Hippotherapy: How a Horse Helps Children with Sensory Processing Disorders

The healing powers of horses have been recognized for thousands of years with the earliest recorded mention in the ancient Greek writing of Hippocrates. However, it wasn’t until the 1960’s that the discipline of “hippotherapy” was developed in Europe as an adjunct to physical therapy and soon after used in the United States to treat impairments in balance, strength and motor control. As an occupational therapist my focus is to utilize the sensory aspects of riding to treat the sensory processing disorders often seen in children on the autism spectrum (ASD) and other disabiities.

“Hippo” is the Greek word for horse. According to the American Hippotherapy Association, “hippotherapy is a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes…..Equine movement offers well-modulated sensory input to vestibular, proprioceptive, tactile and visual channels….Equine movement can be used to facilitate the neurophysicologic systems that support all of our functional daily living skills”.

Much of the hippotherapy efficacy research centers on how the horse’s movement is utilized to improve strength, balance and posture, normalize muscle tone and increase range-of- motion in riders with cerebral palsy, spina bifida or other physical disabilities. Therefore, the efficacy of hippotherapy in promoting sensorimotor skills in the ASD population is largely anecdotal. Indeed, I have seen in my clients  improvements in

• Attention
• speech output, articulation and volume
• decreasing sensory defensiveness
• motor planning and body awareness

What is a Sensory Processing Disorder?

Several terms that refer to difficulty interpreting sensory stimuli (such as touch or movement) have been used interchangeably. These terms include Sensory Processing Disorders (SPD), Sensory Modulation Disorders (SMD), Dysfunction in Sensory Integration (DSI) and Minimal Brain dysfunction (MBD). I will use the term, SPD in this article, since it appears to be most current and widely used.

SPD often coexists with children who have learning disabilities, Attention Deficit Disorder (ADD) and/or autism spectrum disorders. However, a child may have a SPD without having any of these other diagnoses.

Families, teachers and therapists may be all too familiar with behaviors caused by inaccurate interpretation of stimuli such as touch, movement or sound. These children might

• Interpret a friendly tap on the shoulder as a punch
• React to walking barefoot over grass as though needles were stabbing their bare feet
• Fear falling off a low bench because it feels as though they are high up
• Cover their ears and scream to drown out a fire alarm
• Refuse to eat a variety of foods-finding many tastes and textures to be aversive

These children may appear to be emotionally labile because the world is scary and unpredictable. They are challenged to maintain the even keel that is required to attend and learn. Occupational therapists often create what is called a “sensory diet” that fills a child’s day with sensory experiences designed to promote self-regulation. Occupational therapists Mary Sue Williams and Sherry Shellenberger, authors of “How Does Your Engine Run?” compare the brain to an engine that sometimes runs too high-producing hyperactivity and anxiety or an engine that runs too low producing lethargy and slouching posture. High and low engines make it difficult to focus and follow directions. Sensory diet activities are individualized and designed to help the brain or “engine” work just right.

Foundations of a Sensory Diet: Vestibular, Proprioceptive and Tactile Stimulation

Sensory Integration theory based on the research of its creator-A. Jean Ayres, describes early brain development as dependent on

• Vestibular stimulation which affects the sensory receptors in the inner ear as children engage in rotary, up and down, linear or movements on inclined surfaces. Sometimes called “the balance sense”, the vestibular system helps children develop body awareness as they respond to changes in their center of gravity.
• Proprioception stimulation which affects sensory receptors in muscles and joints when engaged in pushing and pulling or experiencing deep pressure (i.e. swaddling a baby in a blanket or wearing a weighted vest). The proprioceptive sense tell us where we are in space. Impaired sensory processing makes children appear clumsy- since they may trip and lack coordination.
• Tactile stimulation which affects sensory receptors in the skin and is the first sensory system to develop in the womb. Early experiences such as being cuddled in a snuggly develop the tactile system and future touch discrimination abilities (i.e. identify objects by touch). The tactile sensory system is also a warning system that tells us to take our finger off the stove. But children with a SPD may have an overly active protective tactile system- they find that practically everything they touch is unpleasant. This keeps them in a constant state of vigilance and anxiety.
• Full body deep pressure tactile stimulation while dismounting from horse

Horses Provide Sensory Stimulation! 

