Tal-li Matild Aviv, Yaacov J. Katz, and Ety Berant


Attention-deficit hyperactive disorder (ADHD) is a common neurodevelopmental disorder experienced by about 5% of children and about 2.5% of adults in most cultures. ADHD is characterized by a pattern of inattention and/or hyperactivity-impulsivity (American Psychiatric Association [APA], 2013). Among children, ADHD is associated with low school performance, poor family relations, anxiety, depression, aggression, conduct problems, and adjustment difficulties (APA, 2013; Tarver et al., 2014). Furthermore, several studies have referred to the difficulties in executive functions (EFs) as the core problem of ADHD (Barkley, 2014).

EFs

The term EFs refers to the cognitive mechanisms that are responsible for self-regulation in cognitive, behavioral, and emotional functioning including planning, working memory, cognitive shifting, sustaining effort, inhibition, self-monitoring, self-regulation, and initiation (Barkley, 2006; Graziano et al., 2011). EFs difficulties have lifelong implications for behavioral, social, emotional, and adaptive problems, including academic challenges in childhood (APA, 2013; Bailey et al., 2018; Barkley, 2014; Tarver et al., 2014).
A meta-analysis of 83 studies that investigated the link between EFs and ADHD indicated that individuals diagnosed with ADHD show impairments in almost all aspects of EFs to at least at a moderate degree (Willcutt et al., 2005).

ADHD and Self-Esteem

Children with ADHD experience reduced success and greater functional difficulties at school. Their education creates a clash between the demands of the educational system and of the children’s family, as well as the children’s ability to fulfill them, which may lead to negative
environmental feedback, children’s frustration, failure, reduced self-efficacy and self-esteem, and decreased enjoyment of activities (Bailey et al., 2018). When children with ADHD face difficulties in emotional and behavioral regulation and EFs, they tend to expe- rience negative reactions from their surroundings. Thus, emerges a self-sustaining cycle of negative interactions that harm self-esteem and result in further difficulty meeting environmental demands (Capelatto et al., 2014). The evidence for a link between ADHD and self-esteem is inconsistent. Some studies found ADHD to be associated with reduced self-esteem, whereas others showed that ADHD was associated with elevated self-esteem. The latter group of findings were explained as revealing a bias in self-reports of self-esteem such that high scores could be compensatory for underlying denial of vulnerability and difficulties (Capelatto et al., 2014).

Treatment of ADHD

The high costs paid by children with ADHD and their families emphasize the need for developing effective treatments for early intervention. Crucially, early interventions reduce the risk of more extensive difficulties in adulthood (Huber et al., 2015; Maeir et al., 2014). Psychopharmacological treatments, psychological treatments, and combination of these treatments are wellestablished interventions (Evans, Owens, & Bunford, 2014). Medication provides a basic treatment that, for example, effectively reduces the intensity of symptoms, contributes to adaptive adjustment, increases cognitive processing ability, and improves academic achievements (Acosta et al., 2009; Climie & Mastoras, 2015; Cortese, 2012). Although medication may help relieve some symptoms of ADHD, some studies suggest that nonpharmacological treatments can be effective as well: behavioral parental training, cognitive training such as neurofeedback training, and organization training (i.e., teaching and reinforcing time management, planning/ organization, and cooperation skills; Evans, Owens, Wymbs, & Ray, 2018). However, the interventions described above did not necessarily address difficulties in EFs that are necessary for the children’s emotional, behavioral, and social functioning as well as their academic performance (Graziano et al., 2011). Previous studies claimed that the focus of EFs training was not on the children’s overt behavioral problems, but rather focused on improvement in EFs. Some studies showed that games and physical activities significantly improved EFs (Hahn-Markowitz et al., 2011; Horowitz-Kraus, 2015; L. Rosenberg et al., 2015). In the current study, we aimed to investigate the effect of therapeutic horseback riding on the improvement of EFs and self-esteem of children with ADHD.

