Original Articles

The Effect of Therapeutic Horseback Ridingon 5 Children with Attention Deficit Hyperactivity Disorder:

A Pilot Study

Koenraad Cuypers, PT, MSc, PhD(Cand),1 Karin De Ridder, MD, PhD(Cand),2,3

and Arve Strandheim, MD, PhD(Cand)1,4

Abstract

Objectives: The aim of this pilot study was to investigate the effects of therapeutic horseback riding on behavior,health-related quality of life, and motor performance in children with attention deficit hyperactivity disorder(ADHD).Design: The study employed a time series quasi-experimental design with two pretests and two post-testsconducted 8 weeks apart.Setting/location: The study was conducted at a riding school in Levanger, Norway.Subjects: The subjects comprised a convenience sample of 5 children aged 10–11 years with ADHD.Methods: Subjects received a 1-hour therapeutic horseback riding twice a week for 8 weeks as intervention.Outcome measures: Behavior and health-related quality of life was assessed using Strength and DifficultiesQuestionnaire (SDQ) and The KINDLR–Health-Related Quality of Life Questionnaire, respectively. The Mod-ified Function-Neurological Assessment and the Movement Assessment Battery for Children assessed thesubject’s motor performance.Results: The pre- and post-tests scores were compared with the Wilcoxon paired sample tests and the Friedmantest for nonparametric multiple test samples. Positive differences ( p £ 0.05) between the test results at pretest2 and post-test 1 were noted for the behavior SDQ subscore ‘‘Total difficulties’’ reported by children (12.8 – 5.8),by parents (16.6 – 8.2), and by teachers (15.0 – 5.2). A significant difference ( p < 0.05) for the ‘‘Total difficulties’’ inSDQ was found between all 4 tests. In relation to quality of life, significant differences in the ‘‘Total score’’(67.2 – 14.7) were reported by the children themselves. The motor performance improved after the intervention.The effect sizes and power were established.Conclusions: The results of the present study indicate that therapeutic horseback riding had a positive effect on5 children with ADHD in several domains of the social role behavior, quality of life, and motor performance.This pilot study constitutes a good scientific prospect for future studies.

Introduction

Attention deficit hyperactivity disorder (ADHD) isassociated with impairment in all aspects of a child’s

life (i.e., family, social, and academic).1,2 Children withADHD often follow a sustained negative developmental tra-jectory3 due to psychosocial risk factors, and impairments cancontinue into adulthood.4 Many children with ADHD havefunctional motor performance problems,5 social problems,6

and problems with rhythm.7 Motor performance problemsare associated with other problems: low self-esteem, anxiety,8

inattention problems, academic problems,9 and being a victimof harassment.

Hippotherapy is used to increase strength, balance, pos-ture, and function.10 Therapeutic horseback riding is a phy-siotherapeutic treatment, using a horse as an implement, andthe treatment strategy is using the multidimensional move-ment of the horse. It is assumed to have an effect in four

1Hunt Research Center and 2Institute of Public Health, Department of Public Health and General Practice, Faculty of Medicine, NorwegianUniversity of Science and Technology, Levanger, Norway.

Departments of 3Physical Medicine and Rehabilitation and 4Child and Adolescent Psychiatry, Nord-Trondelag Health Trust, Levanger,Norway.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 17, Number 10, 2011, pp. 901–908ª Mary Ann Liebert, Inc.DOI: 10.1089/acm.2010.0547

901

different ways: sensomotoric,11 neuromotoric,12 psychomo-toric,13 and sociomotoric.14,15

The main aim of therapeutic horseback riding is that thesubject also will function better off the horse. The conceptualframework of therapeutic horseback riding may be explainedby using dynamic system theory along with theories ofmotor learning and sensory integration16 and neuropsycho-logic theories, wherein motor planning and intellectualabilities are positively stimulated through stimulation of thevestibular system.

Tyler17 suggests that depressed, stressed, and angry per-sons can experience a positive effect from the physiologicreactions that occur as a result of the rhythmic movement ofthe horse. There are several other therapies using rhythmicstimulation as a method18–21 that indicate the same effects onmotor performance. Basile22 noted no psychologic effects onbehavior and self-esteem in children with ADHD usingEquine Facilitated Psychotherapy.

