Equine-assisted learning in youths at-risk for school or social failure

Abstract

This study examined whether a three-month equine-assisted learning program improved measures of character skills in two independent cohorts of Year 1 youths, in a specialized secondary school for youths with difficulties coping with mainstream curriculum. In 2013, 75 students underwent intervention while 82 students did not. In 2014, 58 students underwent intervention and 59 students were waitlisted in semester 1; cross-over was performed in semester 2. The students were rated a week before, mid-way and a week post-intervention. Results from multi-level modeling indicated that the intervention led to progressive improvements in character skills over the school semester, in the majority of the constructs measured in both the 2013 and 2014 cohorts. The rate of change in measures of character skills over the semester correlated with the grade point average of the students at semester-end. Implications and limitations of the findings are discussed.

Full text

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STUDENT LEARNING, CHILDHOOD & VOICES | RESEARCH ARTICLE
Equine-assisted learning in youths at-risk for
school or social failure
New Fei Ho, Jonathan Zhou, Daniel Shuen Sheng Fung and Phek Hui Jade Kua
Cogent Education (2017), 4: 1334430

Ho et al., Cogent Education (2017),
4: 1334430
https://doi.org/10.1080/2331186X.2017.1334430
STUDENT LEARNING, CHILDHOOD & VOICES | RESEARCH ARTICLE
Equine-assisted learning in youths at-risk for school
or social failure
New Fei Ho
1
*, Jonathan Zhou
2
, Daniel Shuen Sheng Fung
1
and Phek Hui Jade Kua
3
Abstract:This study examined whether a three-month equine-assisted learning
program improved measures of character skills in two independent cohorts of Year
1 youths, in a specialized secondary school for youths with diculties coping with
mainstream curriculum. In 2013, 75 students underwent intervention while 82 stu-
dents did not. In 2014, 58 students underwent intervention and 59 students were
waitlisted in semester 1; cross-over was performed in semester 2. The students
were rated a week before, mid-way and a week post-intervention. Results from
multi-level modeling indicated that the intervention led to progressive improve-
ments in character skills over the school semester, in the majority of the constructs
measured in both the 2013 and 2014 cohorts. The rate of change in measures
of character skills over the semester correlated with the grade point average of
the students at semester-end. Implications and limitations of the findings are
discussed.
Subjects: Development Studies, Environment, Social Work, Urban Studies; Behavioral
Sciences; Education
Keywords: equine therapy; at-risk; pre-vocational school; character skills
*Corresponding author: New Fei Ho,
Department of Child and Adolescent
Psychiatry, Institute of Mental Health,
10 Buangkok View, Buangkok Green
Medical Park, Singapore 539747,
Singapore
E-mail: new_fei_ho@imh.com.sg
Reviewing editor:
Yvonne Xian-han Huang, Hong Kong
Institute of Education, Hong Kong
Additional information is available at
the end of the article
ABOUT THE AUTHORS
New Fei Ho is interested in brain plasticity:
how positive experiences can shape the brain’s
capacity for growth. She holds several research
grants aiming to examine the eects of non-
pharmacological interventions on brain plasticity
in neuropsychiatric disorders.
Jonathan Zhou has a special interest in
equestrian and hopes that the interaction with the
horses can serve as eective and holistic avenues
for youths to learn and grow.
Daniel Shuen Sheng Fung is the Chairman
Medical Board, Institute of Mental Health and a
Senior Consultant with the Department of Child
and Adolescent Psychiatry.
Phek Hui Jade Kua holds joint appointment as
a consultant in the Department of Emergency
Medicine at the KK Women’s and Children’s
Hospital, and Hospital Service Division, Ministry
of Health. She is also the program director of
Dispatcher-Assisted first Responder program, and
is passionate about helping children and youths
overcome their odds in life.
PUBLIC INTEREST STATEMENT
In Singapore, youths who have diculties with
the mainstream curriculum are enrolled in
pre-vocational schools. One such pre-vocational
school, besides cognitive and technical skills,
focuses on nurturing of character-building skill sets
considered to be critical for community functioning
and sustainment of future employment. The
present study found that a semester-long
structured horse therapy program improves the
character skills of Year 1 students, compared to
those not enrolled in the program. The positive
findings extend to a dierent cohort of Year 1
students in semester 1 of the following year, as
well as a separate student cohort in semester 2.
The improvements in character skills related to
horse therapy over the semester are associated
with higher academic grades at the semester-end.
While the results are encouraging, longer-term
studies in future and larger cohorts of students
at-risk for school or social failure are required to
support our findings.
Received: 23 December 2016
Accepted: 16 May 2017
Published: 02 June 2017
© 2017 The Author(s). This open access article is distributed under a Creative Commons Attribution
(CC-BY) 4.0 license.
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1. Introduction
The Singapore education system mandates six years of Primary school education for all children, to
be attended from the ages of 7–12. At the end of the six years, students sit for a national examination
that will determine their qualification for Secondary school (Goh & Gopinathan, 2008). Each year,
2.2–2.9% of Primary school students (approximately 1,200 children per year) fail this national exit
examination (Mourshed, Chijioke, & Barber, 2010). Some of these students remain in Primary School
and retake the examination one year later. Students who do not complete Primary School or who fail
their PSLE may enroll in specialized pre-vocational Schools (Goh & Gopinathan, 2008). Currently,
there are two pre-vocational schools in Singapore that provide four years of schooling for youths
aged 13–16 years (Ministry of Education, 2012). English and Mathematics, as well as socio-emotional
skills and vocational skills are being taught in these pre-vocational schools.
The students in this study come from one of the two pre-vocational schools. Students from this pre-
vocational school were largely from underprivileged backgrounds; about half of them were from fami-
lies with monthly incomes of less than $1,500 (average monthly median incomes in Singapore in the
same year were $6,342) (Department of Statistics Singapore, 2015; Leong, 2009). More than half of their
parents had not received secondary school education (Leong, 2009). In a society of widening income
gap, many had both parents who worked to make ends meet, with little time for them (Leong, 2009).
Many of the others were brought up by a step-parent, single parent, or grandparents (Leong, 2009).
The curriculum of this pre-vocational school diered from mainstream schools. Not only were the
students taught ‘hard’ cognitive skills, focus was on nurturing of “soft” skills. The pioneer teachers and
psychologists of the school wanted additional measures of “soft” character skills—beyond the typical
academic assessments carried out in mainstream schools—that were important for the students’ suc-
cess in school, and beyond school. The upshot of the many rounds of discussion among the teachers and
school board members was the implementation of the “Habits of Mind”, as measures of character devel-
opment. Habits of Mind is a concept introduced by Costa and Kallick on developing certain disposition or
characteristics that would be useful when faced with challenging situations (Costa & Kallick, 2008). The
school teachers and psychologists identified five independent Habits of Mind, namely Persistence,
Thinking Flexibly, Taking Responsible Risks, Managing Impulsivity and Listening with Understanding and
Empathy. The teachers had taken into consideration the challenging circumstances that many of these
at-risk students grew up in, with the belief that the cultivation of these five character skills in their stu-
dents would help develop competencies for lifelong learning, and sustain their future employment.
The “Equine-Assisted Learning” (EQUAL) program was subsequently co-developed by the
Singapore Equestrian Federation and the school, with the aims of cultivating the five selected Habits
of Mind. This program is a combination of mutually inclusive interventions of therapeutic riding, hip-
potherapy, and equine-assisted psychotherapy. Therapeutic riding involves learning how to ride and
horsemanship, and has been suggested to contribute to positive behavioral and socio-emotional
outcomes in at-risk children (Kaiser, Smith, Heleski, & Spence, 2006). Besides being responsible for
ensuring the safety of the students, the employees and volunteers involved in EQUAL provide in-
structions on the interaction with the horses, including grooming, mounting, trotting and lunging.
Hippotherapy refers to the use of equine movement to engage the sensory, neuromotor and cogni-
tive systems to achieve functional outcomes, as part of an integrated program (American
Hippotherapy Association, 2016). The improvements in sensory and muscular systems as a result of
the equine movement have been postulated to confer psychological and social benefits and the
student’s ability to learn (Granados & Agís, 2011). Equine-assisted psychotherapy is carried out by
psychologists employed by the equestrian federation, with the goal of harnessing the horse–human
interactions to achieve therapeutic or educational outcomes (Fine, 2006). Through a series of struc-
tured activities, the psychologists would work with the students in a group setting to relate what has
been learnt and applied through the horse–human interactions, such as Persistence and Taking
Responsible Risks (in learning how to ride and dealing with the horses) to everyday academic and life
situations. Overall, the EQUAL program was designed with the goal of incorporating non-verbal ex-
periential horse-related experiential learning to the behavioral outcomes targeted by school.

