S., & Steinert, T. (2019). Measures to avoid coercion in psychiatry and their efficacy. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0336 | A systematic review was performed in order to evaluate the effectiveness of coercion measures in psychiatry. | Systematic Review of 84 studies in which 16 were RCTs (6 of which were controlled RCTs).
(Level I) |
Eighty-four studies were reviewed, primarily those focused on reducing the use of restraint and seclusion. Sixteen studies had control groups. Of those 16 studies, 6 were randomized control studies. | Researchers reviewed articles that had been found on Medline and Cinahl databases. They also reviewed the references lists on the publications found on Medline and Cinahl. | Seven categories were identified as methods to directly reduce the rates of restraint and seclusion: staff training, organization, risk assessment, environment, debriefings, psychotherapies, and advanced directives. Utilizing this information, it is possible to develop a complex program to reduce restraint and seclusion use in psychiatry. |
| Pérez‐Gómez, J., Amigo‐Gamero, H., Collado‐Mateo, D., Barrios‐Fernandez, S., Muñoz‐Bermejo, L., Garcia‐Gordillo, M. Á., Carlos‐Vivas, J., & Adsuar, J. C. (2021). Equine‐assisted activities and therapies in children with attention‐deficit/hyperactivity disorder: A systematic review. Journal of Psychiatric and Mental Health Nursing. https://doi.org/10.1111/jpm.12710 | The purpose of this article was to perform a systematic review of updated literature about EAAT in children with ADHD | Systematic review of 9 articles
Level I |
Seven studies were found to be evidence level C, and nine articles were evidence level B. | A systematic review was performed until 28 November 2019, in four electronic databases: PubMed, Web of Science, Embase and Google Scholar. The inclusion criteria included were intervention program with pre- and post-data, based on EAAT, studying children with ADHD the articles written in English. | The researchers concluded that the data supported evidence level C, meaning that clinicians should use flexibility when making treatment decisions. There is evidence to support the effectiveness of equine-assisted therapy; however, it is not substantial enough to entirely change current practice. |
| Shelef, A., Brafman, D., Rosing, T., Weizman, A., Stryjer, R., & Barak, Y. (2019). Equine assisted therapy for patients with post traumatic stress disorder: A case series study. Military Medicine, 184(9-10), 394–399. https://doi.org/10.1093/milmed/usz036
|
The purpose of this study was to assess the effect of EAT on patients with PTSD in terms of symptoms and functioning in work, family and social interaction. | Case series study – non-controlled
(Level IV would be case-control study, unsure for this because no control) |
There were 23 total participants, 10 of which withdrew before completion of the study and 13 completed the study. | This study used The Short Post Traumatic Stress Disorder Rating Interview (SPRINT) and the Sheehan Disability Scale (SDS) as measurements | This study concluded that there is evidence to support the potential effectiveness of EAT; however, more research needs to be done to fully conclude this. |
| White‐Lewis, S. (2019). Equine‐assisted therapies using horses as healers: A concept analysis. Nursing Open, 7(1), 58–67. https://doi.org/10.1002/nop2.377 | To clarify the attributes, antecedents and
meaning of equine‐assisted therapy and present an operational definition |
Concept Analysis
(Level VII) |
No Participants or volunteers used. | No measurements used. Article utilized the Walker and Avant concept analysis method | Results indicated that the attributes of equine therapy include the following: a human participant with an equine
physically present to assist the human participant, a treatment or intervention as a result of the interactions between an equine and a human participant, a purposeful and regulated interaction and a positive health outcome goal from the interaction
Antecedents included the following: a live horse with a human physically able to interact with the horse, a facilitator and accessibility to an equine‐assisted therapy (EAT) program.
Consequences include: improved balance, well‐being, quality of life, trust, spasticity, self‐efficacy, self‐esteem, nurse presence, pleasure and a sense of accomplishment |