Horses and ADHD: The ASTride intervention for Cognitive and Emotional Growth

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Methods A prospective cohort study with an Interrupted Time-Series design was conducted. Fifty participants (mean age = 9.51 years, SD = 1.52) were assessed at four time points: baseline, pre-test (following a 12-week waiting period), post-test (after 12 weeks of intervention), and after three-month follow-up. The intervention was administered by a licensed equine assisted occupational therapists, and assessments were conducted by a blinded occupational therapist. Measures included The Behavior Rating Inventory of Executive Function ( BRIEF) for executive functions, and the Hope, Child Anxiety Related Emotional Disorders (SCARED), and The New General Self-Efficacy Scale (NGSE) questionnaires for emotional factors. Results Significant improvements were found in executive functions, hope perception, and self-efficacy. Anxiety levels significantly decreased post-intervention. Conclusion The ASTride intervention showed efficacy in improving executive functions, hope, and self-efficacy, while reducing anxiety in children with ADHD, supporting its potential as a comprehensive therapeutic approach. Trial registration The research is registered at Clinical Trials.gov, identifier number NCT05869253, first registration at 22/5/2023. Equine Assisted Occupational Therapy EAS ADHD Hope Self-efficacy Executive-functions anxiety Background Attention-Deficit/Hyperactivity Disorder (ADHD) , a neurodevelopmental disorder marked by symptoms of inattention, hyperactivity, and impulsivity, remains one of the most prevalent pediatric diagnoses. Boys are diagnosed at a rate 2–9 times higher than girls( 1 ), with recent estimates suggesting that ADHD affects around 9.4% of children, highlighting its continued significance as a public health concern ( 2 ) ADHD is associated with chronic impairments in executive functions− high-level cognitive processes primarily linked to the frontal lobes of the brain. Executive functions are crucial for self-regulation, goal-directed behavior, response inhibition, working memory, and cognitive flexibility, enabling individuals to adapt to new situations and manage their behavior effectively ( 3 ). Additionally, ADHD often involves significant psychosocial challenges such as emotional dysregulation, impulsivity, anxiety, depression, aggression ( 1 , 4 ), low self-esteem, and difficulties in interpersonal relationships ( 5 ). Current best practices for treating ADHD include a combination of pharmacological treatments and evidence-based psychological and behavioral therapies. Stimulant medications such as methylphenidate and amphetamines remain the most common and effective pharmacological treatments for reducing core symptoms ( 6 ). Non-pharmacological interventions often involve cognitive training targeting specific executive functions, utilizing principles of neuroplasticity through intensive, repetitive practice and immediate feedback ( 7 ). However, while these approaches effectively address core symptoms like hyperactivity and inhibition, they do not always translate to improved everyday functioning ( 8 ). Behavioral interventions for ADHD are most effective when they are client-centered and occupation-based, focusing on personal functional goals and strategy acquisition ( 8 ). Although these interventions show promise for improving executive functions and functional skills, they often do not address the full range of psychological difficulties associated with ADHD. Psychological interventions, such as behavioral programs, parental psychoeducation, and expressive therapies, can be beneficial but may not always be occupation-based or focus on strategy acquisition ( 9 ). Recent studies emphasize the need for a more integrated approach that addresses the complex and multifaceted nature of ADHD, combining core symptom management, emotional support, and practical daily functioning ( 2 ). Feasibility of Equine-Assisted Services for Children with ADHD Equine-Assisted Occupational Therapy (EAOT) combines the therapeutic benefits of equine interaction with traditional occupational therapy techniques ( 10 ). EAOT falls within the therapy domain of Equine-Assisted Services (EAS) which includes other licensed professionals who incorporate horses into practices such as physical therapy, psychotherapy, and speech -language pathology. Recent studies have underscored EAS’s effectiveness in reducing anxiety, improving mood and self-esteem ( 11 ), and enhancing attention, EFs, and social skills ( 12 ) in individuals with various disabilities, demonstrating the therapy's broad applicability. However, more rigorous and methodologically sound studies are needed to better understand these effects and confirm the findings across different populations and settings ( 11 , 13 ). Current research on EAS for children with ADHD is limited, with existing studies varying in sample size, intervention length, and the professionals conducting the interventions. To our knowledge, only one study to date has presented a structured intervention protocol addressing both cognitive and emotional aspects for children with ADHD ( 14 ). Given the demonstrated effectiveness of occupational therapy interventions for children with ADHD and the emerging evidence supporting EAS in enhancing cognitive and emotional functions, this study seeks to further validate ASTride protocol for this population, focusing on enhancing and promoting cognitive and emotional aspects such as executive functions, hope, self-efficacy and anxiety. Method Participants The study included 50 participants (mean age = 9.51 years, SD = 1.52), recruited from Mount Judah Stables, an EAS provider to over 300 patients (See Table 1 ). Out of the 62 participants initially approached, eight declined due to scheduling conflicts, and four were excluded for beginning new pharmacological treatments during the intervention. Inclusion criteria : ( 1 ) children between 6 and 12 years of age; ( 2 ) diagnosis of ADHD from a medical professional based on DSM-5 criteria with or without medication (e.g., psychostimulant medication); ( 3 ) general doctors' approval and referral for participation in EAS. Exclusion criteria : ( 1 ) moderate to severe cognitive impairment; ( 2 ) neurological disorders (e.g., epilepsy); ( 3 ) children with additional developmental disorders (e.g., Autism, Cerebral Palsy); ( 4 ) children due to begin new medical treatment or change existing treatment during intervention; ( 5 ) children with severe sensory loss (e.g., blindness). Table 1 Sociodemographic participant characteristics Characteristic Participants n (%) Gender Male 33 (66) Female 17 (34) Medication Yes 24 (48) No 26 (52) Residency City 24 (48) Community 23 (46) Town 3 ( 6 ) Education Special Education 7 ( 14 ) Typical Education 43 (86) Note. N = 50. M = Mean; SD = Standard Deviation Measures ASTride protocol The ASTride intervention ( 14 ) employs a blend of theoretical frameworks to address ADHD-related impairments. It integrates the Multi-Context approach ( 15 ), the Cognitive Orientation to Daily Occupational Performance (CO-OP) approach ( 16 ), and Sensory Integration (SI) theory ( 17 ). The Multi-Context approach focuses on enhancing strategy use across a variety of activities to promote generalization and improve functional performance. This approach emphasizes training strategies, practice in diverse contexts, and metacognitive skills, gradually shifting intervention activities to mirror real-life challenges( 15 ). The CO-OP approach complements this by providing a client-centered, performance-based method that uses the Goal-Plan-Do-Check strategy to facilitate skill acquisition, incorporating structured techniques, including visual aids and modeling, to teach basic riding skills and ensure their application in daily activities ( 16 ). SI theory, integral to the ASTride protocol, focuses on how sensory processing impacts behavior and adaptation ( 17 ). In EAOT, riding provides diverse sensory input, such as tactile and vestibular stimuli, with the potential to enhance sensory integration and support overall functioning ( 18 ) Along with its theoretical framework, ASTride is a structured and defined protocol that includes 12 weekly therapeutic sessions, each lasting 45 minutes. It is an intervention administered by an occupational therapist who is an EAS professional. Therapeutic goals are defined at the beginning of the intervention in collaboration with the parents, tailored to meet each child's needs. During the intervention, strategies are learned and practiced within the equine environment, utilizing both mounted and unmounted activities. The learned strategies are later transferred to other environments ( 14 ). The Behavior Rating Inventory of Executive Function (BRIEF) ( 19 ). The BRIEF is an 86-item standardized rating scale completed by parents to assess executive functions in children aged 5–18. It includes eight scales: Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan–Organize, Organization of Materials, and Monitor. The scales generate two indexes: the Behavior Rating Index (BRI) from the first three scales and the Metacognitive Index (MI) from the rest. The Global Executive Composite (GEC) sums all scores. Items are rated on a Likert scale from 1 (never) to 3 (often). Raw scores are converted to t scores, with 65 or higher considered clinically significant (SD = 10). The BRIEF has established reliability and validity and is validated for measuring executive functions