Therapeutic Horseback Riding

Therapeutic horseback riding became popular as a method for treating children with learning disabilities (MacDonald & Cappo, 2003) and ADHD (Jang et al., 2015). It is an experiential psychotherapeutic process aided by horse (Lentini & Knox, 2009). With the participation of the horse, the therapist helps the children explore different dimensions of their life including physical health, emotional awareness, and interpersonal relationships. The treatment includes riding and grooming the horse, working in the stable, and training the horse (North American Riding for Handicapped [NARH]). As the horse is a social animal and the horses respond to human behavior in a similar way that humans do to each other, the horses’ reactions could serve as a mirror to the riders (Jang, Song, Kim, Kim, Lee, Shin, Kwon, Kim, & Joung, 2015) and as positive reinforcement for the children’s behavior. Working with a horse involves numerous behaviors that require EFs including planning and organization, effectively shifting between actions, working memory, monitoring, and self-regulation of emotions and behaviors. The riders are being taught basic riding skills while at the same time their guides are setting goals for them, for example, asking the horse to start walking or stop walking (goals that require EFs). During the ride with the horse, the riders may encounter some difficulties fulfilling their tasks, sometimes because of the horse’s lack of cooperation and other times as a result of the riders’ behavior. After completing the task, fully or partially, a conversation is held between the instructors and the riders. The riders and the instructors analyze the horse’s reactions, and the riders learn how their behavior affected the horse. The riders are required to suggest ways to change their strategy of solving problems and are encouraged to try to act differently than before. Following this guidance the instructors and riders review the training results of the next riding.
The therapeutic work described above is similar to organization training. Organization training is a well-established treatment that strengthens a person’s coping management when the focus is on EFs. The training is done while playing with the children and it is focused on organization, planning, and time management (Evans et al., 2018).
The goal of the therapeutic horseback riding is to improve the EFs of the children while they perform tasks. In therapeutic horseback riding there are elements that resemble behavioral therapy such as reinforcing the children’s behaviors and their adaptive responses to the horse’s behaviors, but unlike behavioral therapy, the goal is not to reinforce or extinguish specific behavior, but rather to train their behaviors that can improve EFs such as problem-solving skills and self-regulation (Jang et al., 2015; Masini, 2010).
Previous studies done among children indicated that therapeutic horseback riding contributed to the improvement of their functional skills, behavioral, emotional, and social behaviors (Masini, 2010; Smith-Osborne & Selby, 2010). Therapeutic horseback riding improved behavioral regulation of difficult-to-treat populations, such as children on the autistic spectrum and children at high risk (Bass et al., 2009; Kaiser et al., 2006). It has been suggested by Brooks and McCullough (2008) that improvement was due to the relationship of the children with the horse and the reinforcement of positive behaviors during riding. However, only a few studies were done with children having ADHD (Jang et al., 2015) and only one pilot study examined the effect of therapeutic horseback riding on EFs (Gilboa & Helmer, 2020). Another pilot study showed that therapeutic horseback riding that was given to five children with ADHD had a positive effect on their behaviors, their quality of life, and motor performance (Cuypers et al., 2011). Another study found that an equine-assisted activity was effective for improving core symptoms of ADHD. The study lasted for 12 weeks and included 24 sessions of equine-assisted activities. The number of participants was rather small (N = 20), with no control group (CG; Jang et al., 2015). Another study investigated the effect of equine-assisted therapy on resting-state brain functions among 10 children with ADHD. In two tests using rs-fMRI (restingstate functional magnetic resonance imaging) before and after equine-assisted activities, the results indicated that in addition to symptoms’ improvement even without medication, changes on resting-state brain functions were demonstrated, which were associated with the symptoms’ improvement (Yoo et al., 2016).
Finally, a study that examined self-management of attention and EFs’ difficulties using equestrian riding–assisted therapy (among 25 children with ADHD ranging in age from 6 to 14 years), without a CG revealed preliminary evidence of improvement in EFs and occupational performance (Gilboa & Helmer, 2020).
In summary, the studies mentioned above that examined therapeutic horseback riding had deficiencies in their methodology (as described above) including using small sample, lack of CG and failing to conduct proper standardization (Kendall et al., 2015; Masini, 2010; Smith-Osborne & Selby, 2010).

 

