Equine-therapy services, speech-language-hearing therapy, and communication: An analysis of linguistic reorganizations in children with autism spectrum disorder

ABSTRACT

Purpose:  to analyze the effects of equine-therapy services on the verbal and nonverbal communicative abilities of children with autism spectrum disorder, after 10 sessions of the Step-by-Step Communication Program.

Methods:  a longitudinal case series with 10 children aged 2 to 10 years, diagnosed with autism spectrum disorder. The procedures consisted of speech-language-hearing assessments before and after intervention, using the following instruments and scales: Language Development Assessment (ADL); Behavioral Observation Protocol (PROC), based on systemic functional language; and the Child Language Test (ABFW) - part D (pragmatics), as well as 10 sessions of equine-therapy service. The children's speech also underwent systemic-functional analysis, which involves treating speech segments as communication resources available in a given situation. The statistical analysis was descriptive, using the progression coefficient and progress points to measure differences before and after the intervention.

Results:  communicative and linguistic reorganizations were observed in 10 children with autism who received the first 10 sessions of equine-therapy service. The participants’ pragmatic and grammatical aspects progressed, with different communicative developments among them. All children who began the program without verbal utterances started to use this communicative means.

Conclusion:  the partial application of the speech-language-hearing intervention program in equine-therapy services, called "Step-by-Step in Communication," had positive results regarding the progress of pragmatic, semantic, and morphosyntactic skills in most of the children in the study sample.

Keywords:
Equine-Assisted Therapy; Autism Spectrum Disorder; Language; Communication; Speech-Language Pathology

RESUMO

Objetivo:  analisar os efeitos da equoterapia nas faculdades comunicativas verbais e não verbais de crianças com Transtorno do Espectro Autista, após aplicadas dez sessões do Programa Passo a Passo na Comunicação.

Métodos:  estudo longitudinal do tipo série de casos, com 10 crianças entre 2 e 10 anos, diagnosticadas com transtorno do espectro autista. Os procedimentos deste estudo consistiram de avaliação fonoaudiológica antes e após intervenção por meio dos instrumentos e escalas: Avaliação do Desenvolvimento da Linguagem (ADL); Protocolo de Observação Comportamental (PROC), pautado na proposta da linguagem funcional sistêmica (LSF) e o Teste de Linguagem Infantil (ABFW) - parte D (pragmática) e 10 sessões de equoterapia. Optou-se também por uma análise sistêmico-funcional da fala das crianças, que consiste em tratar os segmentos de fala como recursos de comunicação que estão disponíveis em uma dada situação. A análise estatística foi descritiva, utilizando o Coeficiente de Progressão e os Pontos de Evolução para mensurar diferenças pré e pós-intervenção.

Resultados:  foram observadas reorganizações comunicativas e linguísticas de dez crianças com autismo que receberam as primeiras dez sessões de equoterapia. Foi possível observar evolução nos aspectos pragmáticos e gramaticais dos participantes, com desenvolvimento comunicativo diferente nos indivíduos. Todas as crianças que iniciaram o Programa sem emissões verbais começaram a utilizam esse meio comunicativo.

Conclusão:  a aplicação parcial do Programa de intervenção fonoaudiológica em equoterapia denominado “Passo a Passo na Comunicação” apresentou resultados positivos quanto à evolução em habilidades pragmáticas, semânticas e morfossintáticas na maioria das crianças da amostra estudada.

Descritores:
Terapia Assistida por Cavalos; Linguagem; Transtorno do Espectro Autista; Comunicação; Fonoaudiologia

INTRODUCTION

Equine-therapy service is the name given to (re)habilitation that uses horses as an interdisciplinary therapeutic method involving riding, health, and education¹. Doctors and therapists in Germany, France, and Italy disseminated the practice between 1500 and 1800. However, health intervention using horses gained prominence in the 20^th century². Given the sensitivity and high perception of these animals³, they react quickly to human actions^3,4, and children with autism, the focus of this study, recognize the horses' reactions as responses to their actions and reinterpret their actions as potential commands for the horses to move as they wish^5,6. As also demonstrated in this study, after equine-therapy services, these children make eye contact, point at objects, and talk to other people, even though these behaviors had not been previously observed⁶. The transfer hypothesis is that the children become aware of the potential of some of their attitudes as semantic contributions in interactions with horses and that they remain aware of this potential in exchanges of service and information with other human beings, which is essential for interpersonal interactions.