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Although used for years in the treatment of physical and psychiatric ailments, empirical evidence
from well-conducted studies of equine-related therapy, or even animal-assisted therapy on the
whole, remain scarce and inconclusive (Anestis, Anestis, Zawilinski, Hopkins, & Lilienfeld, 2014;
Kamioka et al., 2014; Selby & Smith-Osborne, 2013; Whalen & Case-Smith, 2012). Till date, findings
from studies of equine-related therapy on youths at-risk for school or social failure are limited by
their small sample sizes (Bachi, Terkel, & Teichman, 2012; Kaiser et al., 2006). In the one larger scale
study of at-risk youths (Trotter, Chandler, Goodwin-Bond, & Casey, 2008), the interpretation of the
finding is clouded by selection bias (students could choose their form of therapy between equine-
related intervention and classroom counseling), high unreported drop-out rates and lack of multiple
comparison testing (Anestis et al., 2014). Furthermore, the costs of this complementary approach to
character-building are substantial, as it involves the use of equestrian facilities and several sta to
carry out the EQUAL intervention. Also, the logistics of such an intervention are more complicated
than classroom-based interventions—students have to be transported to a ranch setting for the
equine-related intervention to be carried out. Hence, there is a need to carry out longitudinal studies
with adequate sample sizes to examine whether a structured equine-related intervention can lead
to significantly positive improvements in character skills in a “real-world” school setting, so as to
inform future educational policies and provide a framework for cost-eectiveness studies.
Hence in this study, we sought to determine the eectiveness of a structured horse-related inter-
vention in a specialized school for youths at-risk for academic or life failure. The EQUAL intervention
was incorporated in the school curriculum in the second semester of 2013 and also carried out over
two semesters in 2014, with a three-month washout period (including semester break) in between.
To address our question, we first examined whether there is an improvement in the targeted Habits
of Minds measures over the semester. We then examined the relationship between the rate of
change in Habits of Minds scores over the semester with the grade point average of the students at
each semester-end.
2. Methods
2.1. Participants
A pioneer batch of Year 1 students received EQUAL intervention in 2013 semester 2. Out of the entire
cohort of 157 students l, 75 students from 4 randomly chosen classes (45 males and 30 females)
attended EQUAL and the remaining 82 students from the other 4 classes (58 males and 27 females)
formed the non-intervention group. (Under the Singapore school system, students within the same
class follow similar lesson schedules. They attend the same lessons at the same time as a class.) In
2014, a new cohort of 58 students from four-randomly chosen classes (38 males and 20 females)
received EQUAL in semester 1, and 59 subjects from the remaining four-classes (38 males and 21
females) received EQUAL in semester 2. A three-month interval, which included a one-month school
semester break in between the two semesters, served as the “washout” period.
All the students in the Year 2013 and Year 2014 were born in the years 2000 and 2001, respec-
tively. As Singapore is a multi-racial society, and in view of Article 12 of the Constitution of the
Republic of Singapore “ Equal Protection: the guarantee of equality before law, regardless of religion,
race, descent and place of birth”, the school has specifically requested that information on ethnicity
be withheld from publications for racial sensitivity purposes. Nevertheless, the students are assigned
into classes that had a racial quota, in adherence to the ethnic integration policy implemented by
the Singapore Government (Sim, 2015). The school has also requested for confidentiality of existing
medical conditions of the students. That said, none of the students have any severe physical or men-
tal disability.
This study was approved by the SingHealth Institution Review Board after evaluating the study
protocol for exemption, and waiver of consent for need to obtain written informed consent from
parents/guardians of the children to participate in this study and for their data to be used for re-
search purposes.