With its proposed effects on the four levels of sensomotor,neuromotor, psychomotor, and sociomotor abilities, thera-peutic horseback riding has the potential to be an effectivetreatment intervention for children with ADHD, with anexpectation of carryover into daily life.

The main objective of this pilot study was to revealtrends and effects of therapeutic horseback riding on chil-dren with ADHD using the Strength and Difficulties Ques-tionnaire (SDQ),23,24 KINDLR–Health-Related Quality of LifeQuestionnaire (HQoL),25 Movement Assessment Battery forChildren (MABC)26 and Modified Function NeurologicalAssessment (MFNU)* as outcome measures. Secondaryobjectives were to indicate in which domains the positivealterations appear. Additionally, this pilot study was aimingto explore the scientific assumptions for future studies.

Materials and Methods

Subjects

A convenience sample of 5 children with ADHD partici-pated. The researcher contacted the Norwegian Associationfor ADHD to recruit subjects. The subjects were required tohave a primary diagnose of ADHD. The diagnosis was madeby an independent psychiatric specialist team using stan-dardized screening methods and a double-blind test proce-dure. The subjects, aged 10–11 years, who reacted positivelyon the medicament (Concerta�) and took the medicine formore than 1 year, were selected. Earlier horseback riding andsevere comorbidities (e.g., severe behavioral problems suchas obsessive–compulsive disorder) were exclusion criteria.Ten (10) children fulfilled the criteria and were willing toparticipate in the study. Finally, 5 subjects were selected atrandom. No girl participated due to the fact that no girl metthe requirements.

Parental written consent was obtained. The study wasapproved by the Norwegian Ethical Committee and fol-lowed the principles outlined in the Declaration of Helsinki.All children had medical clearance to ride a horse and a

referral for physical therapy from their primary physicians.The researcher did not know any of the subjects. The samplesize was limited by pedagogic causes because children withthis diagnosis and this form of therapy need a more indi-vidual approach.

Horseback riding

In this study, therapeutic horseback riding is understood tobe a therapy that combines both the specific advantages ofhippotherapy and recreational therapeutic horseback riding. Inthe latter, equestrian skills are the main objectives. Importantissues in hippotherapy were space and time understanding/attention, and executing tasks in a particular space and timeconstruction alone and together with other subjects or parents.

The five trained horses were owned by one of the hiredinstructors, who did know each particular horse. The medi-um-sized horses were chosen based on characteristics in gatelength, and size in height and width. Those characteristicsgive different stimulations to the rider, but at the start thepersonal interaction between the child and the horse werealso of importance. All the horses had medium level indressage. The researcher selected the appropriate horse foreach subject. In addition, the movements of the horses weremodified during treatment sessions depending on the needs,abilities, and responses of the subjects. These rhythm varia-tions were used with purpose and consequently, but therewere also moments of tranquility and relaxation. Two (2)times they practiced horse vaulting with special tasks. Eachsession was carried out in a very structured way and endedwith a short debriefing. Other important issues were coop-eration, responsibility, sociability, and respect.

Design

The differences between the subjects were kept as small aspossible to augment reliability. Other similar effect studiesrecommend in their discussion a more homogeneous sam-ple.10,12 All of the boys had the same medication treatmentand fulfilled the selection criteria. To strengthen the internalvalidity, none of the subjects got supplementary therapiesthroughout the 24-week study. The only concurrent eventthat may have affected the results was the summer vacationbetween pretest 1 and pretest 2. Other factors that could havehad an impact on the internal validity could be history,training effect in filling out the tests, and the occasionallydelayed reporting by the teachers.

A time series quasi-experimental research design withfour test dates was selected. The time interval between testdates was held constant at 8 weeks. A therapeutic horsebackriding class of 60 minutes twice weekly for 8 weeks wasprovided between pretest 2 and post-test 1. The implementerof therapeutic horseback riding was a physical therapist with25 years of practice experience and registered as a thera-peutic riding/hippotherapy instructor (certified by the Nor-wegian Physiotherapist Association).