Horses selected for therapy with children with autism spectrum disorder (ASD) typically exhibit a calm temperament and more steady movements than smaller animals of other species⁴. These characteristics promote greater predictability during therapy^4,5, besides having a direct impact on emotional learning processes⁷. In addition to these attributes found in horses, the motivating therapeutic environment in which equine-therapy sessions can take place contributes to the engagement of the child and their families^3,8. This is because the child is in an environment that provides contact with the outdoors and a variety of natural stimuli³.

Another positive influence of equine-therapy services on children with ASD relates to the improvement of motor functions⁹, related to the horse's movement, among other factors. The displacement of the animal's body provides the rider with constant bodily adjustments and proprioceptive and neuromuscular information while the animal is moving¹⁰. The influence of motor aspects on cognitive functions and communication is commonly neglected in children with ASD⁹, despite the well-described associations between motor development and language¹¹.

Specifically addressing communicative aspects, it is known that social communication is altered in ASD, meaning that pragmatic and grammatical aspects of oral language must be taken into consideration¹². A randomized clinical trial with 127 children with ASD detected positive behavioral progress during participation in an equine-therapy service program in the rate of word production per minute. Another study of progress during equine-therapy services analyzed the communicative acts of children with ASD pre- and post-intervention in their pragmatic aspects, with promising results. Reports from parents and therapists indicated that the special interaction between horse and child provided moments of openness, in which participants used speech, eye contact, and symbolic gestures in social interactions⁶.

Despite these promising results, systematic review studies on equine-therapy services show that the ability to communicate verbally has been very little investigated^2,13. Furthermore, none of these studies resulted in an intervention proposal specifically aimed at acquiring this ability. Due to this gap, we proposed the Step-by-Step Communication Program¹⁴, which consists of an intervention approach that aims to stimulate awareness of the communicative potential of human attitudes in children with ASD and thus trigger the development of the communication ability¹³, using interaction with horses in equine-therapy services as a practical stimulus for this awareness. The objectives selected for the equine-therapy service sessions were derived from the various functions of speech in interpersonal interactions, grouped for application purposes into four metafunctions (systemic functional linguistics - SFL)¹⁵. The therapeutic sessions were structured for the child to engage in activities spontaneously while undergoing speech-language-haring (SLH) interventions aimed at developing the ability to select and sequence words and to represent and interact with them¹⁶.

This study aimed to analyze the effects of equine-therapy services on the verbal and nonverbal communicative abilities of children with autism, after 10 sessions of the Step-by-Step Communication Program.

METHODS

Ethical aspects

This research was approved by the Research Ethics Committee of the School of Health Sciences and Technologies of the Universidade de Brasília, DF, Brazil, under CAAE 14946819.8.0000.8093 and approval number 3473484. It was conducted in accordance with resolution 466/2012 of the National Health Council, Ministry of Health, Brazil. All participants signed an informed assent form, and their parents or guardians signed an informed consent form. The assent form was developed as a comic strip, with images appropriate for better comprehension by children.

Study type

This is a longitudinal case series, which was partially interrupted by the closure of health facilities in Brasília, Brazil, at the beginning of the COVID-19 pandemic. Initially, 30 participants were selected to form two distinct groups receiving care at equine-therapy services to participate in the "Step-by-Step in Communication" intervention program. However, the sessions were interrupted, and only half of the program (10 sessions) was implemented, with only the first group starting treatment. Thus, 15 children diagnosed with ASD were eligible. They were on the waiting list of the Associação Nacional de Equoterapia do Brasil (ANDE-BRASIL; Portuguese for Brazilian National Association of Equine-Therapy Services). Ten of the 15 children who started the sessions completed them without absence and were included in this study. Those responsible for their assessments were not involved in the care, and vice versa.

