Acta agriculturae Slovenica, 121/3, 1–13, Ljubljana 2025 doi:10.14720/aas.2025.121.3.19609 Original research article / izvirni znanstveni članek The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder Nika GOMBAČ 1, Lea ŠUC 2, Jaka ŽGAJNAR 3, 4 Received Avgust 26, 2024; accepted July 24, 2025. Delo je prispelo 26. avgusta 2024, sprejeto 24. julija 2025. 1 Center of Physiotherapy Ljubljana, Slovenia 2 University rehabilitation institute Republic of Slovenia Soča, Slovenia 3 University of Ljubljana, Biotechnical Faculty, Department of Animal Science, Domžale, Slovenia 4 Corresponding author, e-mail: jaka.zgajnar@bf.uni-lj.si The effect of occupational therapy in an equine environ- ment on sensory processing in children with autism spec- trum disorder Abstract: In children with autism spectrum disorder (ASD), sensory processing can be atypical, leading to signifi- cant challenges. Studies indicate that occupational therapy in an equine environment (OTEE) can effectively address these sensory processing issues of children with ASD.We conduct- ed the study with 20 boys, aged 4 to 9, adhering to a struc- tured treatment protocol. The findings demonstrated signifi- cant improvements in sensory processing among participants following ten OTEE sessions. Specifically, average scores showed a statistically significant impact at the 5% risk level in the categories of "vestibular", "touch", and "multisensory processing", "modulation related to body position and move- ment", "modulation of sensory input influencing emotional responses in children", "emotional and social responses", and "behavioral outcomes of sensory processing". Additionally, significant changes (p < 0,05) were observed in factors such as "inattention/distractibility", "sensory seeking", "emotional- ly reactive", and "poor registration". A statistically significant impact (p < 0,01) was evident in the "avoiding", "seeking", and "sensitivity" quadrants. Children participating in OTEE exhibited greater adaptability in sensory-rich environments, found increased enjoyment in these settings, and demon- strated improved tolerance for low-stimulation surroundings. They also responded more effectively to sensory stimuli and showed greater situational awareness. Key words: horses, animal-assisted therapy, occupation- al therapy in an equine environment, children, autism spec- trum disorders, sensory processing Učinek delovne terapije s pomočjo konj na senzorično ob- delavo pri otrocih z motnjo avtističnega spektra Izvleček: Pri otrocih z motnjo avtističnega spektra (ASD) je lahko senzorna obdelava netipična, kar povzroča številne izzive. Raziskave kažejo, da lahko delovna terapija s pomočjo konj (OTEE) učinkovito zmanjšuje težave s sen- zorno obdelavo pri otrocih z ASD. Študijo smo izvedli z 20 dečki, starimi od 4 do 9 let, pri čemer smo sledili strukturira- nemu protokolu zdravljenja. Rezultati so pokazali pomembna izboljšanja pri senzorni obdelavi med udeleženci po desetih OTEE terapijah. Natančneje, povprečne ocene so pokazale statistično značilen vpliv (p < 0,05) v naslednjih kategorijah: "vestibularna", "taktilna" in "večsenzorna" obdelava, "modu- lacija povezana s položajem telesa in gibanjem", "modulacija senzornih inputov, ki so pod vplivom čustvenih odgovorov", "čustveni in socialni odgovori" in "vedenje kot rezultat sen- zorne predelave". Poleg tega so se pokazale statistično značilne razlike (p < 0,05) pri dejavnikih "nepozornost/preusmerjanje pozornosti", "senzorno iskanje", "čustveno reagiranje" in "sla- ba registracija". Statistično značilna razlika (p < 0,01) se je po- kazala pri kvadrantih "izogibanje", "iskanje" in "občutljivost". Otroci, vključeni v OTEE, so pokazali večjo prilagodljivost v senzorno bogatih okoljih, v takšnih okoljih so doživljali večje zadovoljstvo ter izkazovali boljšo toleranco do okolij z nizko senzorno stimulacijo. Na senzorične dražljaje so se odzivali učinkoviteje in izkazovali višjo stopnjo zaznavanja situacije. Ključne besede: konji, terapija s pomočjo živali, delov- na terapija s pomočjo konja, otroci, motnje avtističnega spek- tra, senzorična obdelava Acta agriculturae Slovenica, 121/3 – 20252 N. GOMBAČ et al. 1 INTRODUCTION Autism Spectrum Disorder (ASD) is a neurode- velopmental condition marked by difficulties in social interaction, communication and unusual or repetitive behaviors (American Psychiatric Association, 2013). A prominent behavioral phenotype in ASD is atypical sen- sory processing, which often manifests as heightened or reduced responsiveness to sensory stimuli (Mikkelsen, 2018). Study of Chang et al. (2012) suggests that behav- ioral challenges related to sensory inputs, such as audi- tory stimuli, correspond to physiological responses that are outside of the child’s voluntary control. Studies have shown that over 90 % of individuals with ASD, both children and adults, exhibit atypical sensory processing, as assessed by questionnaires like the Sensory Profile (Watling et al., 2001; Dunn et al., 2002; Baird et al., 2006; Kern et al., 2007; Tomchek and Dunn, 2007; Crane et al., 2009; Wiggins et al., 2009; Peters et al., 2020). These sensory differences are thought to stem from disrupted processing of