9/29/14 1 EQUINE ASSISTED THERAPY FOR CHILDREN WITH DEPRESSION, TRAUMA, AND AUTISM: RESEARCH REVIEW AND DESIGN ISSUES 2014 Path International Conference and Annual Meeting October 30, 2014 Kimberly Hoagwood, Ph.D. Meghan Morrissey, M.S.W. Mary Acri, Ph.D. 1. Background: National Context on Unmet Need Among Children with Disabilities 2. Review of Research on EAT for Children with Disabilities 3. Evidence-based Practices: The MAP System 4. Crafting a Research Agenda 5. Design Considerations PRESENTATION OBJECTIVES 1. BACKGROUND
Transcript
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EQUINE ASSISTED THERAPY FOR CHILDREN WITH
DEPRESSION, TRAUMA, AND AUTISM: RESEARCH REVIEW
AND DESIGN ISSUES
2014 Path International Conference and Annual Meeting October 30, 2014 Kimberly Hoagwood, Ph.D. Meghan Morrissey, M.S.W. Mary Acri, Ph.D.
1. Background: National Context on Unmet Need Among Children with Disabilities
2. Review of Research on EAT for Children with Disabilities
3. Evidence-based Practices: The MAP System
4. Crafting a Research Agenda 5. Design Considerations
PRESENTATION OBJECTIVES
1. BACKGROUND
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• Depression is a chronic and debilitating disorder affecting between 12% and 25% of adolescents.1-4
• Adolescent depression is associated with negative academic, social and health outcomes including,
• Poor functioning • Depression in adulthood • Substance abuse • Early pregnancy • Higher medical expenses • Increased suicide risk2,5-13
Depression
• Approximately 1 in every 88 children is diagnosed with an autism spectrum disorder (ASD), such as • Autistic Disorder • Asperger syndrome • Pervasive Developmental Disorders NOS14
• Autism spectrum disorders are characterized by impairments in
social interaction, communication, and behavior.15,16
• Although many children with ASDs improve with age and early intervention, most youth require services throughout their lifetime.17
• The costs associated with ASDs are huge, exceeding $35 to
$90 billion.18
Autism
• 8% of children between 12 and 17 report a lifetime prevalence of sexual assault, 17% report physical assault, 39% report witnessing violence.19
• Traumatic stress reactions are characterized by hyperarousal, avoidance, re-experiencing the event, and impaired functioning20
• Approximately 1 in every 6 children who experience a traumatic event also develop posttraumatic stress disorder. 21
• PTSD is associated with anxiety, depression, impulsivity, aggression, drug and alcohol abuse, and self-harm.22
Traumatic Stress
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• 14-15 million children have a diagnosable psychiatric disorder23
• The 20/20/2 problem24
• Significant workforce shortages exist • Most severe shortages are in children’s mental health25,26
• 7,400 practicing child psychiatrists23
• 2,606 child psychologists registered in the APA directory27
• 93,000 practicing psychologists28
• 55% of counties nationally have no practicing psychiatrists,
psychologists, or social workers26
Unmet Need
The National Context: Healthcare Restructuring and Integration of Mental Health with Other Systems. • Important Federal initiatives
• 2008: Mental Health Parity and Addiction Equity Act • 2010: The Patient Protection and Affordability Care Act (PPACA)
• Impact 1. Medicaid Managed Care 2. Concern with costly services, high end users, access 3. Growing involvement of consumers 4. Workforce shortages and task shifting 5. Health homes and care coordination 6. Data monitoring, EHRs 7. Quality measurement 8. Accountability and outcomes
• Integration of mental health with other systems: schools, foster care, primary care, substance abuse, justice
• Patient-centered care is a key principle encouraging attention to caregivers' experience of therapies for their children.
• Emphasis on accountability and outcomes: Demands for data
Healthcare Reform: Opportunities for EAT
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• Animal therapies have grown in popularity as both a primary and adjunctive treatment for youth with mental health problems including autism and trauma.14,29
• Animal therapies have also been successful for treating depression among adults and symptoms of trauma.30
• Equine therapy targeting child and adolescent mental health needs is a promising yet untested approach.
Animal Therapies
2. REVIEW OF RESEARCH
• We conducted a comprehensive computer search of rigorous studies from 2004-2014 targeting the use of animal assisted therapies for children and adolescents with identified mental health problems.