Participants

The study included 10 children diagnosed with ASD, both males and females, aged 2 to 10 years, without bone, auditory, or visual impairments. Families on ANDE-BRASIL’s waiting list were invited to participate in the research. ASD could be associated with attention-deficit/hyperactivity disorder (ADHD) and/or apraxia of speech. The diagnosis was established by multidisciplinary teams external to the study, based on DSM-5 criteria. The degree of autism was not established as a criterion; the objective was to recruit a heterogeneous range to reflect the reality of the practice of care at the location.

None of the children had a confirmed diagnosis of ADHD. Two children (participants 5 and 9) had an associated diagnosis of apraxia of speech, previously identified by SLH pathologists in a clinical setting and confirmed through medical history survey and reports provided by the families. It should be noted that this study did not apply any specific instrument for assessing apraxia of speech since the focus of the investigation was on communication in the context of equine-therapy services.

However, it is considered that apraxia of speech can directly impact the patient's communication, especially regarding verbal expression and speech intelligibility. Even so, it was observed that children with this comorbidity also progressed throughout the intervention. The methodological decision to keep them in the sample was due to the exploratory nature of the research and the purpose of reflecting clinical reality, in which associated diagnoses are frequent.

Intellectual level was not measured using formal IQ instruments, whereas the degree of ASD was determined by the Childhood Autism Rating Scale (CARS). Regarding schooling, eight participants were enrolled in kindergarten and two in elementary school.

Nine children were receiving parallel therapeutic support, including SLH therapy, psychology, psychopedagogy, occupational therapy, or psychomotor therapy. It is recognized that such approaches may have influenced the results; however, since this is an exploratory study, it was decided to retain these participants to more faithfully represent the clinical reality of care in equine-therapy services. None of the children had had prior contact with the practice of equine-therapy services.

Inclusion criteria required children to be 2 to 10 years old and to have not participated in equine activities, not even recreational ones, in the previous year. Children should have a medical indication for equine-therapy services. Parents or guardians should report any communication difficulties on the part of the children during the medical history survey, and these communication difficulties should be confirmed by professionals during the evaluations for the children to be included in the study. Exclusion criteria were absences not made up, more than two absences, even with make-up, uncorrected vision impairments, atlantoaxial instability, muscular dystrophy, seizures without medication control, hydrocephalus, hip dislocation, severe scoliosis, obesity, and horse phobia. Exclusion criteria also included any other physical or psychological conditions that could compromise the participant’s safety or health, as assessed by the ANDE-BRASIL team. Chart 1 shows the participants’ ages, sex, severity level, and comorbidities.

Chart 1
Characterization of the study sample

Participant	Age	Sex	CARS severity	Comorbidities	Education level	Ongoing therapy
1	5y11m	Male	Mild	-	Kindergarten	SLH 1x/week; Psychologist 1x/week
2	4y7m	Female	Mild/moderate	-	Kindergarten	SLH 2x/week; OT 1x/week
3	4y11m	Male	Mild/moderate	-	Kindergarten	Psychologist 2x/week; OY 1x/week; Psychomotor 1x/week
4	6y2m	Male	Mild/moderate	-	Kindergarten	Psychologist 1x/week
5	6y11m	Male	Moderate	Apraxia of speech	Kindergarten	None
6	5y3m	Male	Severe	-	Kindergarten	SLH 1x/week; Psychologist 1x/week
7	6y4m	Male	Severe	-	Kindergarten	SLH 1x/week
8	5y5m	Male	Severe	-	Kindergarten	OT 1x/week; Psychologist 1x/week
9	8y9m	Female	Severe	Apraxia of speech	Elementary school	SLH 1x/week; Psychopedagogy 1x/week
10	4y11m	Male	Severe	-	Elementary school	Psychologist 2x/week; SLH 1x/week

• In the participants column, the numbers represent the children; in the age column, “y” represents years, and “m” represents months; in the comorbidities column, “-” represents the absence of comorbidities
• Captions: CARS - Childhood Autism Rating Scale; SLH - speech-language-hearing therapy; OT - occupational therapy.