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2.2. Intervention
The EQUAL program was sponsored by Temasek Cares, Tote Board, Lee Foundation, Far East
Organization, Singapore Business Foundation, Keppel Ltd, and generous donors from the commu-
nity. EQUAL was chaired by Dr Melanie Chew, Ms Harpreet Bedi, Dr Jade Kua, Ms Melissa Tan and
Professor Lim Soo Ping, who worked with the teachers of the pre-vocational School to design and
align the EQUAL program to the school’s focus on Habits of Mind. The program comprises 48 h of
horse-related activities, delivered in 16 weekly sessions at three hours per session. During these ses-
sions, a class grouping of 20–40 students takes part in three separate activities. Each activity is de-
signed to illustrate, train and reinforce a Habit of Mind. As an example of a 3 h session, the students
are first gathered in an assembly during which they are briefed on the schedule for the day. Then
they are split into three groups. Each group will participate in all three activities, with the three
groups rotating among the three activities. The activities vary but they generally form three streams:
Horse Play (students engage in individual or group goal-directed exercises with loose horses in an
open arena), Stable Management (students interact with horses in an enclosed stable environment)
and Riding (students learn gymnastics and exercises mounted on a horse). During each activity, and
at the end of each session, the sta comprising of professional instructors, psychologists and trained
volunteers will help the students to recognize, learn and practice Habits of Mind. This is done by al-
lowing the students to point out the Habit of Mind that is the rationale behind that particular activity,
and then linking the newly learned Habit of Mind to everyday situations. For instance, in one such
lesson, the students are made to associate the mindset involved in successful interaction with the
horses to Listening with Understanding and Empathy. In another lesson, the students will learn that
the successful acts of saddling the horse, mounting, riding and dismounting involve impulse control
and will be encouraged to apply act of Managing Impulsivity during the lesson to situations encoun-
tered in school. Parental informed consent was sought before the students embarked on the EQUAL
intervention, as part of a routine school practice for any external activities.
All of the exercises are set down in the EQUAL Manual, which can be provided upon request. The
overall structure of the 16 lessons and the content for each lesson was documented, as well as the
logistics involved e.g. costs, manpower count, skills that are required in program facilitators, and the
potential risks to the participant. It is a policy that all students who attend EQUAL receive a consist-
ent program, regardless of which group and year cohort they are in. The details of adherence of the
EQUAL intervention to the guidelines on treatment fidelity, which are put forth by the Behavioral
Change Consortium of the National Institute of Health (Borrelli, 2011; Borrelli et al., 2005), are de-
scribed in Appendix A.
2.3. Data collection
The Habits of Mind measures were scored at three time-points during the semester for all subjects
undergoing EQUAL intervention, namely before intervention (Week 1 or 2), mid-way through the
three-month intervention period (Week 8) and a week post-intervention (Week 12). Subjects from
the other classes not receiving intervention were also assessed at the same time-points during the
semester.
The five selected Habits of Mind: Persistence, Thinking Flexibly, Taking Responsible Risks, Managing
Impulsivity, and Listening with Understanding and Empathy, were scored on a 10-point fully an-
chored Likert scale (scale of 0–10, with higher scores indicating better Habits of Mind). The scoring
was based on rubrics that the school has given permission for release (detailed in Appendix A). To
ensure standardization across the dierent classes and fair scoring, all the form teachers across the
classes, together with the teacher aide and an EQUAL trainer (who would also collate independent
Habits of Minds scores from the EQUAL facilitators) would conduct periodic benchmarking exercises
at each time-point, by calculation of intra-class correlations of the Habits of Mind scores (see
Appendix A).
Subsequent analysis of the outcomes of the intervention was performed by an investigator (N.F.
Ho) not involved in the intervention or data collection, and had only access to anonymized data.

