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Topic:Equine-Assisted Therapies

Equine-Assisted Therapies (EAT) involve the use of horses in therapeutic settings to support physical, emotional, and psychological well-being. These therapies are implemented in various forms, including therapeutic riding, equine-assisted psychotherapy, and hippotherapy. Horses are integrated into the therapeutic process to facilitate interactions that may promote improvements in motor skills, emotional regulation, and social functioning. The unique characteristics of horses, such as their responsiveness to human behavior and non-verbal communication, are leveraged in these interventions. This page compiles peer-reviewed research studies and scholarly articles that explore the methodologies, outcomes, and applications of equine-assisted therapies in diverse populations.
Evaluation of a Modified Bit Device to Obtain Saliva Samples from Horses.
Veterinary sciences    October 15, 2021   Volume 8, Issue 10 232 doi: 10.3390/vetsci8100232
Vincent A, Peth-Pierce RM, Morrissey MA, Acri MC, Guo F, Seibel L, Hoagwood KE.(1) Background: Accounting for the well-being of equine partners is a responsibility of those engaged in Equine-Assisted Services (EAS). Researchers took heed of this call to action by developing an innovative way to collect data to assess the physiological indicators of stress in equine participants. The collection of saliva is considered to be a minimally invasive method of data collection and is typically performed using a cotton swab; however, in equines, the introduction of a foreign object may induce stress; (2) Methods: Researchers used a modified bit to collect pooled saliva in an effo...
Framing Future of Work Considerations through Climate and Built Environment Assessment of Volunteer Work Practices in the United States Equine Assisted Services.
International journal of environmental research and public health    October 2, 2021   Volume 18, Issue 19 10385 doi: 10.3390/ijerph181910385
Tumlin K, Liu S, Park JH.The foundation of healthy workplace design is an understanding of work practices. Volunteers comprise the majority of the workforce in care centers using horses to address human health issues. Documentation is lacking on protections for worker well-being in equestrian microenvironments which are known to have the potential for dust exposures. Climate acts as a master variable in equestrian facility design and ventilation usage to address dust and temperature concerns. Using climate as an independent variable, our objective was to characterize space usage, safety, environmental control, and org...
Animal-Assisted Interventions for Autism Spectrum Disorder: A Systematic Review of the Literature from 2016 to 2020.
Review journal of autism and developmental disorders    September 30, 2021   Volume 10, Issue 2 255-280 doi: 10.1007/s40489-021-00291-6
Nieforth LO, Schwichtenberg AJ, O'Haire ME.In the last five years, the literature on animal-assisted intervention (AAI) for Autism Spectrum Disorder (ASD) has doubled in size from 42 studies prior to 2015 to 85 studies (cumulative total assessed in 2020). Horses remain the most commonly researched animal for AAI, followed by dogs. The most commonly researched outcome was social interaction, across 21 studies. Though the quantity of studies has increased, issues with methodological rigor remain. Results highlight the need for a continued focus on methodological rigor as well as refining the structure of animal-assisted interventions, ad...
Virtual Reality-Incorporated Horse Riding Simulator to Improve Motor Function and Balance in Children with Cerebral Palsy: A Pilot Study.
Sensors (Basel, Switzerland)    September 24, 2021   Volume 21, Issue 19 doi: 10.3390/s21196394
Chang HJ, Jung YG, Park YS, O SH, Kim DH, Kim CW.The horse riding simulator (HRS) reportedly has a beneficial effect on motor function and balance in children with cerebral palsy (CP). However, by itself, the HRS is not a sufficient source of challenge and motivation for children. To address this issue, we combined the HRS with virtual reality (VR) to promote somatosensory stimulation and motivation. Sixteen children (ages: 5-17 years) with CP and presenting Gross Motor Function Classification System (GMFCS) levels I-IV were enrolled in the study. Using a head-mounted display and controllers, interventions were carried out over 30-min period...
Preliminary Efficacy of Occupational Therapy in an Equine Environment for Youth with Autism Spectrum Disorder.
