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e1
EFFECTS OF 4 WEEKS OF HORSEBACK RIDING ON ANXIETY, DEPRESSION,
AND SELF ESTEEM IN CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY
DISORDER
Wi-Young So1, So-Young Lee2, Yoonjung Park3, Dong-il Seo2
1Associate Professor, Sports and Health Care Major, College of Humanities and Arts, Korea National
University of Transportation, Chungju-si, Republic of Korea
2Researcher, Department of Sport Science, Dongguk University, Gyeongju, Republic of Korea
3Assistant Professor, Department of Health and Human Performance, College of Liberal Arts and Social
Sciences, University of Houston, Texas, USA
2Assistant Professor, Department of Sport Science, Dongguk University, Gyeongju, Republic of Korea
CORRESPONDING AUTHOR: Dong-il Seo: seodi74@dongguk.ac.kr
Submitted: August 26, 2017. Accepted: September 18, 2017. Published: September 28, 2017.
Abstract
Background and Objective
There is no report on the eects of horseback riding on children with attention deficit hyperactivity disorder
(ADHD). Therefore, the purpose of this study was to determine the eects of 4 weeks of horseback riding
on anxiety, depression, self esteem, attention, and learning disorder in children with ADHD.
Materials and Methods
Subjects comprised a convenience sample of 10 children aged 10–12 years with ADHD and 10 children
without ADHD. Horseback riding sessions were performed 2 times (40 minutes/day) per week for 4 weeks.
Before and after the horseback riding program, we measured the children’s anxiety, depression, self esteem,
attention, and learning disorder. The pre-test and post-test scores were analyzed with repeated-measures
analysis of variance.
Results
After participating in the 4-week horseback riding program, anxiety (p = 0.013), depression (p = 0.007),
attention (p < 0.001), and learning disorder (p < 0.001) were significantly improved in the ADHD group
compared to the normal group. However, self esteem was not significantly dierent between the 2 groups
(p = 0.096).
Original Article
DOI: 10.22374/1875-6859.13.2.2
J Mens Health Vol 13(2):e1-e7; September 28, 2017
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Effects Horseback Riding in Children with ADHD
e2
Attention deficit hyperactivity disorder (ADHD) is
a common neurodevelopmental disorder characterized
by developmentally inappropriate levels of inatten-
tion, overactivity, distractibility, and impulsiveness,
which manifest during childhood.1 Recently, ADHD
has become highly prevalent in school-aged children.
According to the Centers for Disease Control and
Prevention report in 2013, the number of children
with ADHD was about 6.8% of the world population.2
In Korea, the number of children with ADHD
is increasing, and special attention is required for
its treatment and prevention. Based on a recent
survey in Korea, about 7.2% (152,640) of students
had symptoms of ADHD in the Student Emotional
and Behavioral Problems Screening Test conducted
in 2,139,243 elementary school, middle school,
and high school students. Especially, among them,
about 6,529 elementary school students were found
to be in the high-risk group that urgently needed
treatment.3
Studies on the improvement and treatment of ADHD
symptoms have been performed in various ways. Some
methods including cognitive treatment, behavioural
(exercise) treatment, pharmacological treatment, and
combinational treatment, etc. have shown positive
results.
4
It has been reported that animal-assisted
therapy positively helps children with mental and
physical disorders in physical, cognitive, and emotional
ways.
5
Horseback riding is a typical exercise that may
improve emotional stability and healthy fitness by
communing with a horse.6 Moreover, studies on the
exercise or mental eects of horseback riding have
been conducted,7–9 but ones on the therapeutic eect
in children with ADHD have not been reported yet.
Therefore, the purpose of this study was to analyze
the changes in anxiety, sense of depression, and self
esteem in children with ADHD who participated in
a horseback riding exercise program for 4 weeks.
METHODS
Participants
In this study, 10 students who were diagnosed as
having ADHD and 10 mentally healthy students who
were selected from physically healthy male elemen-
tary school students participated in this experiment
(Table 1). This study was approved by the Human
Care and Use Committee of the Institute of Sports
Science of Dongguk University. Subjects and their
parents or guardian were informed of the procedures
and provided informed consent before participation.
