Effectiveness of Animal Assisted Therapy on Children with Autism Spectrum Disorder

This systematic review examines the effectiveness of animal assisted therapy on the psychosocial outcome of children with autism spectrum disorder (ASD). The study design, inclusion and exclusion criteria, search procedures, data extraction, and analysis are discussed. The findings suggest that animal assisted therapy can improve communication, motor skills, challenging behavior, and quality of life in children with ASD.

Running head: DISSERTATION
DISSERTATION:
THE EFFECTIVENESS OF ANIMAL ASSISTED THERAPY ON
THEIR PSYCHOSOCIAL OUTCOME OF CHILDREN WITH
AUTISM SPECTRUM DISORDER (ASD)
Name of the Student
Name of the University
Author Note

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Table of Contents
Chapter 2..........................................................................................................................................2
Methodology....................................................................................................................................2
2.1 Study Design (PICOS)...........................................................................................................2
2.2 Inclusion and exclusion criteria (PRISMA Chart).................................................................3
2.3 Search Procedures..................................................................................................................6
2.4 Data extraction.......................................................................................................................6
2.5 Data analysis..........................................................................................................................7
Chapter 3..........................................................................................................................................7
Systematic review findings..............................................................................................................7
3.1 Selection of studies................................................................................................................7
3.2 Risk of bias..........................................................................................................................12
3.3 Implementation of AAT for children with ASD..................................................................12
3.4 Outcomes of AAT for children with ASD...........................................................................21
3.4.1 Improve in communication...........................................................................................21
3.4.2 Improve in motor skills.................................................................................................22
3.4.3 Improve in challenging behaviour................................................................................23
3.4.4 Improve in quality of life (QOL)..................................................................................25
3.5 Data table.............................................................................................................................26
3.6 Quality assessment...............................................................................................................35

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Chapter 4........................................................................................................................................35
Discussions....................................................................................................................................35
4.1 Summarization of result.......................................................................................................35
4.2 Limitations...........................................................................................................................40
4.3 Results and recommendation to adapt the intervention in children with ASD....................41
4.4 Confounding factors............................................................................................................41
Chapter 5........................................................................................................................................42
Conclusion.....................................................................................................................................42
References......................................................................................................................................45
Appendices....................................................................................................................................52
Appendix 1.................................................................................................................................52
CONSORT 2010 Checklist....................................................................................................52

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Chapter 2
Methodology
2.1 Study Design (PICOS)
Systematic reviews are a key technique, supporting practice and informing decision-
making on healthcare (Moher et al., 2015). Conventionally systematic reviews are accomplished
using an objective and above all quantitative approach, by conducting an exhaustive search to
detect all appropriate papers that are then incorporated and assimilated by statistical analyses.
The integrity of the search was seen as an important factor in stopping misrepresentation and
offering a real representation of studies accessible. Therefore, current study on the method of
systematic qualitative examinations focuses on techniques to ensure as extensive and preliminary
searches as possible (Finnerup et al., 2015). Due to the time and resources needed for a
systematic and through search the sensitivity of surveys has been investigated and therefore the
time invested in examining irrelevant papers has been reduced with no advantage. The basis for
qualitative or narrative review, now widely known as syntheses of qualitative evidence, is
nevertheless also extensive research. Qualitative information synthesis is now recognized as a
precious and essential form of data to respond to the study issues of health facilities. However,
problems have been earlier observed in completing a delicate yet thorough search for qualitative
literature, such as: weak indexing and the use of main words in qualitative studies, prevalent
application of titles lacking the keywords describing this article and unorganized abstracts.
A search tool serves as an organizational framework for the preparation of a search
strategy to list terms of the major concepts in the search, particularly in teams where an
experienced information expert cannot become part of the review team. The PICO instrument
focuses on a (normally quantitative) article's population, intervention and comparison results. It
is frequently used to define clinical proof in evidence-based medicine for systematic reviews and

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is supported by the Cochrane cooperation. Because of the basis in the target literature, several of
these search terms, such as "control group," and "intervention," are not applicable to qualitative
studies which does not traditionally use control groups or interventions. These conditions can,
however, become more important in the future, as further studies and interventions include
qualitative research. Since the PICO tool doesn't fulfil qualitative study or particular qualitative
design terms at present, it has in practice often been changed to "PICOS," whereas "S" refers to
the study design and thus limits the number of articles irrelevant (Shamseer et al., 2015).
2.2 Inclusion and exclusion criteria (PRISMA Chart)
If they are written in English and switch studies with compliance as a measured outcome,
original research papers have been entered. Study results had to be reviewed by peers and the full
text had to be accessible through the search portal. Studies that focus on anon-generalized
population were also excluded. While these surveys are important study items, they are excluded
in order to decrease the danger of external variables or access to drugs affecting the outcomes
owing to the demographic features of a research issue. Although quantitative studies have
historically been recognized as the gold standard of health research in order to generalize
outcomes to broader populations, it is essential that nursing practice is based on qualitative
variables such as situational variables and mature influences to develop formulations of plans of
care (Sinnott et al., 2016). Therefore, qualitative trials are included in this systematic review that
provides useful insights into patient preferences and experiences. In order to identify the
appropriate studies to be included in the study research, 178 papers have been tested and
evaluated through title and abstract scanning. The 21 items recognized as having prospective
significance through this technique of screening were then evaluated by retrieving a complete
text and evaluating the inclusion and exclusion criteria. In the excluded study table with a reason

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for exclusion, the eleven papers excluded from this study at this point were recorded. Ten studies
have been recognized as appropriate and included in the study. The included studies examined
the experiences, opinions, attitudes and perceptions of nurses in the field of health care facilities.
Searches were not subject to any date limitation as this was an initial review. Qualitative research
has been described as using both a qualitative information collection technique and qualitative
analysis in the Cochrane Qualitative Methods Group. Consequently, quantitative and blended
methodology studies were excluded (McGrath et al., 2017).

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Records identified
through Medline
database searching
(n = 74)
Records after duplicates removed
(n = 200)
Records screened
(n = 200)
Records screened
(n = 198)
Records excluded
(n = 190)
Records excluded
(n = 186)
Full-text articles assessed
for eligibility
(n = 10)
Full text articles excluded,
with reasons
(n = 3)
Full-text articles excluded,
with reasons
(n = 6)
Included studies in this
investigation for
qualitative synthesis
(n = 7)
Included
Screening
Eligibility
Identification Records identified
through Embase
database searching
(n = 115)
Records identified
through PsychInfo
database searching
(n = 41)
DISSERTATION
Figure 1: PRISMA Diagram for this research investigation

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2.3 Search Procedures
Search conditions were initially recognized by extending the question of PICO studies.
Initial pilot tests were carried out to determine if a number of possibly significant researches
could be recorded. In order to determine and form the research question, a systematic review was
carried out using Population, Intervention, Comparison, Result (PICO) methodology for this
review (McGowan et al., 2016). PICO is a very well-developed medical research framework,
which has been selected to assist to develop a defined and restricted issue that will guide the
study process. Databases have been consistently searched for MEDLINE, Embase and PsycInfo
in order to identify studies to incorporate into this research investigation. Use the Boolean
operator search to search for accurate outcomes with important phrases. Only publications of
complete text were recognized and 'Gray literature' was not searched. Searches were not carried
out for the author and quote. The filters and amount of items discovered are identified in a
PRISMA Flow diagram. In addition to these search strategies, a combination of medical topic
headings and keywords was used to tailor these search strategies to three large medical and
nursing databases (Bovid MeDLin, Ovid Mebass).
2.4 Data extraction
Ten appropriate studies were conducted for their features and methodology when the two
databases were searched. Resources, population description, sample size, intervention vs.
comparator, measurements for the results of adherence and authors ' results, and quality are
summarized in a tabular format. For use within the body of the work, the methodology and
results were extracted and the themes were identified and discussed (Norman, Leeflang &
Névéol, 2018). This systematic review investigator has assessed titles and abstracts against the
criteria for incorporation. If a title and an abstract fulfill the inclusion criteria, complete copies of