Journal of autism and developmental disorders    September 23, 2021   Volume 52, Issue 9 4114-4128 doi: 10.1007/s10803-021-05278-0
Peters BC, Wood W, Hepburn S, Moody EJ.The purpose of this study was to identify appropriate outcome measures and assess preliminary efficacy of occupational therapy in an equine environment (OT HORSPLAY) for youth with autism spectrum disorder (ASD). Twenty-four youth with ASD aged 6-13 were randomized to 10 weeks of OT HORSPLAY or to a waitlist control condition, occupational therapy in a garden. Youth demonstrated significantly improved goal attainment and social motivation, and decreased irritability after OT HORSPLAY. When compared to the subset of participants who completed the waitlist control condition, the OT HORSPLAY gro...
The Role of the Horse in an Equine-Assisted Group Intervention-as Conceptualized by Persons with Psychotic Conditions.
Issues in mental health nursing    September 20, 2021   Volume 43, Issue 3 201-208 doi: 10.1080/01612840.2021.1975332
Hultsjö S, Jormfeldt H.Adopting positive health interventions is necessary to promote self-image, improve well-being, support meaningful social interaction and reduce loneliness, with benefits for psychological and physical health for persons with psychotic conditions. Raised awareness of the potential benefits of involving horses in these kinds of interventions is warranted. Thus, the aim of this study was to explore the role of the horse in equine-assisted interventions (EAI) as conceptualized among persons with psychotic conditions. Interviews were conducted with eight persons with psychotic conditions who had pa...
Physical therapy treatments incorporating equine movement: a pilot study exploring interactions between children with cerebral palsy and the horse.
Journal of neuroengineering and rehabilitation    September 6, 2021   Volume 18, Issue 1 132 doi: 10.1186/s12984-021-00929-w
Lightsey P, Lee Y, Krenek N, Hur P.Physical therapy treatments incorporating equine movement are recognized as an effective tool to treat functional mobility and balance in children with cerebral palsy (CP). To date, only a few studies examined kinematic outputs of the horses and children when mounted. In this pilot study, to better understand the effectiveness of this type of treatment, we examined the interaction between the horses and children with CP during physical therapy sessions where equine movement was utilized. Four children with CP participated in eight physical therapy sessions incorporating hippotherapy as a treat...
Equine-Assisted Therapy for Posttraumatic Stress Disorder Among Military Veterans: An Open Trial.
The Journal of clinical psychiatry    August 31, 2021   Volume 82, Issue 5 21m14005 doi: 10.4088/JCP.21m14005
Fisher PW, Lazarov A, Lowell A, Arnon S, Turner JB, Bergman M, Ryba M, Such S, Marohasy C, Zhu X, Suarez-Jimenez B, Markowitz JC, Neria Y. As veterans have high rates of posttraumatic stress disorder (PTSD) and historically poor treatment outcomes and high attrition, alternative treatments have gained much popularity despite lack of rigorous research. In this study, a recently developed and manualized 8-session group Equine-Assisted Therapy for PTSD (EAT-PTSD) was tested in an open trial to assess its preliminary feasibility, acceptability, and outcomes for military veterans. The study was conducted from July 2016 to July 2019. Sixty-three treatment-seeking veterans with PTSD enrolled. PTSD diagnosis was ascertained using the S...
Interest in Humans: Comparisons between Riding School Lesson Equids and Assisted-Intervention Equids.
Animals : an open access journal from MDPI    August 28, 2021   Volume 11, Issue 9 2533 doi: 10.3390/ani11092533
Lerch N, Cirulli F, Rochais C, Lesimple C, Guilbaud E, Contalbrigo L, Borgi M, Grandgeorge M, Hausberger M.Little is known about the impact of equine-assisted interventions (EAI) on equids' perception of humans. In this study 172 equids, living in 12 riding centres, were submitted to a standardised human-horse relationship test: the motionless person test. Age, sex, type (horse/pony), housing, and feeding conditions of subjects were recorded. Overall, 17 equids worked in EAI, 95 in riding school lessons (RS), and 60 in both (EAI-RS). There were high inter-individual variations in the number of interactive behaviours directed towards the experimenter: negative binomial general linear models showed t...
Horse Behavior towards Familiar and Unfamiliar Humans: Implications for Equine-Assisted Services.
Animals : an open access journal from MDPI    August 11, 2021   Volume 11, Issue 8 2369 doi: 10.3390/ani11082369
Brubaker L, Schroeder K, Sherwood D, Stroud D, Udell MAR.While human benefits of animal-assisted therapy programs have been documented, relatively little research has been conducted on behavioral factors that predict a successful equine-assisted services (EAS) horse. This study compares the behavior of experienced and non-experienced EAS horses as well as horses selected for future EAS work in a series of sociability and temperament tests. No significant differences were found between experienced and non-experienced horses in the sociability measures or for most of the temperament tests; however, significant differences were found between groups in ...