auditory, visual, vestibular, tactile, multi- sensory, or oral-sensory stimuli. The sensory processing pathway involves a complex chain, from the mechan- ical-to-electrical signal conversion in sensory recep- tors, transmission to subcortical and cortical regions, integration in the primary somatosensory cortex, and finally, the selection of appropriate emotional and be- havioral responses at both conscious and subconscious levels (Mikkelsen et al., 2018; Thye et al., 2018; Pastor- Cerezuela et al., 2020). These behavioral and emotional responses are considered appropriate when they align with the child’s developmental stage, demonstrating fundamental emo- tional and social competencies such as emotional regu- lation, social inclusion, connection with others, affec- tive interaction, appropriate responses to social stimuli, etc. Abnormal development at any one of these sensory processing pathways could result in abnormal sensory processing (Cvetek, 2014). Sensory dysfunctions in ASD originate in the cen- tral nervous system and engage various brain struc- tures (Mikkelsen, 2018; Thye et al., 2018). The under- lying processes leading to brain dysfunction may also produce associated pathophysiological abnormalities. ASD is commonly linked to conditions such as seizure and epilepsy, neurotransmitter disorders, sleep distur- bances, metabolic irregularities, and immune and gas- trointestinal disorders. Conversely, some of these ab- normalities may contribute to brain dysfunctions that manifest as ASD symptoms, indicating a bidirectional relationship between neurological and physiological factors (Frye and Rossignol 2016; Purpura et al., 2022). The selection of a preferred treatment approach is guided by the specific set of symptoms present in each individual, as the manifestation of issues can vary sig- nificantly among children. The primary treatment goal is to enhance functional skills in core areas of deficit and reduce the impact of other associated challenges (Levy et al., 2009). The authors recommend educational and behavioral therapy (Levy and Hyman, 2008; Volk- mar et al., 2014; Trzmiel et al., 2019), pharmacotherapy (Trzmiel et al., 2019), communication therapy (Levy and Hyman, 2008; Volkmar et al., 2014) and social skills support (Levy and Hyman, 2008). Authors promote also occupational and physical therapy (Levy and Hyman, 2008; Domínguez-Lucio et al., 2023) and other inter- ventions such as psychosocial intervention and sensory oriented interventions (Volkmar et al., 2014). Comple- mentary and alternative medical treatments, biologi- cally based or non-biological treatment are the one that are also the most often applied in practice (Levy et al., 2009). One of the complementary forms of rehabilita- tion is also occupational therapy in an equine environ- ment (OTEE) (Dingman, 2008; Peters et al., 2022). OTEE is performed by occupational therapists, physical therapists or speech language pathologists whose goal is to engage an individual’s sensory, neuro- motor and cognitive system and achieve certain func- tional outcomes (Koca and Ataseven, 2016; Srinivasan et al., 2018). Interaction with horses is a pleasant ex- perience and has numerous positive effects, including improving the quality of life and reducing restlessness or negative mood (Peters et al., 2020). Studies high- light the positive impacts of OTEE in ASD, including improvements in social functioning (Bass et al., 2009; Memishevikj and Hodzhikj, 2010; Van den Hout and Bragonje, 2010; Ward et al., 2013; Lanning et al., 2014; Chen et al., 2015; Borgi et al., 2016), communication (Memishevikj and Hodzhikj, 2010; Gabriels et al., 2012; Coffey, 2014; Holm et al., 2014; Anderson and Maints, 2016), reduction of unusual behaviour (Memishevikj and Hodzhikj, 2010; Kern et al., 2011; Gabriels et al., 2012; Ajzenman et al., 2013; Coffey, 2014; ; García- Gómez et al., 2014; Holm et al., 2014; Lanning et al., 2014; Anderson and Maints, 2016; Llambias et al., 2016) and other important areas such as sensory processing (Bass et al., 2009; Memishevikj and Hodzhikj, 2010; Van den Hout and Bragonje, 2010; Wuang et al., 2010; Kern et al., 2011; Ward et al., 2013; Coffey, 2014). As the literature indicates, abnormalities in auditory process- ing are present in the vast majority of individuals with ASD (Tomchek and Dunn, 2007; Bolton et al., 2012), as some authors states, 65 % of individuals with ASD have atypical processing of sound (Chang et al., 2012; Bishop et al., 2013). This is exactly the area that OTEE has been shown to have significant impact (Ward et al., 2013). Acta agriculturae Slovenica, 121/3 – 2025 3 The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder Also, in tactile processing, studies showed important impact, because there are always many different tex- tures and surfaces to feel in contact with a horse (Ward et al., 2013; Coffey, 2014). All physical and sensory ac- tivities in the OTEE environment, both on the ground and while on the horse, provide rich tactile, vestibular, proprioceptive, and olfactory stimulation, which also contribute to improving behavioral regulation (Peters et al., 2020). Because of the diversity of sensory stim- uli involved in contact