**4. Discussion**

The present study investigated e ffects of DAT on psychomotor development of children with mild intellectual disability. Even though DAT has been used for years, the related gains from this type of intervention have rarely been assessed in children with intellectual disability [8,14]. Conversely, a quick review of the literature shows a number of publications assessing e ffects of DAT on the development of children with cerebral palsy, various motor disabilities, and autism [36–38].

The current study involved a group of children with mild intellectual disability, aged 10–13 years (mean age 11 years ± 2.3 years). The children presented poorer abilities reflected by scores in finger identification, postural imitation, and kinaesthesia tests, compared to healthy children in the same age group [30]. Bülent et al. assessed sensory integration and activities of daily living in children with developmental coordination disorder; the scores achieved by the study group in postural imitation tests were considerably lower, compared to the scores of their healthy peers. Similar results were obtained in localisation of tactile stimuli and kinaesthesia tests [39]. Schoemaker et al. reported similar findings in a study assessing perceptual skills in children with impaired coordination. Children from the study group achieved poorer scores in a test assessing tactile perception and attention [40].

The present study suggests that DAT contributes to improvement in concentration reflected by the scores in finger identification test and Bourdon–Wiersma Dot Cancellation test. Before the therapy, the children achieved the lowest results; in the measurement immediately after the therapy, there was a statistically significant increase. Likewise, François et al. in their publication discussed e ffects of DAT on the functioning of children with pervasive developmental disorders and reported that during the therapy the children focused mainly on the dog. When they were assisted by a therapy dog, they were able to concentrate better and they exhibited greater awareness of their social environment [39]. Reed et al. conducted a study focusing on DAT and its e ffectiveness in children with autism. Children with autism disorder participating in DAT were found with better ability to concentrate and focus their attention, had higher intellectual potential and ability to learn as well as decreased level of anxiety [41].

In accordance with the protocol of the current study, the DAT sessions were carried out in groups of six children, and aimed to improve functioning of memory and attention processes, to ensure adequate level of motivation, increase sense of security and self-confidence in the presence of the dog, boost the ability to cope with di fficult emotions, improve motor function and the sense of balance, and reduce the sense of anxiety and loneliness through the contact with the therapist and the dog. The results achieved by the children in the DAT group in kinaesthetic sense, perception of tactile stimuli, ability to visualise tactile sensations without visual control, and ability to sense the location of tactile stimuli were significantly improved immediately after therapy. Nawrocka-Rohnka conducted a study involving children with cerebral palsy, autism, and intellectual disability. The DAT sessions were held in groups of three children. The greatest progress was observed in the ability to communicate commands (mean improvement by 37.89%). This result may reflect improved functioning related to both the intellectual domain—remembering the instruction and the sequence of gestures necessary in communicating commands—and the mental domain—development of the sense of self-e fficacy and improved self-esteem. Another area of significant progress observed in that study was related to "expression on emotions" (mean improvement by 30.96%), corresponding to the socioemotional domain. The poorest e ffects were found in the area of "mobility" (mean improvement by 30.96%), corresponding to the motor domain [42].

In another study, Gee et al. investigated e ffects of DAT on motor e fficiency of pre-schoolers with language disorders. The researchers assessed locomotion, balance, and coordination before and after DAT. The children achieved better scores when they were working in the presence of a dog [43]. In the current study, DAT sessions were designed to include practice of gross motor skills, balance, and motor coordination. The analysis did not confirm statistically significant di fferences between the results in motor planning measured before the DAT and immediately after the DAT. Importantly, however, the further improvement, reflected by the di fference in the measurements immediately after the DAT and at the two-month follow-up, was statistically significant. The result identified in the final measurement at the two-month follow-up, differed significantly from the baseline. It is likely that this result is associated with the fact that the effects of DAT in the study group were strengthened by the children's involvement in basic and complex activities of daily living in home setting during summer holidays. The learning process in fact may have required more time, and the summer break, which involved a change of the environment, enabled a consolidation of the skills acquired during the 10 months, since they had to be "brought home" from the setting of the day care centre. Other researchers also observed that assistance of a dog during therapy sessions is associated with patients' greater motivation and confidence during therapeutic activities as well as improved motor skills following the therapy; the children are more independent and function more effectively in the daily life [44,45].

The current study compared effects of the therapy (short-term—at the end of a 10-month DAT and long-term—at the two-month follow-up). As for the effect size reflected by the relation between measurements I and II, as well as II and III, the long-term effect (measurement III versus II) was significantly greater than the short-term effect in the category of postural imitation while a reverse situation was observed in the results of kinaesthesia test. It can be assumed that the change identified at the end of the therapy program is directly associated with the effectiveness of DAT, while the significant change identified two months later may reflect the fact that during the therapy the children received a certain stimulus and learned new psychomotor skills, which required sufficient time to be further improved. Similar long-term effects of DAT were reported by Piek et al. who concluded that this type of therapy favourably affects development of motor functions in children. They examined 511 children and their results were compared after 6 months and then again after 18 months. They found a statistically significant difference (*p* = 0.035) in the improved motor skills in the children taking part in the DAT sessions [10].