Measures

The SDQ, KindlR-HQoL, MABC, and MNFU were selectedas quantitative measures for the selected outcomes.

The SDQ recorded by subjects, parents, and teachers is abrief behavioral screening questionnaire assessing mental

*Larsen Stray L. Motoric function in children with AD/HD: Aretrospective study of motor problems in children with AD/HDbased on Modifisert Funksjonnevrologisk Undersøkelse (MNFU,modified function-neurological assessment). Master of Science dis-sertation, Faculty of medicine, University of Bergen, 2001.

902 CUYPERS ET AL.

health in children and adolescents, aged 4–16 years.23,24

Reliability and validity were found to be satisfactory in Eu-ropean studies with best results for parent report.

KindlR-HQoL recorded by subjects and parents is aquestionnaire measuring health-related quality of life inchildren and adolescents, for use in clinical populations butalso with healthy children and adolescents.25 In this study,the version for children aged 8–12 years and the proxy ver-sion for parents were used.

MABC is an age-regulated standardized clinical test tomeasure and assess manual skills, eye–hand coordination,and balance.26 The version for children aged 9–10 years and11–12 years was used. MABC is a primarily quantitative testwith possibilities for qualitative evaluations.

MFNU is a clinical qualitative assessment test to screenchildren with motor performance problems. This test issensitive to identify motor difficulties in children withADHD. The version for children aged 8–11 years was used.

Testing procedure

All four test batteries were carried out on each test date.An independent trained physiotherapist administrated theMFNU and MABC. The test results were not discussed withthe researcher during or after the study. The SDQ andKINDL-HQoL were administered by the researcher. Thespecific rules characteristic to self-reported questionnaireswere followed.

Pretreatment phase. The subjects were tested at baselinepretest 1. The form teachers of the subjects were asked by aninformation letter to fill out the teacher version of the SDQ.Several days before pretest 2, the subjects got an invitationletter for pretest 2, inquiring about concurrent events. Allsubjects showed up for pretest 2. The only event reportedwas school vacation.

Treatment phase. The children had therapeutic horse-back riding in a group, twice weekly for 8 consecutive weeks,in an enclosed area 20 · 40 m or outdoors in the woods. Theparents were present in each session. Two hired (2) instruc-tors were present to give commands to the subjects. Theywere informed in advance about the study and they wereinstructed in what kind of approach and tasks the researcherwanted to accomplish in accordance with the principles oftherapeutic riding/hippotherapy. Thus, the researcher hadhis hands free to look at reactions of the subjects and giveindividual responses to these. Individual therapeutic horse-back riding appointments were 60 minutes, but the actualamount of time on the horse varied. At the start, a lot of timewas spent on caring for the horses and learning about how tomanage them. The actual riding time was about 15 minutes.After a few times, the riding time increased to about 40minutes on the horse; the rest of the time was spent ongrooming horses.

The four riding tours in the woods were used as a rewardfor their good effort. At the first riding lesson, the parentsheld the horses in a line. Gradually, after two sessions, thesubjects had to steer their horses themselves. They learned toride figures and react instantly and consequently on thecommands. In the beginning, they had to concentrate ontheir own horses, but gradually, they had to look at the other

subjects and their horses to keep the same distance betweenthem and to react together at the same moment. The parentswere instructed to fulfill some exercises together with theirchildren by specific rules. The children were asked to varytheir positions on the horse: forward facing, rear facing, sidefacing, modified side sitting, prone, quadruped, and stand-ing. Meanwhile, the tempo of the horses was varied fromhalt, walk, trot, and gallop. While riding on the horse, thesubjects were encouraged to maintain postural alignmentwith symmetry of head, trunk, and lower and upper ex-tremities. To keep the spirit up, once in a while the sessionswere ended with simple kinds of mounted games. Rhythmvariations were used with a purpose and consequently, butmoments of tranquility and relaxation were part of the ar-rangement. The subjects had to ride occasionally without asaddle.

Post-treatment phase. Post-test 1 was carried out duringthe week after the final therapeutic horseback riding session.The post-test 2 was 8 weeks later. To examine confoundingvariables, the parents were asked to report concurrentevents.