with a horse, we incorporated guidelines from Chang et al. (2012) into our treatment protocol for children with ASD who demonstrate gen- eral sensory processing difficulties. In our experiment we included interventions to facilitate development of sensory modulation and self-regulation across multiple sensory systems. Therapies were always performed in the same way, within a predictable environment and routine. Anticipated changes in routine or environment were also planned, following Chang et al. (2012), which we incorporated into our study. The aim of our study was to explore the relation- ship between OTEE and the sensory processing skills in children with ASD, focusing particularly on auditory, tactile and vestibular processing. We examined the ef- fects of a stable, predictable environment and routine on children’s sensory responsivness, looking at how these factors might influence sensory input processing, attention and emotional responses. Our study encom- passed both individual analyses and group-level in- sights, with a sample of 20 preschool and school-aged boys. Building on literature that underscores OTEE’s positive effects on children with ASD, our study sought to answer a primary question: what is the average pro- gression in sensory processing outcomes observed among participants across individual OTEE sessions? To ensure consistency, each therapy session adhered strictly to a detailed treatment protocol, which is thor- oughly outlined in the paper. This protocol facilitated uniformity in approach while allowing us to observe changes systematically, enabling an accurate assessment of sensory processing improvements over the course of the intervention. 2 MATERIAL AND METHODS 2.1 PROCEDURE The practical part of the study took place at the Ed- ucational research centre for Horse breeding Krumperk (Gorjuša 19a, 1233 Dob pri Domžalah), which is a part of Biotechnical Faculty, University of Ljubljana. The ex- periment took place in an indoor riding arena, where only the children’s parents were present, if they chose to be, and no other people were allowed during the ses- sions. This setup minimized external influences, such as presence of unfamiliar people, noise, and other poten- tial disturbances, creating an environment conducive to accurately measuring the effects of the therapy. 2.2 THE COURSE OF THE EXPERIMENT The study extended over a four-month period, with each participant completing ten individualised treatment sessions across ten weeks (one session treat- ment per week). Each session lasted 60 minutes, with a median time (the middle value in a sorted set of num- bers, dividing the set into two equal halve) of 26.1 min- utes dedicated to horseback riding and 22.4 minutes of ground-based activities. The remaining time was set aside for a closing phase. The exact time spent on the horse and on the ground varied among children due to differences in functioning, sensory processing, and overall well-being. Over successive sessions, the time spent on the ground activities typically decreased, al- lowing for relatively longer time on the horse. A com- prehensive treatment protocol detailing the structure and activities planned for each session is included. At the treatments three occupational therapists were present. One of the therapists led the horse by the hand, the other planned and carried out the treatment with the child and the third therapist recorded all in details and walked by the horse and assisted if neces- sary. A specially trained 15-year-old Lipizzaner horse was selected for the OTEE treatments. This horse was in a good state of health and showed stable behaviour.2.3 Treatment protocol The treatments were structured following the American Framework of Practice – AOTA (2013), drawing on rehabilitation and cognitive perceptual models, incorporating a range of approaches tailored to individual needs. The primary aim of the activities on the ground and on the horseback (without saddle) was to enhance children’s responses to daily sensory experiences. Activ- ities were designed through games personalized to each child’s specific sensory challenges, abilities and needs, as assessed by the sensory profile prior to the first session, aligning with the treatment protocol. The activities dur- ing treatments escalated in different areas, depending on the individual participant. Each OTEE session began with sensory-based ac- tivities on the ground, emphasing tactile processing. Children were introduced to the horse by initially at- tending to, touching and petting various parts of the Acta agriculturae Slovenica, 121/3 – 20254 N. GOMBAČ et al. horse, followed by grooming activities using a sequence of brushes (first a steel horse brush, then bristles brush) (see Figure 1). As sessions progressed, activities includ- ed saddling and horseback riding, beginning with exer- cises targeting vestibular and proprioceptive processing (see Figure 1). These activities gradually expanded to integrate additional sensory systems—such as audito- ry, tactile, and visual—using various objects like rings, cones, and cards to enrich the sensory experience. The final phase, or closure, took place on the ground, where children unsaddled the horse, tidying up used acces- sories and rewarding the horse. This phase also empha- sized safety practices (e.g. avoiding the area behind the horse), improving their basic knowledge of the horses and to remind the children of their behavior (do not kick at the hooves, do not hit the horse, etc.). Each well done completed task was followed by a praise or a re- ward (verbal encouragement ‘excellent’, high-five). understanding, communication and behavior in chil- dren with ASD (Lauren Harrell, 2023). 