Procedures

Assessments

The procedures for this study consisted of psychological and physiotherapy assessments by the ANDE-BRASIL team, SLH assessments before the intervention, 10 sessions of equine-therapy services, and a SLH reassessment. ANDE-BRASIL assesses all individuals arriving at the equine-therapy services center to evaluate psychological and physiotherapy aspects that may hinder the practice of equine-therapy services. All participants must have a prior medical referral authorizing the practice.

This study used the following instruments and scales: Language Development Assessment (ADL)¹⁷; Behavioral Observation Protocol (PROC)¹⁸, based on the SFL approach¹⁵; and the Child Language Test (ABFW)¹⁹ - part D (pragmatics). The tests were applied in an organized and structured environment, following the guidelines of the manuals and/or articles. The interactions between the evaluators and the participants were recorded for analysis.

Intervention

Professionals involved and the Step-by-Step Communication Program

SLH pathologists and interns, mediators, side assistants, guide assistants, and equestrians were involved in the research.

The Step-by-Step Communication Program is an intervention program offered by equine-therapy services for children with social communication difficulties. It consists of eight modules and 24 sessions and can be implemented once or twice a week¹⁴.

Treatment fidelity

Before beginning their work, all professionals at ANDE-BRASIL and the Universidade de Brasília who acted as mediators, side assistants, animal trainers, and horse guides received training provided by the program coordinator and research group. The training had both theoretical (in an expository format) and practical aspects, including activities with the horses.

Each specific activity for the children was scheduled weekly based on the results of individual assessments and progress on the monitoring chart. The team measured/scored each specific objective of the program in each session¹⁴. All weekly sessions were filmed by undergraduate SLH students to help verify the professionals' attitudes during the sessions in weekly meetings with the program coordinator. Real-time observations of the sessions were made by the program coordinator on a case-by-case basis to provide relevant instructions to the pathologists who were applying the intervention. All sessions were conducted by professionals who did not participate in the application of the pre- and post-intervention assessments.

Analyses

Analysis of pragmatics

The interactions for the PROC applications of the 10 children participating in the study were transcribed before and after the intervention. The communicative acts were analyzed according to the ABFW¹⁹ guidelines for the analysis of communicative acts, which correlate with the first three communicative skills presented in the PROC¹⁸, namely: 1) dialogic or conversational skill; 2) communicative function; and 3) communicative medium. The scores proposed by the PROC were not performed since the original article presented results for children up to 3 years old¹⁸.

All communicative acts of those involved were transcribed, and all acts were analyzed one at a time within their production contexts. The marking was made in the PROC¹⁸ based on the quantification and classification of functioning proposed for communicative acts by the ABFW-part D¹⁹.

The variables analyzed were dialogic skills (initiative, response, taking one's turn, participating in dialogic activity), communicative functions (instrumental, protest, interactive, naming, informative, heuristic, narrative), means of communication (vocal, gestural, verbal), and communicative acts. The progression coefficient (PC) was measured, calculated from the ratio between the post-intervention result and the pre-intervention result. A PC result greater than 1 represents progress, and a result less than 1 represents worsening. The collected data were organized in an Excel spreadsheet, tabulated, analyzed, and described through quantitative and qualitative analysis.

Analysis of semantics and formal morphosyntax

Formal semantic and morphosyntactic analysis was performed using the ADL¹⁷ and was based on the degrees of disorders inherent to the test itself, as well as on the results in receptive, expressive, and global language of each child.