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2.4. Statistical analysis
All analyses were performed using R version 3.2 (The R Core Team, 2015). To test possible gender
dierences between the intervention and non-intervention group student participants of year 2013,
as well as year 2014, Yates-corrected χ2 tests were used.
To examine whether equine therapy resulted in changes in each Habit of Mind measure over time
in each semester, a linear mixed-eect model (conditional three-level growth model) was fitted
(Singer & Wilett, 2003). Linear mixed-eect models are extensions of traditional linear regression
models, with individual-level terms introduced to the regression models to account for the variability
in change among individuals. Here, this multi-level model embodies dierent sub-models about how
the construct measured in an individual student changes over time, and how these changes vary
between all students across the dierent classes. Various research questions are asked in the model
fitted below: level 1 questions about within-student changes over time, level 2 questions about be-
tween-student changes within a class, and level 3 questions about between-class changes.
2.4.1. Level 1 (within-student)
where Scoresijk represent the Habit of Mind score at time-point i for student j in class k; Timeijk repre-
sents the time-point in which the Habit of Mind is measured, i.e. pre-intervention, mid-intervention,
and post-intervention for student j in class k; β0jk refers to the score for student j at pre-intervention;
rijk refers to the within-student deviation between the observed and predicted scores (random error)
at time i for student j in class k.
2.4.2. Level 2 (between-student, within-class)
where γ00k refers to the mean at of the scores at time i across the students in class k; γ01k refers to
fixed regression coecient of the gender of student j in class k; γ10 refers to the average rate of
change in scores across all the students within class k; μ0jk refers to the between-student random
error in class k; μ1j refers to the between-student variation over time for class k.
2.4.2. Level 3 (between-class)
where, η000 refers to the grand mean; η100 refers to the grand intercept; ζ000k refers to the between-
class random error; ζ000k refers to the between-class random error over time.
2.4.4. Substitute level 3 into level 2, and then level 1 models
In the model fitted, the fixed-eect variables included intercept, intervention, time, interaction
between intervention and time, and gender; random-eect variables included slope of time, and
intercept of time, student and class (as ratings are performed at dierent time-points on the
students, which are nested within eight classes). An analysis of variance (ANOVA) was performed on
the linear mixed-eect model to determine whether there is statistical evidence of an interaction
Scoresijk
=
𝛽
0
jk
+
𝛽
1
jkTimeijk
+
rijk
𝛽0jk =𝛾00k+𝛾01jkGenderjk +𝜇0jk
𝛽1jk =𝛾10k+𝜇1jk
𝛾00k
=𝜂
000
+𝜂
001 Interventionk
+𝜁
000k
𝛾10k
=𝜂
100
+𝜂
101 Interventionk
+𝜁
001k
Scores
ijk
=
𝜂000
+
𝜂001
Intervention
k
+
𝜂100
Time
ijk
+
𝜂101
Intervention
k
×Timeijk
+𝛾01
jk
Gender
jk
+(r
ijk
+𝜇0
jk
+𝜁000
k
+𝜇1
jk
Time
ijk
+𝜁100
k
Time
ijk
)

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between intervention and time. To correct for multiple testing across the five Habits of Mind
constructs, the Holm–Bonferonni method was used, which corrected for family wise error rate at an
alpha of p < 0.05.
To examine the relationship between the rate of change in Habits of Mind over the semester and
academic performance at the end of the semester, the students’ individual grade point averages
were regressed on the individual slope estimates of the longitudinal change in each construct (i.e.
the η101 extracted from the above linear-mixed eect models), adjusting for gender.
To correct for multiple testing across the five Habits of Mind constructs, the Holm–Bonferonni meth-
od was used, which corrected for family wise error rate at an alpha of p < 0.05.
3. Results
No dierences in gender were found between students in the non-intervention and intervention
group in both the 2013 and 2014 cohorts.
3.1. Progressive increase in Habits of Mind scores across the three semesters in 2013
and 2014
Significant equine intervention by time eect were found across the five Habits of Mind examined
(all p < 0.0001), which survived correction for multiple comparisons (Table 1(A) and Figure 1). No ini-
tial group dierences in Habits of Mind scores were found at baseline. For the year 2014 semester 1
cohort, significant intervention by time eect was found for all constructs, except for Managing
Impulsivity (Table 1(B) and Figure 2). In semester 2, significant intervention by time eect in the
waitlisted group of students was found for all constructs, which survived multiple comparison test-
ing (Table 1(C) and Figure 3). However, unlike the cohort in 2013, the group receiving EQUAL inter-
vention in both semester 1 and 2 exhibited higher baseline measures compared with non-intervention
subjects in several Habits of Minds constructs (Semester 1: Thinking Flexibly, Taking Responsible
Risks, Managing Impulsivity, Persistence (Figure 2); Semester 2: Managing Impulsivity, (D) Persistence,
and (E) Listening with Understanding and Empathy (Figure 3); p < 0.0001).
3.2. Association between rate of change in character skills and grade point average
across the semesters
Across all the five Habits of Mind examined, we found positive correlations between the longitudinal
changes in the scores and grade point average across many constructs that survived multiple com-
parisons (Table 2, Year 2013 semester 2: Thinking Flexibly, Taking Responsible Risks, Managing
Impulsivity, and Listening with Understanding and Empathy; Year 2014 semester 1: Thinking Flexibly,
Managing Impulsivity, and Listening with Understanding and Empathy; Listening with Understanding
and Empathy; Year 2014 semester 2: Thinking Flexibly, Taking Responsible Risks, Managing
Impulsivity, and Persistence.)
4. Discussion
The current findings indicate that three months of an equine-assisted learning program resulted in
improvements in character skills in two independent cohorts of Year 1 students at-risk for academic
and life failure across the three semesters in 2013 and 2014. The rate of change in character meas-
ures over the semester is associated with the students’ grade point average at semester-end.
EQUAL is unique in that it is the first program of its kind in Asia, and is part of a school’s core cur-
riculum. Prior to the present study, its perceived success had been largely anecdotal, with positive
feedback captured online and on film from participating children, volunteers, teachers and parents
over the first three years of its inception. The present findings indicate that the equine-learning pro-
gram has a significant eect on Habits of Mind measures over the semester in students in 2013 that
was replicated in an independent cohort of 2014. We discuss how the EQUAL program could have
Grade Point Averagejk
=𝛽
0k
+𝛽
1jkChange in scores of constructjk
+
Genderjk
+
rjk