2.3 SAMPLE OF PARTICIPANTS The group of potential study participants was formed by contacting parents who were interested in participating in our study. The inclusion criteria for par- ticipants were male, aged between three and ten years, with verbal or non-verbal ability, with sensory process- ing problems, with a diagnosis of autism or Asperger’s syndrome or in process of being diagnosed, with prior experience of learning to ride, therapeutic riding, or no previous contact with horses. Exclusion criteria in- cluded female participants, children over the age of 10, lack of interest in horses, and severe behavioural and sensory processing issues. From a study sample of 29 Figure 1: Some of the treatment activitis on the ground and on the horseback OTEE sessions included routine activities. For en- couragement we used cards and symbols (for example horse equipment, rider equipment, horse body parts, food for the horse, numbers, ‘stop’ and ‘forward’ sym- bols and activity schedule for non-verbal participants; see Figure 2). This has a positive effect on improving participants, 9 were excluded either due to disinterest for horses (n = 3), major problems with sensory pro- cessing (n = 3) or behaviour that was difficult to control on a horse (n = 3). The final study sample consisted of 20 participants, aged between 4 and 9 years (Median = 7, SD = 1.9) with Figure 2: Use of cards and symbols when saddling a horse and during horseback riding Acta agriculturae Slovenica, 121/3 – 2025 5 The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder a current clinical diagnosis of ASD (n = 17), Asperger’s syndrome (n = 2) or in the process of being diagnosed with Asperger’s syndrome (n = 1). Some of ASD popu- lation (70 % of study sample) had comorbid disorders, including attention deficit hyperactivity disorder – ADHD (15 %), developmental deficit (20 %), mental disorders (5 %), condition after feverish cramps (5 %), speech problems (15 %) and attention deficit disorder (10 %). More than half of the participants (n = 13) were verbal, with limited verbal ability, others (n = 7) were non-verbal. Contact with horses prior to the study was reported for 15 participants, only two of whom had contact in the context of equine assisted therapy. 2.4 SENSORY PROFILE The sensory profile (SP) was evaluated before first (t1) and after final (t10) OTEE session. In such a man- ner we were able to compare how OTEE, effects on the sensory processing of children with ASD. The SP is a valid and reliable detailed questionnaire for parents/ caregivers (Dunn,1999). It uses the five-point Likert scale (5 = never (5 % or less of the time), 4 = seldom (25 % of the time), 3 = occasionally (50 % of the time), 2 = frequently (75 % of the time), 1 = always (95 % or more of the time)) to rate 125 items evaluating chil- dren’s responses to daily sensory experiences. Items are grouped into forteen categories (A. “auditory process- ing”, B. “visual processing”, C. “vestibular processing”, D. “touch processing”, E. “multisensory processing”, F. “oral sensory processing”, G. “sensory processing relat- ed to endurance/tone”, H. “modulation related to body position and movement”, I. “modulation of movement affecting activity level”, J. “modulation of sensory in- put affecting emotional responses”, K. “modulation of visual input affecting emotional responses and activity level”, L. “emotional/social responses”, M. “behavioral outcomes of sensory processing”, N. “items indicating thresholds for response”), nine factors (1. “sensory seek- ing”, 2. “emotionally reactive”, 3. “low endurance/tone”, 4. “oral sensory sensitivity”, 5. “inattention/distractibility”, 6. “poor registration”, 7. “sensory sensitivity”, 8. “seden- tary”, 9. “fine motor/perceptual”) and four quadrants (1. “registration”, 2. “seeking”, 3. “sensitivity”, 4. “avoiding”) (Dunn, 1999). Categories encompass all sensory systems, as well as the behavioral and emotional responses and modula- tions that reflect the integration of sensory inputs used in daily life. The factors describe children based on their Figure 3: Quadrants in Sensory Profile (Butera et al., 2020) Acta agriculturae Slovenica, 121/3 – 20256 N. GOMBAČ et al. responsiveness to sensory input (e.g., overly responsive or underresponsive). Quadrants (Figure 3) describe four subtypes of sensory functioning (Register, Seeker, Sensor, and Avoider), which represent scores for senso- ry patterns and are defined by a combination of neuro- logical thresholds and self-regulation. The registration pattern represents a high neurological threshold with a passive response, the seeking pattern represents a high neurological threshold with an active