Study Design
Subjects’ physical characteristics, the ADHD
rating scale score, and learning disorder test results
were obtained from the children’s guardians, and in-
formation about depression, anxiety, and self esteem
was obtained directly from the subjects. All measure-
ments were performed before and after completing
the 4-week horseback riding exercise.
Anthropometric Measurements
Subjects’ height and weight were measured to the
nearest 0.1 cm and 0.1 kg, respectively, by using a
stadiometer, digital electronic scale, and body mass
index (kg/m2).
Conclusion
These results indicate that the 4-week horseback riding program used in this study was very eective for
significantly improving anxiety, depression, and attention in children with ADHD.
Key Words: anxiety, depression, self esteem, attention, attention deficit disorder, horseback riding therapy
Table 1 Participants’ Physical Characteristics
Group nAge (years) Height (cm) Weight (kg) Body mass index (kg/m2)
ADHD 10 10.3 ± 1.8 141.3 ± 4.5 41.9 ± 4.0 21.0 ± 1.7
Normal 10 11.2 ± 1.3 139.9 ± 4.8 41.4 ± 6.6 21.0 ± 1.9
Data expressed as a mean ± standard deviation.
ADHD = attention decit hyperactivity disorder.
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Effects Horseback Riding in Children with ADHD
e3
Assessment of ADHD, Anxiety, Depression, Self
Esteem and Attention and Learning Disorders
The ADHD rating scale was developed by Dupaul
et al.
10
based on The Fourth Edition of the Diagnostic
and Statistical Manual of Mental Disorders. It is useful
for diagnosing ADHD and assessing the eectiveness
of treatment since it is based on sex and age, and it
is observed and written by parents and teacher. The
ADHD Rating Scale-4 consists of 18 questions divided
into inquiries about symptoms of attention deficit
disorder, hyperactivity, and impulsivity. Each ques-
tion is graded from 0 to 3, and ADHD was diagnosed
when parents obtained a total score of 19 points and
teachers obtained a total score of 17 points.
The Child Anxiety Scale is a children’s version
of the Manifest Anxiety Scale for Adults developed
by Taylor in 1953 and used as the Revised Children’s
Manifest Anxiety Scale (RCMAS) by Reynolds and
Richmond in 1978.
11
This scale, which is used to
evaluate anxiety disorder, is composed of 37 questions
in self-report form, and each question is answered as
yes or no by children and adolescents. The total score
is calculated, and higher scores indicate more severe
anxiety symptoms; additionally, the symptoms related
to various types of anxiety are evaluated.
The Center for Epidemiological Studies Depres-
sion Scale (CES-D)12 developed by the United States
Mental Health Research Institute for epidemiological
studies of depression was used to evaluate depression.
This scale consists of 20 questions and is a self-report
scale rated by 0 to 3 points. It can measure depression,
guilt, feelings of selflessness, helplessness, hopeless-
ness, delay of mental movement, loss of appetite, and
sleep disorder. Additionally, it is used to compare the
prevalence of depression among countries, ethnic
groups, age groups, and between men and women.
Scores range from 0 to 60, with a cut-o score of 21
for local epidemiology and a cut-o score of 25 for
diagnosing major depression.
The Self Esteem Scale (SES) developed by Rosen-
berg in 1965 was used to assess self esteem,
13
and
the self-report questionnaire consisted of 5 items of
positive and negative self esteem. A high score on the
4-point scale was diagnosed as a high self esteem.
The learning disorder test was conducted by the
parents as a measure to assess the degree of learning
disorder. Seventeen items were marked as not at all
present, slightly present, fairly present, or very sig-
nificant, and the total was recorded. Generally, more
than 10 points of fairly present or very significant are
likely to indicate a learning disorder.