The Current Study

In recent decades, therapeutic horseback riding has evolved as a treatment method designed for children with ADHD, but it has been insufficiently studied. Therefore, we sought to examine the effect of therapeutic horseback riding on difficulties with EFs (assessed by questionnaires) (Duckworth & Kern, 2011), the core feature of ADHD, and EF-related self-esteem. Improvements in these areas have been widely reported for protocols designed for children with ADHD that directly target EFs (Hahn-Markowitz et al., 2011; Maeir et al., 2014; L. Rosenberg et al., 2015) and selfesteem (Harpin et al., 2016). However, there is a lack of empirically sound research examining the contribution of therapeutic horseback riding to EFs and self-esteem among children with ADHD. Hence, the objective of the present study was to examine the contribution of therapeutic horseback riding to the improvement of EFs and self-esteem among children with ADHD. In addition, we wanted to explore the bidirectional association between the improvement in EFs and self-esteem over time as related to the intervention. In other words, we aimed to explore whether improvement in EFs would contribute to the improvement in self-esteem and vice versa, among children treated with therapeutic horseback riding and medication compared with those who were treated only with medication:
Hypothesis: It is anticipated that therapeutic horseback riding will contribute significantly to the improvement of EFs and self-esteem from T1 (beginning of therapy) to T2 (20 weeks—the end of the therapy) and to maintain improvement in EFs and self-esteem from point T2 to T3 (12 weeks after therapy ends). In addition, we wished to explore the bidirectional association between EFs and self-esteem over time not only in response to the intervention but also as the variables influenced each other over the three measurement points.

Method

Participants

The study’s sample consisted of 123 Israeli children and their mothers. The children: (intervention group [IG]: boys = 72.6%, girls = 27.4%; CG: boys = 72.1%, girls = 27.9%) ranging in age from 6 to 12 years (IG: M = 9, SD = 1.68; CG: M = 8.95, SD = 1.68) who were diagnosed by a pediatric neurologist as having ADHD according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). The participants did not suffer from any other mental disorder in accordance with the neurologists’ medical report and all of them were receiving medication. Mothers were selected to participate in the study because, in most cases, the mothers were the ones who were engaged in the child’s care more than the fathers were, and they were the ones who brought the children to the horseback riding training (Craig, 2006)

A total of 187 mothers agreed initially to take part in the study. Of them, 8.02% dropped out before the screening stage (ignored attempts to contact them), 7.48% did not meet the criteria of the study (as described in the “Measures” section). Finally, 15.5% of mothers found suitable for the study chose not to participate for various reasons (difficulty of filling out the questionnaires, resistance of children, and difficulty of getting to the ranch). The IG included 64 children and their mothers, but two of them dropped out (after the fifth and 10th sessions, respectively) due to the children’s resistance that developed during the sessions. The CG, who received only medication, consisted of 65 children. Of them, four children dropped out at the beginning of the study due to their parents’ refusal to fill out the questionnaires (Figure 1)

Procedure

The Institutional Review Board (IRB) of Bar-Ilan University approved the study before it started. Mothers of children with ADHD were recruited through internet advertising and school counselors. The promotion of the study indicated that research supported the contribution of therapeutic horseback riding on





Figure 1. Consort diagram: description of enrollment participation, retention, and drop-out

the questionnaires, resistance of children, and difficulty of getting to the ranch). The IG included 64 children and their mothers, but two of them dropped out (after the fifth and 10th sessions, respectively) due to the children’s resistance that developed during the sessions. The CG, who received only medication, consisted of 65 children. Of them, four children dropped out at the beginning of the study due to their parents’ refusal to fill out the questionnaires (Figure 1)

Procedure

The Institutional Review Board (IRB) of Bar-Ilan University approved the study before it started. Mothers of children with ADHD were recruited through internet advertising and school counselors. The promotion of the study indicated that research supported the contribution of therapeutic horseback riding on improving the situation of children with ADHD. It also stated that the applicants would be divided into two groups at random. One group of children will receive therapeutic horseback riding lessons and at riding school stables in addition to medication and the other group will receive medication alone until the end of the study. At the end of the study, this second group would be offered horseback riding as the first group had received.
The mothers who responded by contacting the research assistant received a brief explanation about the purpose of the study. After the completion of the consent forms to

participate in the study, the children and their mothers were randomized: one child to the IG and one to the CG until obtaining the requested number of participants. The mothers of the IG were referred to riding school stables near their homes, and they paid for the sessions directly to the riding school stables. The mothers of the children in the CG were asked not to take their children for any other therapy in addition to the medication they received during the 32 weeks of the study.
After granting informed consent to participate in the study and being assured of anonymity, participants were admitted into the study. Data were collected in three stages: At Time 1, mothers and children from both groups completed preliminary questionnaires. Time 2 data were collected from mothers and children at the end of the treatment 20 weeks later. A follow-up assessment was completed 12 weeks after treatment ended (Time 3), which included measures administered to both mothers and children.