in children with ADHD ( 19 , 20 ). The Children’s Hope Scale (Hope) ( 21 , 22 ) comprises 6 statements to which participants respond using a 6-point Likert scale, ranging from 1 (none of the time) to 6 (all of the time). It includes three agency items (e.g., "I think I am doing pretty well") and three pathway items (e.g., "I can think of many ways to get things in life"). The total score of all items forms an overall scale that indicates change. In this study, a Cronbach alpha of .77 was found for the questionnaire. The New General Self-Efficacy Scale (NGSE ) ( 23 ) is an 11-item, 5-point Likert scale, self-report questionnaire designed to assess an individual's general expectations and perceived abilities to achieve goals and overcome challenges across various situations. The NGSE: (a) predicts specific self-efficacy (SSE) across different contexts and tasks, (b) forecasts general and comprehensive performance outcomes, and (c) mitigates the negative effects of adverse experiences on subsequent SSE. The scale has demonstrated high internal consistency and test-retest reliability. The Screen for Child Anxiety Related Emotional Disorders (SCARED ) ( 24 ) is a 41-question self-report scale for children and parents that screens DSM-5 anxiety disorders. Responses range from 1("usually true") to 3 ("seldomly true"). A total score of ≥ 25 indicates an anxiety disorder, while > 30 is more definitive. The child and parent SCARED each produce five robust factors: somatic/panic anxiety, general anxiety, separation anxiety, social phobia, and school phobia. The SCARED has demonstrated good reliability and validity ( 24 ). Procedure After obtaining ethical approval from the university IRB ethical committee (number 0003949-3), relevant participants on the Mount Judah Stables wait list were approached to participate in the study. Once the consent forms were signed by child and parents, participants were asked to complete a baseline assessment which included the BRIEF, the Hope, the NGSE, and the SCARED. After baseline assessment (time 1), participants proceeded to a 12-week wait period. Following the wait period, assessments were repeated, and directly followed by 12 weeks of ASTride intervention ( 14 ) (time 2). Assessments were conducted once again directly at the end of the intervention period (time 3), with follow up (time 4) assessments taking place 12 weeks following the end of intervention and including the BRIEF, NGSE and Hope questionnaires. All assessments were administered by a research assistant blinded to the participant’s stage in the intervention. Data analysis Statistical analysis was performed using SPSS statistical software Version 27.0, with statistical significance set at p < .05. To compare the four assessment time points (baseline, pre-test, post-test, and follow-up), a Repeated-Measures ANOVA was employed. Post-hoc analyses were conducted using Bonferroni adjustments to identify specific time points where significant differences occurred. Where applicable, effect sizes were calculated to assess the magnitude of the intervention’s impact on outcome measures. Partial eta square was calculated, the values of which are typically referred to as small (0.01), medium (0.06), and large (0.14) ( 25 ) . Results Fifty children (33 boys, 17 girls) aged 6–12 participated in the study (mean age 9.51, SD = 1.52). Approximately half of the participants were under pharmacological treatment for ADHD symptoms. Most attended mainstream education system. Demographic characteristics of participants are presented in Table 1 . Insert Table 1 about here Executive Functions A repeated-measures ANOVA was performed to evaluate the effect of time on EFs according to the BRIEF sub scales. Improvement in executive functions, as evidenced by the BRIEF, was found to be statistically significant. Post-hoc analysis with a Bonferroni adjustment indicated that for all subscales no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, all scales (inhibition, shift, emotional control, initiate, working memory, plan/organize, and monitor) were significantly lower compared to time 2, indicating improvements in executive functions (all p’s < 0.001). Furthermore, Partial Eta Square for all BRIEF subscales were high, indicating clinical improvement in executive functions (see Table 2 ). Table 2 Changes in Executive Functions using the BRIEF questionnaire across three time points (N=50) Time 1 Time 2 Time 3 M (SD) F p Partial Eta Square Inhibit 63.50 (10.96) 62.62 (12.74) 57.88 (10.92) 9.76 .001 .28 Shift 67.66 (11.67) 65.14 (11.77) 61.64 (11.46) 10.17 .001 .29 Emotional Control 66.42 (10.89) 64.26 (11.47) 56.72 (12.55) 15.07 .001 .38 Initiate 63.10 (10.68) 61.62 (9.64) 56.52 (10.38) 13.65 .001 .36 Working Memory 68.86 (8.02) 67.92 (8.52) 62.34 (8.48) 22.86 .001 .48 Plan/Organize 66 (9.94) 65.58 (8.58) 59.36 (8.67) 20 .001 .45 Organization of Materials 55.92 (9.64) 56.98 (10.50) 51.54 (8.79) 22.88 .001 .48 Monitor 59.92 (9.89) 58.60 (10.53) 53.04 (9.34) 12.66 .001 .34 BRI 67.70 (11.20) 66.02 (11.88) 59.02 (13.05) 12.86 .001 .34 MI 65.56 (8.53) 64.94 (8.42) 58.34 (8.30) 35.63 .001 .59 GEC 67.64 (8.34) 66.24 (8.56) 59.68 (8.46) 35.23 .001 .59 *Note . M = Mean; SD = Standard Deviation; BRI = Behavioral Regulation Index; MI = Metacognition Index; GEC = Global Executive Composite Insert Table 2 about here Emotional functions A repeated-measures ANOVA was performed to evaluate the effect of time on anxiety according to the SCARED sub scales. Improvement in anxiety levels, as evidenced by the SCARED, was found to be statistically significant (all p's < 0.001). Post-hoc analysis with a Bonferroni adjustment indicated that, for all subscales, no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, all scales (all p’s < 0.001) except school avoidance (p < .627) were significantly lower compared to time 2. Partial Eta Square was high as well, indicating a clinical improvement in anxiety level post-intervention. See Tables 3 , 4 . Table 3 Changes in Hope and Self-efficacy across three time points (N = 50) Time 1 Time 2 Time 3 M (SD) F p Partial Eta Square Hope 1 29.50 (5.28) 29.20 (4.50) 33.04 (3.75) 17.35 .001 .42 NGSE 2 20.50 (14.52) 18.20 (3.22) 20.80 (2.34) 22.80 .001 .48 *Note . M = mean; SD = Standard Deviation 2 Hope − The Children’s Hope Scale 1 NGSE – The New General Self-Efficacy Scale Table 4 Changes in Anxiety levels according to the SCARED sub-scales questionnaire across three times points (N = 50) Time 1 Time 2 Time 3 M (SD) F p Partial Eta Square Panic Disorder 6.12 (3.96) 5.16 (3.50) 3.38 (2.60) 16.96 .001 .41 Generalized Anxiety Disorder 7.18 (3.61) 6.50 (3.93) 4.60 (3.70) 12.74 .001 .34 Separation Anxiety Disorder 6.94 (2.93) 6.76 (3.03) 4.70 (3.01) 14.78 .001 .38 Social Anxiety Disorder 5.50 (3.74) 5.64 (3.32) 3.74 (3.19) 9.78 .001 .29 School Avoidance 2.40 (3.94) 2.68 (3.29) 2.28 (4.30) .82 .446 .03 SCARED 1 26.84 (11.30) 26.02 (11.47) 17.68 (9.98) 20.33 .001 .45 *Note . M = mean; SD = Standard Deviation 1 SCARED – Child Anxiety Related Emotional Disorders Insert Table 3 about here Insert Table 4 about here A repeated-measures ANOVA was performed to evaluate the effect of time on hope and self-efficacy. Improvement in hope and self-efficacy levels, as evidenced by the Hope and NGSE, were found to be statistically significant (p < 0.001). Post-hoc analysis with a Bonferroni adjustment indicated that no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, scores were significantly higher (p < 0.001) compared to time 2. High levels of Partial Eta Square indicate a clinical improvement post intervention. See Tables 4 . Follow-up assessments were conducted with 12 participants to evaluate the long-term effects of the ASTride intervention. Results demonstrated improvement in performance across several measures from post-intervention (Time 3) to follow-up (Time 4). Specifically, the BRIEF GEC scores showed a slight improvement, with a mean decrease from 63 (SD = 10.89) at Time 3 to 54.57 (SD = 24.04) at Time 4. However, the change was not statistically significant (Partial Eta Square = .09), indicating only a small effect size. In contrast, Hope scores showed a statistically significant decrease from Time 3 to Time 4. This suggests a decline in hope perception over time. Similarly, the NGSE scores showed a reduction from Time 3 to Time 4, though the difference was not statistically significant. See Table 5 . Table 5 Changes in executive functions, hope and self-efficacy at time 3 compared to follow up at time 4 (N = 50) Time 3 Time 4 M (SD) F p Partial Eta Square BRIEF 1 ; GEC 2 63 (10.89) 54.57 (24.04) .626 .45 .09 Hope 3 33.29 (4.27) 29.8 (5.17) 8.86 .025 .59 NGSE 4 22.17 (1.16) 19.8 (2.99) 2.50 .175 .33 *Note . M = mean; SD = Standard Deviation 1 BRIEF- Behavior Rating Inventory of Executive Functions; 2 GEC -Global Executive Composite; 3 Hope - The Children’s Hope Scale; 4 NGSE - The New General Self-Efficacy Scale Discussion The present study evaluated the efficacy of the ASTride protocol ( 14 ), an EAOT intervention for children diagnosed with ADHD. Our findings demonstrate significant improvements in executive functions, hope perception, and self-efficacy, as well as reduced anxiety levels following the intervention compared to baseline. These results underscore the potential of EAOT as a comprehensive therapeutic approach for addressing the multifaceted challenges associated with ADHD. Our study aligns with previous research indicating the positive impact of EAS on cognitive and emotional functions. The observed improvements in executive functions, as