Data analysis

SPSS version 15 ( SPSS Inc., Chicago, IL), was used tocomplete all analyses.

1. A binomial statistic method was used to quantify thegeneral nature of the information.

2. Wilcoxon paired-sample test was used to determine thedifference of the mean of pretest 2 and post-test 1.

3. Friedman test for repeated measures was used to de-termine the difference between the two pretests and thetwo post-tests.

4. The effect size (ES) was calculated as proposed byLooney and colleagues.27 The power was calculatedusing GPowerR.28

Results

The results of the different tests showed an improvementin various domains of behavior, quality of life, and motorperformance of the children from pretest 2 to post-test 1. Theeffects according to behavior and quality of life diminishedfrom post-test 1 to post-test 2, while the effects of both theABC- and MFNU-test show a further improvement.

Behavior (SDQ)

The single subject scores for the 5 participants from pretest 2and post-test 1 revealed that the behavioral patterns wereameliorated according to the parents, teacher, and the sub-jects (Fig. 1).

In a clinical diagnostic perspective, using percentile normsstandardized for British 11–15-year-old boys, all participantswere in the 10 upper percentiles before the intervention, in-dicating treatment. After the intervention, it was shown thatonly 2 of 5 boys’ behavior indicated treatment, as reportedby their parents.

The mean values for the subtests were studied, and graphsof the test scores were used to depict the general nature ofthe information. From pretest 2 to post-test 1, the mean

POSITIVE EFFECT OF HORSEBACK RIDING ON CHILDREN WITH ADHD 903

values of the SDQ test (parents, teacher, and the partici-pants themselves) revealed positive changes for 15 of the 18subtests.

The nonparametric Wilcoxon test showed a significantdifference for four of the six items of the SDQ test reportedby subjects (Emotional symptoms, Conduct problems,Hyperactivity/inattention, and Total difficulties). The par-ents reported a significant change for two of the six sub-tests (Hyperactivity/inattention and Total difficulties). Theteachers also noted a significant positive change for Totaldifficulties (Fig. 2).

Finally, all the data were analyzed using a Friedman test,revealing a significant positive change for behavior (TotalDifficulties) between all the pre- and post-tests.

From post-test 1 to post-test 2, there is a decline of thepositive effect on the behavior of the participants, but a betterresult can still be noted for 3 of the 5 participants in com-parison to pretest 2. Just 1 of the 5 boys had a behavior thatdid not indicate treatment.

Quality-of-life data (HQoL)

The single-subject quality-of-life data revealed ameliorationfor only 2 of the 5 participants, as reported by the parentsand the children (Fig. 3).

In a clinical diagnostic perspective, the self-reported totalscores were compared with the standardized reference val-ues for corresponding age, gender, and health status group.Before the intervention, 3 children had a HQoL score as lowas chronically ill boys. After the intervention, only 2 childrenassessed their HQoL as low as chronically ill boys.

Six (6) of 7 items reported by parents showed positivechanges in the mean scores from pretest 2 to post-test 1. Onlythe item ‘‘Family’’ showed a negative tendency. The QoLscores reported by the subjects showed a positive trend frompretest 2 to post-test 1 for just one domain. However, whenthe scores from pretest 2 are excluded, with the fact theywere taken after the summer vacation being a possible con-founder, the scores from pretest 1 to post-test 1 showed apositive trend for 4 of 7 scores (Fig. 4).

The Wilcoxon test showed that the parents reported asignificant positive change for two of seven items (Psychicwell-being and School). The boys themselves reported nosignificant positive changes at post-test 1.

The parents reported a further augmentation in the qualityof life for 3 of the 5 participants from post-test 1 to post-test 2.On the other hand, just 1 child noted a further ameliorationin his quality of life. For the other 4, the positive tendencydeclined, but the scores remained positive in comparison topretest 2. In the QoL test, the subjects noted a positive sig-nificant change for the item ‘‘Total score’’ at post-test 2.