response, the sensitivity pattern reflects a low neurological threshold with a passive response and the avoiding pattern is as- sociated with low neurological threshold and an active response (Dunn, 2006). In presenting results from specific categories, fac- tors, or quadrants, we employed a ranking system with five categories: “definite difference” (much more than others), “probable difference” (more than others), “typi- cal performance” (similar to others), “probable differ- ence” (less than others), and “definite difference” (much less than others). A “probable difference” signaled po- tential sensory processing issues, whereas a “definite difference” indicated established challenges in sensory processing. The sensory profile supplement (Dunn, 2006) was utilized to assess sensory processing abilities and performance patterns across these categories. The data obtained from the SP provides insights into the sensory sensitivities of each child, allowing for tailored adjustments to activities during each session to meet individual needs. Dunn (1994) notes that the information gathered from the SP is based on practi- cal application, making it a valuable tool for monitoring progress over time. 2.5 STATISTICAL ANALYSIS In our data analysis, we employed a combina- tion of descriptive and inferential statistical methods to thoroughly examine sensory processing patterns and behavioral responses. All statistics analyses were conducted using the SPSS 27.0 software package (IBM Corporation, Chicago, IL, USA). To test the normality of the data distribution, we used the Shapiro-Wilk test. When the Shapiro-Wilk test indicated a statistically sig- nificant deviation from normality (p < 0.05) for sensory categories, factors or quadrants, we applied the Wilcox- on test—a non-parametric test suitable for evaluating paired samples differences, to assess changes between initial and final treatment sessions. When the distribu- tion of an individual category, factor, or quadrant did not deviate significantly from normal (p > 0.05), we used a parametric t-test for dependent samples to test the difference between the initial (t1) and final (t10) data. Additionally, we used the chi-square test to exam- ine statistically significant differences between categor- ical variables. This approach allowed us to rigorously analyze the data, ensuring that the statistical methods used were appropriate for the nature of the data and the research questions being addressed. We aimed to identify commonly reported behav- ioral characteristics of sensory processing in the ASD group. The “common behavior” criterion was based on a previous study of children with autism (Kientz and Dunn, 1996) and was met if 80 % or more respondents rated a single behavioral item as occurring frequently or always. 3 RESULTS The primary objective of this study is to demon- strate the efficacy of OTEE for children diagnosed with ASD. The initial part of the paper focuses on the aver- age progression observed among participants between evaluations. In the final part, the statistically significant changes that occurred within the categories (A–N), fac- tors (1–9), and quadrants (1–4) of sensory processing after the completion of OTEE are presented in individ- ual subsections. To evaluate the internal consistency of the sensory profile’s categories, factors, and quadrants, Cronbach’s alpha coefficients were calculated, resulting in values of 0.87 for categories, 0.72 for factors, and 0.85 for quad- rants. The sensory profile demonstrated progress in mean scores (in terms of the total score) between the first and final evaluation for all 14 categories (Table 1), nine factors (Table 2), and four quadrants (Table 3). 3.1 SENSORY PROFILE CATEGORIES After ten treatments, the mean values showed sig- nificant improvements in performance in four areas: “auditory processing” (A), “visual vrocessing” (C), “tac- tile processing” (D), and “emotional/social responses” (K). For two of the sensory processing domains (“au- ditory processing” and “vestibular processing”), “exist- ing problems” were upgraded to “potential problems.” For the other two domains (“tactile processing” and “modulation of visual inputs influenced by emotional responses”), mean values indicating “possible prob- lems” improved to mean values indicating “no more problems”. All categories of the sensory profile (A–N) showed a statistically significant deviation from the normal Acta agriculturae Slovenica, 121/3 – 2025 7 The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder Sensory profile categories (A–N) Possible points AVG SD MIN MAX p Sensory processing A. Auditory processing Pre-treatment testing 40 24.95 6.45 14 37 0.092 Post-treatment testing 26.75 5.65 17 39 B. Visual processing Pre-treatment testing 45 36.75 7.44 20 45 0.068 Post-treatment testing 38.15 6.41 22 45 C. Vestibular processing Pre-treatment testing 55 43.25 5.45 32 52 0.005 Post-treatment testing 44.70 4.72 32 52 D. Touch processing Pre-treatment testing 90 71.10 8.78 56 84 0.007 Post-treatment testing 73.50 7.30 60 84 E. Multisensory processing Pre-treatment testing 35 21.15 4.25 13 28 0.025 Post-treatment testing 22.65 4.51 14 31 F. Oral sensory processing