measured by the BRIEF, are consistent with earlier findings that highlight the benefits of physical activities, including horseback riding, on cognitive performance in children ( 26 ). The significant reduction in the GEC score post-intervention reflects enhancements in key executive functions such as inhibition, working memory, and planning, which are crucial for daily functioning and adaptive behavior ( 3 ). The structured activities in EAS, such as planning and executing tasks related to horse care and riding, provide practical and engaging opportunities for participants to practice and enhance their EF skills and acquire different strategies according to the child's need. The process of learning to communicate and bond with the horse requires sustained attention, adaptability, and emotional regulation. Such activities inherently support the development of cognitive flexibility, as participants must adjust their strategies and behaviors to successfully interact with the animal. Previous studies have shown EAS positively impacts executive functions due to the unique combination of physical activity, therapeutic horse interaction, and the structured, goal-oriented, nature of the therapy sessions ( 13 , 27 ) The increase in hope perception and self-efficacy parallels findings from Gulati et al. (2018) who reported enhanced mood and self-esteem in children with ADHD following animal-assisted interventions. Literature indicates that children with ADHD may experience lower levels of hope due to their challenges, which can negatively affect their goal-setting abilities and the identification of strategies to achieve these goals ( 28 ). Nevertheless, recent studies show that hopefulness can enhance executive functions such as planning, flexibility, inhibition, and emotional regulation, even in the presence of ADHD symptoms ( 29 ). Recent findings highlight the importance of positive belief systems, such as hope, in helping children and their parents manage ADHD-related deficits. These beliefs serve as protective factors that contribute to coping strategies and personal goal achievement. It is presumed that during EAS the therapist provides appropriate physical and cognitive challenges that promote a sense of mastery and success, which in turn boost hopefulness and overall well-being. Our results further contribute to the literature by demonstrating that EAOT can effectively reduce anxiety, as measured by the SCARED. This aligns with studies suggesting that animal-assisted interventions can promote emotional regulation and decrease anxiety through physiological mechanisms, such as reduced cortisol levels and increased oxytocin ( 30 ). It is also hypothesized that the rhythmic movement of the horse can have a calming effect on the rider, which may contribute to the reduction of physiological symptoms of anxiety, such as increased heart rate and muscle tension. This rhythmic motion is thought to stimulate the vestibular system and the body's ability to regulate arousal and maintain a calm state. Furthermore, engaging in horseback riding requires a focus on the present moment and the task at hand, which can divert attention away from anxious thoughts and reduce overall anxiety levels. In addition to the physical benefits, the human-animal bond plays a crucial role in reducing anxiety. Interactions with horses provide non-judgmental companionship and emotional support ( 31 , 32 ), which can be particularly comforting for individuals experiencing anxiety. The presence of a horse can serve as a calming influence, helping individuals feel more relaxed and secure. Studies have shown that the social and emotional support provided by horses can decrease feelings of isolation and loneliness ( 31 ), often associated with anxiety. ASTride intervention encourages the development of trust, empathy, and social skills, as participants learn to communicate and build relationships with their horse. These positive interactions can lead to increased self-esteem and confidence, further mitigating anxiety. The structured setting of the sessions provides a predictable and safe environment, which is beneficial for individuals who experience heightened anxiety in uncertain or chaotic situations. Referring to follow-up, only 12 participants participated in the assessments. While improvements were observed post-intervention, some skills appear to diminish over time, suggesting the need for continued intervention to maintain the gains achieved during the study period. Limitations and future directions Despite the promising findings, this study has several limitations. The sample size, while adequate, limits the generalizability of the results. Future research should include larger, more diverse populations to validate the findings across different demographic and cultural contexts. Additionally, while our study utilized blinded assessment methods and standardized valid assessments, potential biases inherent in parental reporting on questionnaires like the BRIEF and SCARED should be considered. This study used an Interrupted Time-Series design, widely recognized as effective quasi-experimental methodology used to assess the effects of interventions and programs implemented in healthcare environments. Future studies may wish to incorporate a randomized controlled trial (RCT) design to assess the ASTride intervention. Moreover, while the follow-up assessment at three months post-intervention provides preliminary evidence for the durability of the intervention's effects, our sample is small due to lack of compliance. Longer-term follow-up studies are needed to evaluate the sustainability of the intervention. Conclusion The ASTride EAOT intervention demonstrates significant potential as a comprehensive treatment for children with ADHD, addressing both cognitive and emotional challenges. The findings support the integration of equine-assisted therapies into the broader spectrum of therapeutic options for ADHD, offering a novel, engaging, and effective approach. Further research with more rigorous methodologies and diverse populations will be essential to confirm these findings and establish standardized protocols for widespread application. Abbreviations ADHD – Attention Deficit/Hyperactivity Disorder ASTride – Attention Skill Training (ASTride) protocol EAOT – Equine-Assisted Occupational Therapy EAS – Equine-Assisted Services BRIEF – Behavior Rating Inventory of Executive Function GEC – Global Executive Composite BRI – Behavioral Regulation Index MI – Metacognition Index Hope – The Children’s Hope Scale NGSE – New General Self-Efficacy Scale SCARED – Screen for Child Anxiety Related Emotional Disorders SI – Sensory Integration DSM-5 – Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition RCT – Randomized Controlled Trial ANOVA – Analysis of Variance SD – Standard Deviation M – Mean SPSS – Statistical Package for the Social Sciences IRB – Institutional Review Board Declarations Ethics approval and consent to participate Human Ethics Statement Ethical approval was received from the Sackler Faculty of Medicine of Tel-Aviv University IRB No:0003949-2. All methods were approved and carried out in accordance with the IRB guidelines. Informed consent was obtained from Parents or Legally Authorized Representative of the child participants before conducting the study. Animal Ethics Statement The experiment with equines were approved by the Sackler Faculty of Medicine of Tel-Aviv University IRB No:0003949-2. All methods were approved and carried out in accordance with the IRB guidelines and ARRIVE guidelines for reporting research involving animals (NC3RS, 2023). Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this article. Authors' contributions All authors contributed equally to this article. Acknowledgements No funding was received for this article. References Wehmeier PM, Schacht A, Barkley RA. 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Impact of the Cognitive–Functional (Cog–Fun) intervention on executive functions and participation among children with attention deficit hyperactivity disorder: A. research.aota.org. 2017; Snyder CR. Hope theory: Rainbows in the mind. Psychol Inq. 2002;13(4):249–75. Snyder CR, Hoza B, Pelham WE, Rapoff M, Ware L, Danovsky M, et al. The Development and Validation of the Children’s Hope Scale 1. J Pediatr Psychol. 1997;22(3):399–421. Chen G, Gully SM, Eden D. Validation of a New General Self-Efficacy Scale. Organ Res Methods. 2001;4(1):62–83. Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale Construction and Psychometric Characteristics. J Am Acad Child Adolesc Psychiatry. 1997 Apr 1;36(4):545–53. Schelly D, Ohl A. Examining Clinical Meaningfulness in Randomized Controlled Trials: Revisiting the Well Elderly II. The American Journal of Occupational Therapy [Internet]. 2019 Jan 1 [cited 2024 Oct 11];73(1):7301205120p1–13. Available from: /ajot/article/73/1/7301205120p1/6552/Examining-Clinical-Meaningfulness-in-Randomized Tottori N, Morita N, Ueta K, Fujita S. Effects of high intensity interval training on executive function in children aged 8–12 years. mdpi.com [Internet]. 2019 [cited 2022 Sep 21]; Available from: https://www.mdpi.com/561072 White E, Zippel J, Kumar S. The effect of equine-assisted therapies on behavioural, psychological and physical symptoms for children with attention deficit/hyperactivity disorder: A systematic review. Complement Ther Clin Pract. 2020 May 1;39. Margalit M, Leyser Y, Ankonina D. Community support in Israeli kibbutz and city families of children with disabilities: Family climate and parental coherence. journals.sagepub.com [Internet]. 