Descriptive Analysis: SFL

The children’s speech underwent systemic-functional analysis, which consists of treating speech segments as communication resources available in a given situation. This type of analysis has two steps. First, the semantic features of the resources used are identified and organized into systems of options, then, this description is applied to the analysis of segments¹⁵. On the one hand, this method of analysis allowed us to extrapolate both the resources available in the child-pathologist interaction and the repertoire of a specific child. We correctly assumed that the size and quality of the repertoires would be correlated with the degrees of autism. On the other hand, this also allowed us to explain the children's choice of resources in greater detail. We again correctly assumed that the abundance of detail would reveal subtle progress in the children's speech, about which we could not even hypothesize.

The interaction between the pathologist and child during the application of PROC¹⁸, before and after equine-therapy services, occurred in the same environment and was recorded in audio and video. The medial 5 minutes of this recording were transcribed and analyzed by five researchers. Three of them jointly performed a ranked segmentation of the text in two ways. The first was by composition/grammar into sentences, groups, and words. The second was ranked by melody/rhythm in lines and steps. The other two researchers, specialists in the subject, reviewed the product of the analysis in detail. This article only considered the ranking categories of the segments, and not the categories of type or function, such as sentence types and the function of a specific sentence in the situation. The sentences, groups, words, and steps were counted in two 5-minute strata for each child. Taking α as the frequency of segments of a given rank after therapy and taking β as the frequency of segments of the same rank before therapy, we developed the progress points (pre) as 100 times the natural logarithm of the division of β by α: 100 * ln(α/β). Thus, a child who starts producing twice as many sentences progresses 69 steps, and one who produces three times as many progresses 110 steps. Likewise, one who produces half of what they used to, regresses 69 steps, and one who produces a third, regresses 110 steps.

RESULTS

The analysis of the children’s communicative acts, supplemented by the PC to measure their performance, shows progress in nine of the 10 participating children. Six of them had a PC > 1 and an increase in the number of communication initiatives, two remained stable, and another two regressed. Participant number 3, with a mild/moderate impairment, had a visible reduction in the number of initiatives. The results are presented in Table 1.

Table 1
Communicative acts, initiative dialogic skill, and response dialogic skill with a progression coefficient before and after participation in the equine-therapy services program

Participant	Degree	Communicative acts
		Before	After	PC	Point A	Point B	Steps
1	mild	49	53	>1	56	57	1
2	mild/moderate	18	30	>1	42	49	7
3	mild/moderate	42	31	<1	54	50	-4
4	mild/moderate	42	46	>1	54	55	1
5	moderate	24	48	>1	46	56	10
6	severe	15	24	>1	39	46	7
7	severe	7	9	>1	28	32	4
8	severe	2	9	>1	10	32	22
9	severe	4	8	>1	20	30	10
10	severe	0	2	>1	---	10	---
		Initiative dialogic skill
		Before	After	PC	Point A	Point B	Steps
1	mild	25	24	<1	46	46	-1
2	mild/moderate	5	10	>1	23	33	10
3	mild/moderate	24	11	<1	46	35	-11
4	mild/moderate	17	21	>1	41	44	3
5	moderate	11	24	>1	35	46	11
6	severe	7	18	>1	28	42	14
7	severe	4	4	1	20	20	0
8	severe	1	5	>1	0	23	23
9	severe	2	3	>1	10	16	6
10	severe	0	0	1	---	---	---
		Response dialogic skill
		Before	After	PC	Point A	Point B	Steps
1	mild	24	29	>1	46	49	3
2	mild/moderate	13	20	>1	37	43	6
3	mild/moderate	18	20	>1	42	43	2
4	mild/moderate	25	25	1	46	46	0
5	moderate	13	24	>1	37	46	9
6	severe	8	6	<1	30	26	-4
7	severe	3	5	>1	16	23	7
8	severe	1	4	>1	0	20	20
9	severe	2	5	>1	10	23	13
10	severe	0	2	>1	---	10	---

• Before: results before intervention; After: results after intervention
• Caption: PC - progression coefficient.

The instrumental, naming, and informational functions were the communicative functions with a positive development in most children. The communicative function results are presented in Table 2.