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improved each Habit of Mind construct. Taking Responsible Risks refers to the willingness to attempt
safe tasks that are new and dierent, and not balk at the fear of making mistakes with this attempt
(Costa & Kallick, 2008). The youths largely come from underprivileged family backgrounds, and
would have likely never ridden a horse before. As they attempt to gain the trust of the horses, learn
to groom, mount and ride them, the youths would learn that as long as they listen and follow the
instructions given, these novel acts might not be intimidating as seemed initially. Persistence is the
act of focusing and completing the task on hand. The youths could have gradually gain insight that
as long as they stick to the instructor’s instructions during the lessons, and not give up in the tasks,
they would eventually be able to master the skills to ride the horse successfully and engage in team
games. Listening with Understanding and Empathy requires paying attention to another person’s
opinion and to put oneself into the other party’s shoes. The horses elicit a range of emotions and
emotions that are similar to humans (Bachi et al., 2012). In order to develop rapport with the horse,
the youths are required to understand their behavior to gain their trust. Thinking Flexibly refers to
the ability to change one’s stance after considering another person’s viewpoint. For instance, in a
lesson while the youth is expected to trot the horse, the horse could be unwilling to move due to
tiredness or fright; the youth has to learn to interpret the horses’ actions, and to react accordingly.
Managing Impulsivity is to think carefully and consider various options before an action. As the
Table 1. Statistical values showing an EQUAL intervention-by-time interaction in at-risk youths
in (A) 2013 semester 2, and a similar interaction eect in an independent cross-over cohort in
(B) 2014 semester 1, and (C) 2014 semester 2
Notes: A multi-level model was used to test whether there were group dierences in the scores of each Habit of Mind
construct over time. The betas indicate the dierences in slopes between the group receiving equine therapy and the
group that did not, and standard errors (SE) indicate the variability of the sample cohorts. For example, for the construct
Thinking Flexibly, the mean score of the group that received equine therapy relative to the group that did not improved
by 1.30 over time. The betas can be considered as unstandardized eect sizes. The 95% confidence intervals (CI) are
also shown; a CI covering the value of zero means the null hypothesis cannot be rejected. Finally, multiple comparisons
correction (Bonferroni–Holm) was applied across the five constructs measured at an alpha of 0.05.
*Indicates that the significance survived multiple comparisons.
Statistical values of the interaction eect between
equine therapy and time
Habits of Mind construct βSE 95% CI p-value
A) Year 2013 cohort semester 2
Thinking Flexibly 1.30 0.13 [1.02, 1.58] <0.0001*
Taking Responsible Risks 1.35 0.08 [1.21, 1.59] <0.0001*
Managing Impulsivity 1.13 0.07 [0.97, 1.29] <0.0001*
Persistence 1.40 0.11 [1.14, 1.65] <0.0001*
Listening with Understanding and Empathy 1.22 0.08 [1.07, 1.37] <0.0001*
B) Year 2014 cohort semester 1
Thinking Flexibly 0.69 0.14 [0.38, 1.01] <0.0001*
Taking Responsible Risks 0.96 0.17 [0.57, 1.35] <0.0001*
Managing Impulsivity 0.42 0.24 [−0.11, 0.96] <0.081
Persistence 0.55 0.2 [0.11, 1.00] <0.005*
Listening with Understanding and Empathy 0.49 0.29 [0.74, 1.62] <0.010*
C) Year 2014 cohort semester 2
Thinking Flexibly 1.18 0.20 [0.74, 1.61] <0.0001*
Taking Responsible Risks 1.64 0.30 [0.97, 2.32] <0.0001*
Managing Impulsivity 1.27 0.18 [0.86, 1.67] <0.0001*
Persistence 1.50 0.17 [1.12, 1.87] <0.0001*
Listening with Understanding and Empathy 1.35 0.23 [0.84, 1.86] <0.0001*

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youth riding the horse is expected to lead the horse (for instance changing the pace from cantering
to trotting, and not collide with other youths in the arena), this calls for him/her to consider the en-
vironment around, and to communicate with the horse his/her intention.
The present findings of equine-related behavioral improvements over time agree with those from
a randomized controlled study of an 11-week once-weekly equine facilitated learning after-school
program on 5th–8th grade children, which included normal children and those at-risk of academic
failure (Pendry, Carr, Smith, & Roeter, 2014). Parents of the children had rated their social compe-
tence pre-test and post-test, and the results of the study had indicated a moderate treatment eect
on social competence (Pendry et al., 2014). Higher program attendance had also predicted the chil-
dren’s behavior (Pendry et al., 2014), although the outcomes in the waitlisted group were not ana-
lyzed. Equine-related intervention has also been shown to increase perception of social support in
typically developing youths (without psychological or behavioral problems) (Hauge, Kvalem, Berget,
Enders-Slegers, & Braastad, 2014).
Figure 1. Equine therapy
improves Habit of Mind scores
over time in one semester in
2013. The teacher ratings for
the Habits of Mind constructs:
(A) Thinking Flexibly, (B)
Taking Responsible Risks, (C)
Managing Impulsivity, (D)
Persistence, and (E) Listening
with Understanding and
Empathy, for students of the
2013 cohort who were in the
EQUAL program compared with
students who did not partake
in the program, showed an
increase over the semester.