Pre-treatment testing 60 41.80 8.81 26 57 0.130 Post-treatment testing 43.50 7.45 32 57 Modulation G. Sensory processing related to endurance/tone Pre-treatment testing 45 34.80 6.03 23 45 0.666 Post-treatment testing 34.95 5.82 23 45 H. Modulation related to body position and movement Pre-treatment testing 50 41.10 5.10 26 50 0.019 Post-treatment testing 42.50 4.28 32 50 I. Modulation of movement affecting activity level Pre-treatment testing 35 25.10 5.00 13 33 0.057 Post-treatment testing 26.20 3.52 19 33 J. Modulation of sensory input affecting emotional responses Pre-treatment testing 20 13.75 2.53 8 18 0.040 Post-treatment testing 14.20 2.46 9 19 K. Modulation of visual input affecting emotional responses and activity level Pre-treatment testing 20 14.15 1.82 11 19 0.071 Post-treatment testing 14.60 1.98 11 19 Behavior and emotional responses L. Emotional/social responses Pre-treatment testing 85 57.55 10.67 31 75 0.002 Post-treatment testing 61.05 10.32 32 77 M. Behavioral outcomes of sensory processing Pre-treatment testing 30 17.70 3.80 10 25 0.032 Post-treatment testing 18.40 3.37 10 24 N. Items indicating thresholds for response Pre-treatment testing 15 10.90 2.34 7 14 0.103 Post-treatment testing 11.45 1.72 7 14 Table 1: Results and one sample t-test result of the sensory profile categories for the whole group (N = 20) Acta agriculturae Slovenica, 121/3 – 20258 N. GOMBAČ et al. distribution (p < 0.05). Consequently, we used a non- parametric test for dependent samples (Wilcoxon test) to examine the differences between the initial (t1) and final (t10) evaluations. The results confirm that a statistically significant difference between the initial (t1) and final (t10) as- sessments, at the 5% risk level (p < 0.05), occurred in seven sensory categories. In vestibular processing (C) (p = 0.005), which provides information about the body’s position in space and informs us whether the body is stationary or in motion, including the speed and direction of movement, significant effects were observed. Similarly, significant effects were found in touch processing (D) (p = 0.007), which is responsible for transmitting information to the brain regarding the texture, shape, temperature, and other characteristics of objects and surfaces we touch. Significant effects were also noted in multisensory processing (E) (p = 0.025), which involves the integration of signals arriving al- most simultaneously from different sensory modalities. The movement of the horse had a pronounced posi- tive influence on modulation related to body position and movement (H) (p = 0.019). Additionally, contact with a horse positively affected modulation of sensory input influencing emotional responses in children (J) (p = 0.040), emotional/social responses (L) (p = 0.002), and behavioral outcomes of sensory processing (M) (p = 0.032) (Table 1). Sensory Profile Factors (1–9) Possible points AVG SD MIN MAX p 1. Sensory Seeking Pre-treatment testing 85 59.15 9.40 44 76 0.002 Post-treatment testing 62.10 8.17 51 77 2. Emotionally Reactive Pre-treatment testing 80 50.45 10.32 25 71 0.003 Post-treatment testing 53.60 10.39 25 70 3. Low Endurance/Tone Pre-treatment testing 45 34.80 6.03 23 45 0.666 Post-treatment testing 34.95 5.82 23 45 4. Oral Sensory Sensitivity Pre-treatment testing 45 30.50 7.92 17 43 0.262 Post-treatment testing 31.55 7.43 18 43 5. Inattention/Distractibility Pre-treatment testing 35 20.20 5.18 12 27 0.021 Post-treatment testing 22.15 4.41 14 32 6. Poor Registration Pre-treatment testing 40 30.65 4.20 22 38 0.013 Post-treatment testing 31.55 4.09 24 39 7. Sensory Sensitivity Pre-treatment testing 20 16.85 2.95 11 20 0.034 Post-treatment testing 17.40 2.42 11 20 8. Sedentary Pre-treatment testing 20 15.15 4.27 4 20 0.397 Post-treatment testing 15.50 3.34 8 20 9. Fine motor/perceptual Pre-treatment testing 15 10.10 2.17 6 13 0.124 Post-treatment testing 10.45 1.94 6 13 Table 2: One sample t-test and paired samples t-test result of the sensory profile factors for the whole group (N = 20) Note. Ha μ ≠ 0; p shows the results of a one sample t-test and paired samples t-test (Factor 5) Acta agriculturae Slovenica, 121/3 – 2025 9 The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder 3.2 SENSORY PROFILE FACTORS On average, the greatest improvement in sen- sory processing factors (1–9) (Table 2) was achieved in “emotional responsiveness” (2), while the least im- provement was observed in “low endurance/tone” (3). The smallest differences between children occurred in both evaluations in the factor “poor registration” (6). Conversely, the greatest differences between boys ap- peared in the factor “sedentary activity” (8) during the initial assessment and in “oral sensory sensitivity” (4) during the final assessment. After ten treatments, the average values show a significant progression to a better category only in the factor “inattention/ distractibility” (5), indicating a shift from “existing problems” to the presence of only “pos- sible problems” in sensory processing. For all factors except one, the Shapiro-Wilk test in- dicated a statistically significant deviation from normal distribution (p < 0.05). 