FIG. 1. Trends of behavioral assessment values of theStrength and Difficulties Questionnaire (0–30; reported sumscores by parents) in 5 children from pretest 1 (1) to post-test2 (4). Diminishing value means improvement.

FIG. 2. Means of subtest scores and mean of total score onpre- and post-tests of the Strength and Difficulty (SDQ) test,parent version. n = 5. A decreasing mean value of the scoresindicates a positive trend. A significant difference ( p £ 0.05)between the means of the subtest scores on pretest 2 andpost-test 1 for domain Hyperactivity/inattention, and totalscore of the subtests Total difficulties.

FIG. 3. Trends of KindlR–Health-Related Quality of LifeQuestionnaire assessment values (0–90; reported sum scoresin percent by children) in 5 children from pretest 1 (1) topost-test 2 (4). Increasing value means improvement.

904 CUYPERS ET AL.

The motor performance (MABC, MFNU)

The single subject scores for motor performance were betterat post-test 1 for 3 of 5 participants (Fig. 5).

For both motor performance tests, the mean test resultsrevealed a positive change after the intervention and themotor performance improvement became significant 2months after the therapeutic horseback riding for 4 of 5participants.

Table 1 presents the means, standard deviation, effect size,and power for the different domains that showed a positive

significant change after the intervention. The effect size wascalculated using the pretest standard deviation for repeatedmeasure. The positive changes due to the interventionseemed to be meaningful (ES = 0.21–6.30). The power variedfrom 0.11 to 1.

Discussion

The purpose of the present study was to evaluate the effectof therapeutic horseback riding on children with ADHD. Theprimary objective was to determine whether therapeutichorseback riding had a positive effect on behavior, health-related quality of life, and motor performance.

The results demonstrate a treatment effect on behaviorand on quality of life after the intervention phase, while therewas no significant change during the nontreatment phase.On the other hand, the positive change in motor performanceafter the intervention became significant in the post-treat-ment phase. This strengthens the research hypothesis andmay illuminate a certain carryover effect of therapeutichorseback riding on the motor functioning in daily life, alsoafter ending the intervention.

The secondary objective was to define in which domainsof behavior—quality of life and motor performance—thepositive alterations appeared. The results were studied intwo different ways.

First, the tendencies of the single subject scores werestudied to detect clinical changes individually by usingclinical standardized reference values. Most boys achieved abetter behavior, quality of life, and motor performance afterthe intervention, reported by the parents, teacher, andthemselves.

Second, the means of the different subtests and items wereanalyzed to find on which levels changes appeared. Theteachers, parents, and the participants reported a significantpositive change for the daily life behavior. The participantsthemselves reported that the impact of all these behavioraldifficulties was significantly diminished after the interven-tion. The boys also reported that the problems in the area ofthe emotions, conduct, and hyperactivity/inattention chan-ged significantly. The latter was also confirmed by the par-ents. This is congruent with the study of Bizub andcolleagues.13 The parents also reported an amelioration ofdaily life quality related to the school environment. The re-sults of the present study assume that therapeutic horsebackriding may be used to support and improve the alteredlearning mechanism in boys with ADHD.{ The parents alsoreported that their children had a positive change in socialcontext, but the boys themselves experienced that the rela-tionship with peers (SDQ) and friends (QoL) did not changepositively. An explanation can be that peers may react to asudden social behavior change, caused by an alteration inself-esteem or self-confidence. The subjects reported thattheir social qualifications became better directly after, butalso further after ending the intervention. This finding iscongruent with the studies of Tucker15 and Macauley andGutierrez14 and provides better understanding of the

FIG. 4. Means of subtest scores and mean of total score onpre- and post-tests of the Kindl R–Health-Related Quality ofLife test, children version. n = 5. An increasing mean value ofthe scores indicates a positive trend. There was no significantdifference ( p £ 0.05) between the means of the subtest scoresor total score of the subtests on pretest 2 and post-test 1.

FIG. 5. Trends of motor performance assessment values (0–60; sum-score movement Assessment Battery for Childrenand Modified Function–Neurological Assessment in 5 chil-dren from pretest 1 (1) to post-test 2 (4). Diminishing valuemeans improvement.