1991 [cited 2022 Sep 21]; Available from: https://journals.sagepub.com/doi/abs/10.1177/002246699102400404 Dixson DD, Scalcucci SG. Psychosocial perceptions and executive functioning: Hope and school belonging predict students’ executive functioning. Psychol Sch. 2021 May 1;58(5):853–72. Bass MM, Duchowny CA, Llabre MM. The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord. 2009 Sep;39(9):1261–7. Scopa C, Contalbrigo L, Greco A, Lanatà A, Scilingo EP, Baragli P. Emotional transfer in human–horse interaction: New perspectives on equine assisted interventions. mdpi.com [Internet]. 2019 [cited 2022 Sep 21];9. Available from: https://www.mdpi.com/581844 Weiss-Dagan S, Naim-Levi N, adolescent DBC and, 2022 undefined. Therapeutic horseback riding for at-risk adolescents in residential care. SpringerS Weiss-Dagan, N Naim-Levi, D BrafmanChild and adolescent psychiatry and mental health, 2022•Springer [Internet]. 2022 Dec 1 [cited 2024 Oct 29];16(1):90. Available from: https://link.springer.com/article/10.1186/s13034-022-00523-5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Nov, 2025 Read the published version in Child and Adolescent Psychiatry and Mental Health → Version 1 posted Editorial decision: Revision requested 24 Aug, 2025 Reviews received at journal 06 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviews received at journal 04 Mar, 2025 Reviewers agreed at journal 04 Feb, 2025 Reviewers agreed at journal 20 Jan, 2025 Reviewers invited by journal 13 Nov, 2024 Editor assigned by journal 12 Nov, 2024 Submission checks completed at journal 02 Nov, 2024 First submitted to journal 31 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Boys are diagnosed at a rate 2–9 times higher than girls(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), with recent estimates suggesting that ADHD affects around 9.4% of children, highlighting its continued significance as a public health concern (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eADHD is associated with chronic impairments in executive functions− high-level cognitive processes primarily linked to the frontal lobes of the brain. Executive functions are crucial for self-regulation, goal-directed behavior, response inhibition, working memory, and cognitive flexibility, enabling individuals to adapt to new situations and manage their behavior effectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Additionally, ADHD often involves significant psychosocial challenges such as emotional dysregulation, impulsivity, anxiety, depression, aggression (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), low self-esteem, and difficulties in interpersonal relationships (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent best practices for treating ADHD include a combination of pharmacological treatments and evidence-based psychological and behavioral therapies. Stimulant medications such as methylphenidate and amphetamines remain the most common and effective pharmacological treatments for reducing core symptoms (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Non-pharmacological interventions often involve cognitive training targeting specific executive functions, utilizing principles of neuroplasticity through intensive, repetitive practice and immediate feedback (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, while these approaches effectively address core symptoms like hyperactivity and inhibition, they do not always translate to improved everyday functioning (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Behavioral interventions for ADHD are most effective when they are client-centered and occupation-based, focusing on personal functional goals and strategy acquisition (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Although these interventions show promise for improving executive functions and functional skills, they often do not address the full range of psychological difficulties associated with ADHD. Psychological interventions, such as behavioral programs, parental psychoeducation, and expressive therapies, can be beneficial but may not always be occupation-based or focus on strategy acquisition (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Recent studies emphasize the need for a more integrated approach that addresses the complex and multifaceted nature of ADHD, combining core symptom management, emotional support, and practical daily functioning (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eFeasibility of Equine-Assisted Services for Children with ADHD\u003c/h3\u003e\n\u003cp\u003eEquine-Assisted Occupational Therapy (EAOT) combines the therapeutic benefits of equine interaction with traditional occupational therapy techniques (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). EAOT falls within the therapy domain of Equine-Assisted Services (EAS) which includes other licensed professionals who incorporate horses into practices such as physical therapy, psychotherapy, and speech -language pathology. Recent studies have underscored EAS’s effectiveness in reducing anxiety, improving mood and self-esteem (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and enhancing attention, EFs, and social skills (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) in individuals with various disabilities, demonstrating the therapy's broad applicability. However, more rigorous and methodologically sound studies are needed to better understand these effects and confirm the findings across different populations and settings (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent research on EAS for children with ADHD is limited, with existing studies varying in sample size, intervention length, and the professionals conducting the interventions. To our knowledge, only one study to date has presented a structured intervention protocol addressing both cognitive and emotional aspects for children with ADHD (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Given the demonstrated effectiveness of occupational therapy interventions for children with ADHD and the emerging evidence supporting EAS in enhancing cognitive and emotional functions, this study seeks to further validate ASTride protocol for this population, focusing on enhancing and promoting cognitive and emotional aspects such as executive functions, hope, self-efficacy and anxiety.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n "},{"header":"Method","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThe study included 50 participants (mean age = 9.51 years, SD = 1.52), recruited from Mount Judah Stables, an EAS provider to over 300 patients (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Out of the 62 participants initially approached, eight declined due to scheduling conflicts, and four were excluded for beginning new pharmacological treatments during the intervention. \u003cem\u003eInclusion criteria\u003c/em\u003e: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) children between 6 and 12 years of age; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) diagnosis of ADHD from a medical professional based on DSM-5 criteria with or without medication (e.g., psychostimulant medication); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) general doctors' approval and referral for participation in EAS. \u003cem\u003eExclusion criteria\u003c/em\u003e: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) moderate to severe cognitive impairment; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) neurological disorders (e.g., epilepsy); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) children with additional developmental disorders (e.g., Autism, Cerebral Palsy); (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) children due to begin new medical treatment or change existing treatment during intervention; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) children with severe sensory loss (e.g., blindness).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic participant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (66)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (34)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (48)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (52)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidency\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (48)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (46)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTown\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial Education\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypical Education\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (86)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eNote. N\u003c/em\u003e = 50. \u003cem\u003eM\u003c/em\u003e = Mean; \u003cem\u003eSD\u003c/em\u003e = Standard Deviation\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003ch2\u003eASTride protocol\u003c/h2\u003e\u003cp\u003eThe ASTride intervention (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) employs a blend of theoretical frameworks to address ADHD-related impairments. It integrates the Multi-Context approach (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the Cognitive Orientation to Daily Occupational Performance (CO-OP) approach (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and Sensory Integration (SI) theory (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The Multi-Context approach focuses on enhancing strategy use across a variety of activities to promote