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In the 2013 cohort of students, the baseline measures for both the intervention group and non-
intervention group did not vary. However, we did note that in the cohort of 2014 students, across
both semesters, higher baseline measures were found in the group that were about to participate in
the EQUAL program in a weeks’ time. This suggests that the students were possibly excited about the
prospect of participating in the program and may have behaved better. Nonetheless, the gradual
improvements in their Habits of Mind mid-way and one-week post-EQUAL intervention in the student
cohort of 2014 were still found. This begets the question of whether the behavioral improvements are
due to novelty eects i.e. the elation and energy that ensues from a new and exciting experience
(Anestis et al., 2014; Shadish, Cook, & Campbell, 2002). Also, the students in the classes involved in
the EQUAL program were transported to the ranch while the other students remained in school, and
this may give rise to resentful demoralization (e.g. knowledge that they are missing out on a novel
experience) (Anestis et al., 2014; Cook & Campbell, 1979). Alternatively, there was the possibility of
an demand eect (McCambridge, de Bruin, & Witton, 2012). The teachers were aware that their stu-
dents were attending the EQUAL program, and might possibly rated the intervention condition group
higher if they had preconceived notions of the eectiveness of the intervention (Orne & Whitehouse,
2000). Nonetheless, the teachers, the aide and the EQUAL trainers had benchmarking sessions for
Figure 2. Equine therapy
improves Habit of Mind scores
over time in 2014 semester 1.
Higher baseline measures were
found in the students about to
enroll in the EQUAL program
in semester 1 of year 2014 for
the following four Habits of
Mind constructs: (A) Thinking
Flexibly, (B) Taking Responsible
Risks, (C) Managing Impulsivity,
(D) Persistence, but not (E)
Listening with Understanding
and Empathy. The teacher
ratings for four Habits of Mind
constructs (A) Thinking Flexibly,
(B) Taking Responsible Risks, (D)
Persistence, and (E) Listening
with Understanding and
Empathy, for those students in
the EQUAL program, compared
with students not in the
program, showed an increase
over the semester.

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grading the students pre-, mid- and post-intervention, so the demand eect would have been miti-
gated. Also, there was a correlation between the rate of change in character skills over the semester
and the students’ grade point averages at the end of the semester, suggesting that the EQUAL-
related improvements in character skills may have translated into better academic performances.
The findings of this real-world study, however, should be interpreted in light of several limitations.
First, due to the strict confidentiality of student school and medical records, we do not have access to
the possible medical conditions of the students within each class (e.g. anxiety disorders, ADHD, au-
tism spectrum disorders, or neurological impairments), as well as the knowledge of their family envi-
ronment, that could likely shaped their behavior, and confounded the findings. The medical conditions
or parental social-economic conditions could have been used to adjust for eects of findings, or to
better match the participants in the non-intervention and intervention groups. Second, although
more widely used instruments of behavior, social and emotion measures are available (Achenbach,
2014; Epstein, 2004), the EQUAL program was aligned with the less empirically studied Habits of Mind
constructs that were used systematically by the school for the past 10 years in all aspects of the
Figure 3. Equine therapy
improves Habit of Mind scores
over time in two semesters in
2014. Higher baseline measures
were found in the waitlisted
students about to enroll in the
EQUAL program in semester 2
of year 2014 for the following
three Habits of Mind constructs:
(C) Managing Impulsivity, (D)
Persistence, and (E) Listening
with Understanding and
Empathy. The teacher ratings
across five Habits of Mind: (A)
Thinking Flexibly, (B) Taking
Responsible Risks, (C) Managing
Impulsivity, (D) Persistence,
and (E) Listening with
Understanding and Empathy,
for those students in the
EQUAL program, compared with
students not in the program,
showed an increase over the
semester.