Horseback Riding Program
The rehabilitative horseback riding program used
in this study was modified and supplemented based
on the program used by the American Equestrian
Therapist Association
14
and the youth equestrian
Table 2 Details of the Rehabilitative Equestrian Program
Time Description Other
Getting ready 5 minutes Wear safety equipment
(a safety vest and helmet)
Say hello to the horse
Stroke the horse
Horseback riding 30 minutes Warm-up
Main exercise
Cool-down
Learn a riding skill by
phase and level 8 times
Organize 5 minutes Stroke the horse
Dismount from the horse
Say goodbye to the
instructor and assistant
Take o safety equipment
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Effects Horseback Riding in Children with ADHD
e4
program designed by the Korea Racing Authority. The
basic framework is shown in Table 2. The frequency
of participation was 4 weeks, twice per week for no
more than 40 minutes, which included the preparation
time from the start to finish.
Statistical Analysis
Descriptive variables are presented as a mean
± standard deviation. Data analysis was performed
using 2 × 2 repeated-measures analysis of variance.
Statistical significance was set at p < 0.05. SPSS 21.0
(SPSS Inc., Chicago, IL, USA) was used to perform
all analyses.
RESULTS
The anxiety score before and after the 4-week
horseback riding program decreased from 20 to 16.9
points in the ADHD group, and this was statistically
significantly dierent compared to the normal group
(p = 0.013) (Table 3). The depression score before and
after the 4-week horseback riding program decreased
from 18.4 to 13.1 in the ADHD group, and this was
statistically significantly dierent compared to that in
the normal group (p = 0.007). The self-esteem score
before and after the 4-week horseback riding program
in the ADHD group increased from 30.1 to 31.8; this
was not statistically significantly dierent compared
to that in the normal group. The attention total score
before and after the 4-week horseback riding program
in the ADHD group decreased from 28.4 points to
22.8 points. The attention deficit component of the
ADHD score decreased from 16.2 to 13.4 points, and
the hyperactivity/impulsivity score decreased from
12.2 to 9.4 points; these findings were statistically
significantly dierent compared to those of the
normal group (p < 0.001). The learning disorder
score
before and after the 4-week horseback riding
program
decreased from 30.2 to 27.2 in the ADHD
group, and
this was statistically significantly
dierent compared
to that in the normal group (p <
0.001). However, self
esteem was not significantly
dierent between the 2 groups (p = 0.096).
DISCUSSION
The result of the RCMAS test, which was used
to evaluate anxiety before and after rehabilitative
horseback riding in this study, decreased from 20
to 16.9 points. This result suggests that the exercise
can be used as an intervention program to reduce the
problematic behaviours of children with ADHD.
15
Performing rehabilitative horseback riding improved
anxiety. This eect seems to be the result of experi-
encing less anxiousness when interacting with an
animal, confidence in that they can move on a horse,
self-ecacy in that they can horseback ride, and the
sense of accomplishment.
Table 3 Changes in ADHD Variables after the 4-Week Horseback Riding Program
Variable Group n Pre-test Post-test Interaction (time × group)
Fp-value
Anxiety ADHD 10 20.0 ± 5.8 16.9 ± 5.2 7.661 0.013*
Normal 10 16.8 ± 8.4 15.6 ± 7.0
Depression ADHD 10 18.4 ± 8.1 13.1 ± 6.1 9.430 0.007**
Normal 10 12.3 ± 7.9 11.8 ± 7.2
Self Esteem ADHD 10 30.1 ± 5.8 31.8 ± 4.5 3.093 0.096
Normal 10 34.4 ± 1.9 35.1 ± 2.1
Attention ADHD 10 28.4 ± 9.7 22.8 ± 11.0 4.826 <0.001***
Normal 10 9.5 ± 5.9 9.0 ± 5.3
Learning
Disorder
ADHD 10 30.2 ± 5.1 27.2 ± 5.1 18.409 <0.001***
Normal 10 22.7 ± 4.5 21.9 ± 4.0
Data are expressed as a mean ± standard deviation.
ADHD = attention decit hyperactivity disorder
*p < 0.05, **p < 0.01, ***p < 0.001, tested by repeated-measures analysis of variance
J Mens Health Vol 13(2):e1-e7; September 28, 2017
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Effects Horseback Riding in Children with ADHD
e5
In the CES-D test for depressive symptoms, the
score decreased from 18.4 to 13.1 points. Archer and
Kostrzewa16 reported a relationship between regular
exercise and decreased depression, and that state anxi-
ety can be eectively reduced with physical exercise.