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all papers for further research have been obtained. The data from the research included were
obtained separately by both reviewers to guarantee precision and saved on a spreadsheet of
Microsoft Excel. Ethics consent was not pursued before this systematic review, because there
was no primary research undertaken, but each of the studies included in this systematic
review was evaluated to ensure that it was done when required (Jonnalagadda, Goyal &
Huffman, 2015).
2.5 Data analysis
Research studies recognize, before using it for informing decision, the significance of
critical assessment by systematically examining proof in study. A number of quality frameworks
are accessible for assessing study quality and vary according to whether qualitative or
quantitative research is evaluated. In order to apply their evaluation methodology to the study
studies recognized for use in this systematic review, distinct scales of rating of proof have been
examined and evaluated (Wetterslev, Jakobsen & Gluud, 2017). CONSORT checklist is the tool
for the quality analysis of the articles so that it can be analysed that if there is any bias present in
the articles for the participant selection and sampling process as well (Pandis et al., 2017).
CONSORT checklist has been implemented in order to check the randomised trial method used
among the included articles used in this systematic review process. Based on the analysis the
quality of the articles has been determined (Karpouzis et al., 2016).
Chapter 3
Systematic review findings
3.1 Selection of studies
Based on the research topic the literature for the systematic literature review has been
selected. The literature was selected based on the inclusion criteria that relates to the intervention

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and also the comparison of the procedures for the treatment of the ASD affected children. On
that context it can be seen that among all the literature taken into consideration the 7 articles are
met all the criteria for the research. Hence, it can be seen that the inclusion criteria for this study
was adequate sample size for the study, proper conclusion based on the study result, statistical
analysis and most importantly the factor of the effect of the AAT based on specific animal use.
Based on these factors the process of the study selection has been done. On the other hand the
other studies were excluded based on the exclusion criteria 3 articles were excluded from this
literature review process and the exclusion criteria was improper description and also the
unavailability of the full text of the studies.

Running head: DISSERTATION
Inclusion Criteria
Numbe
r
Author Yea
r
Aim of the
evidence /
article
number of
participant
s included
Interventions
and
comparisons
Methods
used in the
evidence
Outcomes Comments Risk of
Bias
1 Kern et
al.
201
1
Effectiveness
of EAA in
reduction of
severity of
ASD among
the children
with ASD
24 Equine
riding
therapy to
ASD affec
ted children
with
comparison
of four time
points
Childhood
Autism
Rating
Scale
(CARS) and
Cohort
Study
Reduction in
severity of
ASD
symptoms
Sample size
is adequate
Low
2 Lanning
et al.
201
4
Effectiveness
of EAA in
improvement
of social
behaviour of
the ASD
affected child
25 Comaprison
between 12
social circle
activity
attended
children
with ASD
and 13 EAA
attended
children
with ASD
Cohort
study
Social
behaviour
improvemen
t
Sample size
is adequate
Low
3 Silva et
al.
201
8
Finding
effectiveness
of dog
assisted
therapy for
children with
ASD
10 Comparison
of live dog
usage and
robot dog
usage among
the children
with ASD
for the
assessemnt
Exploratory
Experiment
Latency to
distres was
higher in
live dog
experiences
Article is
well
structured
byut the
sample size
is
inadequate
Mediu
m

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of the most
effective
ways to
reduce
severity of
ASD.
4 Borgi et
al.
201
6
Effectiveness
s of EAT in
improving
adaptiveness
and executive
functioning
among
children with
ASD
28 Comparison
between
EAT
attended
children 15
and 13
children in
control
group
Vineland
Adaptive
Behaviour
Scale
(VABS)
scoring
Found
reduced
planning
time for
problem
solving tasks
Sample size
is adequate
and proper
graphical
interpretatio
n of data
Low
5 Funahash
i et al.
201
4
Smiles
quantification
of a child
with autism
spectrum
disorder
during AAA
for
facilitating
social
positive
behaviour
2 Comaprison
between
smile of
ASD child
and a
healthy boy
on the basis
of the AAA
Comparativ
e study
Social
behaviour
improvemen
t
Sample size
is too small
however,
proper and
effective
study
High
6 O’Haire
et al.
201
4
Effectiveness
of the AAT
in the process
of the ASD
effected
children
64 Guinea pig
assisted
therapy and
activities in
the
classroom
Randomise
d controlled
trial
AAI has
been found
effective in
treatment for
ASD
children
Adequate
study for the
knowledge
development
about the
effectivenes
Low

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tretment s of the
process and
sample size
is adequate
7 Azenman
,
Standeve
n and
Shurtleff
201
3
Motor skill
and social
behaviour
improvement
of ASD
children by
Hippotherapy
6 Hippotherap
y and VaBS
II scale as
the
intervention
and
measuremen
t of the
adaptive
behaviour
improvemen
t
Pilot study Hippotherap
y found to
have
positive
influence on
the children
with ASD
Small
sample size,
however
proper study
Description
and
effectivenes
s of the
therapy on
this context
Mediu
m
Exclusion Criteria
Number Author Year Title Reason for exclusion Risk of Bias
1 O'Haire 2013 Systematic review used for the process Did not provide adequate
knowledge
High
2 Satiansukpong 2008 Effects of classroom animal-assisted
activities on social functioning in
children with autism spectrum
disorder.
Full text not available Medium

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3 Anderson &
Meints
2016 Brief report: the effects of equine-
assisted activities on the social
functioning in children and
adolescents with autism spectrum
disorder
Not relevent to the reacher
question
High

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3.2 Risk of bias
Based on the above table it can be seen that the bias risk is present on the basis of the
sample size or the result outcome. It can be seen that the low sample size and also the stereotypic
results of the articles can be related to the risk of biasness. However, the rate of bias risk in the
included studies has been seen to be lower. On the other hand the factor of the excluded studies
has been found with high risk of bias as the inappropriate discussion found in those articles.
Based on this assessment it can be stated that the present study would be completed by
eliminating the biasness and also try to find the proper result based on the research question and
also the facto of proper intervention for the ASD affected children.
3.3 Implementation of AAT for children with ASD
Kern et al. (2011), opined that animal assisted therapy has been used by several
recreational therapists in order to treat different psychological and physical issues of different
patients. Recreational therapy would be a crucial factor in terms of the Autism Spectrum
Disorder (ASD). They also highlighted that the Animal Assisted Therapy (AAT) would be one
of the most effective factor in the process of the ASD treatment among the children. The process
of recreational therapy would include the aspects of reaching the improved behavioural, physical
and psychological expectations (Coyne & Fullerton, 2014). On this context it can be seen that the
recreational therapists work on the effective processes that would be helpful in treating the ASD
affected children. On this context it has been seen that one of the most effective therapies can be
provided by the canines (Gray, 2015). They also found that the specifically Equine Assisted
Therapy (EAT) would more likely to be highly effective in the proper treatment of the children
with ASD. Authors took the scale in consideration with the Childhood Autism Rating Scale
(CARS) and also the Timberlawn Parent-Child Interaction Scale (TPCIS). The study also