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school curriculum. Third, we cannot establish whether the character skills improvements are due to
the EQUAL program or mere novelty eects. Further longer term prospective studies of future cohorts
of students should continue and should include, beyond Habits of Mind constructs, validated neu-
ropsychological scales that are both student- and parent-rated to gain a more holistic perspective of
the impact of equine therapy. To increase the reliability of the findings, a similar study with the same
equine educational curriculum could be carried out in another pre-vocational school. To address the
incremental ecacy and cost-eectiveness of the present intervention, EQUAL should also be com-
pared with other interventional programs e.g. art or music therapy, over the same time period.
Funding
The manuscript is funded by the Department of Child and
Adolescent Psychiatry, Institute of Mental Health.
Author details
New Fei Ho
1
E-mail: new_fei_ho@imh.com.sg
Jonathan Zhou
2
E-mail: jonathan.zhou15@gmail.com
Daniel Shuen Sheng Fung
1
E-mail: daniel_fung@imh.com.sg
Phek Hui Jade Kua
3
E-mail: jade.kua.p.h@singhealth.com.sg
1
Department of Child and Adolescent Psychiatry, Institute of
Mental Health, 10 Buangkok View, Buangkok Green Medical
Park, Singapore 539747, Singapore.
2
Equestrian Federation of Singapore, National Equestrian
Park, 100 Jalan Mashhor, Singapore 299177, Singapore.
3
Department of Emergency Medicine, KK Women’s &
Children’s Hospital, 100 Bukit Timah Road, Singapore
229899, Singapore.
Citation information
Cite this article as: Equine-assisted learning in youths at-
risk for school or social failure, New Fei Ho, Jonathan Zhou,
Daniel Shuen Sheng Fung & Phek Hui Jade Kua, Cogent
Education(2017), 4: 1334430.
Cover image
Source: The chairman of the Equal-Assisted Learning
(EQUAL) program.
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Appendix A
1. Assessment of treatment fidelity of the equine-assisted learning program (EQUAL) Intervention,
adapted from (Borrelli, 2011)
The Behavioral Change Consortium of the National Institute of Health has put forth guidelines for
treatment fidelity across five, mutually exclusive domains: Study Design, Provider Training, Treatment
Delivery, Treatment Receipt, and Treatment Enactment (Borrelli et al., 2005). The following table in-
dicates the adherence of the EQUAL intervention to these guidelines.
1. Treatment design
Information on intervention condition
Length of contact for each session 180 min
Number of contacts 2013: 75 students
2014 semester 1: 58 students; 2014 semester 2: 59 students
Content of treatment There is a structural training manual that the providers follow, which can be furbished on request. An example of the
first session is provided here as an example. The first session is an introductory session where instructors and
participants get to know each other and various general safety behaviors around horses. Thereafter, each session
consist of three activities; horseplay, horsemanship and riding. In horseplay, participants engage in various games with
the horse that emphasizes the various Habits of Mind. An example of such a horseplay activity is “Catch the Pony”. In
this game, participants are to figure out how to catch the horse given the head collar and lead rope. Minimal
instructions are given (largely in regards to safety) and participants have think flexibly and be persistent to be
successful at the activities. Horsemanship consist of activities that revolves around skills regarding care for the horse.
Such skills require the application of the Habits of Mind to be successful. For example, picking the horse hoof for the first
time requires persisting from the participant as it could take a number of attempts before one successfully does it
independently. Riding is a mounted activity where various riding skills are taught. To be successful at riding, participants
would have to practice the various Habits of Mind, due to the nature in which the horse and rider interact with each
other. For example, if the rider is feeling nervous, managing their impulsivity of pulling the reins for balance is
interpreted by the horse to stop instead of continuing to walk. After each activity, a debrief is conducted, processing
with the participants what Habits of Mind was practiced and how they could apply them in various situations
Duration of contact over time 16 sessions × 180 min = 2880 min
Information on comparison condition
Length of contact for each session no contact
Number of contacts 2013: 85 students
2014 semester 1: 59 students; 2014 semester 2: 58 students
Content of treatment none (As EQUAL has been integrated into the core school curriculum, the students attend classes as usual)
Equivalence between intervention and comparison conditions
Method to ensure that the
intervention is equivalent between
conditions
None for the pioneering batch of 2013. In 2014, EQUAL was formally incorporated into the school curriculum, as part of
a cross-over intervention program
Method to ensure that the length
and duration of therapy is
equivalent for participants within
conditions
The providers follow a structured training manual. Since EQUAL is part of the school curriculum, the students partake in
EQUAL during school hours
Specification of provider credentials
needed
The providers in one session comprise of personnel trained in horses (accredited by the British Horse Society) and
personnel with a Bachelors in Psychology
Theoretical model upon which the intervention is based is clearly articulated
The active ingredients are specified
and incorporated into the
intervention
The intervention works on the premise that horse-based activities provide opportunities for students to practice,
experience, and process the positive consequences of the following five Habits of Mind; Persisting, Managing Impulsiv-
ity, Taking Responsible Risk, Thinking Flexibly, and Listening with Understanding and Empathy. This is done by getting
students to verbally reflect if they practiced any of the habits of mind that lead to their success and instructors pointing
out to them the habits of mind skills that were used that allowed them to achieve success at each horse-based activity
(as each activity is ongoing and during the debrief/wrap up segment after completion of each activity). Reflection
sheets are also given to the students to reflect on each habit of mind

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Use of experts to determine
whether the intervention protocol
reflects the underlying theoretical
model
The intervention was primarily based on the Habits of Mind, developed by the Costa [cite), that was embraced by the
school as integral character skillsets. The program was designed together with the teachers of the school
Plan to ensure that the measures
reflect the hypothesized theoretical
constructs/mechanisms of action
The activities of each session were planned with the aim of eliciting the Habits of Mind
Potential confounders that limit the
ability to make conclusions at the
end of the intervention are
identified
The session is conducted to a large group of students. Although many personnel are involved in each session, it is
acknowledged that some students may be slower to learn, and that the duration of the session may not be sucient
for these students to fully grasp and link the activities to the Habits of Mind
Plan to address possible setbacks in
implementation (i.e. back-up
systems or providers)
There are contingency plans to conduct the sessions indoors in case of inclemental weather such as rain. For example
for the horseplay activity Pinky and the Brain, the activity was to get the horse and tack it up with some taking the role
of the hand and others the brain. While the activity conducted outdoors allows for more dynamism (e.g. getting the
horse in a sand paddock might require more persistence), it could be conducted within the confines of the stable too
2. Training of the providers of intervention
Description of how providers will be
trained (manual of training
procedures)
The main facilitator of the program would meet up with the treatment providers(facilitators) before the start of each
semester, and go through the sessions with them. Hence, before the start of each semester, all facilitators have to be
familiar with the entire EQUAL lesson manual. Briefings at the start and the debriefings at the end of each session were
performed to ensure every facilitator was on the right track. Before the start of the sessions, the facilitators would run
simulated activities to familiarize themselves with the intervention procedures. At the end of each session, debriefing
would be held for feedback
Standardization of provider training In the case of new sta members, they would be assigned to an experience mentor to guide them through the process
Assessment of provider skill
acquisition
Although the horse trainers and psychologists were accredited, no formal assessments specific for EQUAL were carried
out, due to sta and funding limitations. However, the main primary facilitators would always be around during the
sessions to ensure other newer facilitators are adhering to the guidelines of the EQUAL program manual. If need be,
extensive interviews are carried out for the new sta hires before the start of the semester. There was no sta turnover
during the semester
Assessment and monitoring of
provider skill maintenance over time
No formal assessments specific for EQUAL were carried out, due to sta and funding limitations. However, briefings at
the start and the debriefings at the end of each session were performed to ensure every facilitator was on the right
track. Before the start of the sessions, the facilitators would run simulated activities to familiarize themselves with the
intervention procedures
Characteristics being sought in a
treatment provider are articulated a
priori. Characteristics that should be
avoided in a treatment provider are
articulated a priori
Advertisements placed for new hires of facilitator positions specify either a degree in psychology (at least a Bachelor’s
level) and/or formal training in horses (accredited by the British Horse Society). The facilitators are required to have a
good command of English, and are concerned and comfortable with helping children and youths who may be
experiencing problems in an academic setting
At the hiring stage, assessment of
whether or not there is a good fit
between the provider and the
intervention (e.g. ensure that
providers find the intervention
acceptable, credible, and potentially
ecacious
Potential hires were first asked to volunteer for the program to see how they fit (and if they are a good fit with the
program)
3. Delivery of intervention
Method to ensure that the content
of the intervention is delivered as
specified
The treatment manual is given to all treatment providers before the start of the semester so that they can deeply
understand the content of the lessons. Before the start of the school semester (during the term break), the facilitators
would run simulated activities to familiarize themselves with the intervention procedures
Method to ensure that the dose of
the intervention is delivered as
specified
All students who are present goes through the same activities for each session (e.g. session one activities are always
the same for all classes)
Mechanism to assess if the provider
actually adhered to the intervention
plan
The main facilitators of the program, who have been around since the inception of EQUAL, are always around for the
entire sessions
Assessment of non-specific
treatment eects
No
Use of treatment manual Yes
There is a plan for the assessment
of whether or not the active
ingredients were delivered
Yes, this study serves as an assessment of whether EQUAL is eective by examining whether there is improvement in
Habits of Mind over time