A Survey of Horse Selection, Longevity, and Retirement in Equine-Assisted Services in the United States.
Animals : an open access journal from MDPI    August 7, 2021   Volume 11, Issue 8 2333 doi: 10.3390/ani11082333
Rankins EM, Wickens CL, McKeever KH, Malinowski K.Little published information exists on the horses in equine-assisted services (EAS), particularly their selection, longevity, and retirement. The purpose of this study was to characterize horses and procedures used in EAS. A pilot survey was developed using focus group discussions and distributed to Professional Association of Therapeutic Horsemanship, International (PATH Intl) centers in Florida ( = 45, Part I) before further modification and distribution to members of PATH Intl., American Hippotherapy Association (AHA), eagala, and Certified Horsemanship Association (CHA) ( = 26,000, Part II...
Development and Validation of an Instrument to Assess Horseback Mobility in Hippotherapy.
Perceptual and motor skills    August 1, 2021   Volume 128, Issue 5 2117-2131 doi: 10.1177/00315125211036578
Prieto AV, Ayupe KMA, Abreu ACA, Filho PJBG.Improvement in rider mobility represents an important functional gain for people with disabilities undergoing hippotherapy. However, there is no validated measuring instrument to track and document the rider's progress in riding activities. In this study, we aimed to develop and establish validity evidence for an instrument to assess hippotherapy participants' mobility on horseback. We report on this development through the stages of: (a) content validation, (b) construct validation, (c) inter- and intra-rater reliability and (d) internal consistency analysis. We evaluated its factor structure...
Outcomes of an Equine Assisted Learning Curriculum to Support Well-Being of Medical Students and Residents.
Journal of medical education and curricular development    July 26, 2021   Volume 8 23821205211016492 doi: 10.1177/23821205211016492
Artz NL, Robbins J, Millman ST.Objectives of this study were to evaluate an equine assisted learning (EAL) curriculum designed for medical students and resident physicians, and to determine impacts of the curriculum on participant perceptions of burnout and well-being. The EAL curriculum incorporated evidence-based skills and concepts to increase happiness and/or resilience. A pre/post intervention design was used, with 18 EAL participants receiving the curriculum within their month-long community based primary care clerkship elective, and 10 control (CTL) participants who did not receive the curriculum within their clerksh...
Effectiveness of equine-assisted therapies for improving health outcomes in people with multiple sclerosis: A systematic review and meta-analysis.
Multiple sclerosis and related disorders    July 23, 2021   Volume 55 103161 doi: 10.1016/j.msard.2021.103161
Suárez-Iglesias D, Bidaurrazaga-Letona I, Sanchez-Lastra MA, Gil SM, Ayán C.Scientific evidence has shown that equine-assisted therapies (EAT) lead to improvements in the physical function and the quality of life (QoL) of people with disabilities through the practice of hippotherapy or therapeutic riding (TR). There is a need to confirm whether people with multiple sclerosis (PwMS) can also benefit from its practice. This review aimed to systematically evaluate and meta-analyze the available data on the potential health benefits of EAT in PwMS. Methods: Four electronic databases (MEDLINE/PubMed, Web of Science, SPORTDiscus, and Scopus) were searched systematically fro...
Trunk and pelvis biomechanical responses in children with cerebral palsy and with typical development during horseback riding.
Gait & posture    July 15, 2021   Volume 89 115-119 doi: 10.1016/j.gaitpost.2021.07.006
Tabsuri T, Thawinchai N, Peansukmanee S, Lugade V.Children with cerebral palsy (CP) have poor postural control. Horseback riding (HR) is an alternative treatment shown to improve postural control among children with CP. However, there is a paucity of research investigating the underlying mechanisms responsible for improving postural control during HR. What are the three-dimensional biomechanical responses of the trunk and pelvis during HR among children with CP and with typical development (TD)? The participants, aged 4-12 years old, were inexperienced horseback riders, consisting of 10 children with TD and 10 children with spastic diplegia C...