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considers the factors of the sensory processing, quality of life along with the factor of the parent
treatment satisfaction. In order to find the expected result the authors considered the aspects of
the four time points that include the following factors such as, before beginning a 3-to-6 month
waiting period, before starting the riding treatment, after 3 months and 6 months of riding.
Hence, it can be stated that the study depends on the aspect of the interaction of the ASD
children with horse and the effects of the horse riding as well. Hence, it can be stated that the
effective research on this context has been taken out by the authors on the basis of the process of
the proper exclusion and inclusion criteria and also effectively finding the factor of the
effectiveness of the canine assisted therapy for the psychological and the physical balance
development of the children affected by the condition of the ASD (Mannocci et al., 2015). On
this context it has been found that the factor of the autism has reduced among the participants of
the research with respect to the riding therapy for the children used in this case (Altern Ther
Health Med, 2011). Therapeutic riding intervention has been highlighted as the effective
intervention for building up the empathy and the decrease of the maladaptive behaviours among
the children with ASD. On this context it can be seen that the effectiveness of the therapy using
the horse riding process would be effectively helpful in the intervention of the process of the
social behavioural improvement of the ASD children. The process also highlighted that the
equine or the horse can be used in an effective way that could possibly reduce the severity of the
ASD among the participants used in this study. On the other hand the factor of measurement
showed the significant change among the children used in this study. On the basis of the results
found in this research study the authors concluded that the EAT is one of the most effective
therapies in the sector of ASD. Thus the children can be profited if the AAT more specifically
EAT could be used for the children with ASD. The method of this study is dependent on the four

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time point evaluation process on the other the exclusion and inclusion criteria dependent on the
aspect of the age of the participants, diagnosis of the ASD and the participants has been chosen
on the basis of without used any horse riding therapy. Thus the factor of the research study has
been developed based on the proper activity based program. On the other hand it has also been
seen that the measurement of criteria includes the CARS scale of the children, sensory profile of
the children used in the study and also parent treatment satisfaction. Hence, on the basis of this
study the aspect of the result highlighted that the therapeutic horse riding is effective in the
severe reduction of the ASD among the children however, it has also been seen that the pre-
treatment baseline period has not been showed any kind of change in the CARS scale. Thus it
can be stated that the time also effective in the process of the therapy. The limitation of this study
is the small sample size and also the result is limited as the measuring team was blind to the
treatment phase. Thus it can be stated that the factor of the AAT is effective in terms of the
EAAT program on the ASD children. However, the psychological changes of the children by the
measurement scales cannot be assessed properly. On the other hand the aspect of the research
based review could not be able to provide the proper idea about the aspect of the actual thoughts
and feelings of the individuals affected by ASD (Viau et al., 2010). Thus the possibility of risk of
bias can be found in the sampling technique.
According to Lanninget al. (2014), the factor of the AAT can be supported by the Equine
Assisted Activities (EAA). The authors highlighted that the comparison between the participants
with 9 weeks of EAA and also the non-equine intervention participants. The study shows the
factors of the comparison and also highlighted that the aspect of the children with ASD found to
be profited with the EAA treatment whereas the non-equine intervention children showed
improvement as well but in a lower range. Thus it can be stated that the factor of the treatment of

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the ASD children can be done with the animal assistance in this case the horse interaction is used
specifically. Thus it can be stated that the factor of the effectiveness can be seen by the parents
based on the children’s emotional, physical outcomes and also the social functioning aspects as
well. Hence, it can be stated that the aspect of the EAA use in the severity reduction of the ASD
among the participants were successful (Bass et al. 2009). However, the comparison should be
considered for the better idea about the treatment process. The changes among the children have
been seen after 6 weeks of the EAA process for the children in the age group of 3 (American
Psychiatric Association, 2013). Hence, it can be stated that process is time effective as well. The
study has been done on the basis of the comparison between the children with different treatment
that is the EAA and social circle intervention process. The results showed that the effectiveness
of the equine assisted therapy or the animal assisted therapy than the social circle intervention
and also effectively finding out the differences between social interactions of the ASD children
in both the process. The limitation of this study includes the small sample size for the treatment
and comparison group and also the large variance in the statistical data. On the other hand only
one evaluator that is the parent is the other limitation of this study (Limbers et al. 2009). The
limitation of the study also includes the possibility of the risk of biasness as of the sampling
method.
According to Silva et al. (2018), the effectiveness of the AAT, specifically the do assisted
therapy in the treatment of the severe ASD affected children. The study of this article has been
designed on the basis of the within subject design process. The study has been conducted on ten
male children aged between 6 to 9 years of age diagnosed with the ASD. The aspect of the study
revealed that the factor of the dog assisted therapy has been effectively promoting the social
activity of the children and also effectively decrease the behavioural and also the cardiovascular

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distress. The therapy also highlighted that the factor of the prohibition tasks has been improved
although the inactive stimulus still present after the therapy with dogs and the activities regarding
the AAT (Kaboski et al., 2015). The researchers have been using both the live dogs and also the
toy dogs and it has been seen that the live dogs are more effective in the latency improvement
towards the distress (Peterson& Hann, 1999). On this measurement time frame it has been seen
that the interests of the children increased for the participation in the program that is attending
skills and also the social interaction of the children increased, social functioning, social
approach, skill and behavior also improved by the result of this AAA program. Thus the authors
concluded that the feasibility of this program is high as the social behavior and skills of the
children has been developed after the program implementation. The results also highlighted that
the social behavior and also the factor of the heart rate reactivity, tension release behaviours are
significantly changed in case of the usage of the live dogs(Konstantareas & Stewart, 2006).
Hence, it can be stated that the factors of the process would be effective in the proper
supplementation of the severely affected ASD children. On the other hand the factor of the
measurement of the behavioural change among the children has been conducted with the help of
the prohibition task. Thus it can be stated that the factor of the usage of live dogs for the AAT on
the ASD affected children would be one of the most feasible therapy. The limitation of this study
can be highlighted as the usage of the dog as the therapy and there is no control or comparison
group. On the other hand the aspect of the ample size is very low for the study as well. Hence,
the risk of the bias can be found in this study as well.
Borgi et al. (2016), highlighted that the factor of the EAT in the improvement of the
adaptive and also the executive functioning of the participants. On the other hand the factor of
the AAT in the ASD treatment also effectively evaluated in the article. The study developed with

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the consideration of the inclusion criteria that is the IQ level of the participants should be greater
than 70 and there is two groups compared on the basis of the control group (sample size 13) and
the EAT therapy provided (sample size 15). The result of the study highlighted the effectiveness
of the EAT in treating the ASD affected children than the control children and the parameter for
the measurement of the effectiveness is social functioning level of the children. On this context it
can be seen that the horse riding activities developed and improved the social behavioural and
the interacting factors for the participants than the control group participants. The study also
highlighted that the effectiveness of the EAT is more desirable and also can be seen with time.
On this context it can be stated that the EAT is effectively supported the animal assisted
intervention as it improved the executive functioning that is the reduction in the time for the
problem solving tasks. Hence, it can be stated that the factor of the EAT is more effective than
other aspects of the therapeutic programs and also helpful in the proper development of the
social behavior of the participants. The article also highlighted that the cognitive and adaptive
disability along with the self-sufficiency problems could be seen among the ASD children
(Geschwind and Levitt, 2007). On this context it can be seen that the EAT provided children are
improved in regards with these issues as well. The limitation of this study is the small sample
size and also the control group showed very different baseline scores in some sections as well.
Based on the scoring the possibility of risk of the bias for the study outcome can be seen as the
limitation of the study.
Based on the views of Funahashi et al. (2014), the quantitative analysis of the smile in
accordance with the animal assisted activities (AAA) of an autistic boy and a healthy boy as
well. The study has been conducted for 7 months and for the measurement the children were
provided with a wearable device that can be able to measure the computerized smiling of a