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There is a plan for the assessment
of whether or not proscribed
components were delivered
No, this study does not examine whether components of the EQUAL are unhelpful or unnecessary
4. Receipt of intervention
There is an assessment of the
degree to which participants
understood the intervention
Facilitators ensured that the participants were able to perform each horse activity, and corrections were made on the
spot
There are specification of strategies
that will be used to improve
participant comprehension of the
intervention
Facilitators used visual cues to aid their training (e.g. mimicking the motions they were to perform). Also for participants
who learned better kinesthetically, they were taught while participants were simultaneously performing the task
The participants’ ability to perform
the intervention skills will be
assessed during the intervention
period
Although no formal assessments are conducted for the students, the high facilitators-to-students ratio ensure that the
students partake in active on-the-spot learning
A strategy will be used to improve
subject performance of intervention
skills during the intervention period
Activities are planned to ensure that the horse skills are taught in a progressive manner. For example, learning how to
get the horse to walk and halt is taught before learning how to turn the horse)
Multicultural factors considered in
the development and delivery of
the intervention
Yes, for example, in a case of a student whose language abilities are poor, eorts are made to speak in colloquial
language or through the means of hand signals and physical demonstrations. More often visual demonstrations were
used, and when needed, participants were hand guided and/or physically supported when necessary
5. Enactment of treatment skills
Participant performance of the
intervention skills will be assessed in
settings in which the intervention
might be applied
Yes, his or her abilities to handle the horses are performed on the spot, by the facilitator
A strategy will be used to assess
performance of the intervention
skills in settings in which the
intervention might be applied
Yes, there is an academic rubric for assessing how the students, through the EQUAL program, may have cultivated
certain Habits of Mind. The rubric is used by teachers who do not carry out the EQUAL intervention. See below “Rubris
for evaluating students’ Habits of Mind”
2. Rubrics for evaluating students’ Habits of Mind (taken with permission from the NorthLight
school)

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Habit of Mind
Listening with Understanding and Empathy: Ability to be present in the situation. Ability to listen and respond
appropriately to others.
Points to look out for:
• The student makes eye contact with the person speaking to them
• The student faces the person who is speaking to them
• The student responds appropriately
• The student asks questions when they don’t understand
• The student finds ways to understand what is being said
Managing Impulsivity: Ability to respond to a situation by thinking through it rather than reacting to it.
Points to look out for:
• The student listens to instructions
• The student gathers information and things they need before they start work
• The student asks for clarifications when they are unsure about what to do
• The student waits for their turn or raises their hand before answering a question
• The student is in control when on a task
• The student thinks through a question before answering
• The student completes what they set out to do
Thinking Flexibly: Ability to consider the points of view of others. Ability to generate new ideas which take into
consideration varying points of view.
Points to look out for:
• The student listens to other people’s ideas
• The student can compromise and work together with a group
• The student can accept criticisms and suggestions
Taking Responsible Risks: Ability to take risks in the work they do. Willing to try something new despite diculty and
fears of failure.
Points to look out for:
• The student is not afraid of trying even though the task is dicult
• The student volunteers to participate in class activities
• The student tries new things
Persisting: Ability to approach a problem or diculty and try dierent ways of solving or overcoming it.
Points to look out for:
• The student keeps trying
• The student focuses on the task
• The student asks for help
3. Inter-rater reliability
During the periodic bench-marking exercise performed pre-, mid-, and post-intervention, the
Habits of Minds scores from randomly chosen students would be compared among the from the
form teacher, teacher aide, and EQUAL psychologist.
The intra-class correlation among the fixed raters, for each of the Habits of Mind scores of the
randomly selected students, is calculated by (BMS – EMS)/BMS + (k−1) × EMS, where BMS: Between-
student target Mean Square, EMS: residual sum of squares, and k: number of raters.
The intra-class correlation values for each construct in each semester range from 0.62–0.84.

Page 18 of 18
Ho et al., Cogent Education (2017),
4: 1334430
https://doi.org/10.1080/2331186X.2017.1334430
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