{Aase H. Altered reinforcement mechanisms in children withAttention-Deficit/Hyperactivity Disorder (AD/HD). Doctoral thesis,University of Oslo, 2007.

POSITIVE EFFECT OF HORSEBACK RIDING ON CHILDREN WITH ADHD 905

different parts of social life and the challenges these subjectsface.

A possible confounder was the school vacation betweenpretest 1 and pretest 2. The boys reported a relatively toolarge amelioration in all aspects of quality of life at pretest 2.An explanation can be that the boys were feeling better after2 months of holidays, without the demands of daily schoollife. If the results of pretest 1 were compared to the results ofpost-test 1, the trend would have been even more positive.At post-test 1 and 2, the parents felt that the quality of life inthe family situation was diminished. A possible explanationmay be that the 2 months with therapeutic riding had beenstrenuous and that the family situation altered in regard tothe interaction with the boys. They reported that the boysbecame more reflective on how they acted and felt in thefamily situation. The findings of the present study are con-gruent with the statement of Klassen and colleagues29 andAntshel and Remer30 that ADHD has a significant impact onmultiple domains of the health-related quality of life inchildren. The present study suggests that the quality of lifefor these boys can be ameliorated.

The motor performance results showed a positive ten-dency after the intervention and became significant 2 monthsafter ending the intervention. This may be as a result ofmotor learning and sensory integration16 and its carryovereffect on daily life functioning. These findings are congru-ent with earlier studies.11,12 The relation between motorregulation, attention, and executive functions suggests thattechnologies aimed at strengthening motor planning, se-quencing, timing, and rhythm may have a role in improvingthe capacity to attend and learn.31 Other rhythm training21

using vestibular stimulation established limited ameliorationin motor control and attention, but there were minor carry-over effects and little improvement in behavior. These latterimprovements could be established using therapeutichorseback riding, where the most palpable, sociable, and

three-dimensional materials are used.32 It has to be men-tioned that it was not the presence of the horse that wasresponsible for the positive changes, but the physical inter-action and the riding on the horse might have caused thepositive alterations.22 Incongruent with the findings of Butteand colleagues,33 it was not difficult to have the boys par-ticipate in this physical activity.

This pilot study tried to establish an estimate of the ES.The power was kept as high as possible by using strongtreatments (8 weeks, twice a week), administering thosetreatments consistently (in relation to the riding programand instructors), and trying to use the right statistics.Nevertheless, due to the low sample size and no controlgroup, the power was relatively low for most of the subtests.Varying the a up to 0.2 was another possibility and pertinentin a pilot study. The positive trends would have becomemore significant, but the type I error would have become toolarge.

Limitations and strengths

Although the sample was limited to only 5 children, theresults show significant changes. This limitation created thepossibility to study those children more extensively.

Implications for future studies

Even though a planned protocol for testing and inter-vention was followed, replicating this study is a challenge.Therapeutic horseback riding is a treatment strategy withmultiple options. From selection of the horse, equipment,movement patterns of the horse during the treatment, andpositional changes of the participant, the researcher used hisknowledge and experience to choose the best combinationfor each individual. This study could be expanded to amulticenter trial after establishing a treatment protocol toimprove control of the independent variables.

Table 1. Means (m), Standard Deviation (SD) of Subtest Scores, and Total Score of the Subtests (n = 5)

Test Test domain Pretest 2 (m) SD Post-test 1 (m) SD ES Power

SDQSelf Emotional symptoms 4.5 (3.1) 2.4* (2.1) 0.67 0.24

Conduction problems 3.0 (1.4) 2.0* (2.0) 0.71 0.37Hyperactivity/inattention 5.5 (1.9) 4.6* (2.1) 0.47 0.22Total difficulties 16.0 (6.6) 12.8* (5.8) 0.47 0.22Impact 3.5 (3.4) 2.4* (3.2) 0.32 0.14

Parent Hyperactivity/inattention 9.75 (0.5) 6.6* (4.0) 6.30 1.00Total difficulties 22.5 (2.0) 16.6* (8.2) 2.95 0.99