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human. It has been seen that the animal assisted activities of these children facilitated the smile
level increase which resulted in improved social interaction and behavior whereas it also helped
in the elimination of the negative social attitude and behaviours as well (Niedenthal wt al., 2009).
On this context it can be stated that the factor of the behavioural improvement can be developed
by the AAA and also effectively develop the physical and psychological factors of the children
despite ASD affected condition or the healthy child. Thus the factor of the AAA is one of the
aspects in the treatment of the ASD that effectively resulted in the development and
improvement of the cognitive disorders of the child by improvement of the social interaction.
Hence, the possibility of the use of this therapy is very likely to be adapted for the treatment of
the ASD affected children as the effects of this treatment is positive. The process of this therapy
was done with the help of the dogs thus the therapy can be termed as the dog assisted therapy
and also helpful in the smile increase among the children. Thus it can be stated that the factor of
the proper therapy can be provided to the ASD children with the help of the dogs. The
measurement of the effectiveness of the therapy has been conducted with the help of the analysis
of the smile, social behaviours positive and negative with the help of the Dartfish software by the
medical examiner which helps in the determination of the effectiveness of the process. The
process of the evaluation would be taken out by the process of the facial expression and also
uncovering the neck, face and the head (Tager-Flusberg et al. 2001). On the other hand the
effectiveness of the therapy could be properly accepted as the sample size is very small. On the
other hand the factor of the evaluation process is very much time consuming as the video
recordings are to be evaluated by the medical examiner in this process (Cohen et al., 2003). On
the basis of the study the risk of bias can be found as well as the limitation of the outcome.

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Based on the views of O'Haire et al. (2014), it has been found that the animal assisted
activity (AAA) in the classroom would be effective in the social behavior improvement of the
children with ASD. The objective of this study is to find out the effectiveness of this therapy for
the ASD affected children. On this context the authors have taken 64 children of 5 to 12 years of
age from 41 classrooms of 15 schools of Australia. The AAA program has been conducted for 8
weeks and the determinants of change measurement were done by the parents and teachers of the
schools. The factor of this study designed on the basis of the multisite and control-to-intervention
design. The measurement has been done on the basis of the 3 time points which were upon study
entry, after an 8-week waiting period during the week prior to the AAA program and during the
week following the 8-week AAA program. On this measurement time frame it has been seen that
the interests of the children increased for the participation in the program that is attending skills
and also the social interaction of the children increased, social functioning, social approach, skill
and behavior also improved by the result of this AAA program. Thus the authors concluded that
the feasibility of this program is high as the social behavior and skills of the children has been
developed after the program implementation. On the other hand the process of the treatment can
be effective in future as well. Limitation of this study can be seen as possibility of selection bias
for this study is present.
According to Azenman, Standeven and Shurtleff (2013), ASD affected children can be
treated with Hippotherapy that is the session of horse riding of the participants with ASD. On
this factor it can be seen that the social behavioural changes can be achieved by the EAT therapy
that includes the horse riding process. On this context the authors has taken six children affected
with ASD for the EAT therapy more specifically the Hippotherapy. This experiment has been
done with the pre-test and post-test process (Brown & Dunn, 2010). The changes of the social

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behaviour and the adaptive power of the children have been assessed in this process as well. On
this context it can be seen that the therapy was effective for the children with ASD as the social
behaviour and the motor skills of the children (O’Brien & Williams, 2010). On this context it
can be seen that the factor of the EAT therapy was very much effective for the ASD affected
children as it helps in the development of the motor skills of the children also the psychological
improvement as well including the social behavioural improvement along with the social
interaction improvement as well (Baranek, 2002). On the other hand the process of the study has
been done for 12 weeks on the 5 to 12 year old children with ASD. The participants have taken
the 45 minute hippotherapy sessions and for 12 weeks and that leads to the changes of the social
behavioural changes among them directed to the positive outcomes. Hence, it has been
concluded that the hippotherapy that is a type of the EAT treatment process and should be used
for the improved outcome for the children. The study can be found with the risk of bias as of the
sampling method as well. Hence, it can be stated as the limitation of the study.
3.3.1 Target Deficit and Developmental Challenges
Based on the above study it can be stated that the aspect of the deficiency in the target
population with ASD would be found with different developmental issues and also highlight
some mental and physical deficiencies including cardiovascular issues. On the other hand it can
be seen that the factor of the mental issues are more evident among the target population. The
mental issues include the factor of the depression, anxiety, agitation, restlessness and most
importantly social interaction issues and social behavioural issues. On this context it can be
stated that the ASD affected children are socially isolated and depressed most of the time. Thus
their interactions are affected by these mental conditions and also the process of the effective
communication is missing among these children and their family members or friends.

23
DISSERTATION
3.4 Outcomes of AAT for children with ASD
From the aforesaid review of literature of the discussed topic that is autism condition can
be improved by using the animal assisted therapies. From the literature review section a few
themes of the overall findings can be easily generated. The generated themes are as follows:
3.4.1 Improve in communication
The study of Kern et al. (2011) examined the effects of the equine-assisted activities on the
severity of autism signs by using the Childhood Autism Rating Scale (CARS) and the quality of
parent- children interactions was examined using Timberlawn Parent-Child Interaction Scale. In
this study, a riding treatment method was used and the assessment was documented in a four step
manner. The study result reported that, by using the riding treatment, the communicative
approach of the children developed greatly. However, no changes were reported in the CARS
score of the patients. The riding treatment showed significant change in the condition of the
autism patients at the 3 months and 6 months. The parent rated quality of life was also reported
to be improved from the pre-treatment condition. Therefore, the study concluded that use of
animal assisted intervention programs can be a good strategy for children with ASD. The EAT
sessions were conducted once in a week for the time period of 6 months with almost 25 sessions
for each patients. One of the important positive aspects of animal assisted therapies among the
ASD patients is the improvement of the communication skills and use of language among the
subjects of ASD in the presence of animals while comparing the condition with the no animal
condition. Apart from that it is again reported that, use of animal services in the treatment of the
ASD patients can reduce the amount of stress and thereby increases the well-being of the patients
with ASD. This study also reported that the use of animal assisted therapy among the ASD

24
DISSERTATION
patients can enhance the smiling and laughing of the subjects and this finding also supported the
findings of the Silva et al. (2018).
3.4.2 Improve in motor skills
The effectiveness of the hippotherapy (HPOT) was again reported. This study reported
that, the use of HPOT can also improve motor control skills and adaptive behaviours among the
ASD patients. In most of the studies, mainly horse are used as animal assisted therapy in the
ASD treatment. However, the study findings were not at all synchronous as most of the studies
are from different countries (Azenman, Standeven & Shurtleff, 2013).The study findings
reported the improvements of social functioning, and ameliorated executive abilities, namely
reduced latency of the first move during a problem-solving task among the children participated
in the EAT program. This study again reported about the improvements of the motor skills after
the EAT program. According to Lanning et al. (2014), the school functioning scores of the
children having EAA treatment was also enhanced than the control group of the study. This
study also reported about the improvement of muscular activities and motor skills improvements
among the children with EAA and thereby the improvement of the skills was reported. . Borgi et
al. (2015) also reported that the study result supported the previous study findings in terms of
improving the social functioning in the group attending the EAT and along with this a little
improvement in the motor skills of the patients with ASD was also reported by the researchers
while comparing with the control group of the study as well. At the end of the EAT program, it
was reported that, children attended the EAT program took lesser amount of time during problem
solving.