generalization and improve functional performance. This approach emphasizes training strategies, practice in diverse contexts, and metacognitive skills, gradually shifting intervention activities to mirror real-life challenges(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The CO-OP approach complements this by providing a client-centered, performance-based method that uses the Goal-Plan-Do-Check strategy to facilitate skill acquisition, incorporating structured techniques, including visual aids and modeling, to teach basic riding skills and ensure their application in daily activities (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). SI theory, integral to the ASTride protocol, focuses on how sensory processing impacts behavior and adaptation (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In EAOT, riding provides diverse sensory input, such as tactile and vestibular stimuli, with the potential to enhance sensory integration and support overall functioning (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAlong with its theoretical framework, ASTride is a structured and defined protocol that includes 12 weekly therapeutic sessions, each lasting 45 minutes. It is an intervention administered by an occupational therapist who is an EAS professional. Therapeutic goals are defined at the beginning of the intervention in collaboration with the parents, tailored to meet each child's needs. During the intervention, strategies are learned and practiced within the equine environment, utilizing both mounted and unmounted activities. The learned strategies are later transferred to other environments (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003cb\u003eThe Behavior Rating Inventory of Executive Function (BRIEF)\u003c/b\u003e (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The BRIEF is an 86-item standardized rating scale completed by parents to assess executive functions in children aged 5–18. It includes eight scales: Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan–Organize, Organization of Materials, and Monitor. The scales generate two indexes: the Behavior Rating Index (BRI) from the first three scales and the Metacognitive Index (MI) from the rest. The Global Executive Composite (GEC) sums all scores. Items are rated on a Likert scale from 1 (never) to 3 (often). Raw scores are converted to t scores, with 65 or higher considered clinically significant (SD = 10). The BRIEF has established reliability and validity and is validated for measuring executive functions in children with ADHD (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003cb\u003eThe Children’s Hope Scale (Hope)\u003c/b\u003e (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) comprises 6 statements to which participants respond using a 6-point Likert scale, ranging from 1 (none of the time) to 6 (all of the time). It includes three agency items (e.g., \"I think I am doing pretty well\") and three pathway items (e.g., \"I can think of many ways to get things in life\"). The total score of all items forms an overall scale that indicates change. In this study, a Cronbach alpha of .77 was found for the questionnaire.\u003c/p\u003e\u003cp\u003e \u003cb\u003eThe New General Self-Efficacy Scale (NGSE\u003c/b\u003e) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) is an 11-item, 5-point Likert scale, self-report questionnaire designed to assess an individual's general expectations and perceived abilities to achieve goals and overcome challenges across various situations. The NGSE: (a) predicts specific self-efficacy (SSE) across different contexts and tasks, (b) forecasts general and comprehensive performance outcomes, and (c) mitigates the negative effects of adverse experiences on subsequent SSE. The scale has demonstrated high internal consistency and test-retest reliability.\u003c/p\u003e\u003cp\u003e \u003cb\u003eThe Screen for Child Anxiety Related Emotional Disorders (SCARED\u003c/b\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) is a 41-question self-report scale for children and parents that screens DSM-5 anxiety disorders. Responses range from 1(\"usually true\") to 3 (\"seldomly true\"). A total score of ≥ 25 indicates an anxiety disorder, while \u0026gt; 30 is more definitive. The child and parent SCARED each produce five robust factors: somatic/panic anxiety, general anxiety, separation anxiety, social phobia, and school phobia. The SCARED has demonstrated good reliability and validity (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eProcedure\u003c/h3\u003e\u003cp\u003eAfter obtaining ethical approval from the university IRB ethical committee (number 0003949-3), relevant participants on the Mount Judah Stables wait list were approached to participate in the study. Once the consent forms were signed by child and parents, participants were asked to complete a baseline assessment which included the BRIEF, the Hope, the NGSE, and the SCARED. After baseline assessment (time 1), participants proceeded to a 12-week wait period. Following the wait period, assessments were repeated, and directly followed by 12 weeks of ASTride intervention (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) (time 2). Assessments were conducted once again directly at the end of the intervention period (time 3), with follow up (time 4) assessments taking place 12 weeks following the end of intervention and including the BRIEF, NGSE and Hope questionnaires. All assessments were administered by a research assistant blinded to the participant’s stage in the intervention.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS statistical software Version 27.0, with statistical significance set at \u003cem\u003ep\u003c/em\u003e \u0026lt; .05. To compare the four assessment time points (baseline, pre-test, post-test, and follow-up), a Repeated-Measures ANOVA was employed. Post-hoc analyses were conducted using Bonferroni adjustments to identify specific time points where significant differences occurred. Where applicable, effect sizes were calculated to assess the magnitude of the intervention’s impact on outcome measures. Partial eta square was calculated, the values of which are typically referred to as small (0.01), medium (0.06), and large (0.14) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) .\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFifty children (33 boys, 17 girls) aged 6\u0026ndash;12 participated in the study (mean age 9.51, SD\u0026thinsp;=\u0026thinsp;1.52). Approximately half of the participants were under pharmacological treatment for ADHD symptoms. Most attended mainstream education system. Demographic characteristics of participants are presented in Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eInsert Table\u0026nbsp; 1 about here\u003c/h3\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eExecutive Functions\u003c/h2\u003e\n \u003cp\u003eA repeated-measures ANOVA was performed to evaluate the effect of time on EFs according to the BRIEF sub scales. Improvement in executive functions, as evidenced by the BRIEF, was found to be statistically significant.\u003c/p\u003e\n \u003cp\u003ePost-hoc analysis with a Bonferroni adjustment indicated that for all subscales no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, all scales (inhibition, shift, emotional control, initiate, working memory, plan/organize, and monitor) were significantly lower compared to time 2, indicating improvements in executive functions (all p\u0026rsquo;s\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, Partial Eta Square for all BRIEF subscales were high, indicating clinical improvement in executive functions (see Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u0026nbsp;\u003c/div\u003e\n \u003ch4\u003eChanges in Executive Functions using the BRIEF questionnaire across three time points (N=50)\u003c/h4\u003e\n \u003cdiv\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePartial Eta Square\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInhibit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.50 (10.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62.62 (12.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.88 (10.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eShift\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.66 (11.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.14 (11.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61.64 (11.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional Control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.42 (10.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.26 (11.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.72 (12.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitiate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.10 (10.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61.62 (9.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.52 (10.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking Memory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.86 (8.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.92 (8.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62.34 (8.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlan/Organize\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66 (9.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.58 (8.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.36 (8.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrganization of Materials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55.92 (9.