Sensory integration treatment is based on the theory that vestibular, proprioceptive and tactile stimulation promote sensory processing and adaptive responses (such as coordination). Riding on a horse provides intense vestibular, proprioceptive and tactile stimulation-as the rider experiences up and down (vertical) movements, side to side (lateral movements) and diagonal movements in response to the horse’s gait.

The type of stimulation varies when the rider faces sideways or backwards, lies supine (on one’s back) or prone (on one’s belly). Even when a horse is just standing stationary, there are subtle movements that the rider’s inner ears, joints and muscles responds to. I have often told parents-nothing makes a child more aware of where his body is in space and the need to focus than when standing on top of a horse. A therapist controls the type and intensity of sensory input to achieve therapeutic objectives by choosing

• Walking in straight lines or curves
• Use of flat or inclined terrain
• The rider’s positioning
• Alternating walk/halt and changing speeds

Propriceptive and tactile stimulation are provided as the rider wraps her body around the horse to hug or bears weight on her hands while placing them on the horse’s mane or croup (the rear end). Children with tactile defensiveness are often motivated to overcome their aversion to touch and place their hands on the fur or riding pad. Mounting and dismounting the horse provide opportunities for full body tactile contact as the client presses against the horse while sliding off. The intensity of proprioceptive input also varies depending on the horse’s gait (kids on the autism spectrum often love a jerky gait), speed and incline. For example, facing backwards while the horse walks uphill stimulates shoulder, arm and hand muscles as she bears weight on palms pressed against the horse’s croup.

Activities to Promote Body Awareness and Motor Planning Skills

As previously mentioned, simply being on the horse increases body awareness. I frequently ask the child to check to see if he is sitting “centered” by pressing his feet into the stirrups to stand (this is called posting). Children work on motor planning as they transition from facing forwards to sideways, learning to let go of the reins (or handle) in order to swing one leg over the mane- shifting their weight to the other side. Then I tell them to sit in the middle of the horse, centered so that they don’t fall into my arms. After they learn how to do this while the horse is stationary they are ready to learn these skills while the horse is walking.

This girl in the photo is removing toys that are attached with Velcro to the bottle and inserting them inside. This activity develops her body awareness, balance and postural control. 

Other motor planning challenges include:

• Touching the pony’s ears and tail.
• Touching right hand to left foot, left hand to right foot
• Holding arms out to sides like an airplane
• Making arm circles
• Sit-ups (while facing forwards) or push ups (while facing backwards)
• Reaching to insert a ball in the basket

These types of repetitive exercises provide an opportunity for the rider to practice following directions, sequencing and counting. Assuming and maintaining a variety of positions, first while stationary and then during the walk, also promote body awareness and motor control. Possible activities include

• Quadruped position (while grasping handle or hands on horse)
• Kneeling while grasping handle or with arms extended
• Prone over horse’s barrel with arms and legs extended like ‘Superman” or engaging in target activities
• Supine over horse’s barrel with head, arms and legs hanging like a “Sack of Potatoes”

The Use of Sensory Reinforcement

A reinforcement is any result that makes the action likely to be repeated. For example, helping children and a paycheck motivates me to go back to work.  Food, stickers and praise are often effective reinforcers. However, I have found that often the ideal "sensory reinforcers" both motivate and provide the types of sensory stimulation that help children move toward an optimal “brain engine”- ready for learning.

Many young children on the autism spectrum have figured out that if people ask them to do things (i.e. put dishes in the sink) and don’t respond-the adults will do the task for them. We adults often find it easier to just do things ourselves!. Hippotherapy provides an opportunity to show a child that they just can’t ignore social interactions. When I sing the song If you’re happy and you know it –clap your hands- I expect the child to clap and if he doesn’t I stop the horse and help move his hands. Most of my clients have figured out that if they want to keep moving they should join me in singing with hand movements and follow directions- such as- touch the pony’s tail. I may start out requesting movements that I can help them perform by placing my hands over theirs using hand-over-hand techniques. Next I move into requesting sounds such as “i.e. raspberries”, sneezing “ah choo” or making animal sounds. This is more challenging because I can’t physically assist them to produce sounds other than by touching their lips. But many of my clients learn that if they vocalize any sound at all the horse will start moving again.