Role and Effects of Hippotherapy in the Treatment of Children with Cerebral Palsy: A Systematic Review of the Literature.
Journal of clinical medicine    June 11, 2021   Volume 10, Issue 12 2589 doi: 10.3390/jcm10122589
Menor-Rodríguez MJ, Sevilla Martín M, Sánchez-García JC, Montiel-Troya M, Cortés-Martín J, Rodríguez-Blanque R.Cerebral palsy is described as a group of permanent neuromotor-type disorders caused by non-progressive injuries in the developmental stages of the central nervous system, and which have serious repercussions on the quality of life of affected children due to the physical and psychological damage it entails for them. Today, it is the leading cause of physical disability in childhood. Since there is no cure for this disorder, treatment is based on the improvement of symptoms, which is not always achieved through conventional therapies. For this reason, the need arises to investigate other alter...
Equine-Assisted Interventions (EAIs) for Children with Autism Spectrum Disorders (ASD): Behavioural and Physiological Indices of Stress in Domestic Horses (Equus caballus) during Riding Sessions.
Animals : an open access journal from MDPI    May 27, 2021   Volume 11, Issue 6 1562 doi: 10.3390/ani11061562
Contalbrigo L, Borgi M, De Santis M, Collacchi B, Tuozzi A, Toson M, Redaelli V, Odore R, Vercelli C, Stefani A, Luzi F, Valle E, Cirulli F.Equine-assisted interventions (EAIs) are well-known complementary practices combining physical activity with emotional/cognitive stimulation. They are especially suited for children with autism spectrum disorders (ASD) who need a high degree of physical and psychological enrichment. Even though EAIs have become a common practice, stress responses in horses interacting with individuals that can manifest inappropriate behaviours, such as ASD children, have not been thoroughly investigated. Our multicentre study aimed to investigate behavioural and physiological indices of stress in horses involv...
The Horse as a Therapist: Effects of an Equine Program Without “Therapy” on the Attention and Behavior of Youth Disengaged from Traditional School.
Journal of alternative and complementary medicine (New York, N.Y.)    May 4, 2021   Volume 27, Issue 8 678-687 doi: 10.1089/acm.2020.0500
Norwood MF, Lakhani A, Maujean A, Downes M, Fullagar S, Barber BL, Kendall E. Equine-assisted therapy may promote positive behavior change in young people "at risk." However, it is not always clear what therapeutic content is involved and if a trained therapist is included. The therapeutic effects of the key part of the "therapy," the horse, are not understood. To investigate the impact of an equine program without a therapist on attention and behavioral outcomes of young people "at risk." A within subjects pre-post design. A small sample also completed a control period. A small riding center in a rural area of outer Brisbane, Australia. Twelve- to 17-year olds (â€...
Effectiveness of Equine-Assisted Activities and Therapies for Improving Adaptive Behavior and Motor Function in Autism Spectrum Disorder.
Journal of clinical medicine    April 16, 2021   Volume 10, Issue 8 1726 doi: 10.3390/jcm10081726
Zoccante L, Marconi M, Ciceri ML, Gagliardoni S, Gozzi LA, Sabaini S, Di Gennaro G, Colizzi M.Equine-assisted activities and therapies (EAAT) have been suggested to improve adaptive behavior, and possibly motor function, in autism spectrum disorder (ASD). This study investigated the effects of EAAT on adaptive behavior and motor function in 15 children with ASD (13 males) aged 7-15 years as well as the impact of EAAT on the magnitude of stress in the parent-child system and the evolution in the child interaction with both the trained therapist and the therapeutic animal through the 20 weekly sessions of EAAT. EAAT were associated with greater adaptive behavior and coordination (all â‰...
Experiences of Military Veterans in a Therapeutic Horseback Riding Program.
Clinical nursing research    April 15, 2021   Volume 30, Issue 7 923-933 doi: 10.1177/10547738211003580
Johnson RA, Albright DL, Marzolf JR, Bibbo JL, Yaglom HD, Crowder SM, Carlisle GM, Grindler K, Harms N, Willard A, Wassman M, Russell CL.Posttraumatic stress disorder commonly occurs among U.S. military veterans. Therapeutic horseback riding (THR) has emerged as an adjunct therapy. We explored 20 veterans' perceived benefits, drawbacks and views of a 6-week THR program. Participants had confirmed diagnoses of posttraumatic stress disorder, traumatic brain injury, or both. Veterans rode the same horse weekly, the same day, at the same time. Data were collected as part of a randomized clinical trial testing the effects of THR on Post-Traumatic Stress Disorder. Veterans responded to an open-ended questionnaire. Content analysis wa...