• Four separate searches were undertaken in PsycInfo and Ovid Medline.
• Search words included animals (e.g. animal assisted, animal)
or horses specifically (e.g. equine, horse). • Inclusion criteria:
• Used the animal for therapy (not just skills) • Had been published between 2004-2014 • Employed a study design with a control or comparison group • Included data on outcomes not just process
Methods
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• Over 450 articles were reviewed. • 9 studies met criteria for inclusion (see Table 1)
• Most studies included small sample sizes and were pre/post designs.
• 67% (n=6) of the studies include a horse • 56% (n=5) studied the impact of animals on autism spectrum
disorders. All five examined horse/human interaction.
• None specifically studied the impact of animals on childhood depression or trauma.
Results
• Animal therapies have grown in popularity as both a primary and adjunctive treatment for youth with mental health problems, with promising results.
• Very few studies of animal therapies, and specifically equine-based treatments, using rigorous research designs have been conducted.
• Given increasing importance of accountability for outcomes, there
is a need for creation of an evidence base of equine therapies for youth with mental health problems.
Next Steps
3. EVIDENCE-BASED PRACTICES AND THE
MAP SYSTEM
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• Defined as “a body of scientific knowledge about service practices or about the impact of clinical treatments or services on the mental health problems of children and adolescents”31
• Shorthand term that denotes the quality, robustness, or validity of treatments and services for children and adolescents with disabilities.
• Examples:
School-based interventions Incredible Years PCIT Brief Strategic Family Therapy Problem Solving Skills Coping Power CBT TF-CBT Interpersonal Therapy
Evidence-Based Practices
• An evidence-based decision and practice support system (https://www.practicewise.com/)
• Developed to assist clinicians in the selection, adaptation, and/or design of effective treatment components.
• An online comprehensive compilation and coded synthesis of child mental health clinical outcome studies of psychosocial treatments.
• Includes over 370 randomized trials in the areas of childhood anxiety, depression, and autism.
• Enables clinicians to select child and setting characteristics to
identify the “best match” evidence based program for a particular child, and in the absence of such programs, to custom build a treatment based on a summary of common elements.
1. PracticeWise Evidence Based Services Database
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MAPS
• A Microsoft Excel based tool that presents a visual summary of individual client progress along with the history of clinical practices delivered.
• Used to manage client progress and service quality.
2. Clinical Dashboard
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• A set of treatment materials that summarize 27 of the most common elements of evidence-based treatments for youth.
• Each practice is summarized in a handout and checklist format to guide therapists in performing the main steps of the common components of evidence-based practices.
• The components are used as the building blocks for designing promising interventions as needed.
3. Practitioner Guide
• A set of treatment materials that summarize 27 of the most common elements of evidence-‐based treatments for youth.
• Each practice is summarized in a handout and checklist format to guide therapists in performing the main steps of the common components of evidence-‐based practices.
• The components are used as the building blocks for designing promising interventions as needed.
to gather information on what kinds of situations make the child anxious and construct a list of feared itemsto practice exposure to feared items or situations and allow habituation to occurto repeat exposure practice exercises across trials until all ratings for feared items are reduced
Steps
Gather
information
Let the child know that today you want to find out some more about the child’s specific fears or worriesby constructing a hierarchy of anxiety provoking situations. Gather information about the child’sanxieties, including:
the types of situations that provoke anxiety,his/her somatic and cognitive reactions to anxiety, andhis/her behavioral response to the anxiety-provoking situations.
Emphasize
honesty
Emphasize the importance of being as honest and thorough as possible. Explain that this is one of themost important parts of working together, and the better you two do on this task, the better the child willdo with his/her anxiety.
Educate in
rating
anxiety
Make sure the child is familiar with rating his/her fear:Come up with a rating scale (e.g., 1-10, with 10 being very anxious).Practice with sample anchors.Ensure the child can use the full range of the scale, not just the ends.
Establish a
list of
feared
stimuli
Work together to establish a list of feared stimuli. Staying within the selected diagnosis or problemarea, identify as many feared stimuli as possible (e.g., situations, cues, sensations, obsessions). Asyou agree on each item generated, write it down on an index card. Get 10+ items.
Get ratings
for list of
items
Read the items one by one to the child, each time obtaining a fear rating to write down on the card.Get items with a range of intensity levels.