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.98 (10.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.54 (8.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonitor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.92 (9.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.60 (10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.04 (9.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.70 (11.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.02 (11.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.02 (13.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.56 (8.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.94 (8.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.34 (8.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGEC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.64 (8.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.24 (8.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.68 (8.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003e*Note\u003c/em\u003e. \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Mean; \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Standard Deviation; BRI\u0026thinsp;=\u0026thinsp;Behavioral Regulation Index; MI\u0026thinsp;=\u0026thinsp;Metacognition Index; GEC\u0026thinsp;=\u0026thinsp;Global Executive Composite\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eInsert Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e about here\u003c/h2\u003e\n \u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eEmotional functions\u003c/h2\u003e\n \u003cp\u003eA repeated-measures ANOVA was performed to evaluate the effect of time on anxiety according to the SCARED sub scales. Improvement in anxiety levels, as evidenced by the SCARED, was found to be statistically significant (all p\u0026apos;s\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Post-hoc analysis with a Bonferroni adjustment indicated that, for all subscales, no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, all scales (all p\u0026rsquo;s\u0026thinsp;\u0026lt;\u0026thinsp;0.001) except school avoidance (p\u0026thinsp;\u0026lt;\u0026thinsp;.627) were significantly lower compared to time 2. Partial Eta Square was high as well, indicating a clinical improvement in anxiety level post-intervention. See Tables\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e, \u003cspan\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eChanges in Hope and Self-efficacy across three time points (N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePartial Eta Square\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHope\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.50 (5.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.20 (4.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.04 (3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGSE\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.50 (14.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.20 (3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.80 (2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003e*Note\u003c/em\u003e. \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;mean; \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003eHope\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e\u0026minus;\u003c/strong\u003e\u003c/sup\u003e The Children\u0026rsquo;s Hope Scale\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003eNGSE\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003e\u0026ndash;\u003c/strong\u003e\u003c/sup\u003e The New General Self-Efficacy Scale\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eChanges in Anxiety levels according to the SCARED sub-scales questionnaire across three times points (N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePartial Eta Square\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePanic Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.12 (3.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.16 (3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.38 (2.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized Anxiety Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.18 (3.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.50 (3.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.60 (3.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeparation Anxiety Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.94 (2.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.76 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.70 (3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial Anxiety Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.50 (3.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.64 (3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.74 (3.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool Avoidance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.40 (3.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.68 (3.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.28 (4.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCARED\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.84 (11.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.02 (11.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.68 (9.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003e*Note\u003c/em\u003e. \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;mean; \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003eSCARED\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003e\u0026ndash;\u003c/strong\u003e\u003c/sup\u003e Child Anxiety Related Emotional Disorders\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eInsert Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e about here\u003c/h2\u003e\n \u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eInsert Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e about here\u003c/h2\u003e\n \u003cp\u003eA repeated-measures ANOVA was performed to evaluate the effect of time on hope and self-efficacy. Improvement in hope and self-efficacy levels, as evidenced by the Hope and NGSE, were found to be statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Post-hoc analysis with a Bonferroni adjustment indicated that no significant differences were found between time 1 and time 2. However, post-intervention, at time 3, scores were significantly higher (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to time 2. High levels of Partial Eta Square indicate a clinical improvement post intervention. See Tables\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eFollow-up assessments were conducted with 12 participants to evaluate the long-term effects of the ASTride intervention. Results demonstrated improvement in performance across several measures from post-intervention (Time 3) to follow-up (Time 4). Specifically, the BRIEF GEC scores showed a slight improvement, with a mean decrease from 63 (SD\u0026thinsp;=\u0026thinsp;10.89) at Time 3 to 54.57 (SD\u0026thinsp;=\u0026thinsp;24.04) at Time 4. However, the change was not statistically significant (Partial Eta Square\u0026thinsp;=\u0026thinsp;.09), indicating only a small effect size. In contrast, Hope scores showed a statistically significant decrease from Time 3 to Time 4. This suggests a decline in hope perception over time.\u003c/p\u003e\n \u003cp\u003eSimilarly, the NGSE scores showed a reduction from Time 3 to Time 4, though the difference was not statistically significant. See Table\u0026nbsp;\u003cspan\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eChanges in executive functions, hope and self-efficacy at time 3 compared to follow up at time 4 (N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime 4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePartial Eta Square\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRIEF\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e; \u003cstrong\u003eGEC\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (10.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.57 (24.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHope\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.29 (4.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.8 (5.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGSE\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.17 (1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.8 (2.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003e*Note\u003c/em\u003e. \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;mean; \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eBRIEF-\u003c/strong\u003e Behavior Rating Inventory of Executive Functions; \u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eGEC\u003c/strong\u003e-Global Executive Composite; \u003csup\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eHope\u003c/strong\u003e- The Children\u0026rsquo;s Hope Scale; \u003csup\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003eNGSE\u003c/strong\u003e- The New General Self-Efficacy Scale\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study evaluated the efficacy of the ASTride protocol (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), an EAOT intervention for children diagnosed with ADHD. Our findings demonstrate significant improvements in executive functions, hope perception, and self-efficacy, as well as reduced anxiety levels following the intervention compared to baseline. These results underscore the potential of EAOT as a comprehensive therapeutic approach for addressing the multifaceted challenges associated with ADHD.