Introduction

The Child and Adolescent Neuropsychiatry Service (NPIA) intends to launch an equine-assisted rehabilitation project for a group of patients in its care. The aim is to improve the interaction between their bodies and their mental, intellectual, and emotional activities, enabling them to express these abilities in a social setting.

Through sensorimotor experiences that can help organize and reshape their experience of their bodies, participants will be supported in achieving more harmonious self-control and a greater ability to interact with the world around them.

Equine-assisted rehabilitation is a holistic therapeutic approach. Through recreational and sporting activities involving a horse, the individual’s motor, psychological, intellectual, and social capacities are engaged as a whole. Active participation in the rehabilitation process is essential, supported by motivation that encourages involvement.

The project was developed by Dr. Giovanna Mazzotta, a child neuropsychiatrist with the Casalecchio–Porretta NPIA unit and technical coordinator for equine-assisted rehabilitation. She holds a first-level university master’s degree in equine-assisted rehabilitation from the University of Florence’s Faculty of Medicine and Surgery and will lead the practical activities directly.

General Objectives

The horse is a living, tangible, emotionally engaging presence that can evoke intense feelings and emotions. Its movement conveys a vast range of neurosensory stimuli to the rider, offering experiences through visual-spatial, tactile, kinesthetic, and proprioceptive input. When integrated by the central nervous system, these contribute to the individual’s psychomotor development.
The riding environment and relationship with the horse provide rich visual, olfactory, auditory, tactile, and emotional stimulation. These encourage contact with reality and awareness of oneself and one’s body, improving the organization of body awareness and the experience of oneself in relation to others.

Riding, and especially directing a horse, means knowing where one wants to go—defining space—and which route to take through it—orienting oneself. To make the horse move, the rider must organize their own movements in an exact sequence, coordinate them precisely, and direct them toward a goal.

The result is immediate and concrete, producing instant effects on the rider, or more precisely on the horse-rider relationship. If part of the action has not been performed correctly, the rider immediately realizes this: the horse does not move, or moves in a direction other than the one intended.

Failure to achieve the goal is not experienced as punishment, because the horse’s response is understood as the natural reaction of an animal. The rider must find nonverbal ways of communicating what they want. They therefore need to reconsider their actions, plan, coordinate, and organize their abilities, and combine these with appropriate strategies and action patterns to reach the goal.

This encourages the thoughtful use of gestures and actions, creating opportunities to experience and develop confidence and personal satisfaction.

The horse is central to the therapeutic relationship. Instead of a relationship solely between patient and therapist, a three-way relationship develops in which the horse acts as a co-therapist.

The horse participates actively without aggression, showing the rider what it likes or dislikes without offending, humiliating, or belittling them. It has no performance expectations and responds in the here and now.

The horse is experienced as a neutral partner. Its natural behavior and instinctive responses, particularly to undesirable actions, create a direct relational experience free from judgment or demands.

However, a horse is not in itself a universal therapeutic tool. Its therapeutic role depends on the therapist’s mediation. The therapist regulates and organizes the type and intensity of the horse’s stimuli and input within a progressive therapeutic process, helping the patient use them effectively and preventing disorganization rather than development. The therapist interprets and mediates the relationship between rider and animal while preserving the playful and social nature of the experience.

When the horse creates particular stimuli or situations, the therapist immediately provides emotional and mental support. The therapist must recognize and explain what the animal is communicating and suggest responses that enable an increasingly direct relationship between horse and rider. Patients often encounter difficulties they cannot overcome, especially at the beginning. The therapist helps them find appropriate solutions, building trust not only in the horse but above all in themselves and their overall abilities, while adapting to the environment and accepting reality.

People with disabilities are often unable to carry out everyday tasks independently, or prolonged dependence on a caregiver prevents them from doing so. Equine-assisted rehabilitation helps reverse these roles, both because riding necessarily requires active participation and because the animal itself needs attention, care, and consideration.