25
DISSERTATION
3.4.3 Improve in challenging behaviour
Lanning et al. (2014) reported about the behavioural changes among the autism
patients by using the EAA. In this study, the result of EAA induced patients and non- EAA
induced patients was compared. In the first group almost 10 subjects were recruited and in the
latter group 8 participants were recruited. After the 6 weeks of the EAA treatment, the parents
reported about the improvement of their children regarding the child’s physical, social
functioning and emotional behaviours. The study showed that, the children who were given non-
equine treatment, they also had improvement but in a lesser amount in comparing with the
patients received EAA. Along with this, after 6 weeks of EAA, the social functioning of the
patients with ASD was also reported to be improved in a better way than that of the patients not
having any kind of EAA treatments. Moreover, the school functioning scores of the children
having EAA treatment was also enhanced than the control group of the study. Another crucial
finding of the equine assisted therapy was reported by Borgi et al. (2015). This study showed the
equine assisted therapy (EAT) contributed to the improvement of executive and adaptive
behaviours among the children with ASD. The therapeutic interventions for this therapy included
both the horse ridings and work with the horses on the ground as well. The study result supported
the previous study findings in terms of improving the social functioning in the group attending
the EAT. At the end of the EAT program, it was reported that, children attended the EAT
program took lesser amount of time during problem solving. The study result suggested that the
EAA may positively affect the maladaptive behaviour among the autistic children. Another study
by Funahashi et al. (2013) also reported about the effectiveness of the animal assisted therapy in
improving the social behaviours of the patients suffering from ASD. This study focuses on the
social engagement behaviours of the ASD children. The study included one autistic child and a

26
DISSERTATION
normal child under the age group of 10 years. The participants voluntarily participated in this
study. The researchers measured the smiles of the child with ASD by using a wearable interface
device during the animal assisted therapy continued for 7 months. The results were recorded
during the study through a video recorder and then they were coded by using a medical examiner
(ME). Then the recorded smiles were recognized by using computer detected smiles stored in the
ME database. Both the subjects showed positive outcomes in terms of social behaviour as their
smiles were also enhanced. Therefore, it can be stated that, the use of animal assisted therapy in
the ASD child might help in the enhancement of the smiles and this behaviour enhanced the
positive social behaviours. Apart from that, it is also reported that the negative social behaviour
also reduces when the smiles increase in the ASD child. So, it is quite evident that, the more
engagement to the social behaviour of the autistic child may associate with the enhanced smiles
during the animal assisted therapy among the ASD child. The animals in the animal assisted
therapies might enhance the social engagement behaviour and smiling among the ASD patients.
The classroom based animal assisted therapy also helped in the improvement of the social
functioning among the ASD children. The study of O’Haire et al. (2014) conducted their study
by using 64 samples in 41 classrooms in 15 schools in Australia. The classroom based AAA
program comprised of 8 weeks of animal interaction sessions. Reduced social withdrawal
behaviours and increased social skills were reported after the AAA program implementation
among the children participated in the AAA program. The animal assisted classroom programs
for the ASD children in the classroom may provide cost effective means of helping the families
and educators in terms of improving the social functioning of the children with ASD. It is
reported that, almost of the studies selected in this systematic study, reported about the enhanced
social interaction among the children having animal therapy in comparison with the children

27
DISSERTATION
having no animal. Moreover, the animal assisted therapy also improved the socialization skills
among the ASD children.
3.4.4 Improve in quality of life (QOL)
According to Kern et al. (2011), Timberlawn Parent-Child Interaction Scale, CARS score
of the patients and the parent rated quality of life was also reported to be improved from the pre-
treatment condition. Thus it can be stated that he factor of the AAT treatment has been effective
in the process of the care of the ASD affected children. This therapy leads to the effective
communication development among the participants, social behavioural changes towards the
positive direction, effective motor skill development as well. On this context it can be stated that
the factor of the quality of life improved as it is the collective aspect of all these factors.
Funahashi et al. (2013), on the other hand highlighted that the smile of the participants developed
with respect to this process of AAT. Thus the social behavioural changes and emotional
interactions developed in this process of therapy. On the basis of this therapy it can be seen that
the impact of the therapy leads to the quality of life change as well. Other than this Silva et al.
(2018), also highlighted that the smiling, laughing, playing and other behavioural aspects of the
children has been improved in the process of the AAT use as the therapy for the improvement of
the ASD condition of the children. The results found that the aspect of the quality of life also
improved as these aspects are improved among the children after the session with the animals.

28
DISSERTATION
3.5 Data table
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
1 Kern et al.
2011
US Quanti
tative
Horse/
Pony
24
participants
Age: 3-12 years
Gender: 6
females/18 males
Ethnic:
2 Black
1 Hispanic
21 White
Primary diagnosis:
ASD
CARS score > 30
Without previous
participation in
equine-assisted
activities.
Therapeutic Riding
Program
SpiritHorse riding
program uses 146
steps specific to
intervention of ASD
including leading,
grooming and taking
responsibilities.
No
comparison
6 months 60 minutes/
once a
week
The
participants
were assessed
four times
during the
study:
1. When
placed on the
waiting list (the
waiting period
ranged from 3
to 6 months),
2. Immediately
before the
participant
began riding,
3. At 3 months
of riding,
4. At 6 months
after the
participant
began riding.
Childhood Autism
Rating Scale
(CARS) – shows
overall decrease
over the course of
riding treatment.
Timberlawn
Parent-Child
Interaction Scale –
no significant
changes in the 6
subscales.
However, there is a
significant
improvement in the
Mood and Tone
over the first 3
months and 6
months treatment.
Parent-rated
Measures:
Sensory Profile -
no significant
changes in the 8
subscales.
However, there
statistically
significant
improvement in
Auditory High

29
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
Threshold
Quality of Life
Enjoyment and
Satisfaction
Questionnaire
(QLES-Q) – overall
increase in parent-
rated quality of life
Treatment
Satisfaction Survey
– overall parents’
satisfaction at the
end of the riding
program was
between good and
very good.
Disclosure of
medication or other
treatment changes
during the study
took place due to
the unpreventable
long duration of
study.
Overall: Study
outcome suggested
that equine-assisted
activities show a
reduction in the
severity of autism
symptoms and can
benefit the
individual with
ASD.