\u003c/p\u003e \u003cp\u003eOur study aligns with previous research indicating the positive impact of EAS on cognitive and emotional functions. The observed improvements in executive functions, as measured by the BRIEF, are consistent with earlier findings that highlight the benefits of physical activities, including horseback riding, on cognitive performance in children (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The significant reduction in the GEC score post-intervention reflects enhancements in key executive functions such as inhibition, working memory, and planning, which are crucial for daily functioning and adaptive behavior (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe structured activities in EAS, such as planning and executing tasks related to horse care and riding, provide practical and engaging opportunities for participants to practice and enhance their EF skills and acquire different strategies according to the child's need. The process of learning to communicate and bond with the horse requires sustained attention, adaptability, and emotional regulation. Such activities inherently support the development of cognitive flexibility, as participants must adjust their strategies and behaviors to successfully interact with the animal. Previous studies have shown EAS positively impacts executive functions due to the unique combination of physical activity, therapeutic horse interaction, and the structured, goal-oriented, nature of the therapy sessions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe increase in hope perception and self-efficacy parallels findings from Gulati et al. (2018) who reported enhanced mood and self-esteem in children with ADHD following animal-assisted interventions. Literature indicates that children with ADHD may experience lower levels of hope due to their challenges, which can negatively affect their goal-setting abilities and the identification of strategies to achieve these goals (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Nevertheless, recent studies show that hopefulness can enhance executive functions such as planning, flexibility, inhibition, and emotional regulation, even in the presence of ADHD symptoms (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Recent findings highlight the importance of positive belief systems, such as hope, in helping children and their parents manage ADHD-related deficits. These beliefs serve as protective factors that contribute to coping strategies and personal goal achievement. It is presumed that during EAS the therapist provides appropriate physical and cognitive challenges that promote a sense of mastery and success, which in turn boost hopefulness and overall well-being.\u003c/p\u003e \u003cp\u003eOur results further contribute to the literature by demonstrating that EAOT can effectively reduce anxiety, as measured by the SCARED. This aligns with studies suggesting that animal-assisted interventions can promote emotional regulation and decrease anxiety through physiological mechanisms, such as reduced cortisol levels and increased oxytocin (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). It is also hypothesized that the rhythmic movement of the horse can have a calming effect on the rider, which may contribute to the reduction of physiological symptoms of anxiety, such as increased heart rate and muscle tension. This rhythmic motion is thought to stimulate the vestibular system and the body's ability to regulate arousal and maintain a calm state. Furthermore, engaging in horseback riding requires a focus on the present moment and the task at hand, which can divert attention away from anxious thoughts and reduce overall anxiety levels.\u003c/p\u003e \u003cp\u003eIn addition to the physical benefits, the human-animal bond plays a crucial role in reducing anxiety. Interactions with horses provide non-judgmental companionship and emotional support (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), which can be particularly comforting for individuals experiencing anxiety. The presence of a horse can serve as a calming influence, helping individuals feel more relaxed and secure. Studies have shown that the social and emotional support provided by horses can decrease feelings of isolation and loneliness (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), often associated with anxiety. ASTride intervention encourages the development of trust, empathy, and social skills, as participants learn to communicate and build relationships with their horse. These positive interactions can lead to increased self-esteem and confidence, further mitigating anxiety. The structured setting of the sessions provides a predictable and safe environment, which is beneficial for individuals who experience heightened anxiety in uncertain or chaotic situations. Referring to follow-up, only 12 participants participated in the assessments. While improvements were observed post-intervention, some skills appear to diminish over time, suggesting the need for continued intervention to maintain the gains achieved during the study period.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and future directions\u003c/h2\u003e \u003cp\u003eDespite the promising findings, this study has several limitations. The sample size, while adequate, limits the generalizability of the results. Future research should include larger, more diverse populations to validate the findings across different demographic and cultural contexts. Additionally, while our study utilized blinded assessment methods and standardized valid assessments, potential biases inherent in parental reporting on questionnaires like the BRIEF and SCARED should be considered.\u003c/p\u003e \u003cp\u003eThis study used an Interrupted Time-Series design, widely recognized as effective quasi-experimental methodology used to assess the effects of interventions and programs implemented in healthcare environments. Future studies may wish to incorporate a randomized controlled trial (RCT) design to assess the ASTride intervention. Moreover, while the follow-up assessment at three months post-intervention provides preliminary evidence for the durability of the intervention's effects, our sample is small due to lack of compliance. Longer-term follow-up studies are needed to evaluate the sustainability of the intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe ASTride EAOT intervention demonstrates significant potential as a comprehensive treatment for children with ADHD, addressing both cognitive and emotional challenges. The findings support the integration of equine-assisted therapies into the broader spectrum of therapeutic options for ADHD, offering a novel, engaging, and effective approach. Further research with more rigorous methodologies and diverse populations will be essential to confirm these findings and establish standardized protocols for widespread application.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eADHD \u0026ndash; Attention Deficit/Hyperactivity Disorder\u003c/li\u003e\n \u003cli\u003eASTride \u0026ndash; Attention Skill Training (ASTride) protocol\u003c/li\u003e\n \u003cli\u003eEAOT \u0026ndash; Equine-Assisted Occupational Therapy\u003c/li\u003e\n \u003cli\u003eEAS \u0026ndash; Equine-Assisted Services\u003c/li\u003e\n \u003cli\u003eBRIEF \u0026ndash; Behavior Rating Inventory of Executive Function\u003c/li\u003e\n \u003cli\u003eGEC \u0026ndash; Global Executive Composite\u003c/li\u003e\n \u003cli\u003eBRI \u0026ndash; Behavioral Regulation Index\u003c/li\u003e\n \u003cli\u003eMI \u0026ndash; Metacognition Index\u003c/li\u003e\n \u003cli\u003eHope \u0026ndash; The Children\u0026rsquo;s Hope Scale\u003c/li\u003e\n \u003cli\u003eNGSE \u0026ndash; New General Self-Efficacy Scale\u003c/li\u003e\n \u003cli\u003eSCARED \u0026ndash; Screen for Child Anxiety Related Emotional Disorders\u003c/li\u003e\n \u003cli\u003eSI \u0026ndash; Sensory Integration\u003c/li\u003e\n \u003cli\u003eDSM-5 \u0026ndash; Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition\u003c/li\u003e\n \u003cli\u003eRCT \u0026ndash; Randomized Controlled Trial\u003c/li\u003e\n \u003cli\u003eANOVA \u0026ndash; Analysis of Variance\u003c/li\u003e\n \u003cli\u003eSD \u0026ndash; Standard Deviation\u003c/li\u003e\n \u003cli\u003eM \u0026ndash; Mean\u003c/li\u003e\n \u003cli\u003eSPSS \u0026ndash; Statistical Package for the Social Sciences\u003c/li\u003e\n \u003cli\u003eIRB \u0026ndash; Institutional Review Board\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was received from the Sackler Faculty of Medicine of Tel-Aviv University IRB No:0003949-2. All methods were approved and carried out in accordance with the IRB guidelines. Informed consent was obtained from Parents or Legally Authorized Representative of the child participants before conducting the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAnimal Ethics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe experiment with equines were approved by the Sackler Faculty of Medicine of Tel-Aviv University IRB\u0026nbsp;No:0003949-2.\u0026nbsp;All methods were approved and carried out in accordance with the IRB guidelines\u003cspan dir=\"RTL\"\u003e\u0026nbsp;and\u0026nbsp;\u003c/span\u003eARRIVE guidelines for reporting research involving animals (NC3RS, 2023). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed equally to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWehmeier PM, Schacht A, Barkley RA. 