The activity is primarily recreational and sporting: a patient motivated to participate should enjoy it. This does not mean every moment of every session must be satisfying. Rather, there will be moments of joy and pleasure alongside anger and disappointment. What matters is that the experience is never repetitive, boring, or predictable, but always evokes emotion and stimulates mental and physical functions.

The riding center itself also plays a fundamental role in achieving the desired objectives. It offers a broader environment that is safe and protected rather than dangerous, where activities focus on horses rather than patients and which is therefore very different from a healthcare setting. Those attending, despite differing roles and abilities, share a common interest in horses.
Working in a small group—where possible, three riders will be in the arena at the same time—offers another way to relate and socialize. There is mutual encouragement rather than competition. One person may serve as a model, but roles can change at any moment as activities vary. Everyone can follow their own path alongside others, sharing difficulties and supporting one another in overcoming them. Responsible behavior toward others remains essential to prevent accidents, even when negative feelings such as aggression or dislike arise.

Groups will not be formed according to shared diagnoses, but primarily according to developmental level and initial abilities, allowing activities and exercises to be useful and enjoyable for everyone.

Although equine-assisted rehabilitation is proposed as a therapeutic intervention, it is intended to complement other rehabilitation treatments rather than replace them. Accordingly, each patient’s responsible clinician and rehabilitation professionals will be invited to help prepare their individual work plan. Subject to availability, they will also be invited to observe at the riding center, at least at the beginning and end of the overall program.

Project Stages

Stage One
The first stage is to identify patients receiving care from the Casalecchio–Porretta NPIA unit for whom the responsible clinicians, working with rehabilitation professionals, consider equine-assisted rehabilitation appropriate.

To support accurate assessment, service staff have received a basic theoretical introduction to its principles, objectives, indications, and contraindications. They have also had the opportunity to watch videos of hippotherapy and equestrian rehabilitation sessions involving people of different ages and with different conditions.

The project can involve eight to twelve participants. Following initial referrals, each patient’s functional characteristics and difficulties will be considered in greater depth, followed by confirmation of the child’s or young person’s and parents’ interest and willingness to participate.

Stage Two
Families will be invited to visit the selected equestrian center to encourage informed participation and assess their actual interest. This will also allow observation of how participants spontaneously approach the horse, reveal any fears when encountering the animal in person, and encourage questions and reflections that clarify participants’ and parents’ expectations.

The activity leader’s direct acquaintance with each child or young person, together with information from their clinicians, will help form small groups with similar functional abilities and compatible personalities. As far as possible, parents’ availability to accompany their child and existing school or extracurricular commitments will be taken into account.

Stage Three
A clinical record will be prepared for each participant, containing relevant medical history, current treatments, and individualized objectives within the project’s overall aims.
To assess the effectiveness of equine-assisted rehabilitation, observation grids and assessment tools will be selected according to the underlying condition, such as a neuromotor disorder assessment protocol, the Vineland scales, or a checklist based on the ICF-CY classification system.

Parents will be asked to consent to periodic video recordings. These will be viewed and analyzed by staff involved in practical activities, the responsible clinicians, and family members solely to monitor progress and results.

Practical activities are proposed to begin in October 2012 and continue weekly until mid-June 2013, with breaks during the Christmas and Easter holidays in line with the school calendar.

As activities will take place on fixed days and require precise coordination with other activities at the equestrian center, sessions missed because of participants’ or the leader’s health or personal circumstances cannot be made up.

At the end of the program, a social event or celebration will be organized for participants, their families, and friends. It will give participants the opportunity to demonstrate their new skills in an end-of-course display.

Working Methods

Equine-assisted rehabilitation will take place at a suitable equestrian center, currently being identified. Essential features include an indoor arena and horses whose physical characteristics, temperament, and training are appropriate for the work. The center must be accessible to everyone, provide suitable spaces for accompanying people to wait, and have well-maintained toilets.

An indoor arena is essential to:
maintain therapy during winter, since regular sessions are necessary for good results;
help horses remain attentive and responsive and maintain steady, regular gaits;
support pupils’ attention and concentration.