Children who are resistant to grasping objects or using their hands are often willing to let me help them perform simple insertion tasks when they are reinforced with movement after only 1 or 2 repetitions. As skill improves, I require a greater number of steps completed before movement. Then at the end of the activity I may reward with a fast trot. The child is given immediate, repetitive, intense sensory stimulation as a reward. A rocking chair or swing may be used in a similar manner.

Promoting Hand Skills

The key to promoting hand skills is to provide activities that are at the “just right” level- not too challenging as to invite failure, but also not too simple as to be boring. When working with young children I like to begin with familiar basic tasks such as stacking rings or stringing with rings-and then create variation and challenge and involve additional sensory stimulation. For example, instead of using a regular ring stack- I ask children to place rings over the commercially available Princess Wand which makes sounds, has flashy lights and also vibrates.

Another ring stack variation that has worked great during hippotherapy consists of a long pole so that the riders balance is challenged as she reaches for the rings held near her feet, behind or high up near the pony’s ears. I sometimes provide cloth rings (made out of socks stuffed with plastic bags with ends stitched) so that the children must use both hands to open them up and place them over the pole. These cloth rings provide an entirely different tactile experience.

Sometimes I slip them onto the child’s arms or legs so that they have to remove them before placing them over the poles. This game teaches the motor skills required to undress. I have designed many fun fine-motor activities to develop skills such as

• Opening buttons buckles or laces
• Stabilizing with one hand while manipulating with the other
• Scanning the arena to locate needed puzzle pieces
• Motor planning to steer with reins and pull to stop
• Pointing in photo album to choose animal picture to sing about
• Playing catch with a pillow case stuffed with foam (easier to control than a ball)
• Eye hand coordination to string large donut shapes
• Developing pincer grasp to pull squeeze pins off the mane to insert in container
• Placing cloth ring over pole promotes motor planning skills and using hands together

Using materials that are visually exciting, make fun sounds or vibrate often motivate active children challenged to attend and use their hands. Weighted materials such as the medicine balls or heavy sand bags promote body awareness and coordination. Most insertion tasks can be made to vibrate by inserting the motor from an electric toothbrush or a motorized pens (minus the writing tips) in the container. The motor sound alone is often enough to capture a little boy’s attention. The “Feed the bunny” insertion activity pictured below is designed to promote language as well since, the therapist can ask the child to name the food item.

I have found that hippotherapy is surprisingly effective with children who are constantly on the move because they can’t run away from me and my activities when sitting on a horse. Yet, at the same time they are receiving the sensory stimulation that they need and an emotional bond with an animal-developing pride in their accomplishments. These successful motor experiences impact every aspect of a child’s life.

Safety Considerations

Children may be highly motivated by novel and exciting sensory-based activities but the horse must be carefully desensitized and familiar with materials and the movements involved well in advance. The ideal hippotherapy horse has had many years of experience under her belt working with children. She must not react to noise, crying, hitting, kicking and things being tossed about or falling on the ground. Of course, the clients are encouraged to be calm and loving toward the horse. In fact, that is part of the therapy but the staff and horse must be prepared for the types of behaviors that can occur. Hippotherapy horses must be mild mannered. They should sense that a special person is sitting on their backs and need to be extra tolerant. One of my favorite horses is so eager to help, he will stop walking when he senses the child is off center (even when I don’t want him to stop!) I introduce all of my toys/activities well in advance of therapy, especially if lights, sounds or vibration are involved.

There are different levels of training and certification involved in hippotherapy, although all therapists must be registered and licensed occupational, physical or speech and language therapists. I went through certification training with The American Hippotherapy Association in order to enhance my skills and knowledge base. Although my employer did not require this certification before hiring me, some facilities do. In addition the state requires a Massachusetts licensed riding instructor to be present in the facility during hippotherapy.

Hippotherapy is very different than “therapeutic riding”. My goal is to achieve occupational therapy objectives such as increased sitting endurance and hand dexterity. A therapeutic riding instructor is trained to teach people with disabilities how to ride a horse. This person might be an OT, PT or SLP as well, but not necessarily. The riding instructor is nearby during her lesson, whereas, the OT is right next to the rider, with hands on the child or the gait belt. Hippotherapy should always include a “side walker” on the other side of the horse for safety, as well as a person who leads the horse listening carefully for directions. This professional triad, or should I say quad if we include our furry friend- must work well as a team in order to provide a unique, multi-sensory, learning experience for the client with a sensory processing disorder.