30
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
2 Ajzeman,
Standeven &
Shurtleff
2013
Washingt
on, US
Pilot
study
Horse 6
participants
Age: 5-12 years
(Full term birth)
Ability to
independently
ambulate and
follow one step
direction.
Primary diagnosis:
ASD according to
the DSM-IV-TR
Without any
physician
diagnosis of severe
sensory
impairment,
serious health
conditions stated
on PATH’s list of
contraindications
Without previous
exposure to any
type of equine-
assisted activities
or therapies.
Hippotherapy
(HPOT) uses horse
movement as a tool to
affect functional
outcomes based on
five domains:
Motor control
Functional
communication
Cognition
Social skills
Interactive play
In one 45-min HPOT
session, the horse
takes approximately
4,500 steps
No
comparison
12 weeks 45 minutes/
once a
week
After 12 weeks
of HPOT
intervention,
participants
returned for re-
evaluation of
postural
control
variables and
parent-report
measures.
Motor Control and
Postural Stability
(Force Plates and
Video Motion
Capture) – shows a
significant
improvement in
postural stability in
children with ASD.
Adaptive
Behaviour
(Vineland Adaptive
Behavior Scales-II,
VABS-II) – shows
significant changes
in overall adaptive
behaviour
composite score.
Child Activity Card
Slot (CACS):
Participation in
Daily Activities –
shows significant
changes in low
demand leisure
activities and social
interaction in daily
activities.
Overall:
Children with ASD

31
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
showed improved
postural stability
and improvements
in receptive
communication,
coping, and daily
activity
participation.
3 Lanning et al.
2014
US Quanti
tative
Horse 25
participants
Age: 4-15 years
Gender:
EAA treatment
group - 4
females/9 males
Social circles - 12
males
Primary diagnosis:
ASD diagnosed
from a physician
or therapist.
Child and parents
must be able to
communicate with
staff.
The child could
not have
participated in
EAA 6 months
prior to the start of
the study.
EAA treatment
group:
Study followed
PATH International
guidelines.
Horse is chosen for a
child by the
therapeutic riding
team based on their
size and physical
ability.
The weekly lessons
consisted of basic
safety lessons such as
meeting the horse,
respecting the horse,
putting on the helmet,
grooming lessons and
riding activities.
Social Circles Group:
Graduate students in
the School
Psychology program
planned the weekly
activities based on the
three social skills
EAA
treatment
group –
(n=13)
Social circles
group –
(n=12)
12 weeks EAA
treatment
group – 1
hours/once
a week
Social
circles –
one session
per week,
timer is set
for each
activity
Child Health
Questionnaire
Parent
Responses in
both group is
done in week
1, 3, 6 and 9.
Child Health
Questionnaire
Parent Responses:
Social circles group
- Parents shows a
significant increase
mainly in the self-
esteem domain.
EAA treatment
group - Parents
shows a significant
increase in 6 of the
10 subscales score
and both physical
and psychosocial
summary scores.
Largest increase in
the general
behaviour domain.
Pediatric Quality of
Life Child
Responses
(PedsQL 4.0) - both
the comparison and
treatment groups
showed a

32
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
goals the parents
provided.
Each group had 2
graduate students
facilitating and no
more than four
participants.
Goal is to improve
manners, keeping eye
contact, making
friends, being a
friend, taking turns,
showing empathy and
sympathy.
Interventions
included sensory
input activities such
as wearing weighted
vests, tactile toys and
balancing boards.
Card games and
board games were
used to help children
identify feelings and
express emotions.
significant
improvement in all
quality of life
domains.
Overall: Parents
noted significant
improvements in
their child’s
physical, emotional
and social
functioning
following the first 6
weeks of EAA.
4 Borgi et al.
2016
Italy Quanti
tative
Horse 28
participants
Age: 6-12 years
Gender: All males
Primary Diagnosis:
ASD
IQ > 70 on the
Wechsler
Intelligence Scale
for Children- III.
25 sessions for each
participant.
EAT sessions were
held in small groups
of three to four
participants.
Divided into three
phases:
EAT Group -
(n=15), 25
sessions
Control
Group -
(n=13)
6 months 60-70
minutes/
once a
week
No post
follow-up
Overall:
Improvement in
social functioning
in the group
attending EAT
(compared to the
control group) and
a milder effect on
motor abilities.

33
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
Verbal children.
Children need to
be able to focus on
tasks and require
attention.
Grooming and hand
walking the horse.
Horseback riding
On the ground
closure
Improved executive
functioning was
also observed (i.e.
reduced planning
time in a problem-
solving task) at the
end of the EAT
program.
5 Silva et al.
2018
Spain RCT Dog
(a
female
Beagle)
10
participants
Age: 6-9 years
Gender: 10 males
Primary Diagnosis:
Severe ASD
A clinical referral
of compliance
difficulties
warranting
intervention.
The experimental
procedure began
within 24 hours
following the first
meeting and occurred
at participants’
homes.
Two experimenters
(E1 and E2) are
presented during the
session; one
interacted with the
participants and the
other video recorded
the session.
All participants were
involved in three test
session, one per
experimental
condition. Separated
by a 1-week washout
period.
All sessions began
1 Live dog
1 Robotic
dog
1 Child’s
preferred toy
No post
follow-up
That is, participants
might have
captured the
obedient behavior
of the animal
When instructed to
remain quiet and
engaged in some
imitation.
Overall: The live
dog condition
appeared to have a
calming effect on
the participants,
hypothetically
facilitating
compliance.

34
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
with heart rate
electrode application.
Child’s toy aimed at
mimicking a naturally
occurring situation in
children’s routines.
The robotic dog
condition, aimed at
controlling for
potential novelty
effects using a
resembling stimulus
to the live dog.
6 Funahashi et
al. 2014
Japan Quanti
tative
Dog
(6 dogs
consisti
ng:
- 3
Pomera
nians
- 2
Chihuah
uas
- 1
Dachshu
nd)
2
participants
Age: 10 years
Gender: Males
Both boys were put
on a wearable
interface device to
detect smiles during
AAA.
The session for each
child consisted of 4
parts:
Putting on the device.
Pre-session (photo
session and pre-walk
session)
Dog session (AAA
session)
Post-walk session
The wearable device
was designed to
collect EMG signals
from the
neighbouring muscles
1 ASD boy
1 normal
healthy boy
7 months 30-40
minutes/on
ce every 2
months
No post
follow-up
Positive social
behaviours
increased when the
smiles increased.
Negative social
behaviours
decreased when the
smiles increased in
the (ASD-C).

35
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
on the side of the face
and recognize the
facial expression
from these signals
using computational
methods.
The participant can
move freely and feel
comfortable while
wearing this device
since the electrodes
are located on the
side of the face, not
in the front.
The recorded EMG
Signals were filtered
to reduce the
artifacts, separated
into independent
components by
independent
component analysis
(ICA), rectified and
averaged.
The behaviours of the
participants during
the whole session
were video-recorded.
7 O’Haire et
al. 2014
Australia RCT Guinea
pigs
(GP)
64
participants
Age: 5-12 years
Gender: 50
Each participating
classroom housed one
pair of guinea pigs of
the same sex to
Cluster
Assigned to:
Waitlist
Group -
8 weeks 40 minutes/
per week
(two 20
minutes
Post study -
Adoption of
GP offered to
teachers and
Significant
improvements were
identified after the
use of AAA

36
DISSERTATION
NO. REFERENCE
(AUTHOR/
DATE)
COUNTRY STUDY
TYPE
ANIMAL
TYPE
SAMPLE SIZE PARTICIPANTS
INCLUSION &
CHARACTERISTIC
INTERVENTION COMPARISON STUDY
DURATION
DAILY
DURATION
STUDY FOLLOW
UP
OUTCOME
MEASURES
male/14 female
Primary Diagnosis:
Independent
diagnosis of ASD
prevent breeding.
The animals
remained in the
classroom during the
school week
(Monday to Friday)
for the duration of the
program.
Conducted in groups
of 3 participants.
Randomly selecting
two typically
developing peers
from each child’s
classroom to partake
in the sessions
alongside the child
with ASD to simulate
peer presence during
sessions.
The AAA program
consisted of two main
components:
Animal care
(1x15minutes lesson
with GP (Feeding,
cage cleaning)
Animal interaction
(16x20minutes
outside classroom
session involving
exposure and
handling of GP)
(n=37)
Non-waitlist
Group -
(n=27)
sessions) parents. program in social
functioning,
including increases
in social approach
behaviours and
social skills, and
decreases in social
withdrawal
behaviours.
Parents also
reported that
participants
demonstrated an
increased interest in
attending school
during the AAA
program.