Table 2
Communicative functions produced by children before and after intervention.

			INS	PR	INT	NM	INF	HE	NA
1	Mild autism	Before	3	0	0	0	30	3	3
		After	3	0	0	3	33	3	0
		PC	1	1	1	>1	>1	1	<1
2	Mild/moderate autism	Before	3	0	0	4	5	0	0
		After	5	0	0	8	6	1	0
		PC	>1	1	1	>1	>1	>1	1
3	Mild/moderate autism	Before	1	0	3	5	19	5	0
		After	1	0	0	0	18	8	0
		PC	1	1	<1	<1	<1	>1	1
4	Mild/moderate autism	Before	1	0	0	2	32	0	0
		After	2	0	0	10	28	1	0
		PC	>1	1	1	>1	>1	>1	1
5	Moderate autism	Before	0	0	2	0	17	0	0
		After	1	0	1	3	34	0	0
		PC	>1	1	<1	>1	>1	1	1
6	Severe autism	Before	1	0	2	5	3	1	0
		After	1	0	0	7	14	1	0
		PC	1	1	<1	>1	>1	1	1
7	Severe autism	Before	0	2	1	0	1	0	0
		After	1	1	1	1	1	0	0
		PC	>1	<1	1	>1	1	1	1
8	Severe autism	Before	0	0	0	0	0	0	0
		After	2	0	0	4	1	0	0
		PC	>1	1	1	>1	>1	1	1
9	Severe autism	Before	0	0	1	0	2	0	0
		After	1	0	1	0	1	0	0
		PC	>1	1	1	1	<1	1	1
10	Severe autism	Before	0	1	0	0	0	0	0
		After	0	0	0	0	1	0	0
		PC	1	<1	1	1	>1	1	1

• Before: results before intervention; after: results after intervention
• Captions: INS - instrumental function; PR - protest function; INT - interactive function; NM - naming function; INF - informative function; HE - heuristic function; NA - narrative function; PC - progression coefficient.

The study children varied in how they reorganized the use of communicative means. The only one with an overall decreased use was the combined verbal/gestural/vocal means, while the combined gestural/vocal means remained at five uses after the intervention. The communicative means with the highest progress rate was the vocal means, whose use increased by 120%, followed by the combined verbal/gestural means with an increase of 80.9%, the combined verbal/vocal means with an increase of 41.6%, the gestural means with an increase of 27.7%, and lastly the verbal means with an increase of 24.8% in use.

The semantic and morphosyntactic analysis using the ADL test did not verify any progress in receptive language among the children, whereas improvement in expressive language was found in only two children. The severity of the disorder was altered in only one child (Table 3).

Table 3
Results in receptive language, expressive language, and global language before and after intervention

Participant	RL SS		EL SS		GL SS		Severity of the disorder
	Before	After	Before	After	Before	After	Before	After
1	100	82	62	116	79	99	Mild	Normal range
2	114	109	51	50	81	77	Mild	Mild
3	114	109	104	108	110	110	Normal range	Normal range
4	102	102	93	70	97	85	Normal range	Normal range
5	52	52	50	50	50	50	Severe	Severe
6	67	53	50	50	55	50	Severe	Severe
7	52	52	50	50	50	50	Severe	Severe
8	53	53	50	50	50	50	Severe	Severe
9	52	52	50	50	50	50	Severe	Severe
10	53	52	51	50	50	50	Severe	Severe

• Captions: SS - standard score; RL - receptive language; EL - expressive language; GL - global language; pre - results before intervention; post - results after intervention.

The variables for the linguistic analysis results using SFL were words, groups, sentences, and steps - i.e., the study used the constitutive categories. Thus, words, groups, sentences, and steps were counted, adding the PC to measure the participants’ performance. The progress points per patient are shown in Table 4.

This table shows that seven of the 10 study children progressed in words per minute, eight progressed in groups, eight progressed in sentences, and eight progressed in steps. The three children who did not speak before therapy started speaking afterward, acquiring the ability to communicate verbally, a new means for them.