3.3 SENSORY PROFILE QUADRANTS Participants achieved the greatest average progress in the quadrant “seeking” (2) and the smallest in the quadrant “registration” (1) (Table 3). The smallest dif- ferences within the group of children, both at the initial and final assessments, were observed in the “avoiding” (4) quadrant. The greatest variability within the group was detected in the “seeking” quadrant during the ini- tial assessment and in the “registration” (1) quadrant during the final assessment. The maximum possible score was not achieved in any of the sensory processing quadrants. Significant improvements after ten treatments were observed in two quadrants: “seeking” (2) and “avoiding” (4). In the “seeking” (2) quadrant, only “pos- sible problems” were shown after ten treatments, while in the “avoiding” (4) quadrant, the effectiveness of OTEE was demonstrated by the “absence of problems” in this sensory processing quadrant. Three quadrants (registration, seeking, and sensi- tivity) show a statistically significant deviation from the normal distribution (p < 0.05). In contrast, in the avoid- ing quadrant, the distribution does not deviate statisti- cally significantly from normal (p = 0.067; p > 0.05). However, in the area of registration, there is no statistically significant difference in the analysed popu- lation (p = 0.06; p > 0.05). The chi-square test revealed statistically significant differences between categories in all four quadrants at the risk level of 1% before and after OTEE treatment (p < 0.01). 3.4 CATEGORIES PERFORMANCE CLASSIFICA- TIONS Notable progress from “definite difference” (much more than others) to “probable difference” (more than others) was observed in two categories - “auditory pro- cessing” (A) and “vestibular processing” (C) - as well as in the factor “inattention/distractibility” (5) and the quadrant “seeking’’ (2). Additionally, progress from “probable difference” (more than others) to “typical performance” (similar to others) was observed in two categories “touch processing” (D) and “modulation of Sensory profile quadrants (1–4) Possible points AVG SD MIN MAX p 1. Registration Pre-treatment testing 75 55.10 8.11 41 70 0.063 Post-treatment testing 56.25 8.14 41 72 2. Seeking Pre-treatment testing 130 89.55 14.08 65 118 0.006 Post-treatment testing 93.95 11.80 80 118 3. Sensitivity Pre-treatment testing 100 74.25 9.76 55 93 <.001 Post-treatment testing 77.70 8.09 62 96 4. Avoiding Pre-treatment testing 145 111.40 13.07 84 136 0.002 Post-treatment testing 115.55 11.20 96 139 Table 3: One sample t-test and paired samples t-test result of the sensory profile quadrants for the whole group (N = 20) Acta agriculturae Slovenica, 121/3 – 202510 N. GOMBAČ et al. visual input affecting emotional responses and activ- ity level” (K) —and in the quadrant “avoiding” (4), as shown in Figure 4. This indicates that the average dis- tribution within typical performance improved across most categories between the initial and final assess- ments. Simultaneously, the proportion of cases showing a “definite difference” (much more than others) either decreased or remained unchanged, while the propor- tion showing a “probable difference” (more than others) either increased or remained unchanged (Figure 4). 4 DISCUSSION AND CONCLUSIONS The results of this study suggest that OTEE can be an effective intervention for children with ASD and may have an effect on sensory functioning. The study demonstrated significant changes in mean scores and among participants who underwent the OTEE program. After ten treatments, significant improvements in average values towards better perfor- mance were observed in four areas (A, C, D, and K) out of 14. In “Auditory” (A) and “Vestibular processing” (C), “Existing problems” improved to “Potential problems”. Similarly, after ten treatments, only “Possible problems” were present in the factor “Inattention/Distractibility” (5) and in the quadrant “Seeking” (2) In the areas of “Touch processing” (D) and “Modulation of visual in- put affecting emotional responses and activity level” (K), as well as in the “Avoiding” (4) quadrant, the effec- tiveness of OTEE was evident, with an absence of prob- lems in the group of examinees. The results from the initial and final assessments confirmed that OTEE has a statistically significant impact at the 5% risk level in seven categories and four factors and statistically signif- icant impact at the 1% risk level in the areas of “avoid- ing” (p = 0.002; p < 0.01), “seeking” (p = 0.006; p < 0.01), and “sensitivity” (p < 0.001; p < 0.01). This suggests that, following OTEE, children are less burdened by sensory- rich environments, find greater enjoyment in such set- tings, have fewer difficulties tolerating low-stimulation environments, respond more easily to sensory stimuli, and demonstrate heightened awareness of their sur- roundings. These results are in line with previous re- search showing that the outcomes of OTEE for chil- dren with ASD demonstrate significant improvement in the areas of sensory processing (Bass et al., 2009; Memishevikj and Hodzhikj, 2010; Van den Hout and Bragonje, 2010; Wuang et al., 2010; Kern et al., 2011), especially in the field of touch processing (Ward