37
DISSERTATION

38
DISSERTATION
3.6 Quality assessment
Based on the analysis of the 7 articles it can be seen that the quality of these articles are
good enough. The articles are credible as the articles are taken from the reputed sources and also
the authors are the experts of psychology. On this context it can be stated that the factor of the
authenticity would also be stated high as the authors are experts in this sector. On the other hand
it can be stated that the results also authentically addresses the research topic hence, it can be
stated as the authenticity factor for the articles as well. Other than this it can also be stated that
the research satisfied as the result of the articles are related t the research question and also
answers the research questions properly. Thus it can be stated that the articles are significant as
well. On this context it can be stated that the articles are high in quality and effectively satisfies
the research topic.
Chapter 4
Discussions
4.1 Summarization of result
This section of the paper will provide a summative overview of the themes that were
generated from the collected data documented in the literature. Moreover, this section of the
paper will also provide the in-depth research of other authors to in order to provide a beneficial
complementary, non-therapeutic method which can improve quality of life of the patients who
are suffering from medical issues or developmental disabilities’ such as ADHD. While many
researchers highlighted the effectiveness of different animal in improving the wellbeing of
autism children, the maximum attentions are received by canine and equine-assisted therapy and
lowest attention was given to other animals such as dolphin assisted therapy. While dogs are for
short-term therapeutic interactions which can improve the social functioning of children with
health issues, equine-assisted therapies, especially horse riding is highlighted as one of the most

39
DISSERTATION
cost-effective therapies that can improve the quality of the patients who are experiencing
developmental disabilities. While dogs do not require training for elevating mood and wellbeing
of the patients with developmental disabilities, for improving the motor skills of the patients,
dogs require training from the professionals. Other animals such as horse, elephants require
vigorous training from the professionals to assist children in overcoming developmental
disabilities. Majority of the study mentioned that no additional medication therapy is
required for improving the health status of the children as these therapies are long term therapies.
In order to gain short term improvement, medication therapies are effective. However,
medication therapies are costly and have side effects which can worsen the health issues. Hence,
animal-assisted therapies are the most effective therapies which are considered as the cornerstone
of medical therapies. As discussed above Borgi et al. (2016) suggested that equine is most
effective equine-assisted therapy which can improve executive functioning of children. The
researchers conducted a randomized control trial where one group was assigned to be an
intervention group with equine-assisted therapy and another group is the control group. The
result of the study suggested compared to the control group equine-assisted therapy is effective
in the children of the intervention group exhibited improved motor skills, problem-solving skills
and reduced planned to in solving the problem. The main outcome measures, in this case, are an
improvement in cognitive abilities and language abilities of the children. Moreover, researchers
also highlighted the reduced rate of maladaptive behavior and maximize empathizing behavior.
Hence, this therapy is not only effective in improving social behavior but also cheap and have
side effects compared to medication therapy. Lanning et al. (2015), also highlighted the effect of
equine-assisted therapy where they used Quality of life assessments. The result of the study
highlighted the unique aspect of therapy which supports the effectiveness of the therapy. The

40
DISSERTATION
researchers suggested that children who participated in non-equine assisted programs
exhibited improvement in behavior, but to a lesser degree compared to the children
who participated in the equine-assisted therapies. Funahashi et al. (2014) conducted a
comparative experimental study of 10 years boy with ASD with a normal boy in order to
evaluate the smiling frequency in patients and researchers used diverse animals such as dog,
horse, and other animals. The result of the study suggested that animals are able to create a social
environment that may facilitate smiling, and positive behaviors of the autistic child may be
facilitated and on the other hand, his social negative behaviors may be decreased. Silva et al.
(2018), used within-subject design in order to conduct exploratory test between live and robotic
dogs in improving the social and cognitive functioning of children. The result of the study
suggested that while children were accompanied by the therapy, the high level of positive
emotions have been experienced by the children. Moreover, dogs are also able to reduce
cardiovascular issues in patients with an autism spectrum disorder. Another study by Azenman,
Standeven and Shurtleff (2013), the effectiveness of the hippotherapy (HPOT) was again
reported. This study reported that, the use of HPOT can also improve motor control skills and
adaptive behaviors among the ASD patients. It improves social functioning improvement of
children has been observed a significant number of children with autism spectrum disorder
which include an increase in social approach, decrease in social withdrawal behavior and
improved interpersonal skills. In most of the studies, mainly horse are used as animal assisted
therapy in the ASD treatment. However, the study findings were not at all synchronous as most
of the studies are from different countries. Majority of the children with autism have exhibited
inappropriate social behaviour, poor eye contacts, compulsive behaviour, learning disabilities
and lack of common emotions. Hence, animal-assisted activities are able to address these issue

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experienced by children with autism spectrum disorder and able to improve their academic
performance. 16 to 20 minutes animal-assisted activities such as holding, feeding, playing and
grooming is effective would be a relatively cost-effective and simple means of assisting
educators as well as family members in improving the social functioning of autistic children
significant number of researchers highlighted that one of the key players in improving mood and
functioning of the children that oxytocin. Busch et al. (2016) highlighted that interacting with
animal increases the level of oxytocin which is responsible for the emotions such as trust, love
and associated emotions and increases empathy in patient. On the other hand, O'Haire et al.
(2014) multisite, control-to-intervention design studies in order to evaluate the effectiveness of
animal-assisted therapy in the classroom. The author had chosen guanine pig as the animal for
conducting the study. The result of the study suggested that social functioning improvement of
children has been observed a significant number of children with autism spectrum disorder
which include an increase in social approach, decrease in social withdrawal behavior and
improved interpersonal skills. Majority of the children with autism has exhibited inappropriate
social behaviour, poor eye contacts, compulsive beheaviour, learning disabilities and lack of
common emotions. Hence, animal-assisted activities are able to address these issues experienced
by children with autism spectrum disorder and able to improve their academic performance. 16
to 20 minutes animal-assisted activities such as holding, feeding, playing and grooming is
effective would be a relatively cost-effective and simple means of assisting educators as well as
family members in improving the social functioning of autistic children significant number of
researchers highlighted that one of the key players in improving mood and functioning of the
children that oxytocin. Hence, each study highlighted therapeutic effect of animal assisted
therapy on autism and also companions for doing activities with each individual with

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autism. Animals have a calming effect on children which further improve the appropriate
coordination between brain and body responsible for appropriate motor skills. Hence, these
animal-assisted therapies are effective and relatively cheap means which can assist educators and
parents to provide their children with a healthy and satisfactory life. On the other hand, Beetz et
al. (2012), highlighted that Human-animal interactions encompass dynamic and mutual
relationship which promote the physical and mental wellbeing of the human as human consider
the animal as a calming and non-judgmental source of interactions which facilitate social
interactions. Viau et al. (2016) highlighted that autistic child who interacts with the animals on a
daily basis in the pet café and in their house are able to reduce their stress responses. The prime
reason behind this study is that the researchers indicated the reduced rate of cortisol awakening
response which elevates the mood of the patients and eliminates the fear of social
interactions. The children tend to laugh and smile when they interact with animal due to the
enhancement of mood and energy. Hence, animal-assisted therapies, especially equine-assisted
therapies, are the most effective therapies which are considered as the cornerstone of medical
therapies for improving social functioning, cognitive skills, and motor skills. However, equine-
assisted therapies cannot be performed at home; it is the most suitable therapy in the classrooms
where teachers are required to gather training regarding therapies. Canine assisted therapies can
be performed at home easily with the proper expertise. This in-depth research will assist health
professionals, educators and parents to support the autistic children in overcoming their
disabilities and live a satisfactory life. This in-depth research will further shed lights to the area
which cannot be addressed by the researcher.