Table 4
Number of words, groups, sentences, and steps produced by children before and after intervention

Participant	CARS	Before, after, PC	Words	Groups	Sentences	Steps
1	Mild autism	Before	176	145	48	68
		After	198	154	53	96
		PC	>1	>1	>1	>1
2	Mild/moderate autism	Before	7	7	7	8
		After	30	25	24	28
		PC	>1	>1	>1	>1
3	Mild/moderate autism	Before	149	105	43	70
		After	142	88	28	53
		PC	<1	<1	<1	<1
4	Mild/moderate autism	Before	186	130	42	81
		After	176	131	46	82
		PC	<1	>1	>1	>1
5	Moderate autism	Before	67	63	23	31
		After	147	120	47	87
		PC	>1	>1	>1	>1
6	Severe autism	Before	27	32	14	19
		After	59	35	23	31
		PC	>1	>1	>1	>1
7	Severe autism	Before	3	3	7	3
		After	3	3	6	3
		PC	1	1	<1	1
8	Severe autism	Before	0	0	0	0
		After	7	7	7	8
		PC	>1	>1	>1	>1
9	Severe autism	Before	0	0	0	0
		After	2	3	2	2
		PC	>1	>1	>1	>1
10	Severe autism	Before	0	0	0	0
		After	1	1	1	1
		PC	>1	>1	>1	>1

• Before: results before the intervention; after: results after the intervention
• Caption: PC - progression coefficient.

The child identified as participant 3 in this study deserves special mention, as he remained stable or worsened in virtually all his results. It is important to contextualize that this child lost his father a week before starting the equine-therapy services program, but the mother preferred to continue the treatment.

DISCUSSION

This study detected communicative and linguistic reorganizations in 10 children with autism who received the first 10 equine-therapy service sessions from the Step-by-Step Communication Program. The participants progressed in pragmatic and grammatical aspects, with different communicative developments among them. All children who began the program without verbal expressions started to use this means of communication.

They improved in different pragmatic variables of the initial version of the Step-by-Step Communication Program² with 10 sessions, namely: communicative acts, dialogic skills of initiative and response, communicative functions, and communicative means. These results indicate that the program, as a rehabilitation tool in equine-therapy services, has positive language use results in children with autism.

Rehabilitation (or habilitation, since this study addresses a neurodevelopmental disorder) of pragmatics is one of the challenges in children with ASD¹³. This study found an increase in communicative acts in nine of the 10 children who received equine-therapy services, an increase in interaction initiative in 80% of the sample, and an increase in responses to others in 90% of them. Another study also analyzing the results of equine-therapy service intervention for children with ASD reported improvement in pragmatic aspects⁶. The authors point out outcomes that indicate an increase in social interactions initiated by the children, encompassing both speech and gestures to interact with others⁶.

The increase in communicative acts and the ability to initiate and respond to interaction with others after 10 sessions of equine-therapy services can be explained by the relationship between humans and horses, considered to facilitate the emergence of social behaviors in individuals with ASD^5,6. For instance, practitioners bond with horses through activities in which they offer something that the other received with pleasure, such as giving food to the animal or trotting for the child^20,21; such activities favor the construction of an affective and emotional relationship between practitioners and horses, encouraging social behaviors.

The program applies specific strategies that are particular to equine-therapy services²¹, which enable an increase in the person's interest in their surroundings and in others⁶. It is known that perception and interest in others are closely related to maintaining interaction²². This relationship of interest in horses in children with ASD⁴ supports the hypothesis that equine-therapy services can increase their social interest^5,6,23. Equine-therapy services associated with a communication-focused intervention program¹⁴ increased their communicative acts, initiatives, and communication responses (Tables 1 and 2).

The increased interest in social interactions, initiated in a therapeutic setting, enables them to put communication and language into practice. This heightened interest in communication first increases the person’s number of social interactions; then, they acquire and develop language functions that were previously unused due to a lack of attempts at social participation.