Therapeutic Intervention

The study group participated in 20 weekly 30-min therapeutic horseback riding by therapeutic horseback riding instructors having 3 to 5 years of experience. During the 20 sessions, the children learned to sit and ride on the horse, use the reins, plan the work with the horse, clean and brush the horse, clean the stable, train the horse, and take the horse for a walk. After completing each activity with the horse, the instructors and the children analyzed the children’s and the horse’s behaviors according to a built-in protocol composed by the first author. The purpose of the analysis was to strengthen the riders’ monitoring abilities by teaching them to observe and analyze their actions using the horse’s reactions as a feedback and to correct their behaviors accordingly. The process included the following steps. (a) Goals selection while riding the horse, for example, stopping the horse. The goal was to improve the ability to initiate the horse’s response. (b) Checking with the riders whether the mission was achieved. If the goal was achieved, the children continued to the next exercise. (c) If the goal was not achieved, the children and the riding instructors tried to understand what went wrong in the communication with the horse. (d) Attempt to achieve the required goal again.
The horseback riding instructors received a protocol according to which they worked with the children and were supervised during the whole process by the first author. At the three time points, in addition to filling out the questionnaires, the mothers of the CG affirmed that their children continued to take medication and do not receive any other therapy. The authors were blind to the children’s affiliation while analyzing the data. Participants’ parents did not take an active part in the process and did not watch it.

Measures

The questionnaires were translated into Hebrew according to the back-translation method.
The Revised Conners’ Parent Rating Scales (CPRS-R; Conners et al., 1998) aims to be filled by the parents of children ages 3 to 17 years. It refers to problems in the child’s behaviors as reflected in hyperactivity, attention, and oppositional behaviors. The questionnaire was filled out by the children’s mothers to select the appropriate candidates for the study. In the current study, we used the short version of 10 items. The 10-item scale is a 4-point Likert-type scale ranging from (0) = not at all to (3) = to a great extent. A score of 15 and above is considered to indicate elevated level of symptoms of ADHD and was the inclusion criteria for participation in research. The shortened version consists of a hyperactivity index, attention deficit index, and oppositional behavior index. The internal consistency in this sample was adequate (Cronbach’s α: hyperactivity index: .68, attention deficit index: .78, and oppositional behavior index: .86).
Behavior Rating Inventory of Executive Functions (BRIEF; Gioia et al., 2000) is an 86-item ecological rating scale designed to reflect the neuropsychological constructs of EFs in everyday situations for children ages 5 to 18 years. The Hebrew version of the scale was filled out by the children’s mothers. It comprises eight scales, two indices, and a Global Executive Composite. The BRI includes the inhibition, shift, and emotional control scales. The Metacognition Index includes the work initiation, working memory, planning/organization, organization of materials, and monitoring scales. The internal consistency in this sample was good (Cronbach’s α ranging from .89 to .95 in the three time measurements).
Self Esteem Scale (SES; M. Rosenberg, 1965) is a selfreport questionnaire that measures overall self-esteem. The children completed 10 statements expressing positive or negative attitudes toward themselves, and they rated their agreement with each item on a 4-point scale ranging from (1) strongly agree to (4) strongly disagree. The internal consistency in this sample was good (Cronbach’α ranging from .77 to .82 in the three time measurements).


  

 

The Bidirectional Association Between EFs and Self-Esteem Over Time as a Function of Intervention

In this section, we estimated a multigroup Auto-Regressive Cross-Lagged (ARCL) model to examine the bidirectional association between EFs and self-esteem over time as a function of intervention using MPlus 8.3 Structural Equation Modeling (SEM) package. In this model, EFs was a latent variable on which were loaded the following EFs measures at each time point: emotion control, inhibition, work initiation, organization of the environment, monitoring, BRI, and meta-cognition, self-esteem was an observed variable and intervention (intervention /control) served as the grouping variable. ARCL models examine whether a change in one construct over time is linked with a change in a second construct in a later time. The model is summarized in Figure 2. Model fit is estimated by Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), and root mean square error of approximation (RMSEA). Differences between groups were estimated using a deviance test, which has chi-square distribution, such that a freely estimated model is compared with a model in which a specific path is constrained to be equal. Significance was estimated by bias-corrected bootstrap analysis with 1,000 resamples cycles.
  =The model had adequate fit to the observed data, CFI =

 