Meeting
with
caregiver(s)
1. Meet with the caregiver(s) alone. Make sure the caregiver(s) are familiar with fear ratings.2. Without revealing the child’s ratings, read each item and get a caregiver rating.3. Bring everyone together. Get fear ratings from the child for the caregiver generated items.
Select
items
Select 10-12 items that will be used to guide later exposure exercises:select items that translate quite easily into exposure exercises andsuggest a logical progression of these exercises from easiest to hardest.
Introduce
exposure
Explain that practice is critical in building skills for coping with anxiety.Assist the child in choosing a situation from his or her fear hierarchy, easy ones at first, harderones later.Ask the child to define overt behavioral goals for that situation.If necessary, discuss and modify the goal so that it is not so hard that the child will refuse. Smallsteps are OK. If the exposure situation is too difficult, practice may need to be role-played first.
Practice
exposure
1. Practice the exposure together in vivo (in the actual situation).2. Exposure can also be imaginal, depending on the feared situation. Imaginal exposure is well-
suited to situations that are difficult to arrange (e.g., as in the case of a fear of storms) or in caseswhere a child’s anxiety is too great to begin with an in vivo situation.
3. Before beginning, get a fear rating and record it.4. During discrete exposure practice (e.g., holding one’s breath, or asking someone a question),
take fear ratings only before and after each trial.5. During continuous exposure practice (e.g., standing in a dark room, giving a speech, or touching
a feared object), take additional fear ratings at about 1-minute intervals during the exercise(intervals can be longer).
HabituationHabituation can be determined by various means, including:
the therapist’s observation of the child’s behavior andthe child’s quantitative rating of fear (e.g., 1 [not at all afraid] to 10 [extremely afraid]).
If fear levels decreased during the exposure, ask the child what happened to his or her anxiety. Ask ifthe feared consequences occurred or if anything bad happened. Show that his/her anxiety went downover time.
Repeat
practice
If there is time, repeat the practice exercise again after a short break. Ask the child if he or she noticedthat the second time was easier in any way.
to organize discussion of difficult topics using a “communication hierarchy”to teach and practice communication skills to members of the family to improve positive relations among family members
Steps
Create
communication
hierarchy
Work with caregiver and child to generate a list of topics that are difficult to discuss without conflict. Set clearground rules here: (a) this is NOT a time to discuss the topics, just to list them;; (b) each member has the “right” tosuggest topics—the immediate goal is not consensus;; (c) turn-taking during list-making helps a lot. Reframe and/orsummarize the topics. Ask each person to assign each topic a difficulty rating and record the mean rating for eachtopic. Ensure that you have topics that are in the “low” “middle” and “high” ranges.
Teach intent
and impact
Present basic intent-impact model of communication:Speaker has an “intended message”Message has an “impact” on the listenerMessage is affected by filters that the speaker hasMessage is also affected by the listener’s filtersGoal is for intent to equal impact
Discuss filtersFilters are influenced by a person’s current mood, recent events (good or bad), recent interactions with the speakeror listener (good or bad), and other factors (e.g., is the person hungry, tired, etc.?).
Introduce
speaker skills
The speaker can help intent to match impact in several ways:Be brief—keep message to a few sentencesBe clear—make the message focused on one thingBe “filter-free”—avoid mixing in bad feelings about other things into the message, either by adding “mean”words or “mean” non-verbalsUse of “I” statements can help: “I feel XX when you YY” where XX is a feeling and YY is a specific behavior(and not a character trait, for example).Emphasize importance of verbal and nonverbal aspects of the message.
Introduce
listener skills
The listener can also help intent to match impact:Make eye contact, nod, avoid negative posture/gesturesSay as little as possible until speaker is doneSummarize what the speaker has said without commenting on itAllow the speaker to state whether the listener has correctly understood
Discuss the
“floor”
Discuss importance of establishing who has the floor, which means who is the speaker. Everyone will have a turn,but a key to communication is allowing one person to have the floor until s/he is heard and understood. It can helpto use an object, like a laminated card, to pass back and forth to indicate who has the floor.
Practice on
neutral topics
Practice speaking and listening skills and use of the floor on a variety of easy topics. These can be practiced oneat a time at first, and then combined into a full discussion or conversation. Praise use of skills.