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Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jpm.12710\u003c/li\u003e\n\u003cli\u003eHelmer A, Wechsler T, Gilboa Y. Equine-Assisted Services for Children with Attention-Deficit/Hyperactivity Disorder: A Systematic Review. Journal of Alternative and Complementary Medicine [Internet]. 2021 Jun 1 [cited 2023 Dec 27];27(6):477\u0026ndash;88. Available from: https://www.liebertpub.com/doi/10.1089/acm.2020.0482\u003c/li\u003e\n\u003cli\u003eHelmer A, Delore E, Bart O. Equine Assisted Occupational Therapy for Children with Adhd (Astride): Protocol Development and Preliminary Study. Clin Neuropsychiatry [Internet]. 2024 Feb 1 [cited 2024 Jul 1];21(1):88. Available from: /pmc/articles/PMC10979790/\u003c/li\u003e\n\u003cli\u003eToglia J, Katz N. The dynamic interactional model of cognition in cognitive rehabilitation. In: Katz N, editor. Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy [Internet]. American Occupational Therapy Association; 2011 [cited 2023 Mar 29]. p. 161\u0026ndash;201. Available from: https://psycnet.apa.org/record/2012-33545-009\u003c/li\u003e\n\u003cli\u003ePolatajko HJ, Mandich AD, Missiuna C, Miller LT, Macnab JJ, Malloy-Miller T, et al. Cognitive Orientation to Daily Occupational Performance(CO-OP). http://dx.doi.org/101080/J006v20n02_07 [Internet]. 2001 Jan 1 [cited 2023 Mar 29];20(42038):107\u0026ndash;23. Available from: https://www.tandfonline.com/doi/abs/10.1080/J006v20n02_07\u003c/li\u003e\n\u003cli\u003eJ Ayres. Sensory integration and learning disorders. American Journal of Occupational Therapy [Internet]. 1972 [cited 2024 Apr 15]; Available from: https://cir.nii.ac.jp/crid/1130282273180619136\u003c/li\u003e\n\u003cli\u003eBracher M. Therapeutic horse riding: What has this to do with occupational therapists? British Journal of Occupational Therapy. 2000;63(6):277\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eGioia GA, Isquith PK, Guy SC, Kenworthy L. TEST REVIEW behavior rating inventory of executive function. Child Neuropsychology. 2000;6(3):235\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHahn-Markowitz J, Berger I, \u0026hellip; IMTAJ of, 2017 undefined. Impact of the Cognitive\u0026ndash;Functional (Cog\u0026ndash;Fun) intervention on executive functions and participation among children with attention deficit hyperactivity disorder: A. research.aota.org. 2017; \u003c/li\u003e\n\u003cli\u003eSnyder CR. Hope theory: Rainbows in the mind. Psychol Inq. 2002;13(4):249\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eSnyder CR, Hoza B, Pelham WE, Rapoff M, Ware L, Danovsky M, et al. The Development and Validation of the Children\u0026rsquo;s Hope Scale 1. J Pediatr Psychol. 1997;22(3):399\u0026ndash;421. \u003c/li\u003e\n\u003cli\u003eChen G, Gully SM, Eden D. Validation of a New General Self-Efficacy Scale. Organ Res Methods. 2001;4(1):62\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eBirmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale Construction and Psychometric Characteristics. J Am Acad Child Adolesc Psychiatry. 1997 Apr 1;36(4):545\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eSchelly D, Ohl A. Examining Clinical Meaningfulness in Randomized Controlled Trials: Revisiting the Well Elderly II. The American Journal of Occupational Therapy [Internet]. 2019 Jan 1 [cited 2024 Oct 11];73(1):7301205120p1\u0026ndash;13. Available from: /ajot/article/73/1/7301205120p1/6552/Examining-Clinical-Meaningfulness-in-Randomized\u003c/li\u003e\n\u003cli\u003eTottori N, Morita N, Ueta K, Fujita S. Effects of high intensity interval training on executive function in children aged 8\u0026ndash;12 years. mdpi.com [Internet]. 2019 [cited 2022 Sep 21]; Available from: https://www.mdpi.com/561072\u003c/li\u003e\n\u003cli\u003eWhite E, Zippel J, Kumar S. The effect of equine-assisted therapies on behavioural, psychological and physical symptoms for children with attention deficit/hyperactivity disorder: A systematic review. Complement Ther Clin Pract. 2020 May 1;39. \u003c/li\u003e\n\u003cli\u003eMargalit M, Leyser Y, Ankonina D. Community support in Israeli kibbutz and city families of children with disabilities: Family climate and parental coherence. journals.sagepub.com [Internet]. 1991 [cited 2022 Sep 21]; Available from: https://journals.sagepub.com/doi/abs/10.1177/002246699102400404\u003c/li\u003e\n\u003cli\u003eDixson DD, Scalcucci SG. Psychosocial perceptions and executive functioning: Hope and school belonging predict students\u0026rsquo; executive functioning. Psychol Sch. 2021 May 1;58(5):853\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eBass MM, Duchowny CA, Llabre MM. The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord. 2009 Sep;39(9):1261\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eScopa C, Contalbrigo L, Greco A, Lanat\u0026agrave; A, Scilingo EP, Baragli P. Emotional transfer in human\u0026ndash;horse interaction: New perspectives on equine assisted interventions. mdpi.com [Internet]. 2019 [cited 2022 Sep 21];9. Available from: https://www.mdpi.com/581844\u003c/li\u003e\n\u003cli\u003eWeiss-Dagan S, Naim-Levi N, adolescent DBC and, 2022 undefined. Therapeutic horseback riding for at-risk adolescents in residential care. SpringerS Weiss-Dagan, N Naim-Levi, D BrafmanChild and adolescent psychiatry and mental health, 2022\u0026bull;Springer [Internet]. 2022 Dec 1 [cited 2024 Oct 29];16(1):90. Available from: https://link.springer.com/article/10.1186/s13034-022-00523-5\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Equine Assisted Occupational Therapy, EAS, ADHD, Hope, Self-efficacy, Executive-functions, anxiety","lastPublishedDoi":"10.21203/rs.3.rs-5368788/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5368788/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the efficacy of the Attention Skill Training (ASTride) protocol, an Equine-Assisted Occupational Therapy (EAOT) intervention, for children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) in enhancing and promoting cognitive and emotional aspects including executive functions, self-efficacy, anxiety and hope perception.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective cohort study with an Interrupted Time-Series design was conducted. Fifty participants (mean age = 9.51 years, SD = 1.52) were assessed at four time points: baseline, pre-test (following a 12-week waiting period), post-test (after 12 weeks of intervention), and after three-month follow-up. The intervention was administered by a licensed equine assisted occupational therapists, and assessments were conducted by a blinded occupational therapist. Measures included The Behavior Rating Inventory of Executive Function \u003cstrong\u003e(\u003c/strong\u003eBRIEF) for executive functions, and the Hope, Child Anxiety Related Emotional Disorders (SCARED), and The New General Self-Efficacy Scale (NGSE) questionnaires for emotional factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant improvements were found in executive functions, hope perception, and self-efficacy. Anxiety levels significantly decreased post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ASTride intervention showed efficacy in improving executive functions, hope, and self-efficacy, while reducing anxiety in children with ADHD, supporting its potential as a comprehensive therapeutic approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research is registered at Clinical Trials.gov, identifier number NCT05869253, first registration at 22/5/2023.\u003c/p\u003e","manuscriptTitle":"Horses and ADHD: The ASTride intervention for Cognitive and Emotional Growth","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-14 06:47:56","doi":"10.21203/rs.3.rs-5368788/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-24T12:39:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T07:41:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4161656597939519936390746733874582110","date":"2025-08-04T14:34:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177836909626614815783822616256804032701","date":"2025-05-18T14:40:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4161656597939519936390746733874582110","date":"2025-04-24T08:56:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-04T10:24:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23104670190868591611662349201425313977","date":"2025-02-04T13:05:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33598614531477160963351859062001381993","date":"2025-01-20T19:56:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-13T18:22:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-13T04:29:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-02T08:28:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child and Adolescent Psychiatry and Mental Health","date":"2024-10-31T18:38:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b644ceae-f0c6-49ea-ab0a-e9c8d368794c","owner":[],"postedDate":"November 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:08:34+00:00","versionOfRecord":{"articleIdentity":"rs-5368788","link":"https://doi.org/10.1186/s13034-025-00990-6","journal":{"identity":"child-and-adolescent-psychiatry-and-mental-health","isVorOnly":false,"title":"Child and Adolescent Psychiatry and Mental Health"},"publishedOn":"2025-11-21 15:58:02","publishedOnDateReadable":"November 21st, 2025"},"versionCreatedAt":"2024-11-14 06:47:56","video":"","vorDoi":"10.1186/s13034-025-00990-6","vorDoiUrl":"https://doi.org/10.1186/s13034-025-00990-6","workflowStages":[]},"version":"v1","identity":"rs-5368788","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5368788","identity":"rs-5368788","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}