Figure 2. The ARCL model of the bidirectional association between EFs and self-esteem over time as a function of intervention. (Solid paths refer to
significant paths, whereas dashed paths to nonsignificant paths. EF1–EF7 refer to emotion control, inhibition, work initiation, organization of the environment, monitoring, behavioral regulation index [BRI], and meta-cognition, respectively). Note. ARCL = auto-regressive cross-lagged model; EFs = executive functions
Cross-Lagged (ARCL) model to examine the bidirectional association between EFs and self-esteem over time as a function of intervention using MPlus 8.3 Structural Equation Modeling (SEM) package. In this model, EFs was a latent variable on which were loaded the following EFs measures at each time point: emotion control, inhibition, work initiation, organization of the environment, monitoring, BRI, and meta-cognition, self-esteem was an observed variable and intervention (intervention /control) served as the grouping variable. ARCL models examine whether a change in one construct over time is linked with a change in a second construct in a later time. The model is summarized in Figure 2. Model fit is estimated by Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), and root mean square error of approximation (RMSEA). Differences between groups were estimated using a deviance test, which has chi-square distribution, such that a freely estimated model is compared with a model in which a specific path is constrained to be equal. Significance was estimated by bias-corrected bootstrap analysis with 1,000 resamples cycles.
The model had adequate fit to the observed data, CFI = .95, TLI = .92, RMSEA = .04. We found that resamples and self-esteem were significantly more rigid to change among controls than among children who had therapeutic horseback riding (ps < .01). In addition, only among the therapeutic horseback riding group, we found that an increase in self-esteem from T1 to T2 was linked with a significant increase in EFs from T2 to T3. Thus, the model implies that self-esteem may promote the change in EFs but not vice versa.

Discussion

Difficulties in EF such as difficulties in organizing, planning, working memory, monitoring, and inhibition, complicate crucial cognitive and social development making it challenging to children with ADHD to adapt to the classroom

environment. At the same time, as a result of cycles of frequent academic failures and subsequent criticism, the self-esteem of children with ADHD is likely to be reduced (Bailey et al., 2018). In the present study, we examined whether therapeutic horseback riding, paired with medication, is an effective treatment method to cultivate children’s EFs and restore their self-esteem. Therapeutic horseback riding has emerged as a treatment method for various emotional problems as well as for children with ADHD (Lentini & Knox, 2010; Masini, 2010). To address the methodological problems in former studies about therapeutic horseback riding (Kendall et al., 2015; Masini, 2010), we took methodological steps to increase our confidence in the validity of the findings. First, the intervention and CGs were randomly divided. Second, the treatment was delivered by highly trained horseback riding instructors. Third, we used valid measures to identify children’s EFs difficulties and self-esteem and to measure treatment outcomes. In the therapeutic horseback riding provided in this study, the activities were based on principles of EF-focused interventions (Hahn-Markowitz et al., 2011; Maeir et al., 2014; L. Rosenberg et al., 2015).
The results of the current study showed that children who received therapeutic horseback riding in addition to medication experienced improved EFs and higher selfesteem following 20 weeks of therapeutic riding. Similar to a number of studies that examined follow-up of treatments (Evans et al., 2018), at the follow-up assessment 12 weeks after the termination of therapy, EFs, and self-esteem continued to improve, By contrast, no changes were observed in EFs and self-esteem among participants in the CG, which was only treated by medication. In addition, we wanted to examine the bidirectional association between the change in EFs and self-esteem. We found that only among the therapeutic horseback riding group, the increase in the children’s reported self-esteem from T1 to T2 was linked to a significant increase in EFs from T2 to T3. Thus, the model implied that self-esteem may promote changes in EFs but not vice versa. That is to say, improvement in EFs did not contribute to higher self-esteem.
The results of the current study converge with other therapeutic horseback riding studies, which have found this treatment to be associated with improvements in selfesteem, attention, social behaviors (Jang et al., 2015; Lentini & Knox, 2009), and EFs (Gilboa et al., 2020).
As the current study found that improvement in selfesteem led to improvement EFs and not vice versa, we will discuss self-esteem first. Our study’s results support previous findings that the experience of competency and accomplishment in managing the relationship with the horse likely improved the children’s self-esteem (Lentini & Knox, 2009). The sense of self-efficacy was similarly suggested to explain the effectiveness of biofeedback in reducing ADHD symptoms (Hodgson et al., 2014). In other words, interacting with the horse may create a dynamic cycle of positive interactions that may reverse the often negative experience of children with ADHD. Children diagnosed with ADHD require higher levels of positive reinforcement (Climie & Mastoras, 2015), and with the assistance of the instructor in conceptualizing the horse’s responses the children have many opportunities to engage in and absorb an ongoing positive feedback cycle with the horse. Our results revealed that increased cooperation from the horse led the children to experience increased self-esteem and increased motivation to perform more difficult tasks. It seems that the increases in EF throughout the study were a result of the increased levels of self-esteem and motivation that preceded those changes.
While referring to improvement in EFs, in therapy where the focus was on EFs, the emphasis in treatment was on directing the children’s attention to the way they perform the tasks. The experiences were designed to facilitate improvements in EF such as attention, inhibition, working memory, hand-eye coordination, physical balance, and sensory awareness. The instructors’ comments may have helped the children to develop internal factors that contributed to the regulation of the children’s responses that consequently improved EFs over time (Hahn-Markowitz et al., 2011; Horowitz-Kraus, 2015; Maeir et al., 2014). Similarly, riding and working with horses required from the children inhibition, planning, organization, and other aspects of EFs. As an example, riding a horse from one point to another required multiple EFs. The riders had to examine the environment and initiate a request that the horse would begin to move. To perform this task, working memory is necessary to perform a series of operations. In addition, when the riders felt frustrated because they struggled to steer the horse properly, they were required to regulate their frustration and inhibit their reactions until they succeeded. Importantly, the exercises were tailored so that the level of difficulty will gradually increase in a way that challenges the riders, but will not frustrate them and cause them despair. Finally, after completing the mission, the riders monitored their work with the instructors and corrected themselves when necessary. Riders became more capable at regulating responses and succeeding in various tasks due to the heightened self-awareness and improved self-monitoring ability that they have developed in this process. The training described above is similar to the training that improves EFs through various activities that were found to be helpful (Evans et al., 2018). We presume that the extension of the toolbox of the children to deal with tasks with the horse has been generalized to everyday life. This generalization could have explained the continued improvement in EFs, which was tested 12 weeks after the study, was completed.