Teacher Total difficulties 16.0 (4.8) 15.0* (5.2) 0.21 0.11

HQoLParent Psychologic well-being 62.5 (5.1) 76.3* (15.6) 2.69 0.99

School 62.5 (12.5) 70.0* (13.5) 0.60 0.29

MABCHand function 4.3 (3.8) 2.9 (1.5) 0.37 0.17

MFNUMotor performance 36.0 (5.0) 33.4 (3.3) 0.52 0.25

Effect Sizes (ES) and Power of the significant differences between the means (m) of the subtest scores and total score of the subtests ondifferent test domains of behavior (Strength and Difficulties Questionnaire, SDQ), quality of life (KINDLR-HQoL), and motor performance(Movement Assessment Battery for Children, MABC; Modified Function Neurological Assessment, MFNU).

*p < 0.05.ES: 0.20 = small; 0.50 = moderate.Power: 0 = low; 1 = strong.

906 CUYPERS ET AL.

Conclusions

The use of therapeutic horseback riding could, as a resultof this present study, be a viable treatment strategy as a partof a multimodal therapy for children with ADHD. The studyassumes positive trends in certain domains of behavior,quality of life, and motor performance. This pilot studyprovides good scientific prospects for future studies to doc-ument these positive trends on larger samples.

Acknowledgments

The researchers wish to thank the Norwegian Foundationfor Health and Rehabilitation for their financial support.

Disclosure Statement

No competing financial interests exist.

References

1. Biederman J. Attention-deficit/hyperactivity disorder: Aselective overview. Biol Psychiatry 2005;57:1215–1220.

2. Daley D. Attention deficit hyperactivity disorder: A reviewof the essential facts. Child Care Health Dev 2006;32:193–204.

3. Fischer M, Barkley RA, Smallish L, Fletcher K. Hyperactivechildren as young adults: Driving abilities, safe driving be-havior, and adverse driving outcomes. Accid Anal Prev2007;39:94–105.

4. DiScala C, Lescohier I, Barthel M, Li G. Injuries to childrenwith attention deficit hyperactivity disorder. Pediatrics1998;102:1415–1421.

5. Karatekin C, Markiewicz SW, Siegel MA. A preliminarystudy of motor problems in children with attention-deficit/hyperactivity disorder. Percept Mot Skills 2003;97:1267–1280.

6. Biederman J, Faraone S, Milberger S, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity andrelated disorders. Arch Gen Psychiatry 1996;53:437–446.

7. Toplak ME, Rucklidge JJ, Hetherington R, et al. Time per-ception deficits in attention-deficit/hyperactivity disorderand comorbid reading difficulties in child and adolescentsamples. J Child Psychol Psychiatry 2003;44:888–903.

8. Busch B, Biederman J, Cohen LG, et al. Correlates of ADHDamong children in pediatric and psychiatric clinics. Psy-chiatr Serv 2002;53:1103–1111.

9. Rodriguez A, Jarvelin MR, Obel C, et al. Do inattention andhyperactivity symptoms equal scholastic impairment? Evi-dence from three European cohorts. BMC Public Health2007;7:327.

10. Casady RL, Nichols-Larsen DS. The effect of hippotherapyon ten children with cerebral palsy. Pediatr Phys Ther2004;16:165–172.

11. Yack H, Bartels C, Irlmeier J, et al. The effects of therapeutichorseback riding on the quality of balance control in chil-dren with attention disorders. Sci J Ther Riding 1997;3:3–9.

12. McGibbon NH, Andrade CK, Widener G, Cintas HL. Effectof an equine-movement therapy program on gait, energyexpenditure, and motor function in children with spasticcerebral palsy: A pilot study. Dev Med Child Neurol1998;40:754–762.

13. Bizub AL, Joy A, Davidson L. "It’s like being in anotherworld": Demonstrating the benefits of therapeutic horsebackriding for individuals with psychiatric disability. PsychiatrRehabil J 2003;26:377–384.

14. Macauley B, Gutierrez K. The effectiveness of hippotherapyfor children with language-learning disabilities. CommunDisord Q 2004;25:205–217.