Despite this study’s less-than-satisfactory results in the form and content analysis using the ADL¹⁷, it found significant improvements in pragmatic and communicative aspects analyzed using the ABFW Pragmatics Test¹⁹ and the PROC¹⁸. Moreover, the ADL¹⁷ was developed and validated to assess children with language disorders rather than specifically children with autism. Therefore, this study was designed as descriptive due to the lack of grammatical analysis instruments based on the SFL¹⁵ for Brazilian Portuguese.

Based on the assumptions of the SFL¹⁵ analysis, we observed that most children improved their production of words, groups, sentences, and steps - i.e., positive progress in all SFL initial variables in this study (Table 4). Contrary to the ADL findings (Table 3), we found an indication of improvement in grammatical units among the study participants (Table 4).

The study measured positive progress in the frequency of sentences, groups, words, and steps (Table 4), a measurable progress undetected by the ADL test (Table 4). This demonstrates that the progress points used in this research are more sensitive and probably more suitable for clinical practice than the ADL test in measuring subtle progress in the behavior of children with ASD before and after equine-therapy service sessions.

The results presented in this article, as stated earlier, include only the ranking categories, not encompassing all the type and function categories applied in the analysis of the interactions. Other findings will be published in future articles.

One limitation of the research is the number of participants, 10 children, which prevents us from generalizing the clinical practice of equine-therapy services. Furthermore, it prevents us from stating more strongly that points of progress would in fact be due to the proposed treatment, since there were other associated therapies. Another limitation is the absence of a control group, which prevents us from stating that progress is due to the intervention, rather than the children’s spontaneous progress. However, since until now we did not have a sensitive test for the visible progress that parents and therapists attest to, this study introduces a measurement method that deserves consideration in larger studies to corroborate its sensitivity and prove the causal link between therapy and progress.

Another limitation of this study is its exclusive focus on the interactive functions of speech through systemic-functional analysis as a component of social semiotics. A holistic analysis of the participants' interaction would need to include the ability to communicate through any and all means (not only through speech) and to perform individual tasks and cooperate in collective tasks, which would encompass motor and sensory aspects and everything we can infer about cognitive processes from observation²⁴. Measurements in these other aspects would not only verify the participants' progress promoted by equine-therapy services, as we propose here, but would also better guide the intervention according to each child’s needs.

CONCLUSION

The partial application of the SLH intervention program in equine-therapy services, called "Step-by-Step in Communication," had positive results regarding the progress in pragmatic, semantic, and morphosyntactic skills in most of the children in the study sample. Since this is a case series, studies with a larger sample size, such as case-control studies and clinical trials, to increase the generalizability of the results, are suggested.

ACKNOWLEDGMENT

Gratitude is extended to the Associação Nacional de Equoterapia do Brasil - ANDE-BRASIL.

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• A study conducted at the Universidade de Brasília, Brasília, DF, Brazil.
• Financial support: Nothing to declare
• Data sharing statement
  The underlying content of the manuscript text is already available in its entirety and without restrictions, being contained within the manuscript itself. All data, program codes, and materials used in the research are fully described and documented, ensuring the reproducibility of results and enabling detailed evaluation by reviewers. There are no legal or ethical restrictions preventing access to the content, and it will be fully available upon publication of the article.

Edited by

• Chief Editor
  Giédre Berretin-Felix

• Associate Editor
  Ana Paula Mackay

Data availability

The underlying content of the manuscript text is already available in its entirety and without restrictions, being contained within the manuscript itself. All data, program codes, and materials used in the research are fully described and documented, ensuring the reproducibility of results and enabling detailed evaluation by reviewers. There are no legal or ethical restrictions preventing access to the content, and it will be fully available upon publication of the article.

Publication Dates

• Publication in this collection
  23 Jan 2026
• Date of issue
  2026

History

• Received
  21 Aug 2025
• Reviewed
  13 Sept 2025
• Accepted
  24 Sept 2025