Limitations

Along with its strengths like other field studies the current study has some limitations. The basic assumption of the study was that horseback riding improved EFs. However, to confirm this assumption, and improve the methodology of the study, it would be helpful to compare therapeutic horseback riding to other activities involving horses without riding, such as EAGALA (Equine Assisted Growth and Learning Association).
The current study examined the contribution of therapeutic horseback riding compared with the medical therapeutic intervention, but it did not compare the therapeutic horseback riding to other physical activities that require EFs involvement such as cycling, tennis, and karate or compared with training treatments. Such a comparison could help to distinguish the horse’s role in the process of therapeutic change. Finally, in our study, we did not have a third group who received cognitive behavioral therapy (CBT) in addition to medication to test the effectiveness of therapeutic riding compared with CBT among children with ADHD.

The Unique Contribution of the Study

The study demonstrated that therapeutic horseback riding is a useful intervention to improve children’s functioning and quality of life. Adaptive coping and well-being rely on skills and basic sense of self-esteem. Our finding that building self-esteem improves EFs has important implications for many clinical and educational factors in diverse contexts. Therapeutic horseback riding specifically provides a promising avenue for strengthening self-esteem. It constitutes an enjoyable activity that allows a novel learning experience that lacks the criticism and pressure that children with ADHD may experience at school. Overall, our study suggests that therapeutic horseback riding proffers a novel and empirically supported method for improving self-esteem and cultivating EFs skills, specifically among children with ADHD. This study contributed to the evolving body of knowledge on the subject of targeted interventions and EFs, as well as to the insufficient amount of research that has been conducted on the subject of therapeutic horseback riding.

Authors’ Note

The research was done as part of a doctoral program at Bar-Ilan University, Israel, by Dr Aviv under the supervision of the second and third authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tal-li Matild Aviv  https://orcid.org

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Author Biographies

Tal-Li Matild Aviv is a clinical and education psychologist. She is a lecturer at the Michlalah—Jerusalem Academic College and at the animal therapy program of the Magid Institute of the Hebrew University in Jerusalem. She is a horseback riding instructor and has conducted horse-guided psychotherapy for many years.
Yaacov J. Katz is professor emeritus at the School of Education, Bar-Ilan University in Israel and now serves as president of Michlalah, Jerusalem Academic College. He specializes in religious education and values, affective education, ICT use in education, and social attitudes in education. He served as head of the School of Education at Bar-Ilan University and as chief pedagogic officer of the Israel Ministry of Education where he was responsible for all subject matter taught in Israeli state schools.
Ety Berant is the head of the Baruch Ivcher School of Psychology clinic. She is on the faculty of the Baruch Ivcher School of Psychology in the Interdisciplinary center, Herzliya. She has served as the head of the graduate clinical track in Bar-Ilan University. She is also a senior clinical psychologist and has practiced and supervised psychotherapy and personality assessment for three decades.