Horse-riding simulators in treatment of chronic low back pain: A meta-analysis.
International journal of clinical practice    April 8, 2021   Volume 75, Issue 7 e14198 doi: 10.1111/ijcp.14198
Ren C, Liu T, Zhang J.The use of horse-riding simulators in the treatment of chronic low back pain has drawn considerable attention for its efficacy and acceptability to reduce chronic low back pain; because of the similarities in movements provided by equine-assisted therapies and the possible accessibility advantages. However, the results are conflicting. This study aimed to perform a meta-analysis of randomised controlled trials to assess the impact of treatments based on horse-riding simulators on chronic low back pain. Methods: A systematic literature search up to January 2021 was performed and 11 studies were...
Recurrent equine capillary haemangioma treated with adjunctive laser photocoagulation therapy: a case report.
Veterinary dermatology    April 6, 2021   Volume 32, Issue 3 290-e78 doi: 10.1111/vde.12951
Conturba B, Lo Feudo CM, Stucchi L, Stancari G, Olivieri L, Ferrucci F.The aim of the present work was to describe a case of recurrent capillary haemangioma at the coronary border of the left front limb in a 6-month-old thoroughbred filly successfully treated with diode laser ablation and adjunctive laser photocoagulation therapy. Le but de cette étude était de décrire un cas d’hémangione capillaire récidivant du bord coronaire du membre antérieur gauche chez un cheval de race de 6 mois traité avec succès par une ablation au laser diode et traitement adjuvant de photo-coagulation au laser. El objetivo del presente trabajo fue describir un caso de hemang...
Effects of equine-assisted activities on attention and quality of life in children with cerebral palsy in a randomized trial: examining the comorbidity with attention-deficit/hyperactivity disorder.
BMC pediatrics    March 19, 2021   Volume 21, Issue 1 135 doi: 10.1186/s12887-021-02597-0
Ahn B, Joung YS, Kwon JY, Lee DI, Oh S, Kim BU, Cha JY, Kim JH, Lee JY, Shin HY, Seo YS.Attention problems and decreased quality of life are frequently accompanied in Cerebral Palsy (CP), which can negatively affect rehabilitation of physical disability. However, the majority of affected children remain untreated in the aspects of attention or psychosocial factors. Equine-Assisted Activities and Therapies (EAAT) use horse as a therapeutic modality including grooming as well as mounted riding activities in which patients exercise and experience mounted stimulation. It is known to help improve attention in children with ADHD, so that it can be an exercise therapy that is expected t...
Electromyographic analysis of muscle activation of the trunk and lower limbs during human gait and hippotherapy using different ride mount materials.
Journal of bodywork and movement therapies    March 17, 2021   Volume 27 507-511 doi: 10.1016/j.jbmt.2021.02.013
Silva MAB, Lupianhes AFG, Lage JB, Sande LAP, Rosa RC, Lombardi LA, Espindula AP.Activation of the trunk and lower limb muscles, namely the multifidus, rectus abdominis, rectus femoris, and tibialis anterior, was analyzed using surface electromyographyin 40 young, healthy, and sedentary individuals. Methods: Data were collected from sneaker-clad subjects with independent gait and during hippotherapy using saddles and blankets, with the feet in and out of the stirrups. Results: Surface electromyography results demonstrated a statistically significantly greater activation of the rectus femoris comparison to tibialis anterior muscle during hippotherapy. No statistically signi...
A Commentary on the Contemporary Issues Confronting Animal Assisted and Equine Assisted Interactions.
Journal of equine veterinary science    March 8, 2021   Volume 100 103436 doi: 10.1016/j.jevs.2021.103436
Fine AH, Andersen SJ.The field of human-animal interactions and, more specifically, animal-assisted interventions and equine assisted interactions (equine assisted interactions have significantly evolved over the past half century. The primary purpose of this paper is to provide a brief commentary of both fields and the challenges they are presently experiencing as they move forward in their future. More specifically within this commentary, attention will be given to highlighting some of the directions taken in both fields, including clarifying their terminology as it applies to scope of practices, trends in resea...
Animal Interaction Affecting Core Deficit Domains Among Children with Autism: A Meta-Analysis.
Journal of autism and developmental disorders    February 13, 2021   Volume 51, Issue 12 4605-4620 doi: 10.1007/s10803-021-04891-3
Droboniku MJ, Mychailyszyn MP.Animal-assisted intervention (AAI) has garnered public interest and has been implemented for youth with autism spectrum disorders-a practice supported by anecdotal evidence. While investigations of AAI for children with autism have been conducted, the extant literature is characterized by significant variability in methodology and practice. The present meta-analysis examines the aggregated effects of equine AAI on adaptive functioning among children with autism. Results indicated that interacting with an equine specifically during AAI produced small-to-medium effects (g = 0.40) on the adap...
Facilitating new movement strategies: Equine assisted physiotherapy for children with cerebral palsy.
Journal of bodywork and movement therapies    February 10, 2021   Volume 26 364-373 doi: 10.1016/j.jbmt.2020.12.022
Norrud BC, Råheim M, Sudmann TT, Håkanson M.Equine Assisted Physiotherapy (EAPT) offers children with cerebral palsy (CP) opportunities for new movement experiences, and may influence movement qualities. Descriptions of how, and to what extent EAPT affects trunk control is missing. The aim of this study was to explore if, and how changes in trunk control and changes in other movement aspects were observable in children with CP during EAPT, and if potential changes in trunk control could be measured. Methods: A multiple case study with a mixed methods design was completed. Two children with CP, GMFCS grade 1, were observed using video du...
Neural changes following equine-assisted therapy for posttraumatic stress disorder: A longitudinal multimodal imaging study.
Human brain mapping    February 5, 2021   Volume 42, Issue 6 1930-1939 doi: 10.1002/hbm.25360
Zhu X, Suarez-Jimenez B, Zilcha-Mano S, Lazarov A, Arnon S, Lowell AL, Bergman M, Ryba M, Hamilton AJ, Hamilton JF, Turner JB, Markowitz JC....While effective treatments for posttraumatic stress disorder (PTSD) exist, many individuals, including military personnel and veterans fail to respond to them. Equine-assisted therapy (EAT), a novel PTSD treatment, may complement existing PTSD interventions. This study employs longitudinal neuro-imaging, including structural magnetic resonance imaging (sMRI), resting state-fMRI (rs-fMRI), and diffusion tensor imaging (DTI), to determine mechanisms and predictors of EAT outcomes for PTSD. Nineteen veterans with PTSD completed eight weekly group sessions of EAT undergoing multimodal MRI assessme...
Effects of equine riding on static and dynamic mechanical contraction of the thighs and trunk muscles in inactive women.
Journal of back and musculoskeletal rehabilitation    February 2, 2021   Volume 34, Issue 4 521-535 doi: 10.3233/BMR-200008
Park S, Park S, Yoo J, Jee YS.This study investigated whether equine riding affects static or dynamic mechanical contractions on the thighs and trunk muscles in inactive women. Methods: Participants consisted of 30 women with a mean (SD) age of 21.06 (0.44) years. They were randomly allotted as follows: equine group (EQG, n= 15) and control group (CON, n= 15). Two types of muscle contraction properties in their thighs and trunk were measured through a tensiomyography (static muscle tester) and an isokinetic device (dynamic muscle tester), respectively. Using the body weights of EQG and CON as covariates, a 2-way between-gr...
Equine-assisted psychotherapy with traumatized couples-Improvement of relationship quality and psychological symptoms.
Journal of marital and family therapy    January 29, 2021   Volume 47, Issue 4 925-944 doi: 10.1111/jmft.12485
Willmund G, Zimmermann P, Alliger-Horn C, Varn A, Fischer C, Parent I, Sobottka A, Bering R, Rose C, Ströhle A, Köhler K.Many traumatised individuals suffering from deployment related PTSD report severe problems in their relationships. Up until now, the therapeutic interventions used by the German Armed Forces have rarely targeted these problems through the integration of partners. For this reason, a Program designed specifically for couples was developed. In this prospective study equine-assisted psychotherapy was applied to soldiers and their spouses. The study population consisted of n = 36 couples, divided in n = 20 therapy group with a inpatient equine-assisted intervention and a 16-couples control grou...
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