15. Tucker S. Effects of equine facilitated therapy on self-concepts, locus of control, impulsivity, and hopelessness inadolescent males. In: Engel BT, ed. Rehabilitation with Aidof a Horse: A Collection of Studies. Durango, CO: BarbaraEngel Therapy Services, 1997:207–220.

16. Shumway-Cook A, Woollacott M. Motor Control, Theoryand Practical Applications. Baltimore: Williams & Wilkins,1995.

17. Tyler J. Equine psychotherapy: Worth more than just a horselaugh. Woman Ther 1994;15:139–146.

18. Clark DL, Arnold LE, Crowl L, et al. Vestibular stimulationfor ADHD: Randomized controlled trial of ComprehensiveMotion Apparatus. J Atten Disord 2008;11:599–611.

19. Shaffer RJ, Jacokes LE, Cassily JF, et al. Effect of interactivemetronome training on children with ADHD. Am J OccupTher 2001;55:155–162.

20. Ahlborg L, Andersson C, Julin P. Whole-body vibrationtraining compared with resistance training: Effect on spas-ticity, muscle strength and motor performance in adultswith cerebral palsy. J Rehabil Med 2006;38:302–308.

21. Majorek M, Tuchelmann T, Heusser P. Therapeutic Eur-ythmy-movement therapy for children with attention deficithyperactivity disorder (ADHD): A pilot study. ComplementTher Nurs Midwifery 2004;10:46–53.

22. Basile R. The psychological effects of equine facilitatedpsychotherapy on behaviour and self-esteem in childrenwith attention deficit/hyperactivity disorder (ADHD). Sci JTher Riding 1997;3:10–15.

23. Heyerdahl S. SDQ—Strength and Difficulties Questionnaire:A new questionnaire for mental health assessment in chil-dren and adolescents used in recent Norwegion surveys:UNGHUBRO, OPPHED og TROFINN. Norsk Epidemiol2003;13:127–135.

24. Goodman R. The Strengths and Difficulties Questionnaire: Aresearch note. J Child Psychol Psychiatry 1997;38:581–586.

25. Ravens-Sieberer U, Bullinger M. KINDL� English. Ques-tionnaire for Measuring Health-Related Quality of Life inChildren and Adolescents. Revised Version. Berlin: RobertKoch Institute, 2000.

26. Henderson S, Sugden D. Movement Assessment Battery forChildren. London: The Psychological Corporation, 1992.

27. Looney MA, Feltz CJ, VanVleet CN. The reporting andanalysis of research findings for within-subject designs:Methodological issues for meta-analysis. Res Q Exerc Sport1994;65:363–366.

28. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: Aflexible statistical power analysis program for the social,behavioral, and biomedical sciences. Behav Res Methods2007;39:175–191.

29. Klassen AF, Miller A, Fine S. Health-related quality of life inchildren and adolescents who have a diagnosis of attention-deficit/hyperactivity disorder. Pediatrics 2004;114:e541–e547.

30. Antshel K, Remer R. Social skills training in children withattention deficit hyperactivity disorder: A randomized-controlled clinical trial. J Clin Child Adolesc Psychol 2003;32:153–165.

31. Greenspan SI, Wieder S. The Interdisciplinary Council onDevelopmental and Learning Disorders Diagnostic Manualfor Infants and Young Children: An overview. J Can AcadChild Adolesc Psychiatry 2008;17:76.

POSITIVE EFFECT OF HORSEBACK RIDING ON CHILDREN WITH ADHD 907

32. Grunspun H. Equine therapy: A psycho-pedagogical proposi-tion. In: Neurotic Disturbances of the Child: Pathopsychologyand Psychodynamics. Rio de Janeiro: Atheneu, 1966:567–598.

33. Butte NF, Treuth MS, Voigt RG, et al. Stimulant medicationsdecrease energy expenditure and physical activity in chil-dren with attention-deficit/hyperactivity disorder. J Pediatr1999;135:203–7.

Address correspondence to:Koenraad Cuypers, PT, MSc, PhD(Cand)

Skjesol ØstreAsenfjord 7632

Norway

E-mail: koenraad.cuypers@ntnu.no

908 CUYPERS ET AL.