Bowers and McDonald
17
reported that adolescents with
severe emotional disturbances described a decrease
in depression after a rehabilitative horseback riding
program. Iannuzzi and Rowan18 found that adolescent
exercise decreased psychological depression and
improved quality of life. Similar to previous stud-
ies, this study also showed that the performance of
short-term rehabilitative horseback riding decreased
depression. This decrease in depression was due to
the improvement of self esteem through special ex-
periences of working with and communicating with
horses, and sharing special empathy,
19
the relative
reliance of not being alone, and improvement of hap-
piness through skin contact with animals. However,
before and after the rehabilitative horseback riding
program, the experimental group and control group
showed a statistically significant positive eect on the
CES-D test result. However, the results of the CES-D
test were not significant. Therefore, it was confirmed
that participants’ depression in this study was not a
cause for concern.
In the SES test for self esteem, the score tended to
increase from 30.1 to 31.8. A previous study reported
that regular exercise was associated with a decrease
in depression and anxiety, as well as an improvement
in self esteem.20 However, the present study did not
show any statistically significant results, suggesting
that the application of short-term rehabilitative horse-
back riding may have aected the results.
The children who met this study’s criteria were
generally sensitive to the mood and changes in the
program environment. During each session, participants
were asked questions about the horse that they would
ride on, and they were curious about the condition of
the horses and were surprised or even afraid of the
horse’s small, unexpected movements. Participants
were afraid of the horses, which were bigger than
them, but the children’s interest in horses increased.
Thus, after they finished their educational classes,
they approached the horses first, stroked them and
fed them, and described their experience afterward.
We observed participants overcome their fear gradu-
ally in unexpected situations because they began to
trust the riding sta and concentrated on the program
activities. This result suggests that emotional stabil-
ity was achieved through interaction with a horse,
and physical activity had a positive impact on other
social functions.
In this study, the attention deficit score of the
ADHD group decreased from 16.2 to 13.4 points
on the subsection score of the ARS test in the as-
sessment of the concentration of attention before
and after short-term rehabilitative horseback riding.
This result supports that rehabilitative horseback rid-
ing, which had a positive eect on ADHD children’s
attention as a psychological exercise, improves in-
dividual performance through physical activity and
social functioning,21 and aerobic exercise improves
the attention deficit disorder.20 Unlike previous
studies, just participating in the short-term rehabili-
tative horseback riding program showed a positive
result in the improvement of the attention deficit
disorder.
The learning disorder score decreased from 30.2
to 27.2. This result supports that of Iannuzzi and
Rowan’s
18
study, in which the riding exercise positively
aected the quality of life of adolescents, and that of
Hong and Yoon’s
22
study, in which psychotherapy was
performed with a horse, making self-control and the
management of behaviour possible through a non-
verbal relationship with horses. We consider that this
improvement of a learning disorder induced the learn-
ing eects because of the instinct to solve diculties
in new experiences through knowledge acquisition.
Additionally, the horseback riding, which was once
considered dangerous and dicult, became possible
to perform because we induced children’s interest in
learning by building their confidence and sense of
accomplishment. We heard that the parents of the
children who participated in our study were delighted
to talk about their children’s changed attitudes in daily
life at the end of this study; other academic guidance
teachers also perceived the change in these children
since they were interested and concentrated on this
study more than any other therapies.
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Effects Horseback Riding in Children with ADHD
e6
We believe that short-term rehabilitative horseback
riding for children with ADHD has enough elements
to enhance their attention through the very special
experiences of working with horses and developing
a relationship with them.
The limitation of this study was that it did not ana-
lyze the change in physiological variables of children
with ADHD. However, improvement of psychological
variables is very meaningful for children with ADHD.
CONCLUSIONS
We consider that the rehabilitative horseback riding
program conducted in this study was able to improve
the anxiety, depression, concentration of attention, and
learning ability of children with ADHD, although it
was only in the short term. This study’s results show
that there is a need to apply the equestrian training
program to children with ADHD. For eective ADHD
treatment, a horseback riding training program should
be included.
ACKNOWLEDGEMENT
This study was supported by the Dongguk Uni-
versity Research Fund, Gyeongju, Korea.
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4.0 International License.