The ideal arena size is 15 × 20 meters. This can be created within a larger arena using jump standards, poles, or chains.
Official dressage letters, accompanied by drawings, will be displayed to provide clear reference points for spatial and temporal orientation, help riders maintain direction, and serve as starting or finishing points for games.

Poles, jump standards, cones, balls, a basketball hoop, rings, and other play equipment will be used for mounted exercises and exchange games, and to provide language and cognitive stimulation. Courses may also be arranged with specific activities to perform in sequence, encouraging attention, memory, and the use of cognitive strategies.
The center must have a mounting platform for pupils whose physical disability or other characteristics prevent them from mounting conventionally by placing the left foot in the stirrup on the horse’s left side and swinging the right leg over its back.

The horse will wear an English saddle meeting the basic requirements for a correct riding position, together with a bridle and reins as used in English riding. A neck strap and/or martingale will be used if necessary.

Depending on individual objectives and the stage of the program, a vaulting surcingle may also be used. Entire sessions or parts of sessions may use the “maternage” technique, in which the practitioner sits behind the participant on the horse.

For safety, pupils will be required to wear a riding helmet, which may be provided by the center, and a body protector when riding independently. Riding footwear—ankle boots with or without chaps, or rubber or leather boots—is recommended but not essential and may be replaced by high-top sneakers or winter boots. Pupils may wear jeans to protect their legs from abrasions and irritation from horse sweat in hot weather, along with a T-shirt, fleece, or jacket appropriate to the season. Clothing must allow movement of the arms, legs, and torso without risking entanglement in the saddle or other tack.

Sessions will begin with groundwork to prepare the horse, where the participant’s functional abilities permit. This will be followed by leading the horse on a lead rope, mounting, ridden activities such as relaxation, exercises, and games, and a correct dismount. The session ends by saying goodbye to the horse with a carrot or sugar cube.

Each session will last no more than one hour per pupil, with shorter sessions where individual needs require them.
As noted above, groups will consist of no more than three pupils, with the aim of working together on the same exercises simultaneously. Once participants are known, it will be assessed whether this is possible from the outset or should be a short-, medium-, or long-term objective. This will determine the need for auxiliary staff in the arena to ensure pupils’ physical safety, prevent accidents, encourage attention and participation, and provide practical or verbal support as needed.

If one or more participants attend during school hours and the activity is included in their Individualized Education Plan, ways of involving classmates will be explored with school staff. This will support inclusion and, especially, allow peers to recognize abilities and skills beyond those demonstrated in academic learning, where difficulties often negatively affect how a student with disabilities is perceived.

Cost Estimate

No additional payment will be required for the intervention leader, Dr. Giovanna Mazzotta, as she will carry out this work during her working hours. The cost will therefore be borne by the NPIA service, like other direct and indirect clinical and therapeutic activities performed at its clinics.
If auxiliary staff are needed in the arena, existing support resources assigned to the participant will be considered, such as professional educators in healthcare or social services. They must have specific training in equine-assisted rehabilitation or at least sufficient familiarity with horses and the setting to work calmly without constant guidance and suggestions. Volunteers or trainees with the same characteristics may also participate, provided they can attend as regularly as possible.
If additional educational staff and/or riding instructors are needed for one-to-one support beyond these arrangements, a cost must be budgeted.
Assuming a 34-week program from the first week of October to mid-June, the total estimated cost per participant, excluding membership and equestrian center registration if the proposal is accepted, ranges from €340–€442 without individual auxiliary support to €680–€782 where such support is required.
Materials needed for the activities, including tack, arena equipment, and games, will be provided by the activity leader or obtained at the equestrian center.
We hope to receive donations from associations and foundations so that family finances do not become a determining factor in whether a child or young person can participate.
The proposals outlined here may, of course, be reconsidered and revised, while preserving the project’s fundamental elements: its aims, working methods, and the essential characteristics of the equestrian center.

Dr. Giovanna Mazzotta
Child Neuropsychiatrist
Technical Coordinator, Equine-Assisted Rehabilitation Project

Bologna, August 20, 2012