Select topics
from
communication
hierarchy
Once skills are well-practiced, you can begin discussing topics on the communication hierarchy. This usuallyrequires multiple meetings or sessions to work through the many items on the hierarchy, and homeworkassignments are common. Begin by selecting items that are rated as easier to discuss, and gradually work towardsharder items over time as skills develop.
Practice on
hierarchy
topics
Discuss a topic together, employing the new skills taught. Act as coach, referee, and consultant, encouragingfamily members to use the skills, calling “time-outs” when things are headed into trouble, and “huddling” with thefamily to think through how to proceed when they become stuck.
Plan and
assess
As time runs down, stop the practice to get feedback from the family about next steps with the topic, with a planmade to do one of the following:
a. resume same topic next week,b. continue discussing topic as “homework”, orc. determine that the topic is “done.”
Assign
homework
Once the family demonstrates some skill with communication, assign topics from the hierarchy as homework.
Helpful Tips
Remember to praise often, and encourage family members to praise one anotherBeing playful may help defuse tension;; for example, during practice, you can pretend to be a referee, even “blowing a whistle” or“throwing a penalty flag.”Start hierarchy work with topics that are mutually deemed “low”—in other words, only use topics that everyone thinks are low conflict.Be cautious in assigning homework early on, especially if you are not sure how well the experiences will go. Prescribe a “moratorium”of communication on topics on the list except during sessions until you give the green light.This skill is usually covered in more than one session/meeting
Print current
• We conducted a search specifying the best evidence for depression and autism within the PracticeWise Evidence Based Services Database.
• Inclusion criteria: • Children and adolescents 8-23 years of age. • Diagnosis of depression, autism spectrum disorder, or
PTSD.
Effective Therapeutic Components for Depression, Trauma, and Autism
• Most common practice treatment/elements across protocols
• Adapt these treatment elements for equine assisted therapy: Where can horses augment the evidence-based therapies?
• Example for depression (see Table 2)
Next Steps
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4. PILOT STUDY
• Objectives: To evaluate the impact of a therapeutic riding camp for youth 8-16 years of age with autism spectrum disorders upon child and parent outcomes, including; • Child attention, communication/language • Child/horse interaction • Parent stress
• Five caregivers of youth involved in the therapeutic camp were
asked to complete questionnaires measuring child outcomes and parental stress on the first and last days of camp. The riding instructor and a member of the research team assessed the child’s interaction with the horse.
• Human Animal Bond Scale *Score between 0-44, higher scores indicate greater interaction between the child and animal.
• M= 31.4, SD = 3.02
Results
• What was most helpful about camp? “Riding always gives ____ confidence and the chance to be around
other kids with special needs.” “The social opportunity coupled with the physical therapy of the riding and the chance to connect with the animals. Also the education piece is great.” • What was most valuable about camp? “Bonding with other children that have issues. Learning more about horses. Care of horses increases her desire to want to ride independently.” “___ loved learning about the horses. It built his confidence and focus.” “Direct engagement with and care for the horses.”
Results
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• Caregiver stress levels were high. “How often have you felt you were unable to control the important things in your life?”
67% responded very or fairly often
• Youth were highly interactive with the horses, and caregivers
reported multiple benefits of their children interacting with the horses.
• Instructors noted increased bonding between children and
horses throughout the week. One instructor noted that a rider stated, “[Horse] really listened to me.”
Discussion and Implications
5. FUTURE RESEARCH
Research Design Issues
• Comparative effectiveness studies are needed with active comparison conditions.
• Studies that examine the impact of equine therapy upon a range of symptoms and functioning that include physical, sensory, communicative, and emotional/behavioral
• Studies that differentiate curricula based on core clinical or functional targets for change
• Studies that use rigorous experimental designs
• Studies that examine a range of child and caregiver outcomes, including caregiver stress, self-efficacy, and optimism
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• Kimberly E. Hoagwood, PhD Cathy and Stephen Graham Professor of Clinical Psychology in
Psychiatry and Vice Chair for Research Department of Child and Adolescent Psychiatry New York University School of Medicine One Park Avenue at East 33rd, 8th Floor New York, New York 10016 Phone: 646-754-4888 Fax: 212-263-3691 Email: [email protected]
• Meghan Morrissey Residency Program Coordinator The Child Study Center at NYU Langone Medical Center Department of
Child and Adolescent Psychiatry One Park Avenue, 7th Floor, New York, NY 10016 Phone: 212.263.2072 | Fax: 646.754.9539 [email protected]
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