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4.2 Limitations
The strength of the study is that the study aimed to address the gap that was not
previously addressed by the majority of the researchers and included a significant number of
primary studies to address the gap. A systematic review is considered as level one of evidence
which will increase the credibility of the research. Hence, it can be used as supporting materials
for conducting in-depth research. However, just like any other studies, this systematic review
has numerous limitations which further affected the reliability of the study. The information of
the study was solely gathered from observations of researcher and caregiver which further
presented major limitations the study. The perception of children who are experienced autism
and subjected to the therapies was not documented in the research. In addition, it can be said that
the accuracy of these observations by researchers, caregiver or parents in relation to the actual
thoughts and feelings of individuals with ASD could not be assessed by the researchers which
further affected the outcome of the study. Biases may play a significant role in affecting the
validity of the study. The selection of the paper was solely based on the predetermined
interventions which further limited the exploration of the study. Moreover, the paper that was
incorporated in the study also exhibited selection bias as only recruited the patients with Autism
which further limit the effectiveness of the therapies in addressing the issues faced by patients of
other developmental delays. Hence, in order to increase the credibility of the study primary study
is required to conduct. Moreover, in order to increase the credibility of the study, the feeling of
the patients and the perspective of the patients are required to gather. Moreover, the paper that
was incorporated in the study also exhibited selection bias as only recruited the patients
with Autism which further limit the effectiveness of the therapies in addressing the issues faced
by patients of other developmental delays.

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4.3 Results and recommendation to adapt the intervention in children with ASD
Hence, animal-assisted therapies, especially equine-assisted therapies, are the most
effective therapies which are considered as the cornerstone of medical therapies for improving
social functioning, cognitive skills, and motor skills. However, equine-assisted therapies cannot
be performed at home; it is the most suitable therapy in the classrooms where teachers are
required to gather training regarding therapies. Canine assisted therapies can be performed at
home easily with the proper expertise. This in-depth research will assist health professionals,
educators and parents to support the autistic children in overcoming their disabilities and live a
satisfactory life. This in-depth research will further shed lights to the area which cannot be
addressed by the researcher. . Hence, in order to increase the credibility of the study primary
study is required to conduct. Moreover, in order to increase the credibility of the study, the
feeling of the patients and the perspective of the patients are required to gather.
4.4 Confounding factors
Confounding is often called "mixing effects," in which the effect on a particular result of
the exposure under research are mixed up with the impacts of an extra factor (or set of variables)
leading in a distortion of the real relation (Valente et al., 2017). In a clinical trial this may occur
if there is difference between groups in the distribution of a known prognostic factor.
Confounding factors can mask an actual connection or, more often than not, mistakenly prove
that the therapy is linked to the result, if there is no true association. The presence of
confounding variables in research makes it hard, unless suitable techniques are used to adjust for
the impact of confounding, to create a clear causal link between therapy and outcome.
Confounding variables are the variables that compete in explaining the research result with
exposure of concern (for example, therapy). A better estimate of a real exposure connection is

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given by the quantity of association "above and after" which can be explained by confounding
variables. Even in the lack of exposure, the result is a real cause of confounding. Although it
might be causative to have a potential confounding factor (PCF), it may not be. The main
requirements are that the variable and the result exist independently and that the PCF is not the
result of the exposure (or the result). Many of the PCFs that often have to be assessed are proxies
of complicated and hard-to-measure factors. An intermediate between exposure and outcome
cannot be a confounder.
Based on this discussion it can be stated that the influence of variable other than the
intended therapy effect over the ASD children have not been found in any of the literature as the
articles only focus on the AAT for the treatment of the ASD affected children. On this context it
can be stated that the articles have not deviated the results based on any other aspect of ASD
therapy.
Chapter 5
Conclusion
Based on the above discussion it can be concluded that the factor of the AAT as the
intervention for the ASD affected children would be most effective process. However, the factor
of the research on this aspect should be conducted more effectively for the better knowledge
development about the context of the AAT implementation on ASD affected children. On this
context it can be found that the effectiveness of this treatment process is unanimously positive
however, the systematic review has highlighted that the methods of the studies conducted in this
sector is not proper in most of the time. The process of the improper methodology includes the
aspects of the small sample size, improper research method and thus it results in the improper
proof about the context of the ASD treat. Thus it can be stated that the aspect of the AAT in the
ASD treatment has been found to be the most effective process despite of the improper research

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study. However, this is one of the factors that should be effectively considered for the treatment
of the ASD affected children as it has been found that the therapy is useful in the social
interaction and also the positive behavioural aspects increase after the therapy also in the period
of the therapy. It has also been found in several studies that the smile of the autistic child has
increased by the utilisation of this therapy and that leads to the factor of the elimination of
negative social behaviours of the children and also the improvement of the social interaction and
the social interaction of the children with autism. Thus it can be stated that the effectiveness of
the therapy has been found successfully in many situations and studies. The effectiveness has
been encountered by the parents of the children and also by the teachers of the children as the
program mainly conducted in the classroom of the children targeted. Hence, it can be seen that
the AAT is effective in the treatment of the ASD affected children. Most importantly it has been
found that the most effective animals in this process of the therapy are the horse and dog which
can be termed as the equine assisted therapy (EAT) and dog or canine assisted therapy. On the
other hand it has been state that the factor of the therapy has used elephant and guinea pig in
several studies as well. Thus it can be stated that the factor of the AAT would be effectively
addressing the context of the ASD affected children. It has also been seen that the dogs are
common companions of human thus the factor of training for these animals are very less and
would be restricted in special interpersonal and interaction skill development. However, in case
of other animals it has been seen that the factor of the training would be provided with high
priority as these animals are not the common companions of the human community. On the other
hand the research study has also highlighted the proper answers of other research questions that
include the factor of the non-requirement of any supplementary medication for this process of the
therapy. On this context it can be stated that the effectiveness of this therapy would be found that

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it has been a very effective process for the treatment of the autistic children as it helps in the
social behaviour development. It has been found that in this context the age of the participants
does not matter in the aspect of the AAT for the treatment of the ASD affected individuals.
Hence, it can be seen that the factor of PICO questions has been answered properly by the
systematic review study conducted here. On the other hand the fact of treatment of the ASD
affected children can be found as the recreational therapy process and the trend of the usage of
the animals in this type of therapy is common among the recreational therapists. Hence, it can be
state that the aspect of the therapy of these children should be prioritised based on the factor of
the severity of the condition of the patient and it can be stated that the aspect of the therapy with
the help of the animals would effectively be impacting on the social behaviour of these children
with ASD. On the other hand the EAT is most effective in the aspect of the AAT for the children
and the process of the horse riding helps in the sector of the social behaviour and social
interaction as well. Thus it can be stated that the factor of the AAT is more effective in the social
circular therapy or the medication therapy as well. However, medication therapies are costly
and have side effects which can worsen the health issues. Hence, animal-assisted therapies are
the most effective therapies which are considered as the cornerstone of medical therapies. Thus
finally it can be stated that the factor of the animal assisted therapy would be most effective and
implemented with more priority and the research should be conducted more effectively in this
context as well so that the parameter of the therapy can be evaluated properly.

48
DISSERTATION
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Appendices
Appendix 1
CONSORT 2010 Checklist
Borgi et al.
Funahashi et al.
O’Haire et al.
Silva et al.
Lanning et al.
Kern et al.