et al., 2013; Coffey, 2014) and auditory processing (Ward et al., 2013). Visual, auditory and somatosensory cortices have reciprocal pathways with the cerebellum (Zhua et al., 2006). Because it is linked with motor learning skills, motor control and social engagement, Bass et al. (2009) assumed it is possible that OTEE is linked to cerebellar functioning. Silkwood-Sherer et al. (2012) claimed that the respond to a variety of somatosensory, vestibular, 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% A1 A1 0 B1 B1 0 C1 C1 0 D1 D1 0 E1 E1 0 F1 F1 0 G1 G1 0 H1 H1 0 I1 I1 0 J1 J1 0 K1 K1 0 L1 L1 0 M 1 M 10 N 1 N 10 "probable difference (less than others)" "typical performance (similar to others)" "probable difference (more than others)" "definite difference (much more than others)" Figure 4: Frequency of sensory profile categories performance classifications within group of children with ASD (N = 20) Acta agriculturae Slovenica, 121/3 – 2025 11 The effect of occupational therapy in an equine environment on sensory processing in children with autism spectrum disorder and visual stimuli enables the child’s simultaneous for- ward movement on the horse. Our study found that OTEE had a statistically sig- nificant effect on children’s responsiveness to sensory input. One key outcome was the observed improvemnet in “inattention”, where statistically significant changes were noted. Similar positive outcomes in attentional focus were reported in previous research by Bass et al. (2009) and Lanning et al. (2014), with Chen et al. (2015) noticing increased engagement with the horse, suggesting that interaction with the animal may influ- ence brain activation, particularly in the frontal regions responsible for attentional processes. In our study, statistically significant difference in neurological thresholds for responses was found be- tween the initial (t1) and final (t10) evaluations. While one of the previous studies reported progress in the registration and sensitivity quadrants (Ward et al., 2013), our study showed statistically significant differ- ences at the 1% risk level in three quadrants: “avoiding”, “seeking”, and “sensitivity”. Additionally, the average scores for the “seeking” and “avoiding” quadrants also improved. After treatments children had only possible problems with “Seeking” and no more problems with “avoiding”. The statistically significant improvement in sensory seeking observed in our study is consistent with the statistically significant treatment effects reported by Bass et al. (2009). At the behavioral level, only one item—”looks away from task to notice all actions in the room”—was initially marked as “common behavior”, meeting the threshold of 80 % or more of participants. Notably, OTEE had a significant impact on this behavior, which involves multisensory processing with a low neurologi- cal threshold. Improvements in behavior can be attrib- uted to the multisensory experience of being near a horse and the simultaneous improvement in attention. Findings from our study also demonstrated a positive reduction in challenging behavior traits and difficulty in children’s responses to daily sensory experiences. After treatments, fewer participants exhibited certain behaviors as “always” or “frequently,” and more partici- pants responded without any problems in sensory pro- cessing. Schmitz Olin et al. (2017) reported that some behaviors may occur as a tendency to induce sensory stimulation. According to Marco et al. (2011), atypical behavioral responses to sensory information are com- mon in individuals on the autism spectrum. Our findings suggest that OTEE may be a prom- ising therapeutic option for children with ASD, par- ticularly in enhancing sensory processing, modulating sensory inputs, and supporting positive behavioral and emotional responses. By improving children’s respon- siveness to sensory input and helping align their sen- sory processing with neurological thresholds, OTEE demonstrates notable therapeutic potential. Although our results are promising, further longitudinal studies with larger sample sizes are required to strengthen and generalize these findings. An area that requires further investigation is the role of the horse itself. Only one horse was used in this study, so it would be beneficial to explore how differ- ent horses might influence therapeutic outcomes. Ad- ditionally, it is important to consider the impact of therapy sessions on the horse’s well-being and behav- ior. Future studies focusing on both the therapeutic ef- fects on children and the influence on the participating horses are encouraged. Given the strong indications of positive outcomes, broader integration of OTEE in ASD rehabilitation is recommended. 5 REFERENCES Ajzenman, H. F., Standeven, J. W., & Shurtleff, T. L. (2013). Ef- fect of hippotherapy on motor control, adaptive behav- iors, and participation in children with autism spectrum disorder: A pilot study. The American Journal of Occupa- tional Therapy, 67(6), 653–663. https://doi.org/10.5014/ ajot.2013.008383 American Psychiatric Association, D. S. M. T. F., & Ameri- can Psychiatric Association, D. S. 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