A review of the effects of other therapies on the psychomotor development of children with intellectual disability suggests that Dog-Assisted Therapy evaluated in the present study leads to comparable positive outcomes. For example, Ferreira et al. analysed the effects of a psychomotor intervention from the perspective of sensorial integration in children with intellectual disability. The study group included children aged 5 to 12 years. The therapy was designed to include physical education, described as "psychomotor education/reeducation", and comprised 44 sessions, 50 min each. The findings showed that the program affected the following psychomotor domains: Body schema, tonicity, laterality, as well as global and final praxis. Less visible effects were identified in balance and space-time structure [46]. Similar effects were identified in the current study. Furthermore, Lucas et al. carried out a systematic review with meta-analysis to examine effects of conservative therapies designed to improve gross motor skills in children with various neurodevelopmental disorders. Nine articles met inclusion criteria. The authors reported that some task-oriented interventions can effectively be used for the above purpose [47]. On the other hand, Wuang et al. in quasi-experimental controlled study investigated effectiveness of sensory integrative therapy, perceptual-motor approach, and neurodevelopmental treatment in children with mild intellectual disability. The three types of interventions were applied to 120 children randomly assigned to three specific subgroups. Assessments performed with measures of sensorimotor function carried out after the interventions showed significantly better scores in the treatment groups compared to the controls (receiving no treatment) on almost all measures. Sensory integrative therapy more visibly affected fine motor skills, upper-limb coordination, and sensory integration. Perceptual-motor therapy produced significant gains in the children's gross motor skills, while the neurodevelopmental treatment resulted in the smallest changes in most measures taken into account [48]. Conversely, Bukhovets and Romanchuk assessed effects of Bobath therapy on psychomotor development in children aged 3–6 years, presenting with organic central nervous system involvement. The study was designed to evaluate the children's psychophysical state before and after neurodevelopmental treatment continued for 10 days in hospital. The findings showed a positive dynamics of motor activity and motor skills learning, which confirms the effectiveness of Bobath therapy as a method supporting psychomotor development of children aged 3–6 years with organic lesions in the central nervous system [49]. These observations are not consistent with the findings reported by Zanon et al. who published a systematic review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions to assess the effects of neurodevelopmental treatment (Bobath) for children with cerebral palsy. They performed a comprehensive search for clinical trials designed to assess Bobath method in comparison to conventional physical therapy applied to children with cerebral palsy and identified three randomized clinical trials involving 66 children. The analyses showed that e ffectiveness of neurodevelopmental treatment and conventional physical therapy did not di ffer in the case of gross motor function [50]. In summary, it may be concluded that sensorimotor approaches should be selected taking into account specific needs of a child because each approach may present advantages with regard to certain aspects of sensorimotor functions.

The current analyses did not identify between-group di fferences at the end of the therapy program (i.e., after 10 months), however the DAT Group achieved significantly better scores in postural imitation and finger identification tests, compared to the controls, at the follow-up exam two months after the therapy was completed, which may reflect delayed improvement attributable to the DAT. This may be associated with the fact that the follow-up exam was performed at the end of the summer holidays. Typically, during a break from the day care facility children spend more time at home where they do not receive any specialised therapy. In fact, we interviewed the parents to find out whether their children had participated in additional therapeutic activities in the summer. No parents reported that their children had received any form of therapy in that period. We cannot rule out, with absolute certainty, that some external factors indeed impacted the final results. It can, however, be speculated that the functions stimulated by the DAT therapy were more extensively (and freely) practiced in home setting which possibly provides more opportunities for a variety of independently performed activities, compared to a day care centre where activities are generally more structured. This may have led to the children's increased confidence in the use of the newly acquired abilities. In other words, it could be suggested that the 10-month period of the DAT, which involved exposition of the children to the stimuli, was more of a preliminary (theoretical) training, while the summer break associated with a change of the environment provided room for independent practical training of the skills. It is possible this period of "extra practice" enabled the children from the DAT group to gain greater self-reliance in the activities of daily living, which was eventually reflected by better scores acquired during the follow-up tests, compared to the controls.

In summary, the brief literature review above shows that most studies report positive results; DAT favourably a ffects the patients subjected to such interventions. Hence, it may be postulated that DAT is a good way to promote the process of rehabilitation, which is also supported by the current findings. However, it is necessary to continue the related research in larger groups of subjects and to apply di fferent research tools.

The strength of this study is linked with the fact that the analysis of the long-term e ffects of the therapy program is based on three assessments. Functional implications of this study are related to the fact that the acquired results may be of importance for clinical practice since they present evidence confirming long-term e ffectiveness of DAT and constitute an encouragemen<sup>t</sup> for introducing DAT as a supplementary method, which may be applied along with conventional therapies in children